INTRODUCTION

Mental illness affects Canadians of all ages, education, income levels and cultures. It covers a broad range of diagnosed conditions, such as anxiety disorders, depression, post-traumatic stress disorder, alcohol and/or substance abuse, and other conditions that can interfere with daily functioning. According to the Canadian Mental Health Association, 20% of Canadians will personally experience a mental illness in their lifetime, and all Canadians are at some time indirectly affected by mental illness through a family member, friend or colleague.[1] Canada’s veterans, as well as members still serving in the Canadian Armed Forces, are not immune to mental illness.

 In order to help treat mental illnesses, all residents of a province or territory are entitled to receive mental health services under the terms of their provincial or territorial health plan. For eligible Canadian Armed Forces veterans, Veterans Affairs Canada (VAC) pays for services not covered by their provincial or territorial health plans, such as specialized psychological care, residential treatment and some prescribed medications.

Veterans can access mental health support from VAC through at least six different programs including, among others, the Disability Benefits Program and the Rehabilitation Services and Vocational Assistance Program (henceforth, the Rehabilitation Program). To be eligible for the Disability Benefits Program, veterans must have an operational stress injury, which is a persistent psychological difficulty, resulting from operational duties performed while serving in the Canadian Armed Forces. The Rehabilitation Program helps veterans re-establish themselves in civilian life and is intended to provide transitional support.[2]

According to VAC, veterans with mental health conditions represented 12% of its clients in 2014, up from less than 2% in 2002.[3] As of 31 March 2014, about 15,000 veterans and still-serving personnel were eligible to receive mental health support services through VAC’s Disability Benefits Program, and another 1,000 veterans in the Rehabilitation Program had a mental health condition.[4] In 2012–2013, VAC estimated that its total mental health expenditures were $508 million.[5]

In its Fall 2014 Report, the Office of the Auditor General of Canada (OAG) released a performance audit that examined whether VAC facilitated timely access to services and benefits for veterans with mental illness.[6] The audit also looked at joint initiatives and the transfer of military records with the Department of National Defence and the Canadian Armed Forces, as well as information on reviews and appeals by the Veterans Review and Appeal Board.[7]

The House of Commons Standing Committee on Public Accounts (the Committee) held a hearing on this audit on 25 February 2015.[8] From the OAG, the Committee met with Jerome Berthelette, Assistant Auditor General, and Dawn Campbell, Director. From VAC, the Committee heard from Michel D. Doiron, Assistant Deputy Minister, Service Delivery, and Dr. Cyd Courchesne, Director General of Health Professionals and National Medical Officer. The Department of National Defence was represented by BGen Jean-Robert Bernier, Surgeon General, Commander Canadian Forces Health Services Group.

FACILITATING ACCESS TO MENTAL HEALTH SERVICES

The OAG noted that VAC and other federal departments had put in place important mental health supports. VAC funds nine outpatient and one inpatient operational stress injury (OSI) clinics that provide assessment, counselling and treatment services to eligible veterans and Canadian Armed Forces members. Veterans can be referred for assessments without being eligible for other programs, and treatment services are available once VAC confirms eligibility. VAC’s case managers help veterans receive a variety of supports, including mental health services. Health Canada operates a 24/7 telephone service to enable veterans and their families to reach a mental health professional at any time. VAC and the Department of National Defence jointly fund the Operational Stress Injury Social Support (OSISS) Program, which provides peer support to veterans and their families.[9]

The OAG confirmed that 3,600 of the 15,000 veterans eligible for mental health support under the Disability Benefits Program have also accessed support from the Rehabilitation Program. The two programs are not mutually exclusive.

A VAC representative confirmed that the mental health supports available under the Rehabilitation Program can be extended for the eight months or more that it might take for an eligibility decision under the Disability Benefits Program to be made. He also confirmed that the mental health supports delivered through the Rehabilitation Program are capable of meeting the needs of veterans until the eligibility decision is made. He confirmed that there is no reason for any veteran to wait as long as a year if they have applied for mental health support.

The OAG did not find evidence to contradict the assertion that the timely mental health supports delivered through the Rehabilitation Program are adequate to meet the needs of veterans who request them.

A. Timeliness of Access to Support from the Rehabilitation Program and the Disability Benefits Program

As an eligibility decision is a prerequisite to obtaining mental health care benefits from VAC’s Rehabilitation Program and Disability Benefits Program, the OAG examined the process used by VAC to determine eligibility for these programs.[10] According to the OAG, timeliness is important because VAC has a legislative responsibility to facilitate access to the specialized care required by veterans with mental health conditions.[11]

With respect to the Rehabilitation Program, VAC does not have a standard for the time it should take to access treatment and services, but it does have a standard of making 80% of eligibility decisions within two weeks of determining that an application is complete, and preparing case plans within 45 days of a favourable eligibility decision.[12] The OAG found that VAC was meeting its service standards for providing timely access through the Rehabilitation Program, making 84%, or 1,136 of 1,349, of eligibility decisions within the two-week service standard in 2013-2014.[13]

For the Disability Benefits Program, VAC has a target of providing 80% of applications with a decision on eligibility within 16 weeks of VAC determining that applications are complete. The OAG found that 75%, or 2,160 of 2,893, of decisions were processed within the 16-week standard in 2013-2014; thus, 733 veterans did not receive a decision within the 16-week standard.[14] If VAC had met its target of providing 80% of decisions within 16 weeks, it would have processed 2,314 applications, which means that VAC fell short of its target by 154 applications.

Furthermore, the OAG noted that 90% (10,528 of 11,701) of VAC’s first favourable decisions were made in less than 12 months.

The OAG also noted that 97% (11,339 of 11,701) of VAC’s first favourable decisions were made in less than 24 months.

However, the OAG observed that from the veteran’s perspective, that is, from the time of the veteran’s first contact with VAC, it takes about twice as long, i.e. 32 weeks, to receive an eligibility decision for the Disability Benefits Program due to barriers in that application process.[15] Jerome Berthelette, Assistant Auditor General at the OAG, told the Committee that, “from the veterans perspective, about 20% [of veterans] had to wait more than 8 months, from the first point of contact, for the department to confirm their eligibility to access the specialized mental health services paid for by the department.”[16] Mr. Berthelette explained that there may be factors outside of VAC’s control leading to the delay. For example, veterans may not have access to a family physician, and it may take time to get the information required to support an assessment.[17] The OAG recommended that VAC analyze the Disability Benefits application process, quantify and document barriers to timeliness, and take corrective action.[18]

Michel Doiron, Assistant Deputy Minister at VAC, told the Committee that VAC is trying to be more responsive to veterans and is changing its approach to handling applications. He said VAC is trying to be more veteran-centric and rather than simply denying an application, VAC now contacts the veteran to ask whether there is any further information that can be provided to help support the application. In this way, VAC is giving the benefit of the doubt to the veteran.[19] This approach has increased the approval rate from 71% to 79%.[20]

Mr. Doiron noted that in November 2014 VAC released a Mental Health Services for Veterans Action Plan that includes increasing the number of psychological counselling sessions available to veterans and their families to 20 sessions, up from 8 sessions, establishing a Mental Health First Aid Program to help veterans and their families recognize and deal with mental health issues, making further investments in the OSI Clinic Network, including a new clinic in Halifax in 2015 and OSI clinics in satellite locations, and strengthening the OSISS Program with 15 more peer support coordinators.[21] He also told the Committee that VAC provides services to veterans who are waiting for an eligibility session, stating, “We have the crisis line, which will give them 20 sessions with a psychologist. You can call 24-7, you will get to meet a psychologist. There are peer networks, OSISS, where a veteran can actually talk to a fellow veteran who has been where this individual man or woman has been, and the services are there.”[22]

In order to determine whether veterans were accessing mental health services while waiting for an eligibility decision under the Disability Benefits Program, the OAG selected a random sample of 47 veterans eligible for mental health support and found that 17, or 36%, of the veterans received mental health care while waiting for an eligibility decision. They did not find evidence whether another 11 veterans had or had not received services, and 19 individuals were still-serving and thus the responsibility of the Department of National Defence.[23]

Mr. Berthelette commented that VAC could do more to overcome the barriers that slow down eligibility decisions. He explained, “These barriers are a complex application process, delays in obtaining medical and service records from National Defence and the Canadian Armed Forces, and long wait times for getting access to mental health care professionals in government-funded operational stress injury clinics.”[24]

B. Application Process

The OAG surveyed Royal Canadian Legion service officers who represent veterans and complete their applications. The survey results indicated that veterans find the application process complex and time-consuming.[25] Also, according to the OAG, the Disability Benefits application requests information that should be included in the service records that VAC receives from the Department of National Defence.[26] The OAG recommended that VAC help veterans who may require additional assistance with the application process.[27]

Mr. Doiron told the Committee that VAC has taken steps to simplify the application process. He said:

We went from an 18-page form—and I know 18 pages is incredible. I've only been here a year and I'm reviewing all forms, and our forms are complex. We're down to 11, and you say that's not much better but the form itself is four pages and it includes a quality of life. The other part of the package is information. That was implemented in October. It has been done. We're now doing a secondary review to see if we can simplify that even further.[28]

C. Obtaining Military Records

In order to make an eligibility decision, VAC requires information from service records compiled by the Department of National Defence. The OAG observed that through a joint effort, VAC and the Department of National Defence had improved the timeframe for transferring records from 18 months to approximately 16 weeks.[29] In the opinion of the OAG, 16 weeks is still not timely and it recommended that the Department of National Defence and the Canadian Armed Forces take further steps to accelerate the transfer of service records to VAC.[30]

Mr. Doiron explained some of the reasons for the time taken to transfer files, including removing third party information from the files in order to comply with the Privacy Act, and the time needed to move paper files from bases across Canada to a central location in Ottawa. BGen Jean-Robert Bernier, Surgeon General of the Canadian Forces Health Services Group, told the Committee that the time taken to transfer files had been reduced to five weeks.[31] The digitization of records will also make it easier to move records from the Department of National Defence to VAC, but Mr. Bernier noted that this is an ongoing process and BGen Bernier observed that the Department of National Defence will have paper records for anyone who served prior to 2011.[32]

D. Wait Times for Assessments

To be determined eligible for the Disability Benefits Program, veterans must submit a medical diagnosis from a licensed health professional, which can be obtained at VAC’s OSI Clinics. While VAC had not tracked or reported wait times for assessments at its clinics, VAC informed the OAG that the average wait times from referral were about three months.[33] The OAG recommended that VAC work with its clinics to provide timely access for psychological and psychiatric assessments.[34]

Mr. Doiron informed the Committee that VAC was making investments in its OSI Clinic Network, including adding a new clinic in Halifax, which will accelerate access to mental health services.[35]

Veterans may also receive services at the Department of National Defence’s Operational and Trauma Stress Support Centres (OTSSC); however, the OAG noted that in three of the seven centres the wait times were longer than 50 days.[36] The OAG recommended that the Department of National Defence work with its centres to provide timely access for psychological and psychiatric assessments.[37]

BGen Bernier told the Committee that the situation at the Centres had improved. He said:

In 2014, four of the seven OTSSCs provided an annual average third next available appointment within [the 36-day] benchmark. The other three experienced longer wait times, averaging 49 days among them, primarily due to staff absences for such things as extended sick leave and parental leave. By January 2015—this year—only one centre exceeded the benchmark and then by only two days.[38]

He stressed that Canadian Armed Forces members are able to receive mental health services while waiting for a detailed assessment from an OTSSC, noting, “they’re all seeing and have access to addiction counsellors, mental health nurses, primary care physicians, in addition to sometimes general mental health psychiatrists and psychologists.”[39]

With respect to staffing, BGen Bernier indicated that more staff had been hired, stating, In 2014 the Canadian Armed Forces was authorized to hire an additional 54 mental health staff. Of these, 21 were for clinics with operational and trauma stress support centres. As of mid-January 2015, 94% of our 455 authorized mental health positions were filled and efforts continue to fill the remaining vacancies.”[40] Additionally, the staffing ratio “is the highest per-capita ratio in NATO and close to double the per capita [ratio] in any jurisdiction in Canada.”[41] He noted that the staffing needs were based on a 2002 study and incremental increases have been made over time, which will be reviewed based on the results of the 2013 Canadian Armed Forces Mental Health Survey.[42]

E. Appealing Eligibility Decisions

Of the 15,385 veterans who applied for disability benefits for a mental health condition between April 2006 and June 2014, 3,684 veterans, or 24%, were denied benefits. Of those denied benefits, 1,297 challenged VAC’s decision, and 65% of the challenges were successful.[43] Of the 843 veterans who successfully challenged their denied eligibility, 695 veterans waited between six months and three years for a favourable decision. Another 128 veterans waited from three years to more than seven years for a favourable decision.[44] As VAC had not analyzed what type of information resulted in successful appeals, the OAG recommended that VAC work with the Veterans Review and Appeal Board to identify whether the reasons for successful reviews indicate a need to modify the application process.[45]

Mr. Doiron explained that one of the reasons for the number of successful appeals is that in order to be eligible for benefits, veterans need to make a connection between their disability and their service, and veterans’ files may not have provided sufficient information to make the connection at the time of application.[46] He also noted that VAC will be working with the Veterans Review and Appeal Board to understand better why disability benefit claims are overturned, and this information will be used to improve policies and decision processes.[47]

PROVIDING MENTAL HEALTH OUTREACH

VAC conducts outreach activities to make veterans and other stakeholders aware of the supports available to meet veterans’ health care needs. The OAG found that VAC’s outreach strategy focuses on veterans and military members who are about to be released.[48] In the opinion of the OAG, VAC could do more to educate families and family doctors in their role in encouraging veterans to seek help for mental health concerns.[49] The OAG recommended that VAC update its outreach strategy to include family physicians and carry out a strategy that meets the needs of all target audiences.[50]

VAC’s action plan prepared in response to the audit indicates that VAC will ensure that its outreach activities are comprehensive and will add target audiences to its Outreach Annual Plan, including Reserve Force members, families and family physicians. VAC will also participate in Canadian Armed Forces events where veterans and their families are present, improve the information available through My VAC Account, and undertake a Military Family Resource Centre Pilot Project to provide community support for medically released veterans and their families for two years after release.[51]

MANAGING THE MENTAL HEALTH STRATEGY

In 2009, VAC developed a Mental Health Strategy. The OAG examined whether VAC had performance information to assess the effectiveness of its mental health support provided to veterans.[52]

While the Mental Health Strategy references more than 30 programs and services available to help veterans cope with mental health issues, the OAG found that VAC had not yet developed performance measures to assess the success of the strategy.[53] VAC’s performance measures focused on the number of veterans served and the timeliness of service rather than on the quality of service and the impact on veterans’ lives.[54] The OAG recommended that VAC assess and report on the effectiveness of its Mental Health Strategy and develop performance measures for its outreach activities.[55]

In the audit, the OAG observed that VAC was in the initial stages of implementing the Client-Reporting Outcome Monitoring Information System (CROMIS) into the OSI clinics.[56] The system will collect information from veterans about the state of their mental health and their treatment, which may help VAC develop actionable, timely and evidence-informed recommendations to the veteran and the mental health service provider.[57] Dawn Campbell, Director at the OAG, told the Committee that, “CROMIS is being piloted and it's going to be rolled out to a broader audience. It was our perspective that this was a good initiative and it holds promise.”[58] Dr. Cyd Courchesne, Director General at VAC, added, “With this system we can demonstrate that there are improved cure rates, less time in the system, and fewer people who relapse. We're very excited about the rollout of the system, what we'll be able to learn from that to be able to improve our treatment programs, and sharing that information with our colleagues at the Canadian Armed Forces.”[59]

In its action plan, VAC, commits to finalizing a renewed Mental Health Strategy, developing additional performance measures, partnering with the Royal Ottawa Hospital to create a Centre of Excellence for Military and Veterans’ Mental Health, and implementing CROMIS in OSI clinics and OSISS.[60]

PROGRESS REPORT

Both VAC and the Department of National Defence committed to undertake a number of actions in response to the OAG’s findings and recommendations, and they presented detailed action plans outlining their responses to the audit. A number of VAC’s proposed actions are scheduled to be completed in the final quarter of fiscal year 2015–2016. In order to monitor their progress, the Committee recommends:

RECOMMENDATION

That, by 31 March 2016, Veterans Affairs Canada and the Department of National Defence provide the Standing Committee on Public Accounts with reports outlining their progress in addressing the Office of the Auditor General of Canada’s recommendations contained in Chapter 3 of the Fall 2014 Report.

CONCLUSION

Veterans of the Canadian Armed Forces have made considerable contributions to the safety and security of Canadians. For some veterans, that contribution is accompanied by sacrifice, whether to their physical or their mental health. In recognition of their contribution and reflecting increased awareness of mental health concerns, the federal government offers a number of programs and services to veterans, including VAC’s Rehabilitation Program and Disability Benefits Program, in order to provide them with continuing mental health support. It is important that these programs and services effectively meet veterans’ needs.

The OAG concluded that VAC was not doing enough to facilitate timely access to mental health services and benefits delivered through the Disability Benefits Program. VAC did, however, facilitate timely access for veterans to mental health services and benefits delivered through the Rehabilitation Program. The OAG acknowledged that VAC had put in place important mental health supports, including OSI clinics, a 24/7 telephone service and the OSISS program.[61] The OAG also noted that VAC could do more to provide outreach to family physicians and veterans’ families, and VAC needs to improve its ability to demonstrate that its services are effective in meeting the mental health needs of veterans.[62]

VAC and the Department of National Defence explained to the Committee that they are taking a number of actions in response to the audit, including making investments in OSI clinics, simplifying application forms, accelerating the transfer of documents, improving outreach activities, reducing wait times for assessments, reviewing reasons for favourable appeals, and renewing the Mental Health Strategy with additional performance measures. The Committee expects that the departments will continue to make every effort to ensure that veterans have timely access to needed mental health supports.