:
Thank you, and thanks very much for inviting me to address the committee.
You will have heard from Dr. Victor Marshall, who chairs the Gerontological Advisory Committee, and from Mr. Brian Ferguson and Darragh Mogan from VAC, who have given you some background on the reasons why the advisory committee was invited to write the report Keeping the Promise: The Future of Health Benefits for Canada's War Veterans.
What I'd like to do is briefly address the main issues that they have covered, adding some additional comments based on the questions you asked of them. I have been able to look at those transcripts. I also will highlight issues in the report that we believe will be important in its successful implementation.
I have been a member of the Gerontological Advisory Committee of Veterans Affairs since its inception. My areas of expertise are in families and aging, in rural communities, and in long-term care. I must say that my expertise in mental health is mainly in the areas of how families provide care to older relatives with cognitive illnesses such as Alzheimer's disease, although my research team is now engaged in research on the impact of acquired disabilities on individuals and their families.
I co-direct an international research team for research on aging policies and practice and often consult with government departments and NGOs on social and health policy issues in aging. In my experience, the VAC Gerontological Advisory Committee is unusual, in that it is a standing committee of the department that brings together key stakeholders from the user groups, which are the veterans organizations, and the researchers in an ongoing dialogue with the department. It's actually a great mix of people with the on-the-ground experience of the veterans organizations as well as those with a national view of the issues.
Our mandate on this committee is to speak to the best ways to support health, wellness, and quality of life for war veterans and their families, from World War I—although I think we now have only one survivor—World War II, and Korea.
Keeping the Promise sets out a comprehensive, integrative health and social services system for these older veterans. I am an author of the report, along with Dr. Dorothy Pringle, who I think you're going to speak to in the next few days, and Dr. François Béland. The report was vetted by all members of council and endorsed by the veterans groups.
As you've heard, its main recommendations include combining existing VAC programs into a single program called veterans integrated services. I want to add that we think this integration is really essential. For one thing, the integration allows for a combination of the health, income security, and social connections that we know are key determinants of well-being in later life. Integrated services allow for much more ability to address the needs of a person and to take into account the context in which he lives. Supporting people in later life is not just about addressing physical frailty or providing a pension; it's about helping them to age well in the place where they live.
Integration is also important in that it allows for one point of entry into a set of services that cut across what commonly are stovepipes of health, social services, income, and housing, and to accommodate a range of people, from those who are living independently but could benefit from health promotion activities, to those who need nursing-home-level care. Older adults are incredibly diverse, and we can't forget that. I believe that this model is what the experts in aging see as ideal, and seeing it in practice would be a wonderful gift to Canada's veterans. Integration also drastically reduces the set of eligibility requirements that have become increasingly complex over 60 years of adding and tweaking programs to address the needs of an aging group of veterans, who in the 1940s needed educational programs and affordable housing for their growing families and now may need social connections and supportive housing.
The second principle, which is one I won't dwell on and which has been spoken about by the other presenters, is to base eligibility on needs rather than on the veteran's status. You've heard our phrase that represents this principle: a veteran is a veteran is a veteran.
I think there's unanimous agreement among the GAC, veterans groups, and department members that complex eligibility criteria serve no one well. I'd like to reiterate that this doesn't mean that all veterans would receive services under the proposed VIS, but all would be eligible if the need arose.
The third principle in the report I think also warrants some comment. Our recommendation is for an integrated program of services to veterans and their families. Now by families, the GAC is thinking primarily, though not necessarily exclusively, of older veterans and their spouses. Almost all the World War II and Korea veterans are men. For those with chronic health problems, their wives may have cared for them for many years, providing round-the-clock support and delaying nursing home placement. After the death of their husbands, services to these widows should continue.
But thinking about families also means assessing the needs of these couples while both are alive. For example, it's important to assess the capacity of an older spouse to keep a veteran at home and to support her if the decision is to do so. We're thinking, as well, of other situations, such as those in which the veteran is a caregiver to his wife. Current programs in the department that focus on veterans as clients wouldn't allow for things like the home adaptations needed to accommodate the spouse of the veteran who uses a wheelchair, respite for the veteran who is the caregiver, or management of home care services to provide personal care to the veteran's wife. Family needs are central to this new view of veterans services.
The final point I'd like to emphasis is that VAC is providing services to veterans in all parts of the country. Veterans live in a wide variety of communities with very different resources. Even rural communities, an issue that's come up in your previous discussion, differ greatly, ranging from having, for example, about 1% of people in the community over age 65 to more than 40%. And they differ greatly in the services they provide and their supportiveness to older adults.
This is one of the reasons why we believe that front line staff who will implement the veterans integrated services must have the authority and flexibility to shift and allocate resources to meet veterans' health and social needs and take into account the setting in which the older adult lives.
That concludes my opening comments.
:
Good morning, Dr. Keating.
I am pleased to see that you have experience with the elderly. But one thing you have not mentioned at all is that the elderly must be kept in their regular environments as long as possible, with informal caregivers such as family members.
To give you an idea of what I think, I will give an overview of Quebec's policy on the elderly. There is a program in Quebec to help build or modify what we call multi-generational homes. The government provides financial aid to sons or daughters who want to modify their houses to provide a home for their parents in their later years. In addition to providing money to help purchase concrete, bricks, etc., the program offers financial aid such as tax deductions, etc.
It also provides nursing help from a CLSC, a local community services centre. The nurses provide home care regularly, once a week or more often, when one of the two parents is sick.
According to Quebec studies, because of this approach, the elderly are less sick. They are no longer isolated. I always joke about this and say that when we are alone, the only thing left to do is think about our past sins or the ones we have yet to commit. We are giving them a new view, and the results seem very good. This program has existed for 10 or 12 years now in Quebec, and we keep it going year after year. We are building more and more multi-generational homes in all corners of Quebec, especially in rural areas. My friend Roger had this concern.
I would like to hear your thoughts on the Quebec system. Does this already exist in Canada? If not, would it be possible to do it? I would like to hear your views on this.
Certainly the areas you touch on are ones that are very important. As we have over the last decade or two in Canada focused much more on the family members and friends who are providing care to frail seniors, we've begun to think about what kinds of things would support them in the work they are doing. Fewer and fewer older adults in Canada are in nursing home settings. So as you say, most of the care is being offered to people at home. Many of the services that you talk about that are being offered in Quebec certainly are things that can make a tremendous difference to families in their ability to take on this task.
One of the things that we highlight particularly in the Keeping the Promise report is the question of housing, which you talk about, and that having more housing options, including the ability to adapt one's own home or the home of a child, if that's where you're living, can make a very big difference in people's ability to stay out of nursing homes. What we'd like to avoid, if possible, is people's placement in higher levels of care than they need.
As you know, the services available to caregivers vary tremendously across the country. So I cannot comment specifically on what is available in which locations, but this is a very important issue on the agenda, I think, of most provinces, and certainly of Veterans Affairs, which is to think about families and support those members who are providing care to older adults and to veterans.
:
Okay. I can't speak to the question of income caps in Scandinavia. Unfortunately, I don't have those sorts of data available. It's a good question, but I can't help you in that respect.
On which province it's best to be an older veteran, the nice thing about the Veterans Affairs mandate and programs is that they fill gaps. The whole idea of Veterans Affairs is that wherever you're living, you should have the same access to services provided by the department. So I think, in general, and particularly with the implementation of the recommendations in this report, that veterans across the country should be equally well served.
As for the one aspect I would change in the present system for veterans, I would say, absolutely, the simplification of all these eligibility requirements. I've consulted with the department for ten years, and I'm still not sure if I could fully pass the test of knowing what all the current eligibility requirements are for programs. So that would be the number one change, I think.
:
That's really great to hear, because I happen to agree completely with you. I can't answer all of the questions I asked you. I was asking them of you to see if you could give me some facts.
I'm from British Columbia, and I do recognize there are more and more senior veterans, as well as seniors generally, moving toward the west. I think it probably has a lot to do with the weather, but in terms of services, I'm not sure whether we're keeping up with that sort of thing.
With regard to the taxation levels, I don't have an exact figure either, but my understanding is that it's about double what we pay in Canada. They're able to provide all those additional services because they have a much larger tax base from which to do it. A better way to put it is that they take more taxes.
You also made some interesting comments about rural Canada being older than urban Canada. Maybe as you get older, you get wiser and you get out of the city.
:
An excellent question. I think there is a fairly high level of understanding now that we are in that kind of third era in which families, in particular, are doing the vast amount of care of frail older adults and of younger adults with disability. In fact, in our own work, we and others would suggest that about 80% of the care of older adults is provided by families. And the people who are presently in nursing homes tend to be those who are very old and who have some kind of dementia.
Having said that, I think we're still really beginning to catch up in our understanding of how we might best support families who are providing that kind of care. That's where a lot of the emphasis is now, I think, and that's why this report really is about focusing on not only the individual veteran, but on family members.
There's a lot of interest, I think, in families and caregiving and how to support those family members. I think we can continue to do better by thinking about the variety of caregivers. The kind of support an elderly spouse might need could differ considerably from the support needed by a daughter who's a caregiver, who's trying to juggle her own responsibilities to her children, her labour force engagement, and her care of her mother or father.
A number of years ago the federal government opened or started discussions with the provinces and territories on a national home care plan. There have been conferences, and of course the idea is of a continuum of all ages of the medical needs in a home setting.
You just mentioned in your last response, if I understood you, that not every situation is the same as the next, and their needs would vary. In your thinking, is there a place for a national home care program? Obviously we're leaving aside funding concerns and the extent of such a program. But should we as a nation get more serious about that?
We do have gerontology in-home workers, but it's not regulated, as I understand it, and it's not overly organized. I'm just wondering if you could comment on national home care in this context.
:
It is up to you to decide if you would like me to briefly summarize what I saw and heard on Monday, Tuesday and Wednesday. I will do it for your information. This symposium was very interesting. I think the problems it addressed were fascinating. There were so many information sessions offered that it was hard to choose which ones to attend.
I think I was the only one who was not a psychologist or a psychiatrist, other than the symposium organizers. More than 450 people, psychologists and psychiatrists from all over Canada, the United States and some European countries as well, met to review the current situation.
My first reaction was to notice how far behind we are in terms of research. It is not just in the area of post-traumatic stress or human psychological behaviour that our American friends are much more advanced. In terms of post-traumatic stress, we are very far behind, but fortunately there has been some good research conducted in the United States, which we can use. They have been interested in this since the Vietnam War, while we started taking an interest in it barely five years ago. That is hard to believe.
But there is hope. I brought the program from the symposium to provide you with names of experts, such as Matthew Friedman, one of America's foremost authorities on this topic. During his presentation, he referred to the findings of young psychologists from McGill University, the University of Toronto and the University of Manitoba. So there is an exchange, and our young academics are perhaps better informed than older Canadian psychologists about the experiments conducted by the Americans.
I can also say—although not with as much certainty since I did not meet enough people from these countries—that we are no more advanced or farther behind than France, Belgium, Germany, etc.
What interested me particularly, was to learn who can suffer from post-traumatic stress, and that post-traumatic stress is not restricted to our soldiers. There are about 10 or 12 types of stress that can affect some people at any time in their lives. For example, it could occur following a rape or an automobile accident in which the person witnesses the death of a best friend. These are events of the same type, but naturally, it is much more likely for them to happen on the battle field than in everyday life.
What can we do? First of all, people who are experiencing stress must be able to recognize that they are having problems and realize that they must see someone. Second, the quicker this is done, the better the chances of healing, not 100%, but I think the figure provided was 67%. Yes, I am looking at my notes, and the figure was 67%.
So I have realized the importance of increasing awareness among the young soldiers who are enlisting about this phenomenon which could occur. I also realized that there was a serious shortage of professionals in Canada and Quebec able to treat this condition.
Because of Canada's geography—we have three or four large, urban centres found within one strip of land, while the rest of the country is mainly rural—it is difficult to establish a front line for intervention. When a young soldier suffering from post-traumatic stress begins to feel like something is wrong, he or she does not need to see a specialist for an initial consultation. However, the person he or she does consult must be very familiar with that condition. If PTSD is identified, the patient could be referred to a centre such as Sainte-Anne Hospital, for example.
There is still a lot of work to be done. Most of the psychologists there said we need to find a way to establish networks to provide primary care and initial contact in Canada's more remote areas. This aspect is crucial. We are starting to see this in rural areas, but this will take some time.
As an example, Dr. Friedman said that, since the United States began their research into this area shortly after the Vietnam war, every year, more and more psychologists and psychiatrists are earning their degrees, specializing in this area. He told me an interesting fact during a one-on-one conversation. According to him, we should not be too quick to trust our statisticians, because their calculations are inaccurate. I asked him what percentage of our young soldiers return from combat suffering from various degrees of post-traumatic stress—the intensity is not always the same—and he said that, in the United States, that figure is 39%. Statistics suggest that, in Canada, the percentage is approximately 12%.
My next comment is addressed mainly to Betty. I was surprised to learn—and I would have never believed—that women are more likely to suffer from post-traumatic stress than men. The difference, in terms of percentage, is minimal. The difference is 10% compared to 8% in the general public, not in the army. I was surprised by that. I though the rate would be the same or almost the same. But no, 10% of women suffer from post-traumatic stress compared to 8% of men. What is the reason for this difference? I do not know, I am not an expert. I learned this during the last day, yesterday, but I did not really understand what they were saying.
The three days were very worthwhile. Another surprising piece of information that must be considered is that approximately 25 to 30% of young people who begin treatment leave the program prematurely. Why? No one knows. Psychologists do not know why, but between 25 and 30% of young people who begin treatment abandon it after three or four sessions. Psychologists do not know how to retain them. The success rate of treatment is 67% and the time it takes for the treatment to be successful can vary between a few months and a few years.
I asked about post-traumatic stress among traditional wartime veterans—those we know are now in their 80s—and I learned that the stress dates back so far back that it is nearly impossible for the victims to heal. We can try to make the illness less painful by encouraging them to have a more active social life and become more involved in their families, with more intergenerational contact. We can help them alleviate their problem, but healing PTSD or post-traumatic stress is nearly impossible at that age, because they do not have many years left. Their suffering could take 10, 15 or 20 years to heal.
I could go into greater detail. Furthermore, I asked for a report on all the sessions, and I could forward you that report, if you like. There were 33 sessions in three days, and most were taking place at the same time. I was able to attend about 15% of them. I missed one session that I would have liked to attend, on suicide among people suffering from post-traumatic stress. Unfortunately, I had already decided to go to another, more important session. It would have taken three or four people to attend all the sessions.
:
Maybe Michel would just make note of that thought for a possible future recommendation, if we agree.
You talk about the people taking a bus, maybe, and that's why they're discouraged to go and get treatment. When it comes to mental disorders, a lot of the work is talking. You know, you're talking to your counsellor or you're talking to your doctor.
I know that they now use telephone consultation. Maybe you have to visit the doctor one out of three times, but for the in-between two sessions you can spend the time on the phone. Did that come up at all? I'm just wondering, when you look at the distances and the time, whether more telephone intervention is something we should look at, especially for our rural veterans, and so on. I just wanted to raise that, because lots of it is talking, you know.