Indigenous and Northern Affairs Committee on Nov. 2nd, 2016

[Jenny Kwan, NDP, Vancouver East, BC]

Thanks very much, Mr. Chair, and thank you to both of our witnesses for your presentation.

Ms. McDonald, you mentioned a need for a continuum of services, and right now we have certain gaps and certain missing elements within that. Can you explain to this committee what that continuum of services looked like right from the beginning to the end, and then within that continuum which are the pieces that are missing?

Ms. Vickers, feel free to also jump in to answer that question.

[Dr. Shannon McDonald]

That sounds like a Ph.D.

[Patricia Vickers]

I can give you another example. Frank Brown was his name. He's from Bella Bella. It's the Voyage of Rediscovery. Frank Brown is now in his fifties. When he was a teenager, he broke into an elder's home, assaulted the elder and stole. He was identified and confessed he had done it. He went before the judge. His uncle also went before the judge and said we would like to discipline him in our Heiltsuk way. The judge agreed. Frank was taken to an island where we had to survive for six months. His uncle went to visit him. Whatever it was he knew or didn't know, he was going to have to say in order to survive.

During that period of time he had a spiritual awakening, and Frank Brown now is one of the leaders of Bella Bella. If you've heard of the Qatuwas canoe journey, you'll know he's the organizer of the Qatuwas canoe journey.

That's also an example of culture and people stepping forward from the community. It's also continuous care in the sense that Frank is now helping others in the community.

[Dr. Shannon McDonald]

One of the things that we're looking at is a life course model. For example, on the health promotion, population health point of view, we're looking at young parents and helping them to parent better, to maintain programs in schools that are free from bullying, and that present cultural activities and language and some of the other things so that self-esteem is built up very strongly in the community.

And it's early identification. Part of that hope, health, and healing program is to help individuals in the communities, leaders and caregivers, to identify people who are headed towards a crisis where substance use is an issue. Early identification is absolutely critical, and it's bringing people into some kind of care early on before things are really challenging.

We know, for example, that almost half of the women incarcerated in the province of B.C. are aboriginal and first nations women, and a lot of that comes out of those social determinants of health. How did they get to the point where they were in a crisis that was bad enough that they ended up incarcerated? I think we missed lots of opportunities on the prevention side.

The closer we can get to communities with the services we provide, the better off we are. In B.C., because of the geography and the rural and remote nature of many of our communities, the provision of high levels of care are very challenging. Even primary care is a real challenge to get to those community levels.

It's working with people who are going to the community, our remote certified nurses or nurse practitioners and the itinerant physicians and other caregivers, and helping them to identify individuals who may need help and to set up a helping plan for them in the community. Then, if the community-level services can't provide the care that's needed...to be able to bring people out. In the past a lot of people were brought out and never went home. They came out, were institutionalized, and never had a chance to go home. So we need to make sure that whole circle is there.

[Jenny Kwan, NDP, Vancouver East, BC]

Do we have a clear understanding of the community's need in terms of an assessment of the capacity of the community, all the way from cultural and traditional infrastructure and support for indigenous people and Inuit and Métis, to the medical model of intervention?

We've heard from witnesses who said that, for example, when they have a suicide crisis on their hands, they have to phone 911. They would much rather not phone 911, but phone perhaps the council or some other agency to come in to provide support so that it doesn't create a situation where the person who is in need will no longer reach out for help because he or she would just be institutionalized in a different way.

I'm just wondering. Have we looked at the capacity of our communities across B.C., and what their status is, or what situation they are in?

[Patricia Vickers]

I started my presentation by speaking to conditioning, the conditioned mind, and so the first thing we really have to address and that we are addressing is dependency. What you're speaking to is dependency.

When we look at oppression, dependency is going to be one of the biggest issues that we have to deal with, and that's what we are.... If we look to see cultural protocol, it exists in all of our communities.

As far as capacity goes, it's there. Our biggest challenge is letting go of internalized oppression.

[Jenny Kwan, NDP, Vancouver East, BC]

Are resources not an issue?

[Patricia Vickers]

Of course resources are an issue, but I'm saying the larger problem we have to face is that, and then those who do assist us, their having that understanding—

[Dr. Shannon McDonald]

Each of the regions in the province has developed in partnership with the health authority a crisis protocol, and in that crisis protocol there is an opportunity not only to have the 24-hour crisis line responding, but also to have RCMP, education, mental health services, both ours and the health authority services brought in. Unfortunately, those responses tend to be very short term, so it's time to cover the crisis. The issue is what happens after the crisis.

[The Chair, Liberal, Andy Fillmore]

Thanks for that.

The next question is Don's—

[Don Rusnak, Liberal, Thunder Bay—Rainy River, ON]

—at reduced time.

I read an article a couple of days ago and it was in the Sun, of all places. I don't read the Sun, it was just in my Google news feed. It had to do with spending on administration in health and it compared northern European countries and Canada. We're spending more or the same, but we have worse health outcomes. Part of the argument in the article was that the bureaucracy in our health care system here in Canada is so massive that it takes so long to make decisions and it takes so many layers just to get anything done.

I see in my province of Ontario, LHINs, local health integration networks, which I thought was a horrible idea because I spent a little bit of time in Manitoba Health at the aboriginal health branch years ago. Before I was there, the creation of the regional health authorities of Manitoba took place. I didn't understand why they were created. I understood why they thought it was a good idea but one of the regions, the Winnipeg Regional Health Authority, essentially became Manitoba Health.

Why did we have people at Manitoba Health doing the same things? They became a monster. They kept on growing. They expanded into different office buildings and we had our health budget going to bureaucrats.

The problem I hear in Ontario, and it's from the first nations health directors—again another layer of bureaucracy, if you will—maybe, but they're on the ground. They know what the immediate problems are in the community. I'd rather see that than have someone in Thunder Bay at an LHIN making decisions. What I'm hearing from the first nations and the health directors and the health providers is that the LHINs are making bad decisions. I think we're going to hear this in Sioux Lookout tomorrow. They're designed to make local decisions because they're supposed to be local experts, but they're making bad decisions on all kinds of things that affect the health outcomes of people from northern first nations, from urban aboriginal populations in northwestern Ontario.

I like the idea of a First Nations Health Authority, to get rid of some of the bureaucracy, but to link that more with the communities and the health directors, and having them with you, having one oversight body for all first nations.

I think that would clear up a lot of the duplication that's everywhere. We heard from the Provincial Health Services Authority, an excellent program, but it is a program that the First Nations Health Authority should be delivering on, indigenous mental health, because you guys should be the experts on that. It's just duplication.

What do you see your future becoming? What are your aspirations for the First Nations Health Authority? Was I on the right track with reducing bureaucracy and having you do part of that?

[Dr. Shannon McDonald]

There are risks and benefits to the First Nations Health Authority.

I came to B.C. six years ago from the federal system, so I had an understanding of what they were trying to get away from. Everything that the regional office of first nations and inuit health had been doing—the funding, the building, the people, everything else—was part of the transfer agreement. We are just getting through what organizationally we are calling transition, sort of coming from that system to a transformative system where we have an opportunity to do things very differently.

At the same time, our funders have huge accountability requirements, so that's always a challenge, and because of that, you have to create a bureaucracy to be able to do that work of the planning, the response, the data, and the surveillance, those pieces. There's an element of bureaucracy you can't really avoid.

When the First Nations Health Authority was created, one of the strongest statements that came through from our communities was that everything we do should be community driven and nation based. We have a commitment to engage, and engagement is expensive. We have regional offices and we have regional caucuses. There is constant communication between regional leadership and regional health directors and the organization. But we also have to fit within this broader system and interact within the broader system, so my world is meeting with doctors in B.C., the B.C. coroners service, the provincial Ministry of Health, and some of our federal counterparts, and, and.... Even though we are working very hard to transform to be community responsive, to put as many resources in the region and community as available, it's inevitable that we're going to have some kind of administrative structure to support that.

It takes time to figure all that out. It takes time to unravel how things have been done in the past, how decisions have been made in the past, and how we might want to change the way those decisions are made.

My friends in Ontario would tell you that the chiefs in NAN, the chiefs of Ontario, and others don't necessarily agree on what those priorities are. We were really lucky that the 203 communities in B.C. came together with a single vision and continue to support that.

[Don Rusnak, Liberal, Thunder Bay—Rainy River, ON]

There's no time left.

[The Chair, Liberal, Andy Fillmore]

It's not the favourite part of my job, believe me.

We'll move into the five-minute questions, and the first is from Cathy McLeod, please.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you for the presentations today.

I want to keep going at the 100,000-foot level, and hopefully, if my time master allows, I'll have a question or two sort of on the ground.

The creation of the First Nations Health Authority, the coming together of 203 chiefs with a vision was an extraordinary step. You said there are benefits and negatives, obviously. Is it something that indigenous communities in other provinces are thinking of, or is it really so unique to every province that it's really a creation that works for each community?

[Patricia Vickers]

I'm from B.C.

[Dr. Shannon McDonald]

There are elements that are universal. I think the primacy of first nations and aboriginal voices in what we do is definitely the most important, but the contexts and the needs are different. Part of what we do is trying to balance the fact that those 203 communities are very diverse in size, in needs, in geography.

There is always competition for scarce resources—anybody working in government knows that really well—there's never enough money. Part of our role is to find new ways to do things with the resources we have.

There is universality. There are things we continue to share. My boss is Evan Adams. Some of you may know who he is, another first nations physician from B.C. He spends a lot of time travelling across the country talking to other first nations organizations, as does our CEO, Joe Gallagher, to say this is what we did, this is how we do it, this is how we're continuing in this work, and offering them our lessons learned for them to apply or not apply according to their context.

B.C. is unique in that, except for Treaty No. 8 territory way up in the northeast and a couple of the old historic treaties, like the Douglas Treaty on the island, most of B.C. is not in treaty.

Treaty changes the context. There is a lot more structure to the conversations between the crown and the nations. We're here. This is unceded territory and, how do I say this gently, the Supreme Court seems to agree that the government has gotten a few things wrong.

I think in a resource-based economy where that dichotomy existed it allowed for a really different conversation between province and first nations about how we are going to move forward together.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Both treaty and non-treaty are part of the First Nations Health Authority. There were no exclusions?

[Dr. Shannon McDonald]

Except for the Nisga'a.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

I have two questions, and hopefully I'll have time for both. One is when you mentioned 30 projects. I both love and hate projects because projects show amazing results and then you have the very significant challenges of either funding or moving it out. Talk a little more about the 30 projects that were mentioned in the opening.

[Dr. Shannon McDonald]

We're talking back and forth projects. They are sustainably funded, which is unique. They are part of an agreement between the province and first nations around medical service plan premiums. It was one of the big sticking points on the transfer agreement. First nations had MSP premiums paid on their behalf by Health Canada. First nations' perception was that this was a tax and not a fee, so all kinds of stuff was going on around that.

The agreement was first nations' money that was paid to MSP would be designated to serve first nations communities. Most of the projects, mental health and primary care, focused instead on end-to-end integrated primary care projects in all the regions across the province.

The MSP money pays for the first two years, and after that the province is committed to continuing the sustainable funding.

[The Chair, Liberal, Andy Fillmore]

Thank you.

The next question goes to Mike Bossio, please.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

We've had a number of anecdotal examples—Frank, the drug dealers, and bootleggers—around cultural heritage, language, restorative justice, values and principles, and ancestral laws.

In all of this, trying to take a wraparound approach to a number of issues, mental health and health.... None of this relationship of the wraparound is formalized. We've had anecdotal evidence of the wraparound and how it can work, but none in a formalized fashion.

How do we formalize it? Where should it come from, especially when you have so many different groups, organizations, partners? How do you coordinate the available resources and formalize the relationship so you can establish this wraparound process of dealing with mental health issues?

[Patricia Vickers]

If you can get your mind around ancestral law—

[Dr. Shannon McDonald]

Part of this is memorandums of understanding and letters of understanding and all kinds of things in the political world because that's how the province runs, but that's not how our communities run.