Indigenous and Northern Affairs Committee on May 10th, 2022

[Marceline Tshernish]

All right.

The medical transportation component is underfunded, so the band council has to cover the difference to ensure that families have adequate escort support.

When it comes to mental health counselling, our traditional knowledge is not recognized, so we cannot provide counselling and other services within the community.

What's more, patients do not have the option of requesting a second medical opinion when they are not satisfied with the service available locally. The in-hospital experiences of first nations members, experiences we have all seen, must be taken into account if mistrust in the health care system is to be addressed. Some community members even refuse to seek care outside the community because they do not trust the system.

[The Chair, Liberal, Marc Garneau]

Thank you, Ms. Tshernish.

We will now begin the question-and-answer portion.

Starting things off is Mr. Shields for six minutes.

[Martin Shields, Conservative, Bow River, AB]

Thank you, Mr. Chair.

I appreciate the witnesses today and the information that they're sharing with us.

I'll start with you, Mr. Malak, and the pharmacist world you talked about. I think you talked about connecting with people to get a lot of permissions. I think we may have heard that from other witnesses before, and from others today.

When you call and you need to get approvals, are there people at the other end of the line who have any medical knowledge? Are you talking with people who understand the medical questions that you would need to get approved?

[Rudy Malak]

Thank you for the question.

I do not think so. No. Can I explain just briefly how the process of calling a helpline works?

[Martin Shields, Conservative, Bow River, AB]

You bet.

[Rudy Malak]

The prescription comes from the doctor. We try to process it. It says, “special authorization required”. We call ESI, Express Scripts, Inc., which adjudicates on behalf of NIHB. We apply for the prior approval. NIHB sends the approval to the doctor. The doctor has to fill it out properly and send it back to NIHB. Then NIHB sends it back as either approved or denied.

There are multiple people involved. Faxes get lost. Sometimes the doctors are not available anymore, or the doctor has written a prescription and left already.

I had an incident yesterday where the patient came in and, after one month, the process is not complete. It went to the doctor's office. The paperwork got lost or they didn't know what to do with it, or the doctor wasn't available. The patient has not started their diabetes medication for over one month because of that.

[Martin Shields, Conservative, Bow River, AB]

Thank you for running through an example like that.

From your point of view, when you have to go to that next level, would it make a difference if somebody had medical knowledge when you moved to that next level?

[Rudy Malak]

That might help a little bit, yes, but at the end of the day, it has to go to the prescriber who has actually written the prescription to fill out the paperwork and say whether the patient fits the criteria for that medication.

[Martin Shields, Conservative, Bow River, AB]

What's the step that needs to happen, then, to make it work for you?

[Rudy Malak]

I believe that medications that need prior approval should be like the provincial plan, where there's something called “limited use”, a sheet of paper that we send directly from the pharmacy to the doctor. The doctor signs it and sends it back. If we have that documentation, we're allowed to process it to the provincial plan.

It turns out that the NIHB process is overly complicated. There are four or five different people in between: the prescription to us, the pharmacists; the pharmacist to NIHB; NIHB to the doctor; the doctor back to NIHB; and then NIHB back to the pharmacy. You can imagine how many people are involved.

[Martin Shields, Conservative, Bow River, AB]

How many of them don't have any medical knowledge? That would be my guess.

We've heard this before. It has to be something that's discussed within the pharmaceutical organization. Has this been brought to you? Is it a discussion? Has it been brought forward anywhere?

[Rudy Malak]

Not to my knowledge, no.

As I mentioned in that opening statement, a lot of pharmacies do not know how to deal with and provide service to NIHB clients. Because of the number of different departments and phone numbers, they don't know what to do. Sometimes they just say, we don't know how to do this.

[Martin Shields, Conservative, Bow River, AB]

And the patient gets left.

[Rudy Malak]

The patient's already in stress. They're frustrated, they leave and they don't get care.

[Martin Shields, Conservative, Bow River, AB]

Thank you.

Ms. Grier, thank you for your presentation.

Since 2015 and the delisting in the last seven years, are you familiar with any lobbying or efforts to change this?

[Angela Grier]

Yes, we've been working tirelessly within CCPA to lobby for some of these changes and movements to expand the practitioners. As well, within individual first nations they are doing their best to lobby with NIHB currently within the mental health clinics. That's going on to provide space for CCCs, because in the absence of those spaces we have paraprofessionals filling professional counselling roles.

On federal reserves we don't have regulation like the provinces do. We're not having the unions or all of that oversight that we need. We're not getting the professionals we need for the acute health environments that we have. There is quite a bit of advocacy that continues to go on. Even first nations psychologists are advocating for this.

[Martin Shields, Conservative, Bow River, AB]

What kind of response do you know you've had as you've lobbied for this change back? Have you heard any feedback for why not?

[Angela Grier]

Not that I can say, sir.

[Martin Shields, Conservative, Bow River, AB]

The organizations have made the case and continue to lobby, but has there just been silence?

[Angela Grier]

Within NIHB it's always from the central headquarters' perspective that everything's okay. There are no problems or wait-lists. I work on the ground. I work in these communities that have unregulated colleges, such as Alberta. I can tell you that is not the case. The information that is flowing through these administration systems of NIHB and INAN are not accurately depicting what's happening on the ground.

For the practitioners who are working in these communities NIHB is asking for seven and a half hours a day, for example, of direct client service. That's not industry standard. That's going to burn out any practitioner. Industry standard is four to five clients a day, yet NIHB is pushing our clinicians now in order to say, “You have no wait-list and you have all the therapists you need, because you have seven and a half hours a day.”

What people don't realize is that, on the ground, those clients aren't always showing up to appointments. We have transportation barriers. We have crisis communities. People are struggling with basic needs to be able to make it to their counselling appointment, which they desperately need.

So, yes, there are a lot of inconsistencies throughout this bureaucracy.

[The Chair, Liberal, Marc Garneau]

Thank you.

We'll now go to Mr. Battiste.

Mr. Battiste, you have six minutes.

[Jaime Battiste, Liberal, Sydney—Victoria, NS]

Thank you, Mr. Chair.

I'd like to thank the witnesses for their testimony so far today.

I come from a first nations community in the Mi'kma'ki called Eskasoni, where we have our own health care unit as well as our own mental health. I know that they're hard-working folks and they've at times come to me with very important asks about the importance of having a health care system that's culturally relevant and in the Mi'kmaq language. It's really important that, when we move forward, it's in a way that's reflective of the indigenous cultures in that area.

I'm very happy to see that, in the most recent budget, 2022, we provided $227 million over two years, starting in 2023, to maintain trauma-informed, culturally appropriate, indigenous-led services to improve mental wellness and support efforts initiated through budget 2021 to “co-develop distinctions-based mental health and wellness strategies.”

I'm wondering if the witnesses could talk a little bit about the importance of ensuring that the health care system is culturally appropriate and reflective of the various indigenous cultures across Canada. I think if we can start in the room that would be a good starting point.

[Angela Grier]

Thank you. It's nice to see you, Jaime.

Leroy and Amethyst say oki. I just wanted to pass that on.

What you spoke about is the nation-to-nation relationship that we're hoping for across our communities. We've seen the deferral of different ministries to provinces, such as child welfare and education, and this deferral has not raised the rates of success in those areas. In similar environments, such as health and mental health, because it's easier for the government to treat us as municipalities, we don't necessarily vote in these provincial governments to speak about our issues.

We have first nations governments that speak about those issues. They're being completely overstepped and dismissed in these discussions, yet the provinces are taking on that responsibility. I can tell you, from some of the experiences that I've had, they do not share or understand the intricacies of a first nation, the legal and jurisdictional issues of a first nation and the needs of our first nation.

I would support more of that nation-to-nation relationship and federal acts, such as the family act that was recently implemented to address the children's services overrepresentation in crisis. Along those similar lines, I believe that will help move things forward.

[Jaime Battiste, Liberal, Sydney—Victoria, NS]

Following that, please make sure that you say hello to Leroy and Amethyst for me, as well. Give my best regards to them.

Can you talk to us about any specific areas around Canada that are getting it right with mental health, and doing it in a way that really reflects the nation-to-nation responsibilities that we have as a government? Are there any that have been successful models for the rest of Canada, where we can see progress being made in a culturally appropriate and reflective way?

[Angela Grier]

Yes. I'd like to give an acknowledgement to the Siksika first nation's Siksika Health Services. The mental health clinic there is led by a Blackfoot clinical doctor, Dr. Adolpho. She is a Blackfoot member. Her training as a clinician and as a Blackfoot member is the place where we need to be.

It's providing the most competent model of delivery, because you need people from that community within the senior administrative positions who are practitioners, not lawmakers. You need people on the ground who can have those relations with the province and the federal government in order to negotiate the best needs for the community.

I believe that they have a great system out there. I'm sure there are a lot more, but I'm thinking about locally. From the clinical perspective, I have never seen such an environment on a first nation that has legally and ethically maintained the integrity needed for this type of delivery at this level of the acute health environment.