by Natalie Salat

Clockwise, from top: Brigadier-General Lise Mathieu leads the Canadian Forces Health Service; Master Seaman Jamie Roberts is taken to sick bay during a casualty exercise in HMCS Charlottetown; medic Guylaine Gravel helps an injured soldier.

Canada’s military health-care system is filling a much-needed prescription for change with an ambitious reform program called Rx2000.

After suffering from continual cutbacks and a shortage of personnel during the 1990s, the Canadian Forces Health Services is nursing itself back to health through an injection of funds from the Department of National Defence and new ways of working.

Brigadier-General Lise Mathieu, who has led the CFHS since the launch of Rx2000 in January 2000, emphasizes that the Forces sought a lasting renewal of its medical services. “We didn’t want a band-aid. We wanted to say (the system) is fixed, it’s sustainable.”

A series of military reports issued during the 1990s–including an independent review conducted by the chief of review services in 1999–identified deficiencies in the management and provision of medical care to Forces members. Complaints were rife.

The defence minister at that time, Art Eggleton, launched Rx2000 shortly after the release of the independent report and current minister John McCallum continues to support the program. The leadership and the CF recognized that cuts had gone too far, states Mathieu. “The DND has been nothing but forthcoming in providing us with the resources needed to look after the men and women of the Canadian Forces. We’ve had some pretty sad cases that we’re learning from and we want to make sure they don’t happen again.”

One of the major problems had been providing adequate and timely care for people stationed in Canada (in-garrison), as medical staff had to be deployed for operations abroad.

“There were increasing shortages in our clinics as people kept being pulled off to be sent here, there and everywhere,” says Mathieu. “We started to see gaps in the continuity of our system.” Operations in Rwanda and the Balkans, among others, stretched the CF medical services to its limits.

Former lieutenant-colonel Brad White, now an administrative officer at The Royal Canadian Legion and formerly on the joint planning staff for operations abroad, recalls: “We were looking at critical shortages of doctors and anesthetists. We put medical surgical groups into Bosnia, and you had to continually roll the same people over all the time.” This not only led to a greater chance of burn out for medical staff, but also the potential for a lower quality of care and a lower morale for CF members. He says Rx2000 is “a step in the right direction.”

Under Rx2000, Mathieu and her 5,000 staff in the Forces health services have spent the last three and a half years addressing the combined reports’ 359 recommendations. While her department “participates in just about every (medical staff) attraction program going, our main strategy has been to reintroduce a climate of care that is focused on the needs of the men and women of the CF and also that shows respect for the health care providers.”

The aim is to provide Forces staff with medical and dental care anytime, anywhere, along with the same access to prescription drugs that they would have in Canada. The program has made progress on the dental side, offering swift, round-the-clock access to care; each Forces member is also required to have a yearly examination as a preventive measure. As for pharmaceuticals, “We’ve just acquired the ability to have a pharmacy profile on each member, and that’s online,” says Mathieu. This information is critical in cases of emergency, to prevent dangerous drug interactions.

To address the lack of continuity of care, the health services have introduced case managers to deal individually with Forces members who are suffering from long-term and complex health-care issues. Some 28 case managers, all nurses, are working out of 17 locations in Canada. They help staff navigate the CFHS and look at all the factors that affect their health, such as social support networks, income, education and personal health practices. “It’s the first concrete step we took to make sure people don’t fall between the cracks,” says Mathieu.

Another key step will be an overhaul of primary care at clinics and health care centres in the 35 military installations across Canada. Now being tested at four bases, the Primary Care Renewal Initiative (PCRI) is a new clinical model that employs a care delivery unit made up of civilian and military doctors, nurses, nurse practitioners, medical technicians, physiotherapists, mental health professionals and administrative staff to provide the services that would traditionally have been provided by physicians.

“The PCRI ensures that patients will not be shuffled to different health care providers at every visit,” says Allen MacEachern, PCRI team leader, in The Maple Leaf. “It also tailors health care to the specific needs of the unit and environment, (whether) navy, army or air force.”

While soldiers have to deal with aging like everyone else, notes Mathieu, their needs are unique because of “the cramped conditions in which we live and the environmental conditions in which we deploy all the time. Working in the military is very physically demanding. All you have to do is lift the kit of a soldier to understand.”

Prevention of injuries is key. Under Rx2000, the Forces health services have increased their physiotherapy capability to improve training so that soldiers use better practices to help avoid injury.

Mathieu points to another Rx2000 success–the creation of the Forces Health Protection initiative to protect troops from occupational health hazards and to give them the knowledge needed to maintain a high level of fitness. “It includes health promotion, the ability to do environmental assessments in-theatre so we can have better force protection measures (such as inoculation) and the ability to do epidemiological analysis. That way we can provide better information to clinicians so they can provide better treatment.”

Rx2000 staff are also working with Veterans Affairs to develop a mental health program that fully addresses the needs of CF members, who are often planted in high-stress situations. “We are going to have to be aware of this more and more,” observes Mathieu. In addition, it will be important to “sensitize” lieutenants and privates who come into the Forces “young and gung-ho” but without experience of the dangerous or distressing conditions they could face.

If all goes well, the pilot projects for Rx2000 will end by the summer of 2004 and full implementation will begin. Mathieu acknowledges there have been some bumps along the way, particularly with the reassignment of tasks and the hiring of clinic managers to ensure doctors are focused on medical rather than administrative tasks. Many of the 25 different professions within the health services have experienced considerable change. “All of this (Rx2000) came with new ways of doing business, new scopes of practice, new controls and mechanisms and tests. So we did a lot of consultation and change management sessions that helped give the community an identity consistent with where it’s going as opposed to where we were.”

The Canadian Forces Health Services has come a long way, says Mathieu, but there is still work to be done, particularly in attracting doctors and strengthening morale, which she describes as improved but “fragile.” While the Chief of Defence Staff now passes along praise from the soldiers in the field, instead of complaints, Mathieu concludes, “We don’t want to forget where we came from. What got us where we are today is where we were.”