Health — Issue No. 25 — Monday, July 4, 2016 (HTML)

Present: Linda Larson, MLA (Chair); Judy Darcy, MLA (Deputy Chair); Donna Barnett, MLA; Dr. Doug Bing, MLA; Marc Dalton, MLA; Sue Hammell, MLA; Dr. Darryl Plecas, MLA; Selina Robinson, MLA; Sam Sullivan, MLA

3. The following witnesses appeared before the Committee and answered questions:

The following electronic version is for informational purposes only.
The printed version remains the official version.

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH


CONTENTS
Page
Presentations	327
R. Notarandrea
E. Staples
G. Showler
M. Smith
D. Kelly
D. Behn Smith
S. Grzybowski
D. Fortin
J. Blake
P. Wood
G. Sing

L. Larson (Chair): Good morning, everyone. I’m just going to go through a bit of a preamble to set the stage for what we’re doing over the next few days.

My name is Linda Larson. I am the MLA for Boundary-Similkameen and the Chair of the Select Standing Committee on Health. We are an all-party parliamentary committee of the Legislative Assembly of British Columbia.

As part of its mandate to identify potential strategies to maintain a sustainable health care system for British Columbians, the committee undertook a public consultation in 2014-2015.

This summer, we launched an additional call for submissions. We are holding public hearings in Victoria, Prince George, Kamloops and Vancouver, looking for new or updated information on the following three questions:

(1) How can we improve health and health care services in rural British Columbia, and what long-term solutions can address the challenges of recruitment and retention of health care professionals in rural British Columbia?

(2) How can we create a cost-effective system of primary and community care built around interdisciplinary teams?

British Columbians were also invited to participate by sending a written audio or video submission. For more information, you can visit the website at www.leg.bc.ca/cmt/health. The deadline for submissions is Friday, July 29, 2016. All the input we receive will be carefully considered by the committee as it prepares its final report to the Legislative Assembly.

To launch our public hearings, we have invited officials with the Canadian Centre on Substance Abuse to present to the committee this morning on our third question: how can we enhance the effectiveness of addiction recovery programs?

The format will consist of a 30-minute presentation, followed by 30 minutes for questions from the committee.

Please note that our meeting is being recorded and transcribed by Hansard Services, and a complete transcript of the proceeding will be posted to the committee’s website. All of the meetings are also broadcast as live audio via our website.

I will now ask the members of the committee to introduce themselves, starting with our Deputy Chair.

S. Sullivan: Yes, Sam Sullivan, Vancouver–False Creek. I’m just a few minutes away. I’ll be joining you shortly.

I’d now like to turn the floor over to Rita Notarandrea from the Canadian Centre on Substance Abuse. Welcome, Rita.

CCSA is the short version of the Canadian Centre on Substance Abuse, so I’ll be referring to our organization in that way. First of all, let me thank the committee members for inviting me here today to discuss addiction recovery. It’s a pleasure to be here.

For those of you that are unfamiliar with CCSA, we’re Canada’s only agency with a legislated national mandate to reduce the harms of alcohol and other drugs on Canadians and on Canadian society. We do so by providing the latest body of evidence and sharing that evidence widely, which is what I’m here to do today with you.

We were created by an act of parliament in 1988. CCSA has provided national leadership and expert advice. We have advanced knowledge, and we have prepared information and resources, always based on the latest evidence, to inform policy, practice and programs that bring forward solutions for government, stakeholders and experts in the field. This is one area of our work.

Together with our partners, we help mobilize individual and collective efforts to achieve collective impact nationally on this major health and social issue. Advancing and promoting the evidence surrounding quality programs as well as enhancing access to quality services to address alcohol and drug-related harms is at the core of our work. I hope that you find today’s presentation helpful as you seek solutions to enhancing the effectiveness
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of addiction recovery programs that are unique to the needs of British Columbians.

If you would like more information pertinent to my presentation, I have provided the Clerk of the committee with handouts that cover some of this material in much greater detail.

The agenda. I have provided a PowerPoint presentation. A number of things are listed. I will provide an overview of what is occurring nationally and internationally on this issue, as well as brief examples from provinces that have begun the same journey.

To begin, as you know, addiction is a complex health and social issue that impacts all Canadians. Mothers, daughters, fathers and sons, the person beside you in your day-to-day life, may be feeling fear and shame as they struggle with problematic substance use or addiction due to stigma and discrimination in our society.

In fact, in 2012, the Canadian community health survey found that 4.4 percent of Canadians met the criteria for a substance-use disorder, demonstrating that this is a matter worthy of public discussion, policy debate and political action.

Our vision at CCSA is to ensure that those suffering with substance-use disorder receive the care they need, to elevate the awareness about the science that surrounds these disorders so as to change perception about them and to ensure that problematic substance use and addiction remain on the national agenda and receive the attention they need.

While science and evidence are imperative to achieving this vision, they are not enough on their own. We also need the collective and political will to bring about change at work, in our communities and in our health system. We must stop viewing addiction as though it were a moral failing or a choice. We do not do this when we talk about other disorders or illnesses.

Recognizing recovery as an attainable and sustainable goal for people with a substance-use disorder is step one; ensuring that the right supports and services are in place and that these are based on the evidence is next; and finally, that those delivering the care are held accountable for achieving the outcome they set out to achieve.

Treatment works, yet barriers exist to timely and effective supports and services. For example, we have a fragmented system of care and a complex system to navigate. We need systems in place to ensure that those in recovery can be easily linked to the services and supports they require over the long term, no matter what their particular pathway to recovery has been. We need the system, as well, to have a shared vision and an understanding of what recovery means.

Next, there is a lack of services in rural and remote areas and for specific population segments such as youth and indigenous peoples. Those living in rural areas, as an example, often lack the means to reach and use services, such as transportation to services in distant locations.

The situation is even more complex and challenging when specialized services are needed. Then, of course, there are wait-lists, wait times and financial barriers. Many cannot afford to pay for private treatment facilities and have to face long wait-lists and wait times for publicly funded programs.

Finally, societal stigma. Many are fearful that they will not be supported by family, friends, colleagues and employers, and this prevents many from seeking care.

These are but a few barriers. But training and education of primary health care professionals in the area of addiction is another crucial factor that must be attended to.

Let’s take a step back for a moment and look at what CCSA has been doing in this area and when our work began in the area of addiction recovery. In 2013, CCSA and others convened the recovery round table at Cedars at Cobble Hill, which brought together representatives from the federal and B.C. provincial governments to recognize the recovery movement and to identify measures to help change the stigma around addiction and recovery.

The summit emphasized that support for the recovery movement was needed to ensure that all those dealing with an addiction problem are able to access the help they need and that those faced with addiction are provided with hope, the hope that recovery is real and that it’s an attainable reality. Across the country, committed individuals and organizations began working together to change the conversation about drug and alcohol addiction from focusing on the problem to celebrating the solution.

To harness national efforts, in 2015, CCSA and our partners in the recovery community hosted the first-ever National Summit on Addiction Recovery. Delegates from across Canada collectively developed a national commitment to the recovery from the disease of addiction in Canada, to bring a recovery focus to policies, programs and practices. The commitment put forth a common vision for recovery as well as overarching principles to guide a strength-based recovery approach to substance-use disorders in Canada. It was a beginning of a consensus on a definition of what recovery from addiction means.

There are six principles of recovery, and they were outlined in the national commitment. These were done to ensure that they would be reflected in the Canadian system of care focused on recovery. The principles state that, one, there are many pathways to recovery. Recovery involves a process of personal growth along a continuum leading to abstinence. It includes a range of services and supports that spans peer support, mutual aid, early identification and intervention, outreach and engagement, specialized treatment, relapse prevention and continuing care in the community and in the workplace.

Two, recovery requires collaboration across sectors, including health, social, educational, criminal justice, employment, economic, spiritual and housing.
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Three, recovery is a personal journey toward well-being. It is an ongoing and dynamic process that is unique to the individual’s strengths, culture, gender, personal qualities and experiences. It is tailored.

Four, recovery extends beyond the individual. It involves family, peers, workplaces and the communities.

Five, recovery is multidimensional. It enhances physical, social, mental, emotional and spiritual health.

Six, the last one, recovery involves everyone. Everyone has a role to play in overcoming the stigma of addiction and in supporting and celebrating recovery.

Another key outcome from that summit was the development of a National Recovery Advisory Committee or NRAC. Following the summit, CCSA established the NRAC committee to guide national efforts in recovery over the coming years. The NRAC consists of leaders from across the recovery community from across Canada, with lived experience as well as expertise in recovery research, three of whom are from British Columbia. Working with NRAC, CCSA is continuing our work to bring life to the national commitment for Canadians and to build the evidence and promote awareness about recovery.

This past year NRAC has undertaken projects. I’ll focus on three main ones: (1) the development of knowledge-exchange tools to support a recovery-focused approach and a common understanding, (2) an evidence review and (3) the life in recovery survey.

The first item is the national knowledge-exchange toolkit to support a recovery-focused approach. It will provide an increased understanding of what Canada’s recovery principles mean and what they look like in practice. I will give three examples.

If we look at one of the principles called “Recovery requires collaboration,” it involves linking persons in recovery with primary care providers who can be actively involved in long-term monitoring of clients in recovery, creating a road map for clients and their families to help them navigate the full spectrum of ancillary services with other sectors and meeting regularly with community mental health and addictions support services to collaborate on initiatives in programming for the individual where required.

Another principle is “Recovery is a personal journey towards well-being.” How do we reflect this in service? It means implementing a trauma-informed approach throughout all services and programs, consulting on program design and evaluation with people who reflect the diversity of the Canadian population and incorporating the goals and preferences of clients in their treatment and recovery plans.

The final one that I’ll elaborate on is the principle that speaks to “Recovery extends beyond the individual.” This can be achieved by including people that are supportive of a client’s recovery in the treatment plan, emphasizing the importance to clients and their families of ongoing peer and social support in maintaining recovery — to helping clients build supportive friendships and identify sponsors or peer mentors within their communities while they are in treatment. The fact is evidence has shown that incorporating supportive networks in a client’s recovery significantly improves their outcomes.

The recovery toolkit that I referenced was developed through intensive consultations with service providers, researchers, policy-makers and persons with lived experience. The toolkit is based on input collected through consultations in Toronto and Vancouver. We are conducting the last of the consultations in Newfoundland and Labrador this month to ensure that regional differences in perspectives, policies and practice are represented in this toolkit. It can be used by service providers such as addiction counsellors and other health professionals to move towards a recovery-oriented system of care. It will be available by the end of this year.

The second project that NRAC has been involved with, with CCSA, is the evidence review on recovery in Canada. This will be released in the fall. The findings from this review indicate a few things. There are many additional pathways to recovery, and the experience of recovery is unique to the individual. For some, the pathway to recovery occurs outside of the traditional treatment facilities and involves utilization of resources in the community, especially for those who cannot afford private treatment facilities and find themselves on long wait-lists for publicly funded programs.

The findings have also shown that for many, recovery is viewed as more than abstinence. It is a process of sustained action and addresses the biological, psychological, social and spiritual disturbances that are inherent in addiction.

The findings have shown that there are many stages of recovery, and there are gaps in care when individuals leave the treatment facilities and strive to achieve a long-term wellness in their families, their workplaces and their communities. This latter finding highlights the importance of how crucial that transition period is to recovery maintenance. It requires funding of programs and resources that are readily accessible within the community.

Within a true recovery-oriented system of care, treatment facilities and supports would be able to create linkages with other sectors and programs while clients are actively accessing treatment, ensuring that there are no gaps in care. This is a great example of how we can move towards a recovery-oriented system of care. I will ensure that these documents are sent to committee members when they are released.

The final project undertaken by NRAC this year is a project that we are very proud of, the first Canadian life in recovery survey. It was designed to gather information on the life experiences of individuals in recovery from addiction to alcohol and other drugs in Canada. The sur-
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vey was fielded in the spring of 2016, and we are thrilled to have received 855 responses.

The findings will be released in September 2016, in time for recovery month in Canada, and will include information on the personal journeys and the different pathways that have existed for Canadians. These findings will be used to inform and educate health service providers, decision-makers and the public about the lived experiences of individuals in recovery. The intent is to increase understanding and help address stigma associated with addiction and recovery, and to bring hope.

To provide context to our 855 responses, comparative numbers in previous life-in-recovery surveys include: in the United Kingdom, there were 802 responses; in Australia, 573; and in the U.S., over 3,000.

As we analyze the Canadian data, we will look for commonalities and differences with other countries. But with those other countries, some common themes have emerged. One is that the respondents were highly educated, with most having completed high school and a substantial proportion having participated in post-secondary education.

Another trend. Well over half of the respondents in Australian and U.S. surveys were engaged in some form of employment — 70 percent in Australia and approximately 71 percent in the U.S. This was slightly less common — 58 percent — among individuals participating in the U.K.

Another trend. Of respondents, just under 80 percent in Australia, 75 percent in the U.S. and 65 percent in the U.K. described themselves as “in recovery” as opposed to “recovered” or “used to but no longer have a problem.” This suggests that many individuals with substance-use disorders view recovery as an ongoing process.

A fourth trend. All three surveys suggest that alcohol is the most common substance among respondents and that these individuals frequently struggle with addiction to multiple substances.

A fifth. Slightly more than two-thirds of survey respondents in each country reported having received treatment for their addiction at some point in time, ranging from 69 percent in the U.K. to 70 percent in the U.S.

A sixth trend. Results from all three surveys suggest that recovery from addiction is associated with improvements in many areas, including improved health, improved well-being and a higher likelihood of harmonious relationships and family unity. These improvements tended to be greater for longer durations in recovery.

The results of the first Canadian life in recovery survey will provide us with an understanding of the recovery experiences of individual Canadians as well as how these experiences relate to the international recovery experiences.

As I mentioned earlier, I thought it might be helpful to share examples of additional recovery efforts underway in other Canadian jurisdictions. I will touch on some of them.

An important part of CCSA’s relevance when working with the provinces and territories is how we paint the national picture and help to inform and connect best practices on problematic substance use and addiction, always with a view to not reinventing the wheel when some of the evidence is already there.

For example, through its Action Plan for Mental Health in New Brunswick 2011-18, New Brunswick hopes to design an integrated recovery-oriented system for the future. With support from their Department of Health and their regional health authorities, local recovery teams have been implemented in community-based mental health centres throughout the province to really provide recovery-based approaches to services. These teams consist of persons with lived experience and community representatives as well as health professionals.

By working together with community partners, two demonstration sites have also been set up to really test this recovery model. Program guidelines have been released to guide the work and to guide the training.

In Newfoundland and Labrador, the province has partnered with Consumers’ Health Awareness Network to develop a training module for all staff that work in mental health and addiction. The module is four hours and is comprised of a two-hour, on-line self-study guide and two hours of workshops led by representatives from the Consumer Network, a person with lived experience and a manager from the workplace. The province is also currently developing a recovery toolkit.

Newfoundland and Labrador also launched a campaign called Understanding Changes Everything. This campaign is to raise awareness and to reduce the stigma that exists around mental illness and addiction. The campaign was launched through a mass media campaign in social media. The second stage, launched earlier this year, focuses on changing and improving the workplace by bringing together organizations in the community, to decrease the stigma in the workplace.

Additionally, I would like to highlight the provincial standards here in B.C. for adult residential substance-use services developed by the provincial Ministry of Health. Although the standards are for residential services only, they are recovery oriented, with their focus on the entire continuum of care, including transition back to the community, aftercare supports and resources and continuous monitoring and evaluation of clients.

As I mentioned, I’d also like to share with you what we have learned regarding international efforts in recovery, and I will focus on two countries only.

In the United States, they have developed the Recovery-Oriented Systems of Care Resource Guide, or the ROSC, to facilitate a network of community-based services and supports. The purpose of the guide is to help policy-
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makers for substance-use programming and treatment providers build an infrastructure with all the resources needed to address the whole spectrum of problematic substance use. It was developed by Substance Abuse and Mental Health Services Administration, SAMHSA, an agency within the U.S. Department of Health and Human Services that leads public health efforts.

In their view, a recovery-oriented system of care covers prevention, early intervention and treatment, and continuing care and recovery, with substance-use treatment providers partnering with mental health and primary care providers as needed. The system is designed to give individuals and families more options to make informed decisions about care. A fundamental value is that people in recovery, their values and their communities are all involved in continually improving the system. I have brought copies of the Recovery-Oriented Systems of Care Resource Guide for each of the committee members.

In addition, in the United States, the Comprehensive Addiction and Recovery Act, CARA, was introduced in September of 2014, to establish enhanced grant programs that aim to expand drug prevention programming while promoting treatment and recovery. The aims of the bill related to recovery include expanding prevention and educational efforts aimed at teens, parents and other caretakers and the aging populations and to prevent the abuse of opioids and heroin and to promote treatment and recovery. The bill also is looking to expand recovery support for students in high school or enrolled in institutions of higher learning, and expanding and developing community-based recovery services in communities across the country.

One more international example, and that is in the U.K. Public Health England is leading efforts to focus local services in England on maximizing help for those with substance-use disorders and to sustain recovery from addiction.

Public Health England has published a mapping manual called Routes to Recovery Via the Community. The manual is user-friendly and client focused. It includes elements of effective intervention such as motivational interviewing and cognitive behavioural approaches. It has clinical tools in an easy-to-use format and is designed to be a practical tool to support effective recovery-focused interventions, providing front-line staff access to a range of tools to tackle drug misuse.

I was hoping to bring this to each of you, but it was 103 pages, so my office has provided a link to the Clerk of the committee for those of you who are interested.

In conclusion, I would like to thank you for inviting me and, more importantly, for including addiction and addiction recovery as part of your deliberations regarding the quality and sustainability of your province’s health care system. We need to shine a light on this disorder and give greater attention to it. The science is there. It is a health condition requiring the same level of attention as other health conditions.

I hope I am leaving you with (a) a picture of Canadian and international recovery efforts and resources, (b) the context and resources that will help you enhance the effectiveness of addiction recovery programs in British Columbia, and (c) the belief that with the right prevention services, the right interventions and the right treatments and community supports based on the evidence, long-term recovery and a person’s return to family, to community and the workplace is both obtainable and sustainable.

Today, the many Canadians in recovery contributing to their families and their communities and leading productive lives is proof that recovery from addiction is absolutely real and possible.

I would be pleased to answer any questions you may have at this time. Thank you very much.

L. Larson (Chair): Thank you very much, Rita, for your presentation. A lot of information there, certainly, on a high level as well, internationally and nationally. We really do appreciate knowing what’s going on in the rest of the world and the country.

I’m going to go through the people who would like to ask questions. I just want to start off, though, by welcoming Sue Hammell to the committee this morning. Sam Sullivan is now here also.

J. Darcy (Deputy Chair): Thank you very much. A very instructive presentation. I have a couple of questions. One of them has to do with…. I notice, in the survey, there are questions that relate to dual-diagnosis, multiple diagnosis. I know we don’t have the survey results in yet for Canada, but I wonder if you could speak to it, since the figures seem to be coming in, in other areas, similar in the United States and in the U.K.

The kinds of issues, just as an MLA, when people come into my constituency office seeking support for recovery programs or to deal with addictions, most of the time they’ve got a whole bunch of other things going on, not just dual-diagnosis, but multiple, you know. A young man, last week: schizophrenic, bipolar, on methadone, anxiety disorder, ADHD, in and out of the criminal justice system….

I know that your presentation and your organization deals with recovery programs and addictions, but I wonder if you can speak to what the statistics show about the relationship between those things.

R. Notarandrea: I’ll begin with…. I think one of your questions had to do with the recovery survey and the questions in that survey, and really looking at people in
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recovery and what their experiences and personal journeys have been. Certainly, we will learn from Canada some of those personal journeys, as well as all of the other issues that they had to deal with. What I indicated as one of the principles when we look at recovery is, first of all, it is a personal journey. Many have followed different paths, and we need to respect that. But the other I also talked about was a coordinated approach. I think you’re referencing that right there.

People come in, and they have a lot of issues to deal with. I think our responsibility in service delivery…. I come from a service delivery background with 13 years running a psychiatric hospital, so I’m very much aware of what you’re referring to. People don’t come in with just one issue. Whether we’re dealing with a physical issue or not, they come in with other things. I think, when we speak about those with substance-use disorder, it could be a spinal cord injury as well, a physical disorder that has to be dealt with.

When I talked about looking at other sectors, it’s because we need to really connect with and link with those other sectors so that we are providing a comprehensive approach that can help them sustain their recovery, whether we are dealing with parole officers…. In fact, one of our projects at CCSA is looking at the reintegration of offenders once they leave correctional facilities and how we can do that. So I am familiar with a lot of the things that you mention…. Is it Judy?

R. Notarandrea: I think the idea of recovery is, we have to look at the whole person, connect them to the right services and help them navigate the system so that they are dealt with as a whole person and not just “I only deal with this.” That has been part of the problem. What I’ve also seen in other sectors, when people present with more than one issue, that’s where the problems arise. The complexity of it is: who takes care, who becomes that coordinator to help them navigate the system? Because they’ve got so many issues that have to be dealt with, whether it be social services, disability, pensions — all of those things — someone needs to care for all those aspects.

I’m hoping, through the life in recovery survey, that we can get a handle on what people have been facing and what Canadians have gone through — in terms of the 855 who have responded — so that together, we can try to provide them with the comprehensive supports that they need to sustain them in recovery in the long term.

J. Darcy (Deputy Chair): Yes. Probably as well as you can at this stage, since your survey is still…. You expect it in September?

R. Notarandrea: I can certainly come back and present the survey, if the committee wishes, on some of the results. I’d be more than happy to. Or send it to you — the report.

D. Plecas: Rita, I guess I first want to thank you and CCSA for all that you do. I know what a significant catalyst you are for all things substance abuse and making things better, here and elsewhere — for our efforts to do more for helping people with substance-abuse issues.

I have, actually, three questions. My first one relates to recognizing that the recovery movement, if you will…. I sometimes think of it as that because it seems it’s only in recent times that we’ve started to use the term recovery around the globe.

Can you give us a sense of what the investment is by government, here and elsewhere? It’s not clear to me that that investment is very significant in terms of…. What are governments putting into recovery? I gather, just from what I’ve read, that there’s been a fairly substantial investment in the UK, in Scotland, but beyond that…. Maybe you can give us some insights into that.

R. Notarandrea: The key is, first of all, to focus on addiction, which is why I applaud your efforts. When you’re looking at the whole health system, it is to have a focus on addiction. We really need to look at this area. We’re seeing what is happening, whether we’re talking about opiate or fentanyl or all of those things. We need to really invest in addiction and, when I say that, in a coordinated system of care.

We need to look at the continuum of care. We need to look at a map as to what are best practices. What is the clinical pathway that a person has to go through? How do we support them through that pathway? One way that has been done in other areas is to map the system you currently have when it comes to addiction services in a community. What are the services that are in place, whether we’re talking about youth, whether we’re talking about older adults or the general population? And really following through — what is in existence versus where the gaps are.

Now, I also want to stress that it’s also about the coordination. Some of those services may be in some communities. Some communities may have less. Some communities may have more. But how do you coordinate the system? That is key. So some of it is about that coordination.

The third component I’d like to stress is that some of it is ensuring accountability — ensuring that what you say you’re going to do, you’re actually doing — and people being accountable for achieving the outcomes they set out to achieve.

My final message — I was speaking earlier to another member of the committee — has to do with ensuring that quality services and programs are in place for privately
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funded as well as publicly funded, whether it be through accreditation or whether it be through performance standards. But we need to ensure that those that are providing services to those suffering with a substance-use disorder are being held accountable and are providing quality services and can prove that they are providing those services. So I think investment is part of it. Coordination is another.

When we talk about recovery, you mention that it’s a new term. From my old world in mental health and addiction, recovery and rehab used to be used synonymously. We have defined now what recovery is, and those two terms are not the same. I find recovery is being used quite liberally, but we need to all have a common understanding of what recovery truly means. In some areas, people see recovery as just the rehab component of this. In other areas, like the U.S., they’re saying it’s the whole circle around the system that is recovery so that you have a recovery-oriented approach, which includes the individual, includes the family, includes their workplaces, includes other sectors.

So when we talk about recovery, it’s not just one component of the system of care. It is the principle and the philosophy that surrounds the whole system of care.

L. Larson (Chair): No, you can’t ask another one yet, because I have to watch the time.

L. Larson (Chair): Okay. Yes, you can. I will put you back on the list. Just noting the time, I want to make sure that everybody at least gets one question in.

D. Barnett: Thank you very much for your presentation. I don’t so much have a question as a comment.

My colleague here, Darryl Plecas, went around with the Blue Ribbon Panel, and they did an excellent report. A lot of it relates to the issue we’re talking about. We do have a little bit of success happening.

We have an integrated community safety initiative in my community in Williams Lake. Actually, the service delivery agents are all at the table, and we are going to be hiring a coordinator to take people who need help through the whole process so that you’re guided. Whether you’ve committed a crime, or it’s a mental health issue, or what it is, you will be directed from point A to point B until you get to the end. Hopefully, at the end of this process, you will come out a better person than you went into this committee.

I’m quite excited that what you’re talking about here will work and that we do have a model put together that hopefully will be the beginning of helping the people of British Columbia that need the help.

When you commit a crime, as you said, it’s not always because you’re a bad person. It’s because of how you got to that point. So I’m anxious to see what the results will be.

R. Notarandrea: That’s really interesting. Certainly, when we do the toolkit, that speaks to the practical application of those principles. I’d love to share that with the committee, because then you could apply it to what’s there and say: “Are we applying it in the same way that it has been defined by others across Canada, including Vancouver?”

I think that the system…. One of the things I’ve always said in my speeches, when we talk about…. There are three populations. There are those that are suffering with substance-use disorders, there are those that are suffering with a mental illness, and then there are those that are suffering with both. We need to tailor the care to those three populations.

When I mentioned about “Thank you for focusing on addiction,” we do need to shed a light on this illness and see what we have and what we are providing, as opposed to just always lumping them together as if they are just one big, homogenous group. They are not, and they need the same tailored care that every other suffering from other conditions receives.

D. Barnett: The interesting part about this is that it starts, usually, with a crime. But what caused the crime, and what caused the person to get there? We are finding that it is substance abuse, mental health issues. I’m quite excited to see how it moves forward, and I’d like to see your report too.

A couple of questions. First of all, with regards to the centre, what are your staffing levels across Canada and your funding? Is it through private donors? Is it through the government? That’s the first question — to talk about that.

Secondly, as far as…. It seems like you have a real perspective across the country. Where do you see the most support? If you want to call it shining lights…. As far as provinces, where does B.C. fit with regards to recovery, from your perspective?

R. Notarandrea: In terms of funding, primarily Health Canada. We have received funding for provinces in the past. The most recent one would have been Alberta. They funded our prescription drug strategy, and they provided close to half a million in that.

Primarily, our funding…. We do work with some provinces, depending on where they want the exper-
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tise. So for prescription drugs, Alberta funded some of our work there. But it’s primarily Health Canada. So that’s the first.

The second is that we are, relatively speaking, a small organization. We have 55 people located, primarily, in Ottawa. But the reason I think it works is because we rely….

I mentioned about individual and collective efforts. Everything we do is with partners from across Canada, whether we have an NRAC, which I referred to; a recovery community at the table; or whether we have an alcohol strategy with everyone at the table. But it’s always working with partners.

It’s incredible — the in-kind support that we get from across Canada, from the experts, to produce a lot of the reports that we do produce.

This life in recovery — I’d like to mention that as an example. NRAC has a number of research experts on that committee who have devoted their time with some staff at CCSA to pull together to ensure that we have a reliable, valid survey that is taking place and that the analysis is reliable and valid. I’d like to say that everything that I have itemized, talked about, is always done with partners through engagement and then through the evidence. That’s pretty much our model.

M. Dalton: Just from your perspective of looking across Canada, where would you say, as far as one or two provinces, are really strong in the recovery model? Then just your thoughts about British Columbia, where we’re at as far as government support, the programs and maybe where we could move forward a bit.

R. Notarandrea: I think in Canada, a number of the provinces are pretty much neck and neck. I mentioned a couple — Newfoundland, as I mentioned, and New Brunswick — because they have gone one step further. Having said that, the attention you’re giving to this, the fact that it’s part of your study…. I see that as huge, the fact that you name it as one of the key areas of enhancing addiction recovery. I see that as a huge step forward.

You began, actually, if I might say, the recovery community. Recovery Month in September, to my recollection — and perhaps others can speak to this — began in B.C. The focus on recovery and the recovery movement…. I reference Cedars, when we had the first round table there.

A lot of the discussion about recovery has taken place in B.C. I think, like anything else, we have to move from the dialogue now. How do we make it happen? It’s no different than the science. We know the science is there, but how do we implement that science and make it happen? I think that’s the challenge right now, and the opportunity is making it happen, bringing it about.

L. Larson (Chair): We have four more first-time questions and then a couple more second-time questions. We’re going to go just to 11:06, as we started six minutes late this morning. If we don’t get through the questions, I am sure that we will gather them up and send them to you for response.

S. Sullivan: One of the issues about stigma…. Thank you for recognizing that as important. One of the problems of stigma is that we call people who use some substances criminals, and we’ve criminalized them. That certainly doesn’t help in reducing stigma.

One of the problems of criminalizing these substances is that we can’t have people slowly withdraw from substances, because they’re illegal. Also, this illegality creates a black market, which has driven a lot of the addiction. Do you have an official position on whether we criminalize people who have addictions or not?

R. Notarandrea: The work of CCSA is…. I’m glad you raised that, as to what we do. Let me go back a bit. When we talk about addiction, there are so many perspectives and a lot of emotion. We are able to bring everyone to the table because we rely on the evidence at all times and speak to the evidence.

We don’t come forward and speak to: “We are pro-legalization or anti-legalization.” Instead, what we do…. I’ll use that as an example. I’ll talk about cannabis because it’s in the public dialogue, the discourse. What we did, to contribute to that dialogue with the evidence, is that we visited Colorado and we visited Washington state. We prepared a very balanced Lessons Learned report to inform the dialogue as to: if we are going to have a public health approach to this and we are going to get rid of the black market, these are things to consider.

Our position is not to have a position but rather to provide the best advice based on the latest evidence. That puts us in a unique…. Because everyone can come to the table, we look at things in an objective fashion, as opposed to…. There are enough positions out there, and the role of CCSA is really to find the signal amongst the noise.

When we talk about addiction — and you’ve highlighted one of them — there is a lot of noise. But how do you have an organization like ours bring all of that noise to the table and then find a common path forward that we can all agree on? I can tell you that the recovery summit that I referred to — I don’t know if you had heard it — had a lot of noise. There was a lot of disagreement at that table. But in the end, together, we were able to arrive at a consensus on what we could agree on. Our approach is really to work with the noise and arrive at something that everyone agrees to.

As to the legalization issue, again, what is the evidence? My organization would present the evidence, as it has, in bringing Portugal, the drug coordinator, here,
[ Page 335 ] together with Don MacPherson. What was the evidence associated with the decriminalization model in Portugal? Again, he was able to present. That’s how we do our work — really presenting what the evidence is and making it available for policy-makers and people working in the field.

S. Robinson: Thank you very much, Rita, for this very valuable presentation. You mentioned sort of four steps: map the system we currently have, what the gaps are and how they are coordinated, ensuring accountability and the need to have quality assurance in place — the four components to having a healthy recovery model developed.

I’m always interested in: what if we don’t do that? How do things play out? It’s always about…. All governments will have choices to make, and this committee will be asked to make some recommendations about how we move forward, what we do for British Columbians around this issue. So I always think about what happens if we don’t act in that way. You can choose to do something or to not do something. You might take a few moments to talk about what happens when you don’t cover off on these four different areas.

R. Notarandrea: I mentioned earlier that we have the science. The science is there. Now we need the collective and political will.

I do want to correct Selina, and I’m sorry if I’ve misled you. When we talk about recovery, there are six principles. When that toolkit comes out, what we can do is…. For what’s already in place, is there a common understanding of what that recovery-oriented system of care is? What does it mean to you? Do we have it in all parts of British Columbia?

I go back to the principles of recovery. Are they entrenched in the services that are there? When we talk about recovery, I would say that those principles of recovery…. If we want to have a recovery-oriented system of care, that’s what we need to look at.

In addition to that, you have a wonderful physician who’s doing fantastic work — that’s Dr. Evan Wood — in terms of the latest science, the evidence that’s out there. How do we apply that evidence? That is the challenge and the opportunity that I also referred to, I think, with Marc. We have an opportunity to apply the science and implement what we know.

I also mentioned physician education and training. That’s very important. If we are going to focus on primary care, as an example, if physicians are getting seven hours on addiction in their curricula, that in and of itself is an issue that we need to address — so physician education.

I could go on. But investment is one component. Coordination is another component. A recovery-oriented system of care approach is another. I just didn’t want to leave you with saying only those four. Once you have those things, you need to add in all of those other things that I’ve summarized.

S. Robinson: But what if we don’t? I mean, I get that there’s a lot to go into this. I’m much more interested in: what if we don’t do these things?

R. Notarandrea: You’ll have a continuation. There’s a reason you’re all here and why you zeroed in on addiction and addiction recovery. You’ll have a continuation of what you’ve already seen in your own communities. You’ve already seen the crisis with fentanyl. There’s a reason that British Columbia has declared a state of emergency for that. We need to get the science, and we need to provide the treatment that people need, without having to wait.

I’m sure that if any one of you were touched by this, you wouldn’t want people to be on a wait-list, especially if a son, daughter, husband or grandmother needed the care. You would want immediate access to that care. I think we have to ensure that — whether it be through clinical pathways to ensure that all the components of care are there. But you’ve already determined that you have a problem. That’s why you’ve highlighted it as an issue. You’ll just continue to have the problems you’ve already witnessed.

I’ve got Doug and Sue and three minutes, so if you could make your questions quick and the response relatively short, if possible, to Rita.

I’m really looking forward to the results of your Canadian life in recovery survey in September. I noted some interesting differences between Australia, the United States and the U.K. for employment: 70.2 percent in Australia, 70.8 in the United States and only 58 percent in the U.K. Even for the people who describe themselves in recovery, 79.8 percent in Australia, 75.2 in the U.S. and 64.6 percent in the U.K. It’s going to be really interesting to see where Canada fits in there.

One question I wanted to ask you, though, was: in 2012, you noted that 4 percent of Canadians had substance abuse disorder. Anecdotally, it would seem that this is on an upward trend. I was wondering if the facts back that up. Are we on an upward trend in terms of this substance abuse disorder? Is this what we’re seeing?

R. Notarandrea: We are seeing changes, actually, in the substances that are being utilized. I would have to get back to you as to whether it’s an upward trend. What we are seeing are changes in what people are using. That’s probably what stands out for us more in terms of all of the new psychoactive substances — W-18 that you’re facing
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here in B.C. is one of those. There’s always new psychoactive substances coming on the market.

We’ve also seen an increase in heroin, which is interesting, and the U.S. has experienced that as well.

I’d have to get back to you as to whether, as an overall trend, there is an increase in all of substance-use disorders in Canada.

D. Bing: I’m particularly interested in whether alcohol is stable and whether it is, as you say, these other substances like fentanyl and heroin and these sorts of things.

R. Notarandrea: Certainly, we did a study on the impact on hospital utilization in-patient services only, and alcohol was still the major contributing — much more than opiates and cannabis. So we looked at the three substances.

There are a number of provinces that have done significant work in the mental health area, and particularly — in my reading, in my talking to people — in Ontario and Alberta. You’ve raised Newfoundland and New Brunswick more in the addictions area.

In Ontario and in Alberta, are they wedding the addictions piece with the mental health piece? Or are they focused on one versus the other in terms of their focus?

R. Notarandrea: I would say the focus has been more, even in the two provinces — Newfoundland and New Brunswick…. The focus has actually been greater on looking at both.

R. Notarandrea: Having said that, you were one of the provinces that did that in your previous strategy a number of years ago, and there’s a reason that I’ve been told that you’ve now decided to focus in on just addiction.

What I have seen in Canada is the wave, when there was a greater attention to one and then greater attention to the other. In one of those provinces…. The awareness that I would leave with you is I sat on a provincial advisory group where the consultant said: “We need to enhance mental health and addiction.” What that told me was that they were really, truly focusing on the mental health component of that, because one does not enhance addiction.

We have to be very careful that we are talking about two nouns and two verbs. There’s mental health and mental illness, and then there’s addiction, and there are times when the two come together. Again, we need to tailor our approach to these populations.

L. Larson (Chair): Thank you so much, Rita, for being here this morning and for sharing your information with us.

We’re looking forward to the new information that’s coming out. We’d love to get it as soon as you have access to it as well. Remaining questions we will make sure that they come through to you, and perhaps you could just get back to us with the answers to those questions that we didn’t get a chance to ask this morning.

We’ll move on to our next presenter this morning, from the B.C. Health Coalition — Edward Staples, also somebody that I know.

Welcome this morning. Pleased that you could be here. I’ll turn the floor over to you now. We are switched to our normal format now, which is 15 minutes, and then 15 minutes for questions.

My name is Ed Staples. I’m here actually wearing two hats. I’m representing the B.C. Health Coalition as a member of their steering committee. I’m also president of a grassroots organization in Princeton, B.C., called the Support Our Health Care Society.

I’d like to begin by thanking everyone for providing this opportunity for me and for us to share our views and for you to be listening. Thank you so much for that.

My original interest in the work of this committee was in 2014 when I made a written submission as president of the Support Our Health Care Society of Princeton. We call ourselves SOHC. If you hear me use that term “SOHC,” that’s what I’m talking about.

I’m pleased to see that the committee is looking for more information on three of the original questions and that the information gathered on the end-of-life care has now been released in the report Improving End-of-Life Care for British Columbians. I’d like to congratulate the committee for the work that you’ve done on that very important issue.

I’ve been a resident of Princeton now for eight years and have been actively involved in health care in our community for the past four. For this reason, I feel most comfortable addressing the first question, regarding health care services in rural British Columbia.

Princeton, I believe, is typical of what it means to live a rural, remote community in B.C. Our population base is roughly 5,000, on a good day. Our demographic consists of an ever-larger senior population. Our economy is based on forestry, mining, ranching and, increasingly, tourism. Our nearest regional service centre, Penticton, is about an hour and a half away.

Four years ago the community of Princeton was in a health care crisis, with only one doctor providing on-call service, 24-hour emergency department services only available on weekends, an acute shortage of health care practitioners, and residents who were up in arms. I was one of them, and my wife was one of them.

Since then, through a collaborative effort involving local organizations, elected officials, health care practitioners, Interior Health administrators, Princeton is now in a much better position, with four full-time GPs, two nurse practitioners sharing a full-time job and a full complement of professional staff.

But our situation is still not ideal. We are still short one general practitioner, and many residents are unattached and looking for a family doctor elsewhere in our area.

At present, there are no practitioners accepting patients in the Okanagan-Similkameen region. To give you some idea of how serious the problem is, one of our SOHC executive members recently searched the College of Physicians and Surgeons website to find out where they could find the closest doctor that was accepting patients. The only place that he could find anybody, any doctor that was accepting patients, was in Courtenay, which would be quite a commute for people living in Princeton.

We understand full well that it doesn’t take much time for things to change, and our biggest challenge now is to sustain our present situation and work to make things even better for our local residents.

Even though things are better for us in Princeton, I’m not sure that this is the situation throughout B.C. In fact, I know it isn’t.

To improve things for everyone living in rural British Columbia, we first have to identify the problem, which can be summed up in one word, and that’s “access.” Whether it’s the length of time it takes to get to see a general practitioner, the amount of time and money it takes to get to a specialist appointment or the inability to become attached to a family doctor, for most rural British Columbians, access to health care services remains their primary concern.

The main source of the problem is the shortage of health care professionals in the province. Although there are shortages in most areas, the general impact felt by rural communities is the chronic shortage of general practitioners.

According to advertisements on the Health Match B.C. website…. This goes back to December of 2014. There were 333 advertisements on the Health Match B.C. website for general practitioner vacancies. In Interior Health, where I live, at that time there were 33 communities looking for 66 GPs.

Over the past 18 months, the situation has actually gotten worse. There are now 441 general practitioner vacancies provincewide, and in Interior Health, there are 37 communities now looking for 85 GPs. Based on this information, I think it’s important to understand that asking communities to be responsible for recruitment and retention ignores the reality that there are not enough general practitioners available to fill the present positions.

I believe that most rural communities have made an effort to develop recruitment strategies to attract practitioners, but this becomes an exercise in futility when so many communities are competing for such a small number of candidates. Making your community more attractive or special only works when there are sufficient numbers of physicians available to fill all the vacancies. In the present environment, communities are often tempted to offer incentive programs that can turn into unethical bidding wars where only the richest communities attract doctors.

The other challenge, if you’re lucky enough to recruit a practitioner, is how to get them to stay. From our experience in Princeton, retention of health care providers is most dependent on the level of satisfaction with their working conditions. High levels of stress resulting from staff shortages is the strongest contributor to thoughts of leaving. When there are so many openings, often in lower-stress environments, why would a doctor or a nurse practitioner stay in a situation that is stressful and emotionally draining?

Retention is also affected by the level of satisfaction within the community. The lack of timely access to health care services leads to fear, frustration and anger that is often inappropriately directed at the practitioners and staff. In our community, this has often led to a vicious circle of accusation and repercussion, often unravelled through social media sites like the Facebook vortex. With health care providers powerless to respond, it only increases their level of dissatisfaction and, increasingly, thoughts of getting out of town.

I expect that members of the committee are already fully aware of this situation. I’m probably not telling you anything you don’t already know. What we need to determine is how to address this problem.

One initiative that shows some promise is UBC’s distributed MD program. This program recognizes the importance of building a student base that represents the diversity of B.C.’s communities, particularly among areas that have been traditionally under-represented — for example, the aboriginal community and rural communities.

To achieve this diversity, UBC and UNBC developed a program called the healthcare travelling roadshow — some of you may have heard of this — and also the aboriginal MD admissions program to attract students who are not only familiar with the challenges of rural, remote living but who are also more likely to return to their rural roots to set up their practice after graduation.

Recently SOHC organized a visit by the travelling roadshow to Merritt, Princeton and Keremeos. The roadshow group consisted of 11 university students representing a wide range of health care services, including
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family practice, nursing, speech pathology, lab technology, midwifery, massage therapy and occupational therapy. This was the first time that the travelling roadshow has toured in southern British Columbia.

It is hoped that the introduction of this program to our area will establish a travelling roadshow sponsored by colleges and universities in the south. It’s very effective in the north — it’s been going for a long time there — but nothing like it is going on in southern B.C. Already there is interest from UBC Okanagan in Kelowna and Selkirk College in Castlegar, who sent staff members to observe the tour and learn about the program.

An important side benefit to this program is that it offers university students the opportunity to get a glimpse of what life is really like in rural communities and establishing a practice there.

Another approach that shows potential is the streamlining of hiring procedures for physicians from foreign countries. The provincial government has implemented a fast-track approach where international family physicians are initially screened by Health Match B.C. If they qualify, they’re selected for the province’s new practice-ready assessment program. Princeton is a lucky recipient of this program. We recently recruited a new doctor from Egypt, who qualified through this program and has now established his practice in Princeton at the Cascade Medical Centre.

International medical graduates are most often registered in the provisional class as an interim step in the province, which you’re probably familiar with. At this stage, they apply their knowledge and skill under supervision, usually for a period of two years. Many provisional class doctors are placed in rural communities and provide excellent health care services to communities in need under that supervision. However, this usually has limited potential as a long-term solution.

Using Princeton, again, as an example, recently we’ve had two provisional class doctors completing their two-year required term. Once completed, they both left to set up a practice in the Lower Mainland, where their families were already living. So rural communities provide very convenient openings for foreign doctors to enter our province, but based on our experience in Princeton, a long-term commitment to rural medicine is highly unlikely.

In my 2014 written submission, I was very critical of Health Match B.C., for any of you that read my original submission. Health Match B.C., as you know, is the health professional recruitment service funded by the government of B.C. At that time, their website was what I considered a disaster. It was poorly organized, often not kept up to date and extremely difficult to navigate.

I’m happy to report that these concerns have been addressed, and now their present website is vastly improved. I went on it just recently and found it a much easier place to find the information that’s needed.

Another problem in rural communities is transportation. For people living in rural communities, access to health care services requires access to transportation. As our population ages, this requirement means a greater dependency on transportation provided by others. Public transportation service is limited, and for many elderly residents needing specialist care, an all-day trip to a regional hospital is a daunting proposition, not to mention the out-of-pocket costs that may be a significant hardship for some seniors.

In my view, there are two options for improving this situation: either make it easier for the patient to get to the specialist, or bring the specialist to the patient. Although it’s understood that the Ministry of Health is not responsible for public transportation, improved services that would provide better local service and access to regional centres would have a profound impact on the health outcomes of rural residents.

There are two initiatives that have potential to vastly improve access to health care services for rural residents. As I mentioned, you bring the specialists to the patient. And in Princeton, we have a pilot — it’s no longer a pilot; it’s now an established program — called the Princeton access to specialist care project. Some of you may know of this. This is a program funded by the B.C. Shared Care Committee.

This pilot project brings specialists to Princeton on a regular basis to see patients who are referred by their family physician. In its first year of operation, there were 14 specialist outreach clinics and 135 specialist appointments. For patients who have missed specialist appointments in the past because of transportation difficulties, the clinics provide much-improved access. Numerous patients have stated their great appreciation for these clinics being held in Princeton.

The second is a program which has recently been launched across the province, and that’s the community paramedicine program. This is a provincewide initiative intended to help provide patients with better access to health care in rural and remote communities by expanding the role of qualified paramedics. Princeton was fortunate to be one of two communities selected to prototype this initiative. The full benefit of this program is yet to be realized, but early indications are that it will have an impact on monitoring patients and freeing up health care practitioner time.

According to the 2011 census, the percentage of B.C.’s population aged 65 and older is roughly 13 percent. In rural and remote communities, this percentage is generally much higher. Princeton, for example, sits at 28 percent, and if you look at the percentage of the population in Princeton over the age of 55, it jumps to 46 percent, which is very high.

Adjusting our health care system to meet the needs of our aging population is a challenge for our governments. One way of addressing this challenge is to provide pro-
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grams aimed at keeping seniors living at home longer. Although the benefits of at-home care are proven, the province has yet to provide an adequate model to support seniors who wish to live at home longer. It’s hoped that the Ministry of Health will soon recognize the long-term benefits of adequate home support to the health of seniors and the cost-effectiveness in terms of savings for the provincial health care budget.

I’ve chosen to present what I believe are the most pressing concerns and some of the many initiatives that hold potential for improving health care in rural B.C. There are many more, as I know you’re aware, but I think that’s probably about all the time that I have. I haven’t been watching the clock, but I tried to time myself and keep it within the 15 minutes. I look forward very much to the reports that are going to be generated from these hearings, and I’d be happy to hear any questions that you have at this point.

L. Larson (Chair): Thank you, Ed. I’m going to quickly just ask you a question on the specialist program. It’s become a permanent thing now for Princeton. Do you know whether Interior Health is looking at expanding that to other parts of Interior Health?

E. Staples: At the present time, no. It’s something that is being looked at, and I think that it would be an incredibly valuable thing in other communities, especially in the rural-remote communities like ours. It’s proven. It works. People are satisfied. The specialists like it. The family physicians like it. Above all, the patients like it. I see all sorts of room for this initiative to progress beyond our community.

D. Barnett: I’ve had the pleasure of being in Princeton when you were putting your model together. The community certainly should be very proud of what you’ve done working together and of your accomplishments.

D. Barnett: I’m the only one on this committee that can say they’re really a rural-ite. My colleague Linda can. But I have real rural communities, from Anahim Lake right through to 70 Mile.

Basically, there are programs in place. We are very fortunate in the Chilcotin. We have resident physicians out there that travel. We have teleheath that has made such a big difference throughout rural British Columbia. There are communities that are not hooked up yet, but they will be eventually.

Yes, we all need more doctors. The thing is, doctors are independent, unfortunately, and they can go to whichever country they want to.

There have been many new programs put in place in some of our rural communities, such as the South Cariboo. We now have a urologist specialist who comes to the 100 Mile hospital that didn’t come before, which has really made a huge difference to seniors. We also have the bus service from Northern Health.

Do we need more doctors? Yes, we do. How do we get them and how do we retain them? Because as you said, communities are competing. I think everybody is working as hard as they can to obtain this.

I think one way we can do it is through the College of Physicians and Surgeons. I think the structure there has to be really looked at. I also think that, through UBC, the structure needs to be looked at through the education program. How can we do a better job from that point to get more doctors in British Columbia? I think we have to look right back to those two initiatives to carry us forward.

E. Staples: If I could comment, Donna, that’s absolutely right. I think one of the problems that we face is that it takes a long time, though the turnaround time, to address this problem. I know that there are increased residencies that are being established in rural B.C., and that will address the problem. But that’s going to be several years down the road. How we address the problem today is the biggest challenge.

I believe, with the knowledge that we have now and with all of the people trying to help, that over time, this problem is going to take care of itself. But right now, many communities are in crisis.

Princeton is very lucky. We’ve addressed the situation so that we are in a much better position. But I know of many communities — and you do too, right? — that are in crisis mode.

D. Plecas: Edward, thank you very much for your presentation and for what you do.

One of the things which got me thinking was your comment about…. I think you said there’s a need for one more doctor. Thinking about that would suggest that there’s about 18 percent of people in Princeton who don’t have a family physician. I think that compares favourably to the rest of the province. I don’t mean that’s a good situation. I’m saying you’ve obviously done something right so far.

D. Plecas: I’m wondering if you have a sense of how many of those people are people who’ve come to Princeton. I mean, maybe this is something we have to be attentive to in the future. We have more senior people moving to rural areas. It’s a group who are most likely in need of a family physician, where a storm is creating here.
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E. Staples: Yeah. That’s a very good comment, and you’re right. Princeton and rural communities, especially those that are closer to larger centres, are becoming very much…. They’re the attractive places for seniors that are retiring to move.

I think part of that has to do with the fact that the lifestyle is a little easier, in terms of the pace. I think it’s also that your dollar goes further. For anybody living in the Lower Mainland that has a house that they’ve paid for, they could sell that house and buy a very comfortable home in Princeton and live off the difference for the rest of their life. That’s increasingly becoming an attraction for people that are looking for a different place.

But your point — and it’s a very good one — is that it increases the challenge of how we deal with an ever-increasing senior population in rural communities, when that’s where we have the greatest shortages and that’s where the crisis is occurring. So yeah, it’s a good point.

One way that we’ve done it in Princeton — and the doctors have been very good this way — is they have set up…. Rather than a first-come, first-served basis, if you want to become attached, you go through kind of like a triage system, so those patients who are in the most need will become attached before those that are of lesser need. It doesn’t satisfy those people who still need and want an attachment, but it’s a way of dealing with the greatest need first.

J. Darcy (Deputy Chair): Thank you very much for your work. I’ve had the opportunity to meet with people from Princeton involved with your group, as well as other people in rural communities nearby, and to discuss this issue.

As you know, one of our major focuses is strengthening interdisciplinary team-based care, so I wonder if you could speak a bit more about that. You refer to there being four GPs, two nurse practitioners and other health care professionals.

I certainly know, from speaking with med students at UBC, that very many of them would like to practise family medicine, but they don’t want to do it in the traditional model, where you hang out a shingle, open up a business. And there aren’t a lot of alternative options for how doctors can practise. They would prefer to work, many of them, in team-based care, and they would prefer to not have an entire community dependent upon them, which is what you referred to as the high stress.

So where are the openings? Walk-in clinics, which, as we know, do not provide the kind of coordinated holistic care that we would advocate for. I wonder if you could just speak a little bit more about what the model of practice is for the physicians and nurse practitioners and other health care professionals.

E. Staples: Judy, you’re probably aware that in Princeton we have established something called the Princeton health care steering committee, which is a collaborative….

E. Staples: …group made up of representatives from our physicians, nurse practitioners, elected officials, people like me and Interior Health representatives. Through that committee, we’ve been able to identify the best approach to that interdisciplinary team approach.

J. Darcy (Deputy Chair): We have to come up with a new word. That’s what we’ve got for now. Team-based care.

As a result of that, we are building that team. Through the GP for Me program, Princeton has what is termed a community health care assistant that’s been established in our community. The doctors absolutely love this person because that community health care assistant works with individuals to come up with an approach where they can access who they need when they need it on a team-based approach.

It’s wonderful because rather than the general practitioner or the nurse practitioner spending time with that individual to come up with a plan for that individual, the health care assistant is doing that for them, so it takes time away from the valuable time that the practitioners have.

We’ve also added an on-site physiotherapist, on-site drug and alcohol abuse counsellor all under one roof. So that’s the approach. We tried to follow the Keremeos model. They call theirs “all health care under one roof,” and we’ve been trying to incorporate that idea into it.

So we’re moving in that direction, and I think it’s becoming a much more effective way to deal with, especially, the more chronic issues that patients feel.

E. Staples: It is. But I think it’s also part of the South Okanagan–Similkameen Division of Family Practice that’s involved with that.

J. Darcy (Deputy Chair): Just to understand the occupation, is it like a health care assistant, which is like a care aide, or is it like a medical office assistant? Do you know?
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L. Larson (Chair): I’m thrilled that you’re in my area doing all this wonderful work. I really appreciate that.

The things that you’ve done there are without a doubt leading edge when it comes to rural health care. Certainly, we would hope that, under recommendation, some of those would be available in other parts of the province as well. Thank you for being here.

We’ll move on to our next presenter — the Cool Aid Community Health Care, Victoria Cool Aid Society. It’s Grey Showler.

G. Showler: Thank you very much for having me here today. It’s a real pleasure and an honour to present for you. I’m coming today to speak on behalf of Cool Aid, which is here in Victoria in the community health centre where I work, but also as a representative of the Canadian Association of Community Health Centres and our fledgling B.C. chapter, which is the Federation of Community Health Centres.

I’m speaking today, in part, based on some of the accumulated knowledge I have through doing literature reviews, going to conferences and things like that. But really what I’m speaking from is my experience as a front-line provider. I’m a registered nurse. I’ve been so for the past 15 years. I’ve worked in the hospitals. I’ve worked in home community care. I’ve provided palliative care. For the past ten years or so, I’ve had the privilege to work at the community health centre here in Victoria as a registered nurse, recently moving into a managerial position. So when I’m speaking today, I’m speaking from a broad base of knowledge but really from my experience on the front line.

When the Canadian Association of Community Health Centres asked me to come here today to speak, I saw your summary of findings and it just seemed like such a natural fit for the work that we’re doing at Cool Aid — and health centres across the country, indeed — for the types of problems that we have here in British Columbia. Today I will be speaking to all three of the questions, briefly.

There is a written submission that has gone along with my presentation today. It was initially submitted in 2014. It also addresses the issue of palliative care, which I know you’ve already submitted a report on. I was one of the authors of the section on palliative care.

I’ll first give a brief background on community health centres. I’m sure that you all are familiar with them, so I won’t speak too extensively. There’s more of a fulsome description here in the written submission, which provides some of the evidence from the literature.

Obviously, we’re talking about multidisciplinary teams. We’ve just heard a grasping for a term in the last presentation — integrated multidisciplinary health care teams. Who forms that team is really variable, depending on where it is. But the core of that is primary health care provision — whether that’s through a GP, a nurse practitioner or some combination — and then a team wrapped around them, allied health services, be they nurses, counsellors, psychiatry, physiotherapy and so on and so forth.

Community health centres are obviously not a new idea. They have close to a 100-year history here in Canada. They’re used extensively across the country and throughout the United States. So there’s a long history for community health centres. There’s a large and proven track record of their efficacy, both here and in the United States.

I think one of the really special things about a community health centre is that it’s a home for people to come to. As much as they come there to see their family doctor, there’s also all these other allied services, friendly faces, there. It’s a place with multiple points of contact, so you’re able to come there and get health services for a wide variety of issues. It doesn’t always have to be something that you’re seeing your family doctor for.

Community health centres pay attention to the determinants of health — income security, food security, housing — which we know are important for vulnerable populations, be they the elderly, people with histories of substance use or other groups that are struggling to make ends meet. We know that community health centres provide high-quality, cost-effective care. I think it’s fair to characterize them as being underutilized here in British Columbia.

There are about 100 community health centres throughout the province. That number varies as they are formed and closed and, also, depending on how you define a community health centre.

One of the really important parts of community health centres is this idea of community governance. The degree to which that happens varies on the community health centre. There’s a saying: “Once you’ve seen one community health centre, you’ve seen one community health centre.” That’s because, even though there are a lot of common traits amongst them, this core primary health care service, the allied health services that go along with them…. Really, at their ideal, they’re a reflection of a community within which they’re located. That’s not only in the services that are provided but in the actual governance.
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By definition, most community health centres will have some kind of local governance involved in them. I think it’s a real strength because it makes those community centres able to be responsive to the needs of that particular community, as opposed to coming in and planting a service someplace and a model that was designed somewhere else. There’s the structure, the idea of the community health centre, but the exact nature of it is really able to be developed in a grassroots sense based on the needs of that particular community.

In B.C., we have three basic structures of community health centres. We have independent not-for-profits with organizational funding. That would be the clinic where I work. We’re part of Victoria Cool Aid Society, which runs a lot of supported housing, emergency shelters. We have a community centre, and then we also have the health centre. We have a core operating budget with the health authority which allows us to keep the doors open. It pays for MOA services, nurses and other things that aren’t able to be paid for through separate contracts. Our physicians are paid through APP funding.

Then you have independent not-for profits. They form cooperatives. They contract out the health services, or they just provide a home for people to provide fee-for-service services within them. The James Bay cooperative, just down the street from here, would probably be a good example of that.

By far, the largest number of community health centres are the health authority community health centres, which are found throughout the province. Most of them have a lot of the allied services. They’ll be doing perinatal care. They’ll be doing public health care. They might have a home care component. A lot of them are lacking that primary health care component, and I think that’s a real deficiency of them.

Some of the big issues here in B.C. There’s a lack of a cohesive approach to community health centres. They’ve developed in individual communities, but there’s no overarching structure that guides the development of them. There’s nothing in place that really identifies where the best need is, where the most appropriate place is and where the types of community health centres to be developed are.

There’s also a real lack of a core funding arrangement. As many community health centres as there are in the province, that’s probably how many funding arrangements there are. They’re all relying on a hodgepodge of different contracts. I know at our clinic we have a contract for our core operating. We have a physicians contract. We have a mental health and addictions contract for our counsellors. I could go down the list.

Having stable, ongoing funding arrangements would really help us to provide this service. In our clinic, for example, we sign one-year contracts. It’s very difficult to do long-term planning when you’re not sure what your funding is going to look like from year to year.

Unfortunately, what we see in B.C. is that there’s a real negative effect on the ability of community health centres to prosper based on the fee-for-service model. I’ll talk a little bit more about that later.

Looking at your first question here today — “How can we improve the health and care services in rural British Columbia?” — I think community centres have a lot to offer. Obviously, there is not one magic bullet that’s going to address the situation, but I think that community health centres have a real vital part to play. In listening to the excellent presentation from the gentleman before me, so many of the things that he was talking about would be so ideally suited within a community health centre.

When I look down and I see your list of findings…. “Include rural medical care in the curriculum for medical school programs.” Well, where are those students going to go? Are they going to be located in an individual family doctor’s office or at a community health centre where they can draw on the expertise and knowledge of a group of primary care physicians, where they can learn from allied health care professionals and, if there is local governance, where they can really get a firm grasp on what the needs and issues of that community are? So they’re excellent spots.

I know at our health centre, we always have at least one resident and medical student at all times. In fact, that often serves as our main source of recruitment for future providers down the road. It gives them a chance to see the work we do, and it gives us a chance to get to meet them.

When we talk about recruitment — again, the gentleman before me talked a lot about this — one of the big issues is when people graduate from medical school. They’ve done their residency, and they have a boatload of student debt behind them. When they set out on their own, do they want to become a small business owner?

That’s what, really, becoming a GP is. You have to lease a space, you have to hire an MOA, you have to pay for insurance and so on and so forth. Then, if you decide that you want to take some time off, you have to find a locum. If something happens in your life, again, you have to find a locum. These are real stressors. Increasingly, what we’re seeing is that graduates from primary health care programs are wanting to either be locums or work in walk-in clinics.

Well, the community health centre provides a home for those people to come. They can share the responsibility of caring for clients. It’s not to say that they don’t have their own population of clients, but they’re not solely responsible. That responsibility is shared across a team. If the clinic has a stable and ongoing funding arrangement, then they don’t have to worry about paying for the MOAs; they don’t have to worry about paying for the electricity. That’s all provided for.

So there’s a home for them to come to. There’s less stress associated with the job. There’s less responsibility in
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terms of being responsible for the clients 365 days a year.

Then there’s the real satisfaction that comes with being part of a team. Being an independent provider, having your own office, can be a lonely experience, especially for new graduates — who are often the source of recruitment into rural communities. They come in; there are already social contacts. They’ve met people in the community. They’re able to rely on the expertise of experienced providers already within that clinic. We know that when people come into a setting like that, they’re much more likely to have a higher job satisfaction and, subsequently, more likely to stay in that community longer down the road.

When we look at things like mobile care initiatives, well, where are those going to come from? In some communities, they can come from a hospital, but if you don’t have a hospital in that community, where is that interdisciplinary team going to come from? Well, a health centre is a perfect place for it.

We see in this submission that in Ontario, where there’s an extensive, organized system of community health centres, this is an integral part of a lot of the community health centres that work in rural areas there. The nurses, the doctors, the lab techs — whatever the professionals are — go out in teams. They go out into communities that may be underserved and provide an integrated experience for them.

Is it the ideal? No, but the reality is that for a community of 500 people, the chances of having their own dedicated health services are not that great. While it’s not the ideal, it’s better than what we have in a lot of places. In the particular example we have in the written submission, the travelling team goes out to eight communities, all of which have under 1,000 people living in them, and they’re able to provide medical care for them there.

The other great thing about a community health centre is it provides a home for visiting specialist care. We’ve heard about these programs where specialists come in. Again, a hospital may be one setting, but a community health centre is another setting.

At our own community health centre here in Victoria, we have infectious disease specialists, we have internal medicine, and we have psychiatry. They all come in and they do clinics on site. They’re able to liaise with the primary health care team in real time. They’re, in essence, part of our team there.

It provides a really satisfactory experience both for the client and for the provider. They’re able to come in, and they’re able to sit down with their urologist, their family doctor, the nurse they’ve been working with, the nutritionist. They can all come around the table together and provide care. The key part of that, of course, is the funding models, which we’ll talk a bit more about, going on.

I see here in your findings to date, looking at different technologies as well. Again, I think implementing technology into a series of individual providers is very difficult, but integrating it into a series of allied community health centres is much more realistic. The knowledge, the expertise and the training can be shared across a team, and you’re going to have much more success with something like point-of-care testing.

I’ve changed the order a little bit, because we’ll finish up with the interdisciplinary teams. Addiction recovery programs. In the community health centre that I work in, this is a big focus of what we do. We’re mandated by Island Health to serve people that are homeless, that are living with chronic and severe mental illness and addictions. Over my past decade of working there, I’ve seen time and time again that this is the way to deal with addictions.

We know that addictions have multi-factoral and complex causes — be they trauma, be they mental illness, be they chronic pain. These are substantive issues. It’s very difficult to deal with addiction without being able to deal with the underlying causes. It’s very difficult to be able to deal with the underlying causes in the short kind of segmented care that comes from a residential facility, from detox. They’re great services, but really, dealing with addictions requires a very longitudinal approach.

Very few people are severely addicted and get better in one go. For most of them, it takes years and years, and the appropriate place for them to have that supportive care would be a community health centre over time. It provides multiple points of access.

I always think of a young woman that, when I very first started at the clinic ten years ago, used to come in to drop off needles once a week. That was fine for her for a couple of months. Then one time when she was dropping off the needles, she asked me if I could look at her arm. She pulled up her sleeve, and she had been cutting herself. This part of her addiction and her mental illness was that she was engaging in these self-harm activities, so would I dress the wounds up for her? I dressed the wounds.

We went through this process over time where she’d come in, she’d hand in the needles, and I would dress the wounds for her. And then, eventually, she asked: “Could I get a family doctor here?” We got her a family doctor there. She came in and saw the family doctor, and after time, she wanted to start talking about her addiction. We were able to have her see one of our counsellors. We were able to get her into a residential treatment facility.

I’m happy to say that after this process, she’s now drug-free, fully employed and housed, but that wouldn’t be possible in a stand-alone family doctor’s office. That’s the strength of a community health centre that provides these multiple points of contact.

I think, if we’re talking about rural care as well, there is a lot of stigma associated with mental illness and addiction. In a small community, a lot of people don’t want to walk into a health care facility where it says “addictions, substance use” over the door. We’ve learned this. We
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do a lot of work out in indigenous communities on the southern Island. We do a lot of sexually transmitted disease screening, HIV testing and things like that, and we know that you can’t walk into a small community, hang a banner up that says “get tested for AIDS” and expect people to line up. There’s a lot of stigma.

When you have those services enveloped in another program, like a community health centre, nobody knows what you’re coming in for. You walk in the door. You could be going to see the alcohol and drug counsellor, you could be going to see your family doctor, or you could be going to see the nutritionist. So it creates access by enabling people to go access that care in a place where they’re going to be a little bit more anonymous.

It also allows to share that burden across a bigger team. The hardest clients that you’ll ever work with are going to be people that have chronic, long-term mental illness and addictions. For a family doctor to take on that burden by themselves is incredibly frustrating. Again, if we’re talking about retention in rural areas, sharing that burden across a team, being able to have the support of a team, is going to go a long way towards job satisfaction.

The other thing that the team can also do is help. Often when people are addicted, their housing is at risk, their income is at risk, and a community health care program is able to pay attention to those things, help people find supported housing, help them get hooked up with appropriate income supplements, etc., and prevent homelessness.

This brings us to the last question and the end of my presentation: how can we create a cost-effective system of primary and community care built around interdisciplinary teams? Clearly, I believe the answer is the development of community health centres throughout the province.

How do we do this? Well, it’s not as hard or daunting as it seems. First, we’ll look at the existing community health centres that are in the province and become dedicated to creating funding arrangements that are sustainable and ongoing and that allow us to plan prospectively, that allow some security — so increased, adequate core budgets for existing CHCs.

We do have to do a provincial review of our physician compensation model. It’s clear that fee-for-service is broken. Doctors will tell you that. Community providers, people all around the province will tell you that. I’m not saying that in all settings, all the time, it’s broken. There is room for fee-for-service in some models. But if you’re looking at an integrated primary health care team, fee-for-service doesn’t work — especially, again, if we’re looking at addictions in rural areas.

If someone’s going to drive a couple of hours into the community health centre to see their family doctor, do they want to be told that they can only see them for one complaint? “I can deal with your sore knee today, but you’re going to have to drive back next week again so that I can deal with your hypertension and the week after that so that I can deal with your chronic pain.”

An APP model allows the physician or the primary care provider, whether it’s a nurse practitioner or other, to deal with all of that person’s complaints all in one visit, time allowing. Sometimes people come with long lists, and you have to pare them down. But if we’re looking at the model in rural areas, if we’re looking at addictions, it’s really important that people be able to come in, be able to have all of their needs met and not have it segmented.

It also frees up the physician to be able to consult with other providers. If the nutritionist wants to talk to them about diabetes, then they’re able to do that. They’re being paid by the hour rather than by the particular fee associated with MSP cost.

We’d like to see increased collaboration between all of the existing CHCs. It would be great to have some kind of provincial leadership around that, create a body that allows us to communicate better and really build on our shared knowledge.

In Ontario, they have an association of community health centres. It allows them to do significantly more work around looking at the data, chronic disease management, accumulating data from across a wide variety of health centres. They’re able to employ data analysis to make better population-based decisions. We’re just not able to do that on an independent scale.

In my community health centre, there’s only one person in the entire clinic that’s not involved in direct front-line care, and that’s the manager. We’re busy keeping the lights on. We certainly don’t have time to be looking at prospective population health, but an allied group would be able to do that.

Then the last thing, of course, would be to increase the number of community health centres in British Columbia beyond what we currently have. Some of that may require some actual bricks and mortar, building new centres, but a lot of it could be done by leveraging existing organizations. There’s expertise all over.

If we look at the gentleman that spoke before me and look at the knowledge he has of his own community…. They’ve got a steering committee there. They’ve already got that knowledge. How about giving them the tools to develop a community health centre in their community?

In a lot of communities, there are organizations doing this work, but what they’re lacking is the primary health care services. It’s very cost-effective to go to an existing community that has knowledge of the community and to add the health services.

Finally, doing a needs analysis, identifying those communities that don’t have a community health centre or a reasonable prospect for developing one and putting one in place.
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D. Plecas: Thank you very much for such a well-articulated presentation. I listen to you talk, and I’ve listened to others talk about the need for community health centres. The word that comes to mind is: “duh.” What’s the stall here? What is holding this up? I mean, it’s not like people are saying: “Give us reasons for not doing this.” There are so many reasons to do this. It makes so much sense. What’s the stall?

G. Showler: Personally, I feel there are a few things. The fee-for-service model is a barrier. I think there has been…. A lot of the focus gets placed on the acute care system, and rightly so — looking at taking down emergency time waits, looking at taking down surgical wait-lists and things like that, increasing diagnostic services. I think a lot of attention, prospective health care development, goes that way.

Really, the community health centres would offset that. We know that in communities that have a community health centre, they reduce ER utilization among their clients by up to 25 percent. They practise better preventative health, reducing the need.

So I think fee-for-service. I think the attention is placed elsewhere. I think there is some regionalization and fragmentation in the health care system. Particular health authorities are concerned with the needs within their own health authority. We’re not looking provincially.

I think there is a movement. I know that in Victoria, they’re looking at creating five community health care homes. So I think there is some movement, but I think there has been a bit of a lack of provincial leadership as a movement.

The GP for Me model is a good example — you know, creating an initiative to try and find individual doctors in communities or to increase that rather than looking at a system of health care systems. I think that would have probably been a better way to go, in my opinion.

D. Barnett: One of the questions I have is: community health centres — who is funding these now?

G. Showler: It depends on where they are. Ours is funded by a health authority. That tends to be….

The regional health authority community health centres are funded by those health authorities. Again, many of them are lacking the primary health care services. They have a lot of the other services there.

Then the cooperatives are MSP-based, so they’re fee-for-service. They create a home for providers to work out of. There is some communication between the providers, but at the end of the day, they’re billing individually. Most of those probably don’t have a shared electronic health record, for example, which we do. Everybody in the clinic works off of the same health record.

D. Barnett: So in some communities, we almost have those centres but not quite, because your practitioners — who are private business people, in essence — are not in the equation.

G. Showler: Yeah. I think also — sorry, the piece I forgot — in a lot of indigenous communities, either the band or the First Nations Health Authority is paying for those services.

J. Darcy (Deputy Chair): Thank you so much for your presentation. I wish we had an hour to ask you lots of questions.

You referred to health outcomes and keeping people out of emergency rooms. You also talked about the challenge in B.C., that we don’t actually have a way of analyzing that properly provincially, and we need to do that.

I have worked closely with CHCs in B.C. I’m also familiar with Ontario, where they’ve done studies of emergency room admissions for comparable groups of patients that show 22 percent less emergency room admissions. So the figures you’re referring to are, sort of, broader ones, I take it.

Just one question, although I have a zillion. Your mandate in Cool Aid, is it to deal strictly with vulnerable populations, or is it with a broader community? Because one of the shifts that’s happening elsewhere, as I’m sure you’re familiar with…. In Vancouver, the existing CHCs that were funded by the health authorities were both moved to a fee-for-service model from alternate payment plan. In addition, they were told their mandate was the top 5 percent of, it’s called, RUBs — resource utilization band. The same thing with Mid-Main, and REACH is sort of under those same pressures.

I’m interested in what’s happening with your clinic in that regard and whether the mandate is strictly more vulnerable populations, because there are certainly people who make the case that those are the folks who need this model the most. But if we’re talking about preventative health and holistic health, broader segments of the population can certainly benefit.

G. Showler: We have specific contractual requirements with the health authority, and that’s to serve people that are living in the downtown core that have chronic, complex health challenges — specifically that have addiction, that are homeless or have chronic severe men-
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tal illness. Due to our capacity, we’re quite full, so we’re quite strict with that.

We review all of our clients when we come in. We do a PowerChart. We do a PharmaNet review. We see that there’s a clear need. So yeah, we haven’t been mandated as a 5 percent, I don’t think. In Victoria, the work hasn’t been done to identify who those particular people are, but I think it’s safe to say that a large portion of them would be coming to our clinic.

J. Darcy (Deputy Chair): Are you connected with some of those other programs and services that help to serve the more vulnerable populations?

G. Showler: Yeah. For example, there’s a new 713 outreach team in Victoria, which is for people with severe addictions. Their physician support comes from our clinic. The ACT teams, the local assertive community treatment teams — their physician support comes from our clinic. There are nurse practitioners located in our clinic two days a week. One of our docs provides primary care services at the Native Friendship Centre — goes out to Pacheedaht, out to the reserves.

Already, a lot of the services downtown are using us. They have all these outreach teams. They connect with people, but then what do you do with them? They need a primary health care home, and right now, we’re the only one.

L. Larson (Chair): I have Marc, Doug and Selina — and no time. So if you can make your questions really quick — short, snappy. If not, we will write them down and give them to Grey later.

Just along with the fee-for-service. First of all, this sounds like it’s a great program. What it’s accomplishing is what we need to see.

I’m just wondering about the pressure as far as costs relating to health services. Do you foresee that the service that you are providing at X cost, if it was not a fee for service but…? Are you suggesting that the Health Ministry allocates so much money? What’s your suggestion, No. 1, and No. 2, do you see a big impact upon dollars into the system right here? I know that they do want to control that, yet at the same time, they do want to meet health outcomes too.

G. Showler: Our physicians are paid by APP, alternative payments program. Essentially, they’re paid by the hour.

The difference between us in a lot of areas is that we own the APP contract. We hire the doctors under that contract, whereas often the health authority assigns the APP to a particular physician. So where they go, the funding goes. If a doctor leaves us, the funding stays with us, and they’re off on their way. They’re very reasonably compensated. In terms of the cost difference between APP and fee-for-service, I don’t know. I can’t tell you which one is cheaper.

What happens here is…. Where are the calculations coming from? If you’re spending a little bit more in primary health care, but you’re saving a certain amount at the emergency room…. Everything in the acute care system, we know, is vastly more expensive than in the community.

I think what needs to happen is that we need to be doing these calculations systemwide. As opposed to looking at the particular cost for a particular provider in a particular setting, we need to look at what the cost savings are across the system.

A client that comes to us and is detected early for an abscess from injection drug use does not get endocarditis, does not go to ICU. I mean, a week in ICU…. You’re talking about $50,000 or $60,000 — right? — or north, depending. So the savings are there. They may not be realized when you’re comparing the particular cost of a particular physician at a point in place.

D. Bing: I’m just wondering about the care that you provide. Do you provide after-hours care and weekend care, holiday care, that sort of thing? It’s not strictly a Monday-to-Friday, nine-to-five kind of an operation?

G. Showler: We’re open until eight, and we’re open on the weekends. We’re open on Saturday. We used to do overnight and hospital admitting. Our contract was renegotiated based on the fact that we couldn’t sustain those levels of service. We had so many clients. Currently we’re not providing that 24-hour care. Unfortunately, our clients, at this point, have to go to an emergency room outside of hours.

D. Bing: Well, it sort of seems like that’s no different than a walk-in clinic or….

G. Showler: That’s a fair question. What I would say is the difference is that the quality of care during those hours makes it much more likely that a person would need to access urgent services outside of our business hours.

In reality, we would love to have that model. We’ve had a fixed budget for the past 15 years while we’ve taken 500 to 600 new clients every year, while wage costs have escalated and so on and so forth. We would have to dramatically reinvent our services or increase the funding in order to be able to provide that.

S. Robinson: Thank you very much for this very enlightening presentation, and I want to echo the wise words of my colleague across the way: “Duh.” It sounds like a fabulous model.

I just have a question about one of the barriers which you talked about: eliminate fee-for-service. Is the barrier that docs don’t want it? The GPs are saying: “We don’t want to switch over”? Or is that actually a government…? Is that sort of a political will challenge? Where is that conflict coming?

G. Showler: I’m probably not the best person to…. I mean, I know there is a large contingent of physicians that would like to see fee-for-service abolished. I think there are also a lot of physicians that have a lot committed to that system of service. It certainly works for….

Specialty services, I think, is where a lot of the difficulty comes as well. I think it’s easier to implement in primary health care. To change that model, I think, when you’re looking at specialty services and in the hospital, it becomes a bit more problematic.

S. Robinson: When I just look at “eliminate fee-for-service,” could it be a parallel? There might be still some fee-for-service, but we need to introduce a new model?

G. Showler: Absolutely. That is kind of the pie in the sky, the ideal for a community health centre. It may not be appropriate across all settings, but for a community health centre, it’s absolutely vital if you’re going to have a healthy, functioning, interdisciplinary team.

L. Larson (Chair): Thank you so much, Grey, for your presentation. We really appreciate it. I apologize for running over time. We were lucky. We had a little bit of a window, so we could kind of push our envelope a bit this morning.

Thank you very much for being here. We appreciate the materials and all of the good work that you do.

L. Larson (Chair): I’d like to welcome Marshall Smith from the British Columbia Council for Recovery Excellence. We won’t cut your time short, Marshall. We have allowed for the fact that we’re running late.

M. Smith: Thank you, Madam Chair, and to the members. I want to thank you for the opportunity to appear today. I have a brief statement that I’d like to read before jumping into the PowerPoint presentation.

There are hundreds of thousands of British Columbians living in short- and long-term recovery from addiction to alcohol and other drugs. Thousands more will get well every year, proving that recovery is both possible and sustainable. Those of us living in long-term recovery are the evidence that this serious health problem can be overcome and that there are real solutions to the problems of drug and alcohol addiction.

For too long, a great majority in our communities — those of us in recovery, our families, our workplaces and our recovery allies — have been silent about our experiences and successes. We need to change that. Instead of sensationalizing addiction, which often occurs in the media, it’s time we celebrate recovery and acknowledge recovery.

Despite our great numbers, little is known about what traits we have in common, the most successful pathways we have used to achieve recovery and how we maintain long-term remission. Success, however, is all around us. We must begin to listen to the voices of people in long-term recovery, study their successes and build a community health response based on what has worked.

British Columbians in recovery are now unifying around key priorities to bring attention and resources to this important public health issue and to end the stigma and shame surrounding a life in recovery. Recovery from addiction requires courage and strength, which leads to remission, improved health and positive, engaged citizenship. There are many different pathways to recovery, but regardless of how people achieve it, our lives and the lives of those we touch — our families, our children, our workplaces and our communities — are vastly improved as a result.

We must work to eliminate barriers to recovery for every British Columbian family and to help today’s children and future generations, who are often the biggest winners in the recovery process. Part of this is creating and supporting public policies so that all people have greater access to recovery resources. This government must point the way to recovery by clearly stating the goals for those who are addicted: a drug-free life, improved health and positive, engaged citizenship. As importantly, we must reduce the discrimination and stigma that keeps people from seeking recovery and moving on to better, healthier and more productive lives once we achieve it.

I think in that opening, the key point that I want to impress upon the committee today is an acknowledgement of recovery. For very long now in this province, we have seen a lot of words around mental health and addiction. We’ve had a lot of focus on the disease itself, a lot of talk on the sensational aspects that we can see with addiction, but nary a word of the solution. Very rarely do we talk about the solution to the disease of addiction, which, of course, is recovery.
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Turning our focus to the PowerPoint presentation, I’ll open by saying that over the past decade, however, tremendous accomplishments have been achieved — just an acknowledgement of that. Many people in this room who are dedicated to this issue are responsible for achieving some of those, and on behalf of the recovery community, I want to thank you for your efforts both in the past and today. We still have much work to do, but it is time that both the public health community and the personal health community, which is the recovery community, come together and do this in a united fashion.

There are a number of things. I passed along my bio to spare some time in reading that. I am privileged to wear a lot of hats in this field. I’ll just say briefly that my perspective is derived from both lived experience and education. In fact, I was a staff member in this very Legislature in the first term of this government before I lost my career to drugs and alcohol.

Following my career here in government, I spent about five years living on the streets of the Downtown Eastside in Vancouver as a homeless drug addict, living off of the avails of drugs and everything else that goes on out there. I went through the system. I went to treatment. I found recovery, and my life is incredibly enriched today as a result of recovery.

Today I have the privilege of sitting on many boards and providing leadership in the area of recovery in British Columbia. In fact, you heard this morning from my colleague Rita Notarandrea that I have the privilege of being one of British Columbia’s NRAC members that is helping to guide the work on recovery at the national level. I chaired the new British Columbia Council for Recovery Excellence. I am a director in running one of B.C.’s largest private addiction treatment centres here, Cedars at Cobble Hill, which was referenced earlier.

As well, I sit on the board of the Salvation Army, British Columbia’s largest social service provider, and am involved in countless working groups and looking at different organizations.

Through my journey, from start to finish, the following are some of my observations. I sense a desire from the committee to talk about some nitty-gritty around this, and I’m happy to provide that to you with some straight answers. I’ll go through it quickly so that we can, hopefully, have a long question-and-answer period.

Observation No. 1. We have a fractured or nonexistent system. Often you’ll hear people talk about the fact that the system isn’t working. The system isn’t working because we don’t have one. That is the reality. We don’t have an addiction system in British Columbia. Too many sectors are working in silos. We need connecting tissue urgently.

The system must bring the private sector inside and value their viewpoints. I’ll just hit on that briefly. The established health care infrastructure of the bureaucracy, so to speak, is a very closed shop. There are many other viewpoints beyond what government’s viewpoint is on this issue. Those are not considered, and it is not felt that those viewpoints are important.

The recovery community — people who get well from this disease — and other viewpoints have, for too long, been faces pressed against the window, wanting a seat at the table. That must change. The B.C. centre on substance use, similar to the Canadian Centre on Substance Abuse, should be established. That is a project that’s being headed by Dr. Evan Wood, and we’re hopeful that the Ministry of Health will fund that and allow us the connecting tissue that we need to bring these parties together and begin communicating effectively with each other.

I would also say, further to that, that the adversarial posture that exists between the public health harm-reduction sector and the personal health recovery sector must end. There is a need for both of these in our system. Both are very important parts of a full continuum of care, but we have been operating for too long on only one cylinder. That continuum needs to be expanded, and we need to enjoy a full continuum of services from harm reduction to long-term recovery.

I will say that there’s some light at the end of the tunnel on that. There is a lot of work being done to bring those sectors together. It’s exciting work, and I’m quite thrilled to be a part of that with Dr. Evan Wood. We have a commitment at a very high level between him and me to bring these sectors together to the table. We are beginning to communicate and enjoy each other, and we’re building trust and finding common language. Much of that energy is spent focusing on things that we can get along on and that we agree are things in common that we can work on. We’re making quite a bit of progress there. So that is very positive.

You heard earlier — I’ll just reiterate — that the role of mental health versus addiction needs better defining. We hear too many times in the community the term “mental health and addiction” thrown out there with no attention paid to the nuts and bolts of that. It’s too broad. It needs better defining. Mental health drugs are being given at alarming rates, causing morbidity and mortality when they’re not indicated for addiction care. Legions of people are reporting to treatment, misdiagnosed by community psychiatrists. In most cases, their mental health symptoms will wash away with a period of abstinence and recovery.

I’ll tell you anecdotally that we are spending hundreds of millions of pharmaco dollars needlessly on this problem. It’s certainly true — I’ll echo Rita’s comments earlier — that there are people with mental health, there are people with addiction, and there are people with both, to be sure, and they need tailored care. The problem comes in when we have mental health professionals only — who don’t have an understanding of the disease of addiction, which is a primary neurobiological brain disorder — trying to
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treat the symptoms of addiction as a mental health problem and giving mood drugs to combat addiction. People are becoming further addicted and deeper and deeper into the hole. So that is an area of urgent importance that needs clarity and needs defining.

Large segments of the addicted population are not considered. Because I was one of them — a marginalized person on the Downtown Eastside, homeless and addicted, living out of a shopping cart — I have great respect and understanding and compassion for the needs of these populations that we see.

However, it’s very important to understand that when we’re talking about the disease of addiction in our communities, what we see with our eyes in terms of what’s going on in the streets — the disorder and the chaos — is a very, very small percentage of the overall substance use and addiction problem in our communities.

The majority of the addicted population, in fact, in British Columbia are not marginalized, homeless or have mental health issues and will never access any type of formal care. The system that we have is geared to the super sick. I apologize for the term. Instead, significant early intervention is required, focusing on youth, First Nations, workplaces in particular and suburban environments with non-acute, non-pharmacological interventions. Urgent focus is also required for alcohol, benzodiazepines and prescription opiates, which should be no shock to the committee.

In terms of the segments of the population, it’s important, I think, as well, for the committee to understand…. Again, there’s a lot of noise around what is and what isn’t the problem here.

While there should be no question as to the importance of the issues and the environmental factors in addiction, like homelessness, poverty, trauma — you know, all of these things that we talk about — we should be very clear that addiction is a genetic, neurobiological brain disorder. It is not caused by homelessness, marginalization, poverty, etc. Those are important factors not because they cause addiction. They’re important because they block recovery.

If you have the disease of addiction, if you have this disorder and you have those environmental factors, your ability to achieve a full recovery is going to be significantly impaired, and for those reasons we must ameliorate those conditions. But let’s not believe for a minute that simply by ameliorating those conditions you are going to solve the addiction issue in the individual. Those require two different types of interventions.

When we talk about the different populations, following that line of logic, there should no question, of course, that the most sick that we see in our communities — those on our streets, etc. — have significant blockages to recovery. That’s why they’re out there, because their ability to recover has been impaired.

In the reverse, if you look in suburban areas with people who are more fortunate, who don’t have those blockages, many of them go on to achieve recovery with relative ease. I think that digging down on some of these issues and understanding that they’re important is fine. Understanding why they’re important is essential, because in the misunderstanding of why they’re important, we get all kinds of noise around what we should do about this issue.

The system teaches prescribing without adequate diagnostic assessment and diagnostic evaluation. This is another thing that is causing no end of trouble out there. Doctors require much more education around treating patients where substances are involved.

Medications are being handed out left, right and centre for mood without understanding the root causes. The amount of addiction education in medical schools is almost nonexistent, and the education that they do get is heavily weighted towards pharmaceutical intervention, mainly because of the pharmaceutical industry’s very powerful lobby. In much of this post-secondary education, they manage to get their curriculum in front of the students.

With the understanding that doctors, who go through a very lengthy medical training process, receive a handful of hours of education on addiction, they receive even less on recovery. They’re trained a little bit about what the disease of addiction is and almost not at all how to get somebody well from the problem, despite the fact that a significant number of patients that report to their office for treatment of a myriad of issues are likely substance-involved, whether you’re living in Abbotsford or West Vancouver or the Downtown Eastside.

Again, following up on that, of course practitioners have virtually no education on or about recovery. More education is required across the spectrum of services in evidence-based, recovery-focused practice, shifting from a mindset of being satisfied with just “less sick” to embracing a recovery-oriented system that is focused on “more well.”

Treatment and recovery services are heterogeneous and disorganized, again getting back to the sort of nonexistent system. There’s an acute lack of communication between the recovery system and the health care system’s formal addiction care structure. This is going to require trust building, serious active listening, inclusion, research and an acknowledgment that recovery is real, available, attainable and sustainable.

“We are the evidence.” Again, many definitions of recovery from addiction to substances have been proposed. Until recently, we’ve had no consensus around that, and there are many reasons why a definition around recovery is important.

I have some slides in here that are a duplication from this morning from Rita’s presentation. I’m not going to
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go over again this material, because you have it already, other than to say that the recovery advocacy movement…. People in recovery are a significant constituency of consequence.

We are often silent in our role, because historically we have belonged to anonymous programs. That has been the nature of the community. But more and more, as time goes on here and as things shift, as stigmas shift, we are more and more willing to come out and share that experience, strength and hope with people in the hopes that things will change.

I was thrilled to be part of the national summit. I’ve highlighted here a salient point in the definition of recovery for you, which is that recovery “aims to improve the quality of life by seeking balance and healing in all aspects of health and wellness while addressing the individual’s consistent pursuit of abstinence.” I think the key words for the committee to key in on there are “consistent pursuit of abstinence.”

Certainly, I will acknowledge that abstinence may not be attainable for everybody, but in order to be in recovery requires a consistent pursuit of it. Meaning that people who are…. They may not be ready, and that’s fine. They need an incredible amount of help. But recovery is a particular…. There is a line that is crossed, where you cross from active use, active disease, into the pursuit of something different.

We talked about the national commitment in Rita’s presentation and the NRAC, which of course I’m one of the three British Columbia members. I also am looking forward to seeing the national recovery survey results — they haven’t given them to us yet, but we’re chomping at the bit for it — and the evidence review.

I’ll talk in conclusion about the British Columbia centre for recovery excellence. This is a group that I was asked to put together and chair by Dr. Evan Wood and the folks down at St. Paul’s. This is in our pursuit to bring these communities together to begin communicating.

We’ve had to put together the foundational pieces so that we can sit at the table and prioritize. The people that you will find on this council are the heads of the major addiction treatment centres in British Columbia, a chair of the British Columbia Police Chiefs Association, directors of public safety for major cities, people in recovery, addiction medicine experts with 40-plus years of experience.

We are designed to inform the new B.C. centre on substance use. We are designed to act as your key stakeholder representative to the recovery community. Our goal is to foster excellence in the field of recovery facilities and services; to provide a platform to work on common goals in advocacy; and of course, to provide connecting tissue to stakeholders and clinicians.

We had our first meeting a couple of weeks ago, and I can tell you it was really something else. It was the first time that we’d ever come together with this goal of engaging government in mind, and there were a lot of opinions at the table. We’re looking forward to working with you as a stakeholder representative to the recovery community. I don’t have much more to say about that, other than it’s exciting times.

The last slide. These are our intended key advocacy issues for 2016-17, and these would be the key bullet points that we believe should provide…. These are priorities, right? If we want to make a dent in what’s going on out there right now, these are the key issues that we need to focus on.

Reduce the stigma of recovery in British Columbia. Advocate for better health assessment and referral for people with addiction. Encourage research on recovery-focused facilities and services. Commit to a funding increase for First Nations recovery programs. Foster a complete and total rethink of youth substance-use services in this province. We are nowhere on that issue in British Columbia.

Advocate for a more comprehensive recovery presence in the LGBTQ communities, which are absolutely plagued with addiction and alcoholism. Advocate for a more comprehensive recovery presence in suburban neighbourhoods and workplaces. Of course, we know from our history that often workplace action can be a huge catalyst for change in and around these issues of lifestyle.

Review of and best-practice implementation for recovery residences. Commit to the establishment of recovery community centres. I’m happy to explain what those are.

Establish and promote collegiate recovery programs. Our universities, from Vancouver Island to Fort St. John, are seething hotbeds of drug use and alcoholism and all kinds of other issues that go along with it. It has become cultural amongst our students. We need to get in there. We need to allow places for our students to go when they don’t want to participate in that culture and they want to find recovery if, in fact, they become dependent or addicted to these substances.

I would like to see the government commit to and establish British Columbia’s first recovery high school, which is simply a high school in the province where kids who have substance-use disorders can go to school and support each other in staying in recovery. Instead of taking the kid out and institutionalizing them in a treatment centre, let’s bring the treatment model to the entire education experience. You could have a boarding component for people who need a more intensive experience or an out-patient component with kids coming to class during the day.

This is not new thinking. There are two in Canada, in Ontario, right now — Quest Collegiate recovery programs. They are throughout the United States. Recovery high schools are not new and would make a tremendous impact on early intervention and prevention.
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Promote recovery management checkups, alluding a little bit to the presenter previous to me. We seem to think that this issue with substance-use disorder ends when the drug use stops. That’s just not true. It’s a chronic health condition.

By the way, I will just say that there is no evidence to suggest that people with the chronic disease of addiction relapse or comply with their recovery program at rates any better or any worse than any other chronic health condition.

That is to say, diabetics go off their sugars, right? People who have chronic obesity relapse in their program despite swearing this is the last time. “I’m going to exercise. I’m going to do all of these things.”

Relapse and compliance around chronic health conditions are about the same across the spectrum. Addicts are really no better or no worse than anybody else at maintaining their health. However, the consequences that come along with the relapse of addiction, obviously, are more visible to us in the community.

Then, of course, last but not least, we’re hopeful to see all of you at the Recovery Day celebrations this year. If you haven’t been to one…. This year we expect about 3,000 people in recovery. Bif Naked is performing. It’s going to be in New Westminster this year. It should be really a sight to see. If you want to see what the recovery community looks like, what the energy of people who have beat this thing looks like, I would encourage you to attend. It is really something.

L. Larson (Chair): Thank you so much. Wonderful to hear from you on the work that you’re doing and, obviously, your passion for it, based on your own experiences as well.

M. Dalton: Marshall, thank you for the presentation. It was very clear and articulate and disturbing in many ways, which is what we need as far as action, from what I can hear.

I’m just wondering what type of dollars we are putting in, as a province, to recovery, across the system. Maybe that’s too broad of a question.

The second thing…. I’m just pulling this number out of a hat, okay? If we had $25 million…. I haven’t heard that from anywhere. I’m just making up this number. On a regular basis, how would you disburse that in a way that would be effective?

M. Smith: I will happily send you a well-articulated budget proposal to spend your $25 million. Look, first and foremost, I would appropriately fund the convening organization in B.C., the B.C. centre on substance use. I think that they’re asking for $1.9 million in operating. That would be very helpful, because that would allow us the opportunity to bring these thought leaders together and actually do some of the work that we know we need to do. I think that there has been a lot of talk around what it is that we need to do, but the people around that table are action-oriented, and we want to begin work.

I would tackle…. I would certainly conduct a review of recovery residences, particularly in Surrey and some surrounding areas. I would fund an education component around training for recovery home operators. I could come and present to you on recovery homes for hours on end, because that’s one of my particular areas of interest.

I would put some money into training primary health care workers into identifying and assessing appropriately substance use disorder — to appropriately identify, assess and refer.

There is a new website coming out. In the interests of full disclosure, it’s my website. It’s called Treatment Access B.C., which is something that we have created. Basically, the gist of it is the right care right now. It is a listing of addiction services, recovery services, in the province. It’s free to use.

The user will go to it and put in their demographics. So I’m a, you know, First Nations female between these ages. I’m on alcohol and benzos and methadone, and I’m in a wheelchair — or whatever the specifications of their exact needs are. They’ll click “Search,” and it will bring up all of the services that match their tailored need, and it will tell them who has space available that day.

In order to go on the site, you need to be a licensed and accredited service. It will be a very good place. We’ve received funding from this government to support it. I’m thankful to the government about that. It’s a step in the right direction. So some support around that, perhaps.

Research. We need more research into recovery. Most of the research into addiction that we have…. We have a lot of research into addiction. Most of that is pharmaceutical. Most of the research that we see into addiction is geared around: “What drug do we give somebody to prevent them from using 2 percent less, 15 times out of 20, over a two-week period?” Well, that isn’t going to get us where we need to go. That is a lot of academia. There are a lot of people who are engaged in the work of academia. Some of it is helpful, and much of it is not.

The reality is that we need to know more about recovery. We need to know more about the pathways that people take to achieve success. Then we need to build a health response based on what has worked. Providing that you decide that you want people to be drug-free and have improved health and positive citizenship — if those are your goals — then we need to know more about people who have achieved that. We know almost nothing about them right now.

D. Plecas: Marshall, as always, it’s so inspiring to listen to you talk. I can’t think of many people who know more about this issue than you do. In fact, I can’t think of anyone.
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I guess the first thing I want to do is thank you for the work that I know you’ve done in trying to bring the sectors together, if we want to call them that, and also thank Dr. Evan Wood, who’s not here. I know the two of you, together, have tried to get us to think differently.

Some people on the harm reduction side and then on recovery are not thinking that, really, we’re all talking about the same thing. I know you’ve gone so far as to develop a definition, which could help guide us. But when I hear you talk and I look at that long list of advocacy things to do, I’m thinking to myself: “Whoa.”

We are so on the cusp of doing something important here, something significant. It seems to me that…. It’s almost like we need a strategic plan, if you will. We need a mapping out of how we’re going to best get to all of those things we can do. It seems like there are some barriers there.

Maybe if you could also comment on, as Marc was getting at, the whole funding side of things. It’s not like we haven’t spent hundreds of millions of dollars on substance abuse, and continue to do that. Sometimes we wonder — especially when I read some of the recent research on that, like some of the stuff that has come out of SFU — if that money has been well spent. We can do so much more. Can you make a comment on that?

M. Smith: I’m not exactly sure what you’re asking me, Dr. Plecas. However….

D. Plecas: Well, I guess in a nutshell, I’m saying: clearly, you have a sense of what we need to do to get to a place where we can be proud of what we’re doing for people with mental health and addiction issues. I’m just wanting to get your sense of what it is that’s holding us up right now and how we can get there faster.

M. Smith: What’s holding us up right now is government’s lack of policy around recovery as a goal. That’s number one. Government must move to articulate their goals. Let me put that in perspective. When government articulates their goals succinctly, we have tremendous success.

Let’s look at addiction when it comes in the form of nicotine. We’ve had tremendous success because government has clearly stated the goals: “We expect you to quit. We are going to make bylaws ad nauseam preventing you from harming yourself and other people by doing this. We are going to prohibit this all over the place. We’re going to show you pictures of the consequences. We’re going to confront you with the consequences of your continued use, and we’re going to be very clear and ruthless about our expectations that you go out and you get help, that you stop this and you get healthy.”

We’ve been very clear. When we do that, look at the results: millions of Canadians have stopped smoking. Billions of dollars have been saved in health outcomes, despite the fact that smoking cigarettes is clearly one of the most difficult addictions to beat. So when government is clear about their expectations and priorities, we can literally move mountains. It’s not that we don’t know how to do this.

That’s an easy thing, though, because we’re picking on people who have taken up something that is not good for their health, and through all the work that’s done — the advertising, the promotion — they’re trying to have a healthier lifestyle. But sometimes addictions are not to legal substances, and therefore, it’s more difficult to deal with them.

The issue that really concerns me is the physician medication issue that we are facing. I see it a lot in rural British Columbia. One thing I noticed that isn’t on here is on our seniors. I think the work that you’re doing is absolutely wonderful.

I think we could start there. It is legal drugs, which some people are getting their hands on and they shouldn’t get their hands on. I think your cigarette explanation was great, and I think you could use that with the others, because they are legal drugs.

M. Smith: For sure. I would say this to that. In fact, while the disease of addiction is the same, regardless of whether the substance is legal or not legal — it’s one disease, right? — the recovery from different substances looks a bit different. Same disease. Bit of a different recovery, depending on what the substance is.

For sure, our seniors are often…. You know, I look at my own experience with some of my family members who have gone into care, and God help them when I roll in, because I’m looking at the med sheets. Often with vulnerable populations or others, medications are used as a means of behavioural management and not necessarily health care, and that’s appalling.

I think that we need to recognize the power of the pharmaceutical lobby, the very long reach of the pharmaceutical industry. Pharmaceutical companies, as you know, in Canada, don’t have the ability to advertise like they do in the U.S. As a result of that, they have to find new and creative ways to bring their message to market.

They know that pharmaceuticals are a bit different than other products. They require a doctor to prescribe them. Much of the billions of dollars, in fact, that they spent on schemes to put their message out in front of the public
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— whether that’s through research or whether it’s by hiring thought leaders to appear in the Huffington Post or, you know, whatever it is…. An unassuming public reads these things, and they have no idea that the entire article has been crafted by a pharmaceutical communications specialist.

They’re even hiring mothers of children who have passed away due to fentanyl overdose, etc., and approaching them saying: “You know, you really have a message that the public needs to hear. You should consider becoming a thought leader for our company. Your Johnny might be alive today if we had these new evidence-based medicines on the publicly funded formulary, and the public needs to hear that.”

These people are in absolute distress, not knowing that they’re literally being manipulated by a massive communications agenda. And forth they go. They regurgitate what they’ve been given to regurgitate. That stuff has been flooded into the media, and the effect that it is having is that it’s habituating the public into thinking a particular way about what the real solutions are to some of these issues.

I think that both federally at the…. Health Canada is the one that is responsible for regulating that piece, but I think the province may want to look at the activities of pharmaceutical companies and their communication strategies as well.

S. Sullivan: About the issue of stigma and legalization, I just wanted to ask you: do you think we’d be better off legalizing drugs?

M. Smith: I appreciate the question and welcome it. Certainly, stigma — I’ve spoken to that. I’ve felt that personally.

In and around the issue of legalization, my bias is a decriminalization model. To me, legalization is tantamount to commercialization, and that is what gets me concerned.

I have absolutely no problem with decriminalizing some of these substances. I believe some are still too dangerous to do that. We can have the conversation about decriminalizing only once we have a treatment model pathway that is going to be effective. If somebody is on drugs and they commit a criminal offence, then they need to be moved into a treatment piece. It can’t just be: you commit a criminal offence, and then you’re let go because you were using. There needs to be some action on the person.

The commercialization piece. I lay awake at night. I’m very concerned about that. I think that, again, just like my assertion around the pharmaceutical industry…. They, by the way, I will say — so they’re not waiting in the parking lot for me afterwards — often do some good work and help many people. That can’t be overlooked. It’s not all naysaying.

But big marijuana is an emerging major corporate giant. They have a corporate agenda, which is to make profit and to get their product to market. That can’t be denied or ignored. So I worry about a community where you can phone up Domino’s and order a pepperoni marijuana. I worry about a community where you can go to the pasta aisle and get marijuana-infused penne. I mean, it’s all over the place. We don’t really do a great job regulating industry, so I’m a bit mistrustful still of the agenda of the corporate marijuana field.

I also look at the ensuing downstream impacts, because we know that prevalence and exposure increase use and, by proxy, will increase substance use disorder. I worry about our ability to deal with that.

I also worry about the side effects. We know that prolonged marijuana use is corollary with depression and anxiety. I already know that we have a huge problem with overprescribing benzodiazepines, mood pills, antipsychotics, and so I’m very concerned about the impact that that is going to have.

If we have a generation that is being raised with a very liberalized marijuana environment, what happens when they start getting things that look like significant mental health issues, like significant depressions, significant anxiety, and they begin to reach for pharmaceutical solutions to that? That’s a concern for me as well.

The other concern around legalization is…. I had this great conversation with one of the chiefs — the president, actually — of the Canadian police chiefs association. I’ll stop short of representing it as fact, but I believe that there is likely a correlation between a liberalization of marijuana policy and talk of the dispensaries. We’re already seeing that impact.

If anybody believes that we’re going to remove one of organized crime’s most significant and profitable products out of their hands and that there won’t be any consequences to that, I think we’re kidding ourselves. I believe that one of the results that we’re already seeing is the fentanyl crisis, because we’ve removed one of their biggest cash cows, and now they have to look at the rest of their products and stretch their profit to cover off that lost income.

Believe me, as somebody who’s lived on the streets, who understands how that economy works, they take their existing drugs and they cut them up with things that are cheaper, and they make up the profit difference. That’s simple supply-chain economics. There’s not a lot of depth required to look at that. I think we need to understand that there are potential significant unintended consequences that come along with that market.

S. Hammell: Marshall, it’s always so good to listen to you. One of the things that is observed from the current crisis on fentanyl is that the major crime organizations are killing their customers. You do kind of wonder what thought process goes into that.
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When you also talk about legalization, we moved, particularly in the States, from a prohibition to a…. So we do have some history of legalization versus not. I think I share a lot of your concerns, but I also worry about the forbidden fruit. There’s a tree you can’t touch. It’s been in your garden all your life, but don’t touch that tree. Well, you know that sometime you just go and touch it, right?

I think we have to do a lot of good work around people understanding the consequence. It’s really interesting, your conversation on tobacco, because I do think we have done an amazing job on consequences and then put the social screws on the pressure.

I want to just switch to one. You talked about seniors, managing their behaviour through drugs. I think we do that with methadone to some extent. Methadone is a huge cost to our PharmaCare budget.

S. Hammell: It’s huge — right? — by the time you add all the bits and pieces up. You said 200. I think it’s pretty high.

That is to manage behaviour. My understanding is it’s harder to get off — in other words, to recover from methadone — than it is from the drug that the methadone is replacing, because you’ve gone from a natural drug to a chemical substance. It’s much more difficult.

It seems to me the process has to be where you take your product at face value and you deal with it, rather than creating other formulas and going to the big drug companies to provide solutions that, in the end, aren’t solutions. If I recall, Dr. Evan Wood was one of the major doctors in pushing forward the legalization of marijuana. I don’t know that, but…. I mean, I think I know that. Put it that way.

Let me get to my real question, now that you’ve heard my opinion on a few things. If you have a website now called Treatment Access B.C. and we don’t have a recovery treatment system out there, what the heck is on the website?

M. Smith: You have a good question. Nothing right now. It’s not launched right now.

M. Smith: The system is meant to recognize and assist in a couple of areas. One is that we have individuals, parents, loved ones, workplaces that, when confronted with the crisis of addiction, are literally opening up the Yellow Pages and flipping through. Or they’re phoning Sally, who knows Nancy, whose son went to a place. They’re sort of in this crisis, crazy kind of mode trying to get…. Or they’re googling around the website, and they may or may not find a place that is accredited. They’re certainly going to find some places with nice pictures, and who knows whether they’re good places or not.

The other piece is that we have primary care health practitioners working right now in hospitals. It’s very expensive, by the way, if you didn’t notice — $1,000 a day for a bed. So Nancy comes in, and she’s had it, right? She’s got a substance use disorder, and she wants help. She wants it now. So she lies to the doctor — because, believe it or not, as addicts, sometimes we do that — and says: “I’m dehydrated, and I need to see you.” The doctor comes in, and she says, “Look, I’m an addict, and I need help. I need to find a bed,” etc.

The very expensive physician or the very expensive nurse is then confronted with: “How do I help this person who’s in front of me?” And the clock is ticking on the amount of time that he can spend with her, right? The urgent crowds out the important.

He or she is going to turn around and go to the centre island and pick up the phone and probably take the binder off the shelf of a list of resources that somebody has compiled and start phoning around and is going to say: “I’ve got a female,” etc. “Do you have a bed?” “No, we don’t have a bed.” “Thank you.” Click. Phone the next place. “I’ve got a female. She’s on social services.” “We don’t take social services.” “Thanks.”

This could go on for hours, trying to find an appropriate place for her, and there are a thousand variables — on methadone, off methadone, on social services, no social services, with a mental health issue, no mental health issue. The variables are unbelievable. We need a more efficient way for those primary care providers to simply pull up the website, put in the data of what is in front of them and hit search and get a listing of places that have space right now.

What happens on the site is every morning the system emails the service provider and says: “How many spaces do you have today?” The service provider says: “I’ve got one for women and three for men.” Enter, and it updates the system. So it’s quite simple.

We wanted to bring a really simple solution to what is a very complex problem that will work not just for acute care providers but for counsellors and judges. We showed it to a judge the other day. He said: “This is great. You mean I can sit in my courtroom, and a guy comes in front of me and says he wants help and with a couple of clicks, I can say, ‘Check out these places. They have space available right now.’”

Or the reverse. I’ve got a lawyer trying to tell me that this client is going to ABC House, and that it’s accredited. So I can look up ABC House and say: “Oh yes. It is accredited, and I see they have space. Well, good luck to you, young man.”

L. Larson (Chair): Thank you very much, Marshall. Because we had a bit of a window of time here, we have been able to ask you more questions and get more insight. We really appreciate that.

Our next speaker is here now, though, and so we will have to move on. Thank you so much for being here. We really appreciate it.

M. Smith: By the way, I’m happy to come and see any of you in your constituency and spend as much time as you’d like, if you have any of these issues going on.

L. Larson (Chair): No wandering off, group. We are going to move right into the next presentation.

Welcome, Grand Chief Doug Kelly. We’re very pleased you’re able to be here. We’ve got 15 minutes for you to talk about the First Nations Health Council, and I’ll just let you leap right in.

D. Kelly: Good afternoon. My apologies for being late. I don’t know whether it’s me that has an issue with home-work balance, or whether it’s my staff. It’s really hard to tell. I don’t know who works harder. I’d be really hard pressed to answer that question.

My flight this morning from Chilliwack was delayed. It was a real little puddle jumper. They don’t like flying in weather. There was some weather over Abbotsford, so we were delayed leaving Chilliwack by 15 minutes.

Then when I arrived at your beautiful building here, there’s a whole bunch of kids all excited about coming in to do a tour. I had to wait my turn to get through security. So my apologies.

It has come to my attention recently that a lot of folks don’t understand the notion of Grand Chief. I should probably explain it. In some parts of the country, they’re elected. In some organizations, they are seasoned veterans that are essentially chiefs speaking for an organization of chiefs that represent their people, their Nation.

In British Columbia, it’s more of a gesture of respect. It’s more of an acknowledgment of a lifetime of service. Edward John was recognized by his people at Tl’azt’en, and they named him as a Grand Chief. Stewart Phillip was recognized by his people, the Okanagan, and they named him as a Grand Chief.

In Stó:lō country, where I’m from, there’s eight or nine of us that have been recognized, more for our work…. I’m not quite sure why they recognized me as early as they did. I was recognized in 2005 — see, my memory is starting to fail me. So 2005 I was recognized, and I’m still working. I wasn’t quite sure how I earned mine when I did, but I did. I just wanted to explain that first.

The second that I wanted to address was some of the questions that I understand you’re looking for information on. It’s really around, from my perspective, the seven directives that were adopted by British Columbia chiefs in May 2011.

Chiefs told us to make sure that our work was driven by the community. The community is the basis on which we want to do this work, recognizing our nations based on who we are and where we come from.

It was about making sure that we improve services; making sure that we increase First Nations decision-making; making sure that we collaborate, that we work with all others that are in the field; making sure that we increase our capacity, our ability to do those things that others are doing for us — that we’d do them ourselves.

Making sure that we stay out of section 35 rights. That belongs to the inherent title holder. It doesn’t belong to Doug Kelly or the First Nations Health Council. And to be efficient, to make sure that we make the most of the scarce resources we’re able to secure for addressing health.

When I think about the questions that you’re asking, about physicians and the need for physicians, the first question I have is: well, what are you prepared to do to change? That’s a political question, and that’s what you’re here to tackle.

For me, the forces for status quo are doing very well with the current system. They don’t want change. They’re very happy with the way things are. So that’s an issue you need to look at. Is that serving everyone? Not according to the questions I’ve heard.

The questions I’ve heard are that…. Many are being served well, but not everybody.

Rural and remote communities — how are they being served in terms of physicians? Well, you have a governance structure for the docs for British Columbia that looks after the majority of the docs for British Columbia. They don’t necessarily address the interests of rural and remote physicians, so what are you prepared to do to change that?

Some of that’s going to involve the mandate you provide your government negotiators when they negotiate those contracts. But you have to be prepared for those folks that are going to be opposed to the kinds of changes that you want — from the very physicians, some of which will be very upset at you for having the nerve to change the status quo. “It’s working really well. What the hell is wrong with you?”

That’s the first question that you need to confront: is your job those that are happy or serving everyone? That’s a question you need to confront and respond to, not for me to tell you — although if you ask me, I will. So that’s the first question. What are you prepared to do in terms of real change? That’s really the question.

The second. If you want to look at the current business model, I don’t think anyone’s happy with that. If you ask the physician that is working incredibly hard, with the current fee structure, to pay for all of the student loans, to pay for everything that they have to pay for to
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become credentialed and to practise medicine in British Columbia…. Then they have to get a billing number. They have to satisfy all of those authorities that they’re actually qualified to practise medicine in British Columbia. Then many of them partner with others, and they create a practice — incredible overhead.

The model that you’ve created with that contract is one where, in theory, a patient should get 15 minutes with their doctor. How many of you actually get that? That’s what I thought.

I don’t have my watch on at the moment; you can tell. The most I’ve been able to get from my physician…. I have a very good one, a young woman in West Vancouver. You might ask: “Why in the heck is a fat boy from Chilliwack getting a doctor in West Vancouver?” Because I’m on the road all of the time, and I was more frequently in West Vancouver than I was at home. So my office helped find me a doctor in West Vancouver.

The model…. The most I’ve been able to get from her is seven minutes, and she’s willing to answer my questions.

Those are the kinds of questions you need to tackle yourself with. Are you more concerned about the current business model, or do you actually want to improve health outcomes? If you want to improve health outcomes, then maybe you need to look at that contract very differently. Maybe you need to start rewarding physicians on the kinds of outcomes that they actually achieve with their patients. It’s something to think about.

I know there are other jurisdictions that do just that. They look at trying to make sure that they’re working with a physician to support individuals to claim responsibility for their own health and well-being. Then it’s less about how much time is spent and how much work can be done with those patients or groups of patients.

Sometimes you can deal with a number of issues together in a health education system that a doctor could run very effectively, but it means changes to the billing model. It means changes to the current business model.

When it comes to remote communities, we’re going to have to start looking at more and more telehealth. Now, very early in my term as chair of the First Nations Health Council — I’ve been elected three times; I’ve just finished my sixth year, going into my seventh — I met a doctor from Abbotsford who works in the Carrier-Sekani communities up near Prince George. I struggled with that concept. I didn’t get it. I didn’t see how he could make that work.

What Dr. John Pawlovich does is travel up to those communities on a regular basis, so it means he changes the way he does his work. He has to plan that time in the communities to maintain the relationships with those communities and his patients, to maintain that trust level, human being to human being, so that when he’s at home and he’s accessible by technology — he’s accessible by a phone about this size or another tablet that’s quite a bit bigger — he can actually take an emergency call on his technology.

The health centre in those Carrier-Sekani communities has that capacity, supported by nurse practitioners. Dr. Pawlovich and the nurse practitioner make quite a team, and they do a great job. So Dr. John doesn’t leave Abbotsford. That’s his home. He doesn’t leave there permanently. He leaves there to visit those communities.

That’s a model that I think could be looked at. But it creates challenges for the physician that’s prepared to do work in a different way because the current contract, the current business model, doesn’t work very well for those physicians that are prepared to do business in a different way.

When I meet some of the younger graduates that are prepared to practise medicine, they’re not interested in working their whole damn life, 24-7, being on call and going to the emergency room. They want a life. They want a good life. They want to achieve that work-life balance that I began this discussion with. They want to achieve that early in their career, not at the end of their career.

I think if you’re looking at attracting physicians to go and work in northern and remote communities, then you need to start thinking about what incentives would get them to do that. How many years of service working in those rural and remote communities would it pay off for you to buy off their student loans?

There are some simple things you could do that would make it very appealing for a young doctor incredibly in debt but wanting to achieve a work–personal lifestyle balance if you were to look at those kinds of things. Determine for yourself a business model that’s very different. Authorize your negotiators to negotiate different kinds of arrangements. I think those are really important.

I think the other questions that I was asked to confront were around mental health and substance use and treatment. Well, those aren’t easy issues. They’re not. They’re really not. And they’re made more complicated by privacy and confidentiality mandarins.

Now, if one of you were to stagger out of a bar, it’d be all over Twitter. It’d be all over Facebook. How much privacy do you have? If one of you were caught buying drugs — and I’m not saying your last name’s Ford and you’re a mayor — it’s all over Facebook. It’s all over Twitter. It’s all over national newspapers. There isn’t the privacy that people talk about.

Walk down any street in any town, in any village, in any city. You know there are folks that are suffering some sort of mental health issue. You see it in their behaviour. You see it in that they’re talking to themselves or sometimes they’re swearing at others. Sometimes they’re swearing just out loud. Sometimes they’re visibly angry, visibly upset. They’re behaving differently than everyone else that’s on the street. You know there’s an issue. Where’s the privacy there?
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My eldest daughter, her substance of choice is heroin. I didn’t find out until she was a young adult about childhood trauma. Someone in our family we trusted ought not to have been trusted. They sexually abused my daughter.

I didn’t learn about it until it was too late, but the school had to know. The school had to see the kinds of behaviour that were coming from my daughter to know that something was wrong. There was no discussion with my ex-wife or with me about what was happening with my daughter. Is that because of privacy, or is that because they didn’t want to confront that issue?

The sooner those institutions that are dealing with our children…. When they see something that resembles a mental health issue, a trauma issue or something else that’s going on, then we need to know, and we need to create the space to talk about it. Problems don’t solve themselves, in the same way the lawn doesn’t cut itself, does it, Darryl? Problems will not solve themselves. You’ve got to put it out on the table, and you’ve got to work through it.

Now, the one thing I’ve discovered is that my daughter would be gone already if it weren’t for her mother and if it weren’t for me. It takes someone in the family to stay with that individual, or they end up on the street like the ones we were talking about earlier.

I tried to get my daughter into treatment. She didn’t make it the first couple of times. I put her on a bus because that’s what she wanted. She didn’t want to be lectured by dad all the way to the treatment centre, if I took her. She didn’t make it the first two times. When I phoned the treatment centre to find out if in fact my daughter arrived and was in their care, they wouldn’t respond because of some of the regulations you have put into place as legislators, with this false notion that what you do is somehow private — as though privacy trumps responsibility, as though privacy trumps personal accountability.

I learned really early that there’s right and there’s wrong. No one will say a doggone thing to you if you do something right, but the minute they catch you doing something wrong, they’re going to be all over you.

My dad had seven brothers, and I lived right in the middle of them. Dad was away working, but there was always someone at home. I talked back to an uncle once when I was five. Once — that’s all it took. My uncle laid a beating on me and tuned me up, sent me home. By the time I got home, I got my second one. Mom knew all about it already. I got my second tune-up. And I got the most painful one when Dad got home.

Accountability — if you’re going to do something wrong, you’re going to be held accountable. Where did that value go? It got lost somewhere in privacy. It got lost somewhere in terms of some of the values that get espoused here. You want to make change? You’ve got to start placing a different priority on a different set of values that are going to get the kinds of outcomes that you talk about wanting.

L. Larson (Chair): In order for this committee to be able to ask you some questions about solutions, etc., we need a few minutes of your time for that. So if you wouldn’t mind, we would like to ask you questions instead.

D. Barnett: Thank you very much for coming, Chief. I really appreciate your comments — very truthful.

Something that I don’t understand and I would appreciate a little help with…. What is the mandate of the First Nations Health Council? How much integration with our system have you had?

The First Nations Health Council has, essentially, two mandates. The first is oversight on all of the tripartite health plans that we’ve reached agreement on between and with the government of Canada, the province of British Columbia and the First Nations Health Authority. The health council is not a legal entity. We’re an association of leaders appointed by First Nations, elected by First Nations. So our first job is oversight of all of the commitments that are set out in those plans and to make sure, at a high level, that the work is being done. It’s not political interference. It’s not micromanagement. It’s high-level oversight.

The second mandate is to make progress in the social determinants of health. To that end, we’ve secured a memorandum of understanding between the First Nations Health Council and the province of British Columbia. We’re working together in terms of a schedule of fall regional caucus meetings to jointly present information between various ministries and members of the First Nations Health Council to chiefs and leaders in each of our five caucuses.

That’s our mandate. In terms of integration, the First Nations Health Authority is doing that work now. The health council has created five of five partnership accords. I’m from the Fraser. We were first. We signed off a partnership accord with the Fraser Health Authority. All of my colleagues have done the same. They’ve created a shared decision-making table where the senior decision-makers from that health authority come together with
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their representatives who are on the First Nations Health Council and the First Nations Health Authority, and they jointly take decisions on health priorities.

D. Plecas: Thank you, Chief. I always enjoy listening to you. I learn something every time I do.

You’ve got so many great ideas. What would you say are among the biggest challenges, hurdles, in having you realize some of these things that you think we need to do — like the fee structure, getting more creative, more telehealth? I think so many people would agree with you on that. What’s the stall, or is progress being made?

D. Kelly: I think there is progress being made, but I think the stall is the way that things are always done. What I mean by that is they’re made in back rooms. There isn’t enough engagement.

I often get asked: “How in the hell did you do that? How did you get 200-plus chiefs to give you the authority to create the First Nations Health Authority?” Several years of engagement and talking about it first, with a goal of two things. An informed decision, so if we say yes, we know what yes means. An informed decision, so if we say no, we know why we’re saying no. That’s the first goal.

The second was consensus. Let’s work to a consensus. That means airing out fears, airing out questions, airing out concerns and addressing them in the way that you move the work forward. So whether it’s a consensus paper or a document that reflects that engagement, you need to show that (1) you’ve listened, (2) you’ve heard, (3) you’ve understood and (4) you’re prepared to use that to inform your work.

Too often, we take shortcuts. “I’m the minister of this, so I’ve decided that.” No engagement. No meaningful work towards achieving a consensus. It’s just top-down, or Victoria-down, depending on how you want to look at it, right? Ottawa is no different. It operates the same way.

One of the reasons you run into it is that there are forces for status quo and there are forces for change. The forces for status quo…. It’s against the law to kill them, so they’re always going to be here. You’ve got to figure out how to hear them out, understand their fears, concerns and doubts and make sure you build a mandate that builds on the understanding.

J. Darcy (Deputy Chair): Thank you very much, Grand Chief. Like others have said, I always learn a lot when I hear from you.

The model that you referred to about this doctor who travels…. You touched on some very important things — the relationship with the patient, which is critical, and then having an ongoing relationship but the doctor also not needing to be there all the time.

In this particular case…. I mean, we’re great in health care at having sort of pilot projects or examples of things that work but not scaling them up. Too often, we actually scale them down. But this seems like a model — and we’ve heard of others already here today — that could make a real difference in rural and remote communities.

In this example that you spoke about, the barrier there is that this doctor does not have support under the billing system to be able to travel or to be able to bill appropriately when he or she is back in his or her own community.

Can you just talk a little bit more about the barrier to that model working and being scaled up?

D. Kelly: The biggest part of the problem is the business model itself, right? In order to make the business model work for someone that has the overhead, you have to be seeing — what? — 20 patients an hour. Honestly, that’s what they’re doing in a lot of the cases. It might be a little less. Their goal — I’m sure it’s 20, if not more. They’re churning through them. Well, you can’t maintain that model if you’re flying off to Prince George.

D. Kelly: Well, he’s worked out a pilot project with Northern Health Authority. So they’ve made some arrangements to modify billing. But that doesn’t cover everything that he needs, either. There’s also the issue of electronic medical records and trying to make sure that the community health centre has the data that he needs and that they maintain it together. There are different kinds of challenges.

One of the things that I’ve been after Stephen Brown and Terry Lake for, for some time, is to make sure that the First Nations Health Authority — or better the First Nations Health Council — is at the table the next time they negotiate with the docs for B.C.

I think that if we were able to negotiate our interests in being addressed, we can help you with yours. In many instances, in some of those rural and remote communities that you’re concerned about, the only health capacity is a First Nations Health Authority–funded capacity.

Now, if we work together, we can expand on the kinds of services that are available in that First Nations health program. If it’s properly resourced, we can serve neighbouring communities that aren’t large enough or don’t have an organization advocating on their behalf for the provision of those kinds of services.

I think there’s lots of room for cooperation, and as I said earlier, one of our directives is collaboration. We’re willing to work with anybody, but they have to want change. We want change in outcomes, and we want change in policy. We want change in process. We want
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change in investment. We want to make sure that we’re all moving in the same direction.

I think there are opportunities here if B.C. creates a space for the First Nations Health Council and First Nations Health Authority to be at the table when we negotiate with the Doctors of British Columbia and that we can start creating a more permanent pilot-project approach to identify and resolve the barriers in a way that can then be modelled by the Northern Health Authority, by the Interior Health Authority and so on.

L. Larson (Chair): Thank you, Grand Chief. I really appreciate your thought-provoking ideas, etc.

We personally don’t get to just action what you say. What we do is we put what you’ve suggested into a report that we present to the Legislature. We personally can’t make those changes, but we put the recommendations in a report that we will present to the Legislature. We will capture your recommendations in that process. Our job is just to listen to you, to be the conduit, to take it into the Legislature.

L. Larson (Chair): Maybe we’ll just stall off until you do that. Thank you very much, Grand Chief, for being here.

L. Larson (Chair): Good afternoon. Thank you very much for coming. You are Danièle from the Cowichan Tribes Health Centre. Is that correct? All right.

Welcome to the committee. We’ve set it up so that there are 15 minutes for you to tell us about what you do and then 15 minutes for us to ask you questions. If that’s okay, I’ll let you go right ahead, Danièle.

Good afternoon, everybody. Thank you so much for having me this afternoon. First, I’d like to acknowledge the unceded territories of the Lekwungen and Esquimalt people, on whose territory we’re gathered this afternoon.

My name is Danièle Behn Smith. I am Acho Dene from Fort Nelson First Nation. I am French Canadian and Métis from the Red River Valley. I’m a family physician at Ts’ewulhtun Health Centre Slhexun sun’ts’a’ primary care clinic.

I apologize if I sound very breathless. It’s because I am. This baby is taking up a lot of critical respiratory real estate. I’ll try not to pass out.

I have been a family doctor for the last 14 years, and in the last two years I have seen more people get well and stay well at the Slhexun sun’ts’a’ Clinic or the Ts’ewulhtun Health Centre because we have been working together to change the way we do medicine and change the medicine that we do. So that’s what I’m here to tell you about today.

The Ts’ewulhtun Health Centre’s Slhexun sun’ts’a’ has adopted a teamlet model that provides functional medicine care. As a result, we have created a cost-effective system of primary and community care built around interdisciplinary teams. And so our call to action to the Standing Committee on Health is to hear our story and then, hopefully, try and expand the reach of this really wonderful pair of models.

First, I’ll tell you a little bit about our teamlet, how it works. Then I’ll tell you a little bit about functional medicine and dig a little deeper in terms of some of the small successes that we’ve seen to date.

Slhexun sun’ts’a’ is demonstrating the power of a culturally grounded, teamlet-based medical home. We’re grounded and guided by Hul’qumi’num teachings. We also have our work flow based on primary care best practices. We have a collaborative team that’s focused on accessibility, continuity of care and efficiency.

Our vision is actually our name. Slhexun sun’ts’a’ means “medicine” and “group of people working together,” and it was given to us by the community elders after much deliberation. Our mission is to work together to empower community members to achieve and maintain wellness by honouring their stories, personalizing their care and nourishing the roots of wellness.

Each of our team members plays a critical role in achieving our vision and mission. We have 2.4 FTE health coaches who are LPNs from the communities, and they are most definitely the heart and soul of our teamlet. We have 1.4 full-time-equivalent primary care providers, which is made up of family physicians and a nurse practitioner. We have two full-time RNs. We also have a medical office assistant, who is also critical and should be on this diagram and is not. In the coming months, we will be adding a social determinants of health advocate, OT/PT and a behaviourist to flesh out our team.

Team members work at maximum scope of practice and streamline our work flow to increase access, efficiency and continuity of care. Community members can access the teamlet any way that they want: phone, text, in person. They’re triaged. If they attend an in-person visit, then they’ll have a pre-visit with their health coach, where they’ll do a little bit of a history, establish the goals for the visit, do vitals, measurements, administer questionnaires.

The practitioner will come in and will have the meat of the encounter. Our health coaches stay and do the charting alongside, so as practitioners, we are able to devote our entire attention to the community member, which is so therapeutic. The practitioner leaves, and that’s the time
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when, I think, a lot of magic happens. They go over any outstanding questions that maybe they didn’t feel comfortable asking in front of the doctor or NP. They’ll look at the plan, make sure that it’s feasible and it meets the community member’s goals.

And then there’s this community follow-up piece, which has been so incredible in terms of augmenting our efficiency. Our health coaches will do telephone follow-up. They will go out and do home visits. They’ll attend specialist appointments with particularly vulnerable community members. For example, labs. We can follow up and tweak a treatment plan without having to generate an additional in-person visit, which has just really increased our efficiency.

That tells you a little bit about how we’ve changed the way that we’re doing medicine, and now I’ll tell you about the way we’re changing the medicine that we’re doing.

Community members are achieving wellness, because the functional medicine model uses a holistic client-centred approach to care. It promotes cultural safety and humility in practice. While that’s specifically important in our indigenous communities, I think that translates to better care for everybody. And it addresses the root causes of illness, which is cost-effective.

Functional medicine is a personalized, systems-oriented model that empowers patients and practitioners to achieve the highest expression of health by working in collaboration to address the underlying causes of disease.

The best way to think about this — or a way to think about it — is if we were to walk into a room where the sink was overflowing. We could imagine that that’s the state of our current health care system — sort of being overwhelmed by the burden of chronic disease. In our current system, we’re focusing a lot of effort and attention on making most efficient and optimizing our cleanup efforts downstream. In functional medicine, we walk into that same scenario, and we’re asking ourselves what’s driving these epidemics of obesity, of diabetes, and specific to that individual, what’s driving their illness or constellation of symptoms.

We ask ourselves two important questions. The first is: what does this person need more of? Do they need a more nutrient-dense diet? Do they need more social connection? What do they need to get rid of? Do they need to get rid of toxins, stress or a sedentary lifestyle to restore their optimal physiological function?

In practice, functional medicine looks quite different because we invest a lot of time up front with community members. We do that for three express purposes. The first is because we want to gain a full understanding of that person’s lived experience. We want to understand their family history and all of the things that have brought them to this point in time. We also want to build a very strong therapeutic partnership.

Thirdly, we provide a lot of education. We go over a lot of basics of physiology and tie into that how somebody’s personal lived experience has either supported or disrupted their physiology and created their current state. The payoff for that upfront investment is that our community members are highly motivated to take on some pretty dramatic lifestyle changes.

Functional medicine uses a holistic, client-centred approach to care. We basically are looking deep at the roots to try and understand what is driving the diseased fruit or the different systems. We’re looking very holistically. We don’t necessarily divide things up system by system. We want to know how all the systems are working together.

We also acknowledge the need for mental, emotional and spiritual balance in health. What I’ve found is that this model is such a perfect marriage of the rigour of western science and evidence-based medicine with the teachings that I’ve received from my elders about health and wellness. So it’s really, really fantastic.

Functional medicine promotes cultural safety and humility in practice. Cultural safety is an experience of the community member where they feel valued, heard and respected. Cultural humility is an approach by the practitioner where they position themselves as a learner who’s insightful and reflective.

In functional medicine, we have a heuristic that guides our practice: “GOTOIT.” The first three letters, “GOT” are really what help create this cultural safe space. The first “G” is for “Gather.” It’s actually “to gather.” First, we gather ourselves, as the practitioner, so we’re present and mindful and able to honour somebody’s story. Second, we gather information. That’s where we use the tool on the left, which is our timeline. And we do gather that full, lived experience, family history and everything in between.

The second part of the heuristic is “Organize.” That’s where we would use our functional medicine matrix on the right to organize somebody’s story, their symptoms, their diagnosis, and again, illuminate, in those modifiable lifestyle factors, what things might have triggered their symptoms and what’s driving their ongoing dysfunction.

The best way to illustrate how this works in practice…. I should mention that the “T” is for “Telling the story,” which is where we really create that partnership.

I saw a woman in Cowichan who was 35 years old and actively suicidal. I was asked to see her because she couldn’t contract for safety. She had been experiencing five years of terrible abdominal pain that was getting progressively worse. She had awful nausea and vomiting that just wouldn’t stop.

Two weeks before I’d seen her — she had been through the system for years — her family doctor said: “You know, we’ve done every single test we can think of. You’ve seen every specialist. We can’t figure out what’s going on. Above and beyond that, you’re very overweight, so I’m not sure that you’re telling us the whole story. You
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couldn’t be throwing up as much as you’re saying and still be so overweight.”

That was actually what led her to want to take her life. It wasn’t the symptoms. It was the fact that she was left totally hopeless and helpless and blamed.

I sat with her for about two hours. We did the timeline. We organized her symptoms. She told me about her great-grandparents and grandparents attending residential school and the numerous traumas that she had experienced. She told me about a car accident she’d had five years previous. She was convinced it was connected to her symptoms but had been told repeatedly by practitioners that there was no way. They weren’t connected. I listened, organized and then came time to retell her story. So I honoured and validated all those pieces.

I got to the car accident and said: “What we’re learning now, certainly from the functional medicine perspective, is this cutting-edge science about the gut bacteria and the human microbiome and how, when you disrupt that with antibiotics,” which she had after the car accident…. She had numerous courses of IV antibiotics for complications. I said: “You know, that creates this dysfunction, and it makes total sense that that’s when your symptoms started. When we think about the rest of your story, it makes sense that your symptoms would have progressed.”

In those two hours, she felt valued, heard and respected. Beyond that, she felt really empowered because we were able to look at her matrix and say: “Here are some things that you can do today to work on restoring your physiological balance.” Lo and behold, her suicidal ideation just lifted, and she was able to move forward in her wellness journey.

Functional medicine addresses the root causes of illness, which is cost-effective. Another story. We have a gentleman, a 42-year-old guy, with rheumatoid arthritis who came to see us. He’d been in an active flare for the previous six months and was on short-term disability. His rheumatologist wanted him to start on the anti-rheumatic class of medications, which is the most expensive class of medications on the market. He came to see us because he didn’t want to be on pills for the rest of his life. He was super motivated. We did the timeline, the matrix. He did all of the things that we suggested might be helpful, and within six weeks, he was pain-free and back at work.

Over those six weeks, we probably spent anywhere from six to eight hours with him, which, from the regular fee-for-service model, is astronomical. But if we think of it in context, he rarely comes to see us anymore because he knows how to maintain his physiological balance and be pain-free. He’s not on the most expensive class of medications that we have. He doesn’t need to be monitored monthly for potential complications of those medications. He’s back at work, which has a clear economic impact.

In our communities and, I’m sure, in most communities, there’s this other sphere that we have to consider, which is that now there’s a family who has their dad back. He’s got kids who he can play with actively. He can spear fish and provide salmon for his family. He can dance in the longhouse and maintain his cultural ties. While we can’t assign dollar values to those outcomes, it becomes very clear to me that we can’t afford not to explore and embrace this model.

As a result of adopting a teamlet model that provides functional medicine care, we’re seeing more effective advocacy, decreased ER use, increased compliance, community members who feel heard, a very supportive team. Our staff love coming to work, me included. I love driving up to Duncan, an hour I don’t mind. It’s one of the best parts of my week when I get to be up there. Unfortunately, I don’t think that’s necessarily the norm across the health care system at the moment.

In terms of the B.C. quality and safety matrix, our care models score very highly. The one area where we’re struggling is around accessibility. We are the only clinic in the province that’s providing teamlet functional medicine care within publicly funded dollars. We’re funded through the Joint Project Board. Clearly, there’s a need to widen the reach and the scope of these models of care.

Slhexun sun’ts’a’ has adopted a teamlet model that provides functional medicine care. As a result, we’ve created a cost-effective system of primary and community care built around interdisciplinary teams.

Our call to action to the Select Standing Committee on Health is that in the next 12 months you might consider visiting us at Ts’ewulhtun and seeing us in action. I won’t be there, but the rest of the team will.

Learn more about functional medicine from the Institute for Functional Medicine. I’ve listed their website there for you. They also have a brick-and-mortar academic centre with a focus on functional medicine that started, I guess it would be two falls ago now, at the Cleveland medical clinic. That’s another wonderful place to learn more about the model.

Finally, do anything in your power, I suppose, to support the social determinants of health work that’s happening between the First Nations Health Council and the province and the feds at the moment.

I can tell you there’s nothing more disheartening than to work with a community member and honour their story and organize and retell the story and illuminate the lifestyle changes that would make a difference and would help them get better and to then find that they can’t do that because of poverty, because of disruption of families, because of transportation issues, intergenerational traumas and all of the other impacts and legacies of our shared colonial history but also the colonial policies and structures that still perpetuate some of those inequities.
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Thank you so much. You did that very well without gasping for breath. I appreciate that.

J. Darcy (Deputy Chair): Wow. That’s not very profound. What you shared with us was very profound.

You’ve mentioned, as have a couple of our earlier presenters who were talking about team-based care, that the current funding model doesn’t work for what you’re providing. Can you please explain what funding model you do work on so that you can support this awesome work?

Secondly, you refer to it as teamlet. I wonder why that is. I know that very often, when we talk about team-based care, we don’t include coaches. I’d like to know more about the health care coach. I’d like to know more about the role of the LPNs, I think, you referred to. Are the LPNs the health care coaches?

J. Darcy (Deputy Chair): They are. Okay. Yes, if you could talk more about each of those.

D. Behn Smith: Sure. To address the teamlet question first, we drew that out of the literature. It comes from the South Central Foundation in Alaska. The Nuka model is where we first encountered that term “teamlet.” We have adopted a very similar model to what they use in Alaska.

That’s a very inspiring story. Twenty years ago the communities in Alaska took over the Indian Health Service. What they’ve developed are these teamlets. It’s really meant to identify that core group that works together to provide care so that the community member has continuity of care. Even though they may not be attached to one single primary care provider, they’re connected to that teamlet.

It’s an interesting question around the distinction of: who are the health coaches? In the Alaskan model, they really, really are focused on efficiency. That’s another great place to visit. Their health coaches are actually medical office assistants who have some additional on-the-job training when they join.

We were applying for funding through the Joint Project Board with the FNHA and the province. We were restricted somewhat by the guidelines of what could be funded. They would not fund administrative positions. That’s why we elected to use LPNs, rather than MOAs, with some advanced training and delegation.

I think it’s actually worked out quite well in the sense that our LPNs do have quite a broad scope of practice right out of the gate. We’ve already had our LPNs, who are so inspired by the model — some of them are thinking to go on to be RNs — just progressing. They’re all indigenous, as I mentioned, from the communities.

That’s the teamlet piece. In terms of the funding for the model, we are funded as a pilot under the Joint Project Board. We applied for salaries that were equivalent with the professional guidelines of the specific area. The physicians were paid…. Currently, it’s more of a sessional model. We’re invoicing for our time because the complement is just getting stabilized. In the fall, it’ll be more stable. It will be shifting to a salary, but the income will be equivalent.

D. Plecas: Thank you so much for your presentation. It’s just so wonderful listening to you. As I was listening to you, I was thinking it’s too bad there wasn’t something called functional politics.

D. Behn Smith: Oh, that’s a great question. Cowichan Tribes is the largest First Nation in B.C., and it has roughly 4,000 members. Right now, with our pilot project, the key to that working really well — the accessibility and continuity, all those pieces — is to have a balanced supply and demand. With our current workforce, we’ll probably end up with a patient panel that will be roughly 1,000 to 1,200 community members. We won’t be able to serve the entire community, but that’s why it’s a pilot. That’s why we want to be able to demonstrate the value and bring on other teamlets as needed.

Of course, Duncan is built around Cowichan Tribes — they’re on Cowichan territory — so a number of community members have GPs in the community and feel connected, and that care is working for them. Our target population right now are the more vulnerable community members who feel less attached, who’ve had a lot of negative experiences with the health care system, to try and bring them back in the fold.

I just want to say that the B.C. Cancer Agency actually has a somewhat similar model. I had…. Well, I am a patient there. Always the doctor comes in, and they leave a nurse behind to work with you afterwards, because it’s a lot of information to process. So it’s not like this is unique. I think there are other places where it exists. They consider it a unique model, but it sounds like you’ve just taken it on to another place, and I love it.

I just want to understand where the gaps are in the service. For example, it sounds like you’re doing a fair bit of
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counselling as a physician. It is a pilot, I understand. Do you envision sort of tweaking it to include other allied professionals as part of this team? What are you doing with the data that you’re collecting, in terms of moving it forward?

D. Behn Smith: I didn’t give you the full kind of eagle view of the health centre and all the other professionals that are already there. We do have dietitians and another registered nurse doing healthy lifestyles. But absolutely, the team has just blown my mind away, in terms of how innovative they are, now that they’re all working together.

Some of the things we’re looking at tweaking are having group visits. We’re finding now that we can do a number of consults, and then the teaching is quite similar for many community members. Could we streamline that process and actually capitalize on the impact of peer-to-peer information-sharing? It’s been really fun to watch people kind of say: “Yeah, I want to try the diagnostic elimination diet too, but I’m worried, because how do I go gluten-free for a few weeks in a community that every gathering has bannock?”

How do you navigate those? That’s really where there’s so much richness. Those community members who are living in the community know more about how to implement an elimination diet in that context than I do, or even a dietitian. That’s one of the areas that we want to work on.

D. Behn Smith: Oh yes, the data piece. Everything I’ve shared today has been anecdotal, because we don’t have a formal evaluation plan developed yet. One of the reasons for that is that we are looking to work with the FNHA research and evaluation team to make sure that the data we collect is congruent with our First Nations perspectives on health and wellness. We don’t want to take typical research methodologies…. There’ll be a place for that, but we also want it to have a more broad narrative to share. So no specific data as of yet.

M. Dalton: Thanks a lot, Danièle. I’m also Métis and French Canadian, so….

M. Dalton: Yay. I know it sounds like it’s a great program. How long has it been going on for now — the pilot?

D. Behn Smith: I’ve been at Ts’ewulhtun for four years and practising functional medicine there for the last two. Our pilot started…. We’re just coming up on the year anniversary of hiring our first health coach. So the teamlet is new.

M. Dalton: One of the tensions that we’re hearing is people coming through the doctors’ offices and just a few minutes per patient, which really doesn’t meet the need. A lot of times they’re unable to explore underlying causes and the more holistic type of approach to medicine. At the same time, how much leeway do you give? Obviously, as you mentioned, there’s a cost to it all. That’s the tension. You want to be able to provide the service, meet the needs and yet, at the same time, have the affordability piece.

Is what you have here — in Duncan, is it? — all new services? Or did it replace or amalgamate some of the different positions that were already there and put it in one piece? Or is it all new?

D. Behn Smith: All of the positions that are listed on that graph are all new positions that didn’t exist, with the exception of a 0.4 FTE primary care provider. I was there for two days a week before the teamlet came on board. But everything else is a new service.

The second thing is: how would the health providers, yourself…? How would their caseload or workload with patients compare to, say, normal settings in an urban centre?

D. Behn Smith: Great questions. Right now we’re not at capacity, so we’re still rostering community members. We’re only, I would say, maybe 10 percent into our rostering phase. We’ve got a long way to go to bring community members on board.

In terms of the volume of community members that we would see, our anticipation is that it would be similar or equivalent to other family practice panels, around that 1,000 to 1,200 range, which is typical for a GP. I guess some higher-volume practices might be higher than that.

In terms of the functional medicine model, it still remains to be seen how that fleshes out. I think that’s part of that tension of investing the time up front and then not seeing people very frequently.

The literature shows that people on average see their family doctor 3½ visits a year, if you took a whole panel. Our hope is that by addressing the underlying causes of disease and getting to the root of things that really people don’t need to be coming back so regularly. They don’t need to be coming back for refills on their blood pressure medications because it’s not an issue because they know how to decrease inflammation in their bodies.

I’m not sure that that’s necessarily gotten really fleshed out yet in the broader literature, because the functional
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medicine movement, although it’s been around for about 20 years, has really only picked up steam probably in the last five to ten. That’s where the Cleveland medical clinic is really leading the work around those really important questions. How does it kind of flesh out for the long time?

L. Larson (Chair): Thank you so much for your presentation. We have your documentation as well, and we will certainly put the points in our report. Thank you very much Danièle.

L. Larson (Chair): Dr. Stefan Grzybowski. Welcome, Dr. Stefan. I’m glad you could be here. You are from the Centre for Rural Health Research. You’ve got 15 minutes of floor.

S. Grzybowski: Thank you very much. I really appreciate the opportunity, on behalf of the Centre for Rural Health Research, to be here today. My presentation is going to be, really, about the system of health in rural British Columbia, rural Canada. It’s going to be addressing the first two issues that you have raised, which are: how can we improve health and health care services, and how can we create a cost-effective system of primary and community care?

I just want to give you a little bit of background about myself to try and lay a bit of foundation for the presentation. I’m first and foremost a rural family physician. I’ve worked in a number of B.C.’s rural communities, as well as the Northwest Territories. I just came back from Hay River two weeks ago. I was up there for two weeks. We were short-staffed, down to one, and two on call — 24 on, 24 off — covering a population of between 3,000 and 5,000 people, depending on how large you take the catchment.

I’m director of research in the department of family practice, and I co-direct the Centre for Rural Health Research. It’s somewhat pretentiously named. It’s not a terribly large centre, but it is what it is.

I published my first peer-reviewed manuscript on rural health services 25 years ago in the Canadian Medical Association Journal. I was also a senior scholar with the Michael Smith Foundation for Health Research up until a couple of years ago.

I’m a professor in the department of family practice. I have the privilege of directing the Rural Health Services Research Network of British Columbia. I’m on the executive of the Society of Rural Physicians of Canada, and I’m on the board of the Rural and Remote Division of Family Practice, which is a wonderful initiative of the British Columbia government.

There are really two themes I want to touch on today. The first is supporting and strengthening technology-enabled generalist models of care across the rural health care environment. It’s about generalism and making it stronger.

The second one is using data better, to strengthen our understanding of the links between health services models and population outcomes. I know everybody wants to use data better. I don’t think that anybody who presents to you wouldn’t say that they’d want to use data better. But we have real ideas about how we would like to do that.

I’m just going to expand, then, on the first issue, which was generalist models of health care. We live, as you all know, in an increasingly sub-specialized world. You can find left-lobe hepatic surgeons and right-lobe hepatic surgeons. You can find every subset you want, but generalists are really a vanishing expectation.

As a rural doc, just back from Hay River…. You know, I live and walk the experience of generalist medicine. That’s how rural Canada works. It’s technology-enabled generalist medicine. It’s not just generalists trying to fly by the seat of their pants but generalists working with a wonderful computer networked asset called UpToDate, which you may have heard of. It gives you the latest rendition of the evidence for any clinical problem that you can find. It is a wonderful asset.

It’s generalist medicine attached to telehealth links, to specialists, if you need support in a specific area, if you’ve come up against the edge of what you know. It’s generalist medicine that allows us to deal with….

Just a snapshot of what we did up in Hay River in the last couple of weeks. We had a diabetic ketoacidosis. For those of you who perhaps aren’t aware of that problem, it’s really a complicated presentation of diabetes, where the individual is bound for the ICU in most instances. This was a new diabetic — didn’t know they even had diabetes, let alone diabetic ketoacidosis. He was very ill. We managed him ourselves in the Hay River Hospital, with some support through telehealth and through UpToDate.

Pulmonary edema. We had an elderly woman with pulmonary edema who presented. Again, it would have probably ended up in the ICU in many places. We managed to stabilize her and keep her in the Hay River Hospital.

We had a comminuted wrist fracture — one that I hadn’t seen before. My colleague called me in to give him a hand, and we managed to reduce the fracture. We sent the X-rays pre- and post-reduction to an orthopedic surgeon to get some…. Actually, he was away for five days, so we stabilized and then sent it to him after he got back. He’s still deciding whether he wants to see that fracture or not. We may well have solved that woman’s problem.

Then there were some complex lacerations, as complex as I’ve seen, of the foot and knee that we sewed up. We treated with it antibiotics and kept them from needing any further care. The enhanced skills that are reflected in that value-plus generalism are the backbone of care in rural Canada.
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There’s a listserv called RuralMed that’s put out from the University of McGill Society of Rural Physicians that’s just all about what generalists are doing out there in the hinterland and has real opportunity for us to see what we could do if we were to push generalist medicine as a way of dealing with all the problems that the patient comes in the room with — as opposed to, “Oh no, I only deal with this problem. You have to go and see that person over there and that person over there,” and down the road — especially when you enable it with all the technology that we have now.

For example, the kinds of enhanced skills we’re talking about are enhanced surgical skills, general practice–anaesthetists, palliative care and on and on. There’s a recent publication that’s just come out about networking rural surgical skills. You take a GP-surgeon and you go: “Well, you can do a little bit of operating in your community. Maybe you can underpin your maternity care program. Maybe you can enhance those things, but you can’t really function outside of the support of your general surgeons from larger centres. You need to be linked in a network.”

Right now, there’s a little bit of competitive interprofessional relationship between specialist surgeons and GPs with enhanced skills that isn’t really productive for people. Somehow we need to get on the same team a little more in terms of working together. We can do that through networking and through…. But it’s going to take leadership from government to help us to do that. You probably have had enough of professional perspectives on how we should run the health care system. They tend to be, unfortunately, all too self-serving.

Then interprofessional teams. In a rural community, like Hay River or any place in British Columbia, when you’ve got a sick patient, you’re on a team. You quickly abandon your prickly exterior and your “this is my kind of work.” I need help. I’ll get help from anybody — from the nurse, from the nursing assistants, from you name it — to try and stabilize a patient and get things under control. The whole idea of teamwork is just a natural part of, again, rural care.

The other part of it is that specialists have sub-specialized, but there are also a lot of general specialties, and there’s a movement among specialists to move towards more general care. And general specialists are much more advantageous for us when we have…. If you go up to Yellowknife, for example, you’ll find general internists, general surgeons, orthopedic surgeons who have really embraced a very broad spectrum of practice, because that’s how they live and function. The same thing’s true for Prince George, for Terrace, places like that within our own backyard.

The nurse practitioners. There’s a wave of nurse practitioners coming on board, and we need to be thinking about how we can work effectively with nurse practitioners as part of the team. Each member of our team should function to the limits of their capacity, capability, in where their comfort zones are and as part of a team. Then we can actually have a much more cost-effective approach to providing services to clients, not only in rural.

The great advantage of rural — as far as I think the select standing committee, if I could be so bold as to put it in front of you — is that it’s already functioning as a generalist model of care, because it has to. There is no possibility of having specialized pillared care models in small communities. It just doesn’t work. So you’ve already got that happening.

That really brings me to the second major theme that I want to talk about. That is: how do we know if it works? How do we know if it’s safe? How do we know it’s…? I’ve sometimes considered making some bold gesture about this next point because I’ve been frustrated as a researcher for a long time. It seems to me that we have a wonderful opportunity to measure how innovation works in rural Canada.

If I wanted to look in part of Victoria and look at a new care model and introduce a new interdisciplinary, innovative model, I’d have to try and create some kind of fence around the…. I’d put the team in place, I’d create some kind of fence around it. Maybe I’d look at who came to the clinic.

But I couldn’t look at the health of the population. I couldn’t say: “Does that model change the health of this district?” Lots of examples of struggling with that. Whereas in rural Canada, I can actually define the population. They may not choose to go to access care at the service I put in place, but I can measure their outcomes for the whole population. I can show whether they improve or not. I have a denominator.

We have these golden opportunities to actually measure the effectiveness of innovation, including the cost-effectiveness of those innovations, for the whole population. Yet we haven’t really taken it up. I know the ministry is moving in that direction, but we do not have a transparent approach to creating rural catchments around services and then linking outcomes with the natural catchment.

We’ve done that for maternity care, so I know it works. We’ve published a series of articles about the safety of rural maternity care based on exactly that methodology. We’ve been able to show that rural maternity care works, even without Caesarean sections at the local facility.

We’ve got to build better approaches to data. We’ve got to build rural catchments. We’ve got to enhance our accountability. It’s one thing to advocate for a position, but unless you can prove it works, I don’t think it’s going to get very far. I think that’s probably the greatest frustration for me and for my colleagues, because as generalists, we really believe that the kind of care that we provide is good care. But because of the challenges of rural practice, we’re really behind the rock in terms of trying to demonstrate that it works.
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We’ve got socio-economically disadvantaged folk. We’ve got folk with little education. We’ve got folks who are pursuing dangerous lifestyles. We’ve got all those things we could account for, but in fact, we can’t within the model because we don’t actually have the data sets that we need to do that.

The first one is that I’d like to propose that we renew the medical nursing and allied health professional educational systems in a stepwise manner to encourage practitioners to adopt generalist perspectives and care models. The movement towards generalism is not British Columbia. It’s not local. This is issue 15 from the Cairns Consensus Statement on Rural Generalist Medicine. This is Cairns, Australia. It occurred in 2014. It was attended by 19 countries, and this is about generalism.

This is point 15: “We assert that simply training more doctors using conventional models in the hope that they might trickle out to rural communities is a failed strategy. Paradoxically, this approach may lead to further fragmentation and specialization of care, waste scarce health care resources, undermine the practice of rural generalist medicine and team-based models of care and thereby worsen inequities in health care for rural communities.”

I mean, this is not a British Columbia perspective. This is endorsed by 19 communities, including Australia, our closest neighbours.

The second recommendation is to build rural catchments and link population data, utilization data and costing data with these catchments. The beautiful thing about this, I think, is that…. Let’s look at the Queen Charlotte Islands, Haida Gwaii, and examine the outcomes for that entity. It’s probably our most easily…. I live on Saltspring Island now, which is another island, but I used to live on Haida Gwaii, for 12 years.

If you want a denominator, you couldn’t ask for a sweeter denominator than that. Basically, the nearest next clinic is a six-hour ferry ride that leaves twice a week or a plane ride, and we know everybody who lives there, virtually. There’s one clinic. There’s one pharmacy. There’s one hospital on the south end. It’s just — you really own the data.

We did a maternity care study. We followed every woman who was pregnant on the islands. We were able to not only look after some of them locally but also follow up on everyone who we didn’t look after locally, including one or two who never came to us at all.

We can actually establish that for every rural community in the province, and we could show — as we did in some of the research we did — that if you don’t have Caesarean-section capability, you’re probably going to deliver about 30 percent or 40 percent of the women in your catchment. If you add a GP with enhanced surgical skills, as we’re now advocating for and as the literature is supporting, you’re going to deliver 75 percent of them locally. You’re not going to operate on all of them, but you’re going to have that backup that just lowers everyone’s anxiety and allows them to deliver locally.

The third and next-to-last recommendation I have is that we should establish a system of reporting at local, regional and across stratified levels to encourage innovation, diffusion of innovation and quality improvement across all levels of the system.

Because we don’t know how well things are functioning, we don’t know whether we should emulate them or not. We should establish an open system. We can do this. It would not be hard to do, and I don’t for the life of me understand why we haven’t moved there yet.

The fourth thing is…. I know we’re never going to bring hospital boards back. We used to have a little hospital board up on Haida Gwaii. It was a wonderful working relationship with the hospital board because they were community members who could envision them or their loved ones showing up in the emergency department or in the hospital. They really cared. They really wanted the services to be good. We would have an annual hospital day and raise money for equipment. It was a very strong connection.

Then we moved on and regionalized, as you all know, and we lost those hospital boards. But those people are still there. They just don’t have a very…. You know, they send letters to the regional health authority to see if they can get something. It’s not a very effective model.

That unrealized potential contribution to our overall health care is still sitting there. So what can we do with those people? I would like them to be part of the monitoring, the accountability framework that looks at catchment outcomes — not individual outcomes but catchment outcomes. How is our catchment doing compared to other catchments of a similar size?

If we want a CT scanner on Haida Gwaii, we can look at other communities that have approximately our population and realize that nobody has a CT scanner and that we’re not going to get a CT scanner but that we could have ultrasound. Or we could have…. There are a number of innovative things we could have that would improve our care.

We can also examine the kind of public health issues that are leading to some of the downstream problems and say: “You know, maybe we should put this in place. Maybe we should actually have a drive to decrease alcoholism or to try and cut back on addiction.”

I’ve been bold today and I’ve brought two of my children with me to witness the witness kind of thing. I’ll have to check in with them afterwards. I look forward to any questions you might have.

D. Plecas: I don’t have a comment, but I’ve just got to thank you for your thoughts on this. I just couldn’t agree more. It’s fantastic.

D. Bing: Thank you very much for your presentation. I found your recommendations very interesting. I was particularly interested in No. 1. You were discussing the model that we have now where we generate all these physicians and expect them to trickle out to the remote and rural areas that really need them, and that we need a better system. Could you elaborate on that? How do we get them out to where we need, and how would you change the system?

S. Grzybowski: There are already some promising models, promising innovations, that have occurred in the educational system. There’s something called longitudinal training.

The historical model in family medicine now, which is where most of the generalists will thrive, is that you would do two months of this and two months of that. You’d do sections, and you’d have an extensive exposure, usually in a large hospital where there’s a lot of internal medicine, a lot of surgery, a lot of whatever you need to really get that piece.

In a longitudinal setting, you go to a smaller hospital, a place like Terrace or Prince George, maybe not as small as Hay River. You get, over the course of your six or eight months, exposure to a whole bunch of different things at the same time, just exactly as you would as a generalist.

You take what comes in the door that day, and if you have a surgical service, an internal medicine service, as you would in Yellowknife, you get a little bit of everything and you get attached to everybody at once. It’s a very doable option. We could build that up quite a bit so that we’re actually training more people in that model.

The other thing that we could be doing better is training students together. As a physician, I’m trained as a physician, trained with other physicians. I hardly was ever trained with nurses or with nurse practitioners or with midwives. That’s where you need to put students — together with physios, with OTs, so that they’re actually training together.

If I was restructuring the system, I would think about: how can I get those students together in communities of a reasonable size where they can all learn together and live maybe in a house with multiple rooms or in houses that are next to each other where they could eat together, where they could get to know each other.

I mean, we’re all pluripotential. We all have the potential to be one thing or another. So we need to train students together.

D. Bing: Are you saying that the medical education has to change — the schools themselves, the medical schools?

S. Grzybowski: There’s definitely going to be some changing of those schools. You bet. There are people who are on that page.

D. Barnett: I find it very interesting when you talk about the past hospital boards and how you’d like to see them brought back into more of a monitoring board. How do you perceive that to work?

S. Grzybowski: Some of the individuals I worked with in the community of Haida Gwaii who are on the hospital board are really gold. I mean, they are really idealistic, good people who just want to do well for their community and really care. So they’re still there.

I would create an avenue for them to meet with the health authorities as part of the partnership, and I would talk about planning. I would talk about planning services for your community, and I would talk about monitoring outcomes for your community. How are we doing? How are our services compared to other communities of like size? How are our outcomes compared? How is our maternity service doing? What could we organize together, recognizing that the health authority, because of the efficiencies of scale, is going to be running the money? We can at least focus on the outcomes.

I wanted to pursue this last issue as well. When I’ve travelled various parts of the province, especially in rural B.C., I’ve heard from a lot of people: “Nobody really talks to us about what the needs are in our community.” I know that we’re not spending a lot of time on restructuring health care, which lots of provinces have done. They’ve gone bigger. They’ve gone smaller. I’m not sure that’s where we want to focus, but this issue of a voice for communities and how we define that, I think, is really important.

You’ve talked about planning services and monitoring outcomes. I wonder if you could just talk more…. Haida Gwaii is sort of a…. You’re right. It’s contained. It’s islands. Just talk to us a bit about how you might envision that elsewhere in the province. What do those catchments look like?

S. Grzybowski: Sure. The first thing I would do is break down the catchment of Haida Gwaii demographically. How many people do we have over 60? How many people do we have 40 to 60? I’d break it down by…. I’d have a look at the demographic profiling of the catchment.

Then I would look at the core outcomes. I would look at: how many heart attacks did we have last year? When we had a heart attack, what was the time from the defin-
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ing of the heart attack to thrombolysis, which is the acute treatment? How many of them were transported within a reasonable window of time off island? Did we have any screening in place to pick up people before? How many stress tests were done?

I would look at acute cardiac care as an entity. I’d look at several defining indicators for the quality of cardiac care we have, and I’d probably…. Once you’ve set up a template for that, which isn’t difficult to set up, with some cardiology input, you can apply that to all rural communities. It’s not just a one-off. It would be applicable to any rural community.

I’d look at maternity care. I’d look at surgical care. I’d look at colonoscopy as an example of…. How many people who had positive FIT tests…? Firstly, how many FIT tests were done? How many were positive? How many of the positive FIT tests actually ended up having a colonoscopy at all? Maybe they just said: “I’m not going away to get that done.” Is there any way we could access that better? I think about…. Is there an innovative model for having a colonoscopy service come into a community for our size of community?

I’d explore that with the community and really have an open discussion about that if I was, say, chief of staff there. I’d engage with the local physicians. I’d bring on the nurse practitioners, the midwives. I’d have those kinds of discussions openly in the community. You’re going to have the most clear discussions when it’s your community and your health and your family’s health. There’s not going to be any kind of theory about it. It’s going to be right on the point.

I’m actually a fan of the old hospital boards myself. My small community had one too, and the community did feel engaged and part of the community. For some reason, the health authorities don’t like the word “hospital board,” but maybe we could name it something else and still get the same quality and type of local input that we used to get from those boards.

Thank you very much for being here today. I really appreciate it. Thank you for bringing your family. I hope they’re going to have a look around the Legislature.

Is it Dean that we have this afternoon from the Pacifica Housing Advisory Association? Is that correct?

L. Larson (Chair): I will apologize for the committee coming and going. I don’t even give them time for a bathroom break, so they have to keep coming in and out. But we are very pleased that you’re here today, and we will not miss anything, because it’s all recorded as well. So go right ahead.

D. Fortin: Thank you very much, although you sort of spoiled my opening a little bit, because I was going to say that although there are no hon. members here, I thank you very much for the members with honour, understanding the difference.

I was going to mention His Worship, because my basic title is “Once a mayor, always a mayor.” So there we go. Although he is a member of the Legislature, Sam was, obviously, mayor of Vancouver.

Thank you very much for this opportunity to be here, and yes, I am here in my capacity as executive director of Pacifica Housing.

A one-minute-30-second overview. We provide housing to low-income families and individuals, about 1,500 units throughout Vancouver Island — Nanaimo, Duncan and Greater Victoria — as well as 200 units of supportive housing to those with mental health and addictions and a further 170, now members, to those who are on the streets. How would I put it? A diffused approach, called Streets to Home.

We come knowing our business in housing. I know that this is the Select Standing Committee on Health. Someone said to me: “Why are you going to go talk?” I said: “Well, for me, housing is a determinant of health.” But perhaps in the model that I’m about to put forward to you, it is also a prescription for health, if I may.

Housing-first principles are as easy as I put forward. It’s about involving clients with assistance in finding obtainable, safe, secure and permanent housing as quickly as possible. But I think the key point to understand, and for the reason in front here, is an understanding that the approach runs contrary to the orthodoxy of treatment-first approaches when it comes to mental health and addictions.

It is that third point within your mandate that I thought I would address, on: how do we enhance the effectiveness of addiction and recovery programs within our communities?

Rather than the traditional approach — which is to say that when people are experiencing homelessness and are placed in emergency services and must address their personal issues first, that they must address their addiction or their mental health issues before they’re deemed ready for housing — we turn that model around.

We say that housing-first involves the client housing first — and then with supports. We have so many stories still today of people coming out of the health care sys-
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tem, discharged from emergency wards right back to the streets, members being discharged from detoxes right back to the streets. Then, obviously, the recidivism rate for return is extremely high.

There are five major points that I wanted to bring up regarding housing-first principles within the concept of providing health outcomes.

The first one is the immediate access to permanent housing with no housing readiness provided. We focus on safe, secure and permanent housing. It is not conditional on sobriety or abstinence and is completely voluntary.

One of the points within this is an understanding that although abstinence is not asked, within the spectrum, abstinence can be part of the housing solutions put forward.

This flows into the second one, which is consumer choice and self-determination. That is a client-centred approach that emphasizes that the client chooses supports in terms of housing and the clinical supports that are there. They can exercise some choice in regards to location and the type of housing they receive, whether it be in a neighbourhood, whether it be in congregate care or whether it be in scattered sites. They choose what services they receive and when to start using those services. Ultimately, it is an equal partnership which defines the relationship with their supportive service.

The third point is that housing-first does have, integral to its approach, a recovery orientation. It is about supportive recovery — that we focus on an individual’s well-being — and ensures that those clients have access to supports that enable them to nurture and maintain social, recreational, educational, occupational and vocational activities. But most importantly for those with addiction challenges, the recovery orientation also means access to a harm-reduction model. Again, as we’ve stated, it does not require abstinence, although abstinence may be part of a model that is provided.

The fourth point is individualized and client-driven supports, recognizing that each individual is unique and that financial and diverse client-driven support is important and that there’s voluntary access to these supports.

Some of the supports include housing stability, health and mental health needs, life skills. Income supports and rent supps are an important part of it. Rent supps should ensure that individuals do not pay more than 30 percent of their income on rent.

Of course, the biggest one is in point 4: the social and community integration. We recognize, through avoidance of isolation, that if people are housed and they remain socially isolated, the stability of their housing may be compromised. Some of the key features are the separation of housing and supports, except in those cases of supportive housing, and an understanding that housing models do not stigmatize or isolate clients, which is one reason why scattered-sites approaches are so appreciated.

I wanted to give a quick case study. Pacifica, as I said, has supportive housing. We would now have five projects with between 40 and 50 individuals who will live in, with 24-7 care, with the support workers providing support. But an interesting model that we’ve come up with…. Perhaps I should add this. It’s a bit of the housing side. I will hit all the health stuff in a minute.

On the housing side, it costs about $15,000 to $18,000 a year to provide somebody with emergency services. Supportive housing is about $12,000 a year, and what we have in our Streets to Home is about $7,500 a year. Often you’ll hear us talk about how it’s more expensive to keep someone homeless than it is to provide housing. We actually have all the numbers to back it up.

Our Streets to Home project is nearing the end of its six years. It is, essentially, a supported housing model using individual, private landlords throughout the model. So instead of having 40 people living in one place, you have 40 different landlords, living together, with mobile supports. It also provides a rent subsidy, supports and training to build individual capacity, case-planning services, access to mental health and addiction, access to community referrals and direct support.

What are we starting to see? Here are some of the statistics we’re starting to see. It’s fully subscribed. We have 125 clients. Having said that, we’ve just received funding to move it up to 170. So 82 percent of those people coming in are housed for more than a year, and 63 percent are housed and maintain stable housing. Of those people who have left the program, 43 percent have gone on and no longer need those social support services. They’ve been integrated. And as you would expect, 33 percent have been deemed: “You know what? You need a higher level of care.” It’s about understanding the client that is there.

As an aside, we have 100 percent landlord retention on this, and those are private landlords.

In summary, what we’re seeing is that all of our supportive housing is cost-effective. There are services that provide, for people with significant barriers, secure and maintained housing. It is a way to deal with homelessness.

I wanted to put in the final piece, which is not on the slide, but I have provided you with some evidence. The most recent report takes a look at what’s called the home-alone or housing-first approach.

This is a statistical study financed through the federal government — it just came out in 2014-2015 — using the Housing First report. Our stats are mirrored by the stats that are showing nationally.

So 86 percent of clients experienced housing stability, so we understand that it starts from housing first. Once they’re housed with supports, they maintain their housing. That’s extremely important. For those without supports, the maintenance rate is about 23 percent, to understand the difference.
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The emergency department visits are reduced by 15 percent. On average, they would go to emergency wards seven times a year. The number dropped to 3.5 times. That is significant. I would often argue to people that if you really want to reduce the waiting list for your hip replacement, you understand that housing is important, because it reduces those lineups that you see at the emergency wards.

That was part of the next piece that we saw. It highlighted that there was an increased use of out-patient services, but that was followed with a lower use of acute care. We know the difference between the costs of acute care services versus the out-patient services — an opportunity to be preventive. If you have something, we should look at it now, before…. A week from now, we’ll be phoning the emergency ward and having all of the acute services going on.

For the other side, of course, it’s important to note that there’s a significant reduction in criminal convictions. Once housed, we find that the convictions for crime completely drop. There’s a significant and meaningful improvement in community functioning and quality of life, and so this is an opportunity to advance those. Not only do they improve on the call that they might have on our community health services, whether it be the call for policing…. On other community services, there is a reduction.

Numbers that we haven’t seen repeated, although they continue to be, are for the first 50 hardest to house in Victoria that were put through what was known as ACT team or VICOT team community teams. There was a 75 percent reduction in crime, unanticipated but then marked; a 75 percent reduction in alcohol and drug use; and a 75 percent reduction in visits to emergency wards. So it showed how a small investment in housing, with supports to help them access community services, showed a huge reduction — an 80 percent reduction in service costs for high-need clients. That was phenomenal, when you’re looking for a way to have savings and to enhance your preventive services.

For moderate-need clients, again, they found it was the same, but of course, it shifted from a call on acute care to more of an out-patient type of service.

We wanted to put forward this understanding that housing with supports for many clients is a cost-effective way to provide a quality and meaningful difference in individuals’ lives. But the meaningful difference that happens in those individual lives impacts our community at large, especially when it comes to the delivery and the continued delivery of health care services.

L. Larson (Chair): Thank you so much. Really incredible statistics, without a doubt.

S. Robinson: Other communities are working on a housing-first model. I know that Port Coquitlam has been working on it. They’re having fits and starts in terms of getting their non-profit sort of going and up and running.

I’m fascinated with your 100 percent landlord retention rate. I think it’s amazing. Can you tell us a little bit about why you think it is that you were able to maintain…? It’s the private sector. These are people who have, I’m assuming, basement suites or have, you know, an investment department somewhere. They often have to….

D. Fortin: Yeah, it’s everything from mom and dad, grandfather, secondary suites, to people who own large apartment buildings. We work with Devon Properties and those that do asset management that put them in….

S. Robinson: What do you credit…? If I’m reading this right, if you have 125 clients housed, you have to have at least 125 units and 125 landlords — or less, if they have a block of apartments.

D. Fortin: We probably have about 65 different landlords. Some own ten units, and some have one or two.

S. Robinson: Okay. Fair enough. So tell me why it’s working, that you’re able to maintain 100 percent.

D. Fortin: The key to that is we’ve created a position called a landlord liaison. As much as we work with the clients, we also work with the landlord. An opportunity to say: “Remember when landlording….” It’s politically incorrect, but you love being out where it’s not politically correct. “You know, I call my landlord liaison person,” the landlord says, “my little ball-peen hammer.” When things go a little bit awry, they just come in, give a little tap, and the person gets…. The right thing happens.

What it is, is immediate access. Instead of saying, “I’m done, and this person’s out of here,” we have that ongoing contact, something going on. Can we move the social worker in? Can we take a look at it? Sometimes it’s a case of: “You know what? This is not working. We’re going to take this person out. We’re going to move them to another location and find a person that’s more suitable for you.”

So we continue to have that ongoing relationship that proves really, really successful. I was kind of surprised at that stat myself — like, “Really?”

S. Robinson: Yeah. It’s quite impressive, but it also sounds like you have enough resources to support the person that you’ve placed in the unit.
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D. Fortin: Yeah. this is one of…. It’s interesting. We’ve been invited to talk to Abbotsford, Williams Lake, many other places. One of the things we’re seeing in the Lower Mainland, where we have 120 rent supps to start off…. We will ignore the 60 that just came to the door. But others would have, like, three. Maybe PEERS would have two. They didn’t have the funding to deal with that landlord liaison. They’re going: “It’s hard to find the spots. It’s hard to maintain it.” So we found that there was an economy of scale that allowed us to deal…. Like, one more landlord liaison officer for the numbers….

Of course, what we’ve done is we’ve now gone into a pilot project to say: “Can you use our landlord liaison? You do your rent supp. You have a very special population, the youth population, others.” But we’ll provide our landlord and help them out that way. It’s part of that collaborative community effort that you move forward on. It’s fascinating to see the health outcomes. It really is.

What is your percentage of senior citizens that you are dealing with through your program?

D. Fortin: Okay. Thank you. It’s funny. Within the homeless population, they start to count people at 50 as being a senior population.

The average age of people is 45, so we do have a large cohort that are in the 50-to-65 range. That actually is an interesting challenge we’re about to face. Frankly, as we’re starting to deal with their supportive housing, how do we introduce palliative care? How do we introduce that end-of-life care? We’re starting to see that in those situations.

The population is aging. Often we see homelessness as the face of youth, but truly, homelessness is the face of that older generation. We’re starting to see more and more of it. Our argument is that we support families and individuals with low income. And yes, it is not surprising that there are a lot of seniors in that low-income range.

J. Darcy (Deputy Chair): Thank you very much. It certainly is solid proof about what it means to invest upstream and what impact that can have on health outcomes.

You’ve talked about both health outcomes and cost to the health care system — less hospital admissions and so on. Is that a direct result of people not being homeless and having secure and stable housing, or do you also work with other agencies? We’re doing a lot of work on team-based care. The team we can talk about can be very wide, and if we’re really talking about social determinants of health, obviously it includes housing. How do you connect with people who work in health care or other social agencies to support people?

D. Fortin: Excellent. There is a direct correlation, providing housing with supports or just providing housing — like social and affordable housing. You’ll see it in the study. It’s much more in-depth. They had, to a certain extent, the 50% that got no supports, and you can see the difference that having that person who is there in a supportive capacity can make.

It is about assisting the individual to get to — and this is where we’re rich in most communities — those services that they wouldn’t access. First they get housing, and then they get stabilized. From there, you can move them into the conversations about: “Are you looking at health, psychiatry?” You can move them into getting to the doctor, regular care.

J. Darcy (Deputy Chair): But Dean, who does that with them? What does that look like?

D. Fortin: That’s the workers that we have within our supportive housing, or the worker that’s assigned to the Streets to Home client. They have a case worker, for lack of a better term, and that case worker is a bit of a case management model approach. We are working to sit down and have those larger discussions, about how we can even do that better, with Island Health and with many other service providers.

S. Hammell: This Housing First, or the program supported by the Mental Health Commission, was completed a number of years ago — the original pilot project or the project. I think it went for five years or three years.

D. Fortin: They had a five-year longitudinal study, and the information was presented in 2014-2015.

S. Hammell: So we have known this for a while, right? Logically, our first action would be to house people. Obviously, you’re doing a great job in Victoria. Victoria seems to be, as a community, very focused on this also.

But why has that program just sort of melted away, in many ways? Is the federal government still supporting it? What has happened to that initiative?

D. Fortin: You know, it’s kind of interesting. Someone said to me: “Why are you going to go present? You’ve been doing this for ten years.” And I said: “Because it’s still seen as new and innovative.” It’s funny. They still
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bring in experts from outside of Victoria to come and talk about: “Hey, we’ve discovered a housing-first model.” We’re kind of like: “Okay.”

Having said that, what it is, is an opportunity to present to others and to actually start seeing those results. As I said, I guess it’s a philosophy. Abbotsford came to talk to us because their old approach of how to deal with homelessness wasn’t working and the courts weren’t supportive. All of a sudden they’re like: “Okay, so what is working?” So we would go and present to them and help them set up the model. More and more are starting to understand the value of it — both the economic value and the impact on the health care systems.

S. Hammell: No, you are. But we had…. Fair enough. Victoria’s been doing this for a while, and it has been successful. Nationally they did this in a number of sites across the country. They did prove very clearly that this method worked. That longitudinal study was supported, in my understanding, by the federal government. Anybody would think: “Okay, we’ve got the proof. We know we’ve got places like Victoria. Why are we not moving towards this in a more aggressive manner from the federal government and provincial government and the municipal government?”

D. Fortin: It may be a wrongful upbringing. But perhaps the way I see it is that too often it’s sort of like…. Well, just this. If you present it to your health care authority, they say: “This is a housing issue. This is about housing people.” But then you go to your housing people, and they say: “Well, this is all about supportive care and mental health and addictions. This is a health issue.” Or they say: “This is about reducing criminality. This is an Attorney General issue.”

It may be challenges around budgets and who has the best way. Sometimes you almost want to have that centralized…. I’ve never been inside a cabinet. But someone said this is all our issue. Let’s all kick in. Let’s all ante up what we can and move forward in a collective manner. There’s a variety of things.

I think that’s the challenge — that in the end, you have to deliver a certain amount of deliverables. If you can get someone else’s money, someone else’s department to do it, that can be part of the challenge. I don’t know. That may be a bit cynical in trying to see how that happens. Sometimes it’s convincing the population — just that.

Honestly, we’ve had a conversation from someone on the other side of my maintenance, which is: “Well, people should see housing as a privilege. You’ve got to get rid of that dog if you want to come into housing.” Okay, let’s have an understanding of where the impact…. Where’s the compassion on that?

It’s difficult. Affordable housing is seen as a privilege that we give to low-income people, as opposed to something that’s seen as a determinant of health. If I said to you that we can help you reduce addiction and mental health and the prescription is going to be less than $700 a month, you would go: “Wow. That’s way cheaper than methadone treatments and all of those sorts of medical interventions that we do.” Yet it’s not seen as a valid way to deal with health issues.

S. Hammell: Just one final question on the same line. You said that you have…. The discussion I think people need to hear is how much it saves. Do you have that figure? Is there some number we can, in discussion or talking…? I mean, I use, all the time, this study and talk about the fact that you need to house people first. But is there any sort of empirical evidence that it saves money?

D. Fortin: Within the study in 2014 — and we’re seeing within our numbers — they were seeing, I think, that the cost was about $28,000 to $29,000 worth of services that high-needs clients were accessing per year. Then when they went into a housing-first approach, the numbers dropped, like, $23,000. I mean, they’re down to, like, $8,000 or $9,000 with their services. It was a significant reduction.

We’re seeing that as well. For us, at Pacifica…. The study they did was 500 people. We have 200 people. Our numbers are still pretty comparable, and we’re seeing those numbers hold up in the reduction of visits to emergency wards, in the reduction of alcohol and drug addiction and the reduction in the deterioration of health.

It’s been empirically studied, and I, frankly, am challenging myself to say: “Okay, we have a very large participant number. We can go out and see if we can replicate this.” But we’re seeing it day to day in that savings.

S. Hammell: I think, Darryl, maybe you or somebody there can…. I think it’s $74,000 a year to keep somebody in jail in the provincial system — $74,000 or $75,000.

S. Hammell: Well, in the provincial. The federal, I think, is higher. I mean, some of this stuff is just nuts, right?

D. Bing: In our community, we’ve had a homelessness problem. Right now we have a number of people in subsidized, supportive housing. I guess it’s just transitional. Anyway, they were looking into buying a hotel and converting it into supportive housing for them. There were about 25 people that needed housing, but they were
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wanting to double the size and increase it, and the community was in an uproar about this.

Do you think that the community needs to be involved in the decision? Usually, B.C. Housing makes the decision. “Okay, this is what we’re going to do. We’re going to buy this up and convert it into housing.” Because it’s a real estate transaction, they can’t really discuss it in advance with the community.

D. Fortin: Yeah. It’s been something, actually, that I’ve been struggling with myself. How do you have community consultation when at the same time you have to go buy the building now? Or if someone said, “Where are the amenities for the community?” and you’re going: “But affordable housing for seniors or for families or for homeless is the amenity.”

It’s about engaging the community at the front — “this is what supportive housing looks like” — having those sorts of opportunities and forums. Then when you do it, you’ve at least started to address it. Then again, with community consultation, it is being honest in your consultation. It might be: “We’re going to do this. We’re not going to have a discussion about whether we do it or not, but we will have a discussion about those things that are important for you: ‘How do we integrate in? What are the right numbers? How do we do it?’”

Frankly, there are groups like us, Cool Aid and others, that utilize our experience. We would never open up and put 50 people in right away. I’ve got to tell you: if you put three people who are suffering from paranoid schizophrenia right next to each other, you’re asking for trouble. You know what I mean?

We would move in three or four. “How are we doing this week? Everybody’s okay? Good. Let’s move in the next three or four.” It might take us two months or three months to get a 40-bed facility filled, but then it’s going to be there, it’s going to be stable, and you’re not going to have those incidents where the community goes: “See? We told you.” That only happens because of inexperience, as opposed to how you can do it. So have the conversation before, always. “Do we need affordable housing? What does it look like? What are the impacts?”

I will say this. We have, probably about four blocks from here, a place called Camas. Residents walk by and say: “Can I buy a unit in that condominium there? How do I get a rental there?” You wouldn’t know that it was supportive housing. I’d welcome the members to come and take a look around at any opportunity. Come take the field trip. Come take a look at what supportive housing can look like, how effective it is in changing people’s lives, increasing the outcomes for the clients and actually being a welcoming part of the community.

We recently had the Empress chefs come down. We have a community meal to help build community. Every once in a while, the chefs will come down and they’ll cook a big dinner. We had international students come down and cook a large Chinese dinner. There are many ways for the community to come in, and they start to see it as a community asset. It is a shock to have it just in your home right now if there was no conversation. That’s a difficult place to be.

M. Dalton: Okay, great. Doug and I share the same…. We’re MLAs in the same community, Maple Ridge. With this one facility that it was proposed we were going to purchase, there were about 7,000 people that signed a petition in a matter of two weeks. I’ve never had anything like that in all the years I was an MLA. And it wasn’t just NIMBYism — “Well, you know, I don’t want that in my backyard.” People are concerned about the needles. They’re concerned about…. There’s a lot of those concerns.

I was just looking at one of your slides here. You talk about a focus on safe, secure and permanent — not conditional on sobriety or abstinence. I guess I’m thinking on the public’s side of things. A phone call I had about a couple of weeks ago was from a lady that a neighbour…. Next door, there was a fellow that moved in and started drugs, a lot of problems, women coming in. There were all sorts of things happening that were inappropriate, and she was very concerned for her safety. She got in contact with our office, and I heard about it. And then, the follow-up, that place burned down. The guy burnt the place down.

There’s a safety aspect, too, in the general community. But these are not purpose-built facilities. This is more inside the community. It’s the challenge of community safety and yet providing that housing first. Where do we land on that?

D. Fortin: I’ll put this. For the cost of a ferry ride, I would welcome the opportunity to come over and speak — host a community meeting, host an MLA meeting. Let’s talk about supportive housing and the different ways it looks at it. With some models, you do need what we call that supportive congregate care. That’s the model that works. The model for some people is the Streets to Home approach, with the rent supps, with supports, and then you don’t have that worry of 40 or 50.

With some models, you have to be really aware. We’ve had a couple of hotels where we’ve seen them taken on, and they all have individual access. Much more difficult to control what’s going on than a sort of apartment style, where you have one entrance and you can see who’s coming and going.

The tweaking to deal with some of the issues is there. But the larger discussion you can have, with assurances
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and showing: “Here’s the model. Come take a look at all the various ways we’ve had, from old buildings we’ve taken over to purpose-built buildings, where the community concerns have not borne out but where you can continue to meet with the community.”

I remember we had pretty much the same situation in Nanaimo. We built a place called Uplands Walk. The community was up in arms, like: “How could you even think of putting this? It’s right next to the library, behind the fire department.” The council put it in. We had a meeting — it has now been open for a year — to hear concerns, and were people worried about property devaluation? Three people showed up, and they all came to volunteer to help with the community garden. You know, it changed.

But there is fear that you need to acknowledge. You need to give them examples and then, through the right lead, I believe it can be accomplished with success.

D. Barnett: It all goes to management. I’ve been involved in some of these projects up in my communities. They go along good, and then management would change and the problems would start.

Good management, and good and successful community communication — they work extremely well. Over here, they’re very fortunate they have good management with your organization, and I’m sure that problems are few and far between.

D. Fortin: You just gave me an idea that I need to start writing a little bit more. Like, what has been their experience? What has worked? What hasn’t? Those questions about access to doors, those questions about access to various services. What did we do? What did we learn? That has been a bit of my mentorship model, which is: “Here are all of the mistakes we made. Don’t do these ones. You will learn and take the knowledge farther by your own mistakes, by doing it that way.”

L. Larson (Chair): Thank you very much. I’m intrigued by your model, where you actually have multiple landlords and one or two people in a building versus an entire building that is all this. That, obviously, does not cause as much social issues in a community. It’s just an apartment building, and maybe some of the units are subsidized and the rest of them aren’t.

But from what we’ve heard, it’s your management with those landlords — that connection that you’re making with those landlords on a regular basis — that is making them feel secure in having the subsidized housing in their facility or whatever, and also ensuring the services are there to help people.

A great model — obviously, a great model. Thank you very much for being here today and for taking the time to tell us about it.

D. Fortin: Okay. And my offer stands. Hey, I’ll even pay for the ferry. If you want to have a community meeting, I’d love to come over and speak.

L. Larson (Chair): This is the Parkinson Society British Columbia and Jean Blake, Brian Wood and Paddi Wood.

Welcome to the committee, and please proceed with your presentation. It is recorded. It is live. It does reach a lot of people. Even though you don’t see a lot of us in the room, it is actually being broadcast out on the legislative network. Just go right ahead.

J. Blake: We really appreciate the opportunity. We have had an opportunity to speak to a few of you in a much smaller setting, but we wanted to come again. We understand that this is a very special opportunity in terms of being able to meet with the Select Standing Committee on Health, so thank you.

I have with me Paddi Wood, who has Parkinson’s disease, and her husband, Brian Wood.

When we looked at the select standing committee’s terms of reference, in terms of maintaining a sustainable health care system, and then your subterms for the current year going forward, improving health and care services in rural British Columbia as well as a cost-effective system for primary and community care built around interdisciplinary teams, we felt there was a really good match in terms of what we were proposing for the Parkinson’s community.

Our current campaign is around building a provincial Parkinson’s disease strategy, and really, the focus there is around better patient outcomes and controlling increasing costs. We have data from the Ministry of Health showing that in 2012-13, the ministry spent $112 million in British Columbia. At that time, they had about 12,500 people with Parkinson’s disease.

We know that the number one risk factor for developing this disease, as for many other chronic diseases, is age. Of course, with the aging population, the projection of those costs will be roughly double in another 15 years — $224 million.

Some of the things that we feel can be done is looking at some of the best evidence and best practices right now and doing a provincial plan for integrating care across boundaries. This will not only improve patient outcomes for people with Parkinson’s disease, but it will control increasing costs.

Some of the problems from the medical side that we’re hearing — both practitioners as well as those who are liv-
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ing with this disease — is that to even get in to see a specialist…. This is a very complex disease; it’s not always that easy to diagnose or to treat. Once you get in to see somebody who knows, then it becomes much easier. But you can’t even see somebody for a year and a half to two years if you’re going to UBC.

There is a newish clinic in Surrey. It doesn’t really specialize in movement disorder, but two of the neurologists were trained at the UBC movement disorder clinic, so they’ve been handling some of the overload. And last summer, a half-day a week clinic was started in Kelowna. It can handle 500 patients a year. It has a wait-list of 1,300 people.

We’re also seeing, just in general, a lack of knowledge about Parkinson’s disease — definitely the complexity around treating it — throughout the entire health care system. We are seeing that when someone is getting optimal care, they can maintain a very good quality of life for quite a long period of time. But if they don’t, people end up often in a nursing home situation, which obviously is not a good quality of life if the other is an option — plus, it’s very expensive. I know it’s roughly an average of $80,000 a year right now for a care bed.

We know that there are some interventions that could — of course, we are most interested in achieving better patient outcomes — also help with controlling the increasing costs of managing this disease. We know that our top priorities…. There is a bit of a list, but we’d really like to see some training and funding for that, for specialized Parkinson’s disease neurologists and allied health professionals.

We’re talking about rural. It’s tough in the cities already accessing health professionals that have this training. Just think about what it’s like in rural communities. People are travelling incredible distances, and often the health care system is paying for that, too, as they come down to access services in the larger centres. If we had better access or a different system of access, this could help in reducing those wait times and getting people appropriate therapy.

It’s a complex disease, and the reason why…. First of all, you may not be aware, but Parkinson’s is caused by a loss of dopamine. Roughly 80 percent of the dopamine-producing cells in the brain will have died by the time someone gets this disease. The dopamine is the messenger from the brain to the muscles in terms of telling your body about controlling movement. That’s the visible motor things that people would normally associate with this disease.

There are a lot of non-motor or less visible issues, like pain, sleep disturbances, altered sense of smell, mood changes — lots of things like that that you wouldn’t normally see. Some of the non-motor issues can be even more complex than the motor to treat. There’s currently no known cure or cause, although there is leading research that’s pointing to a connection between genetics and environmental issues.

There is medication that can help with symptom control. We now — in the last five years, roughly — have also seen that exercise can help, at least in the early to moderate stages of the disease, in terms of symptom control.

Parkinson’s. There isn’t a standard test, so it’s not really easy to diagnose, and that’s why access to some of those specialists is so important. A neurologist will do a comprehensive physical examination, as well as medical history, looking at medication, response to medication. Sometimes if they are not sure, they will do tests to rule out other conditions.

That’s why it’s pretty complex, and it can be difficult to diagnose, especially if there’s no tremor. Tremor is what people will often associate with this disease. In about 30 percent of cases, they don’t have a tremor.

It cuts across all races, regions, genders, and as the population ages, the prevalence, the incidence, increases.

Right now our treatments options are, hopefully, getting into seeing a movement-disorder specialist or a community neurologist that has good knowledge about this disease. The goal of treatment is really in terms of helping people with Parkinson’s to continue to enjoy or regain a productive and active lifestyle with good symptom control.

It is a progressive disease, so sometimes the medication and exercise doesn’t always work. I’ll just briefly mention in a moment some of the other surgical treatments that are available and other treatments.

Exercise. The reason why we think that that is so important is there appears to be a neuroprotective impact of exercise. It seems to be, from the research that has been done now in the last five, ten years, that those who have been habitual exercisers just fare better in the long run than those that don’t. That’s partly because it’s a progressive disease. It may delay the progression of the disease.

I want you to see, before somebody is on medication…. You may have seen someone that has that very faltered, stumbling walk. Exercise, sometimes in the early stages, will be enough for someone to control their symptoms. But at some point, usually fairly early on, they will be given a medication that replaces the dopamine. You can see its pretty immediate effects. It can take a week to two weeks before somebody would…. This person has probably been on it for a while.

We have real issues, again, with the lack of knowledge of health care providers about this disease. Once they’ve got a medication regime worked out, they really need to have it on time every time. If someone goes in for hospitalization for, say, a hip or knee surgery, they’re supposed to be there for a couple of days. That can end up being weeks if their medication protocol is not followed. That’s one of the other issues why training of allied health professionals is so important.
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It’s a progressive disease. Early on, you’ve got a wider window of when the medication will be effective. But as it progresses, that window closes. As it gets into an advanced stage, that window is actually quite small. The “medication on time every time” issue becomes more and more important.

I mentioned that if the person is having other issues with their disease, sometimes with the medication, there is a surgical technique called deep brain stimulation. We currently have that available. Only one neurosurgeon in all of British Columbia is able to perform that. We could use some additional resources there.

It’s a very small number of people that will require this, but the wait-list to get this surgery done is three years. The criteria may…. By the time you get to that stage, you may no longer be eligible for the surgery. It’s life-changing.

Similarly, there’s a new therapy with levodopa. It’s given in an intestinal infusion. It’s available in Canada and in B.C. and has been in use across the States and Europe for many years. We’ve only had one person in B.C. have access to this, and that’s because she has a private health care plan that pays for the drug. B.C. PharmaCare has denied access.

It is very expensive. The drug costs $60,000 a year. But again, it is life-changing and allows these people to remain at home, to stay alive for an extended period of time.

We know that there are some interventions that could be done that would make some immediate changes to not only patient health outcomes but in terms of cost. A big chunk of that $112 million is hospitalization costs — almost $70 million. From the information we’ve had from our clinical people, in the majority of those cases, it’s because….

Well, first of all, there could be early-on intervention in terms of earlier diagnosis, getting people on appropriate therapy treatment. But most commonly, the reasons people go into hospital are motor complications, psychiatric issues or issues connected to their DBS. While they’re in hospital, they don’t always get somebody who knows about Parkinson’s disease. There are lots of issues, and they end up usually sicker then when they went in. They stay there much, much longer than need be.

That opportunity to intervene and do something about that $70 million, even before somebody gets into hospital, is there. Then, once they’re in hospital, there’s a second opportunity to intervene again and hopefully keep their stay in hospital shorter.

Those are just the reasons for emergency room visits at Vancouver General. The majority of them are connected to motor complications and include issues with falls. When somebody falls — you can think about that — usually there’s a fracture.

Here are some of the recommendations that we’ve got. We would dearly love to work with the Ministry of Health and the health authorities. We already have got several health authorities that we’ve had conversations with and that would be willing to work with us. We need money. That’s really why we’re here to ask for….

We’ve met with a couple of you — Dr. Plecas, Mr. Sullivan. We’ll be meeting with you, Mr. Dalton, I think next week. You’ve probably heard some of this already. Some of you attended the outreach caucus meetings we did April 11.

There’s a variety of things that would be very helpful. We need to have partners. We’re a very small non-profit. We do a lot. But some of this is really getting into the health care field, so we can’t do it.

For example, we’ve prioritized some of the things we think would work really well. I’ve talked already about the training. There are issues, even just access, when you’re in a rural community — to be able to pick up the phone. You can do that with us, but to have more access to an expert in the field…. That would be for a GP or a physiotherapist or OT or a nurse practitioner as well.

We’ve had some conversations with Providence Health about maybe the RACE program, the rapid access in terms of access to a health professional. Telehealth is an opportunity.

We’re starting to work with Vancouver Coastal about if there is a possibility to do something with, at least, their physios. We’ve done some training for them already. The society has paid for it, but we need to go bigger and provincewide.

I talked about a phone line, training of the GPs and that access issue, which of course is a difficulty in urban centres and much more difficult in rural B.C. We do have Canadian guidelines for managing Parkinson’s. They haven’t been reviewed or implemented here in B.C. — and more funding for those specialists.

There’s also a lot of new technology, and there’s been some research around improving gait with leg monitors. I think there are some things around on-and-off periods. Paddi can talk briefly about that. But dyskinesia is one of the real problems that happens when you’re on, and that, still, will make your quality of life not so great. So there is some work going on, and some funding for that would be helpful. I mentioned already the DBS — expansion of that program and coverage of levodopa in Duodopa form.

Those are our recommendations. I’m just going to ask Paddi to talk a little bit about what it’s like living with this disease before we turn it over to you for questions.

P. Wood: First of all, to be very blunt, it’s absolute hell living with this disease, but I’m sure you’re aware of that. I would like to address, if I may, the young people that have Parkinson’s, because I know that I’m almost 70, so I know I’m considered old.

Jean just gave you the statistics for the number of young people that have it. Well, I don’t know if Vancouver Island is special, but I belong to a group of people with
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Parkinson’s who exercise together. We’re called ParkinGo. Between the peninsula and Victoria, we have 69 people registered in the classes, and 17 of those are called young-onset. They were under 40 when they were diagnosed. We’ve just had a young man join the group who is 29. They’re the people that I’m really concerned about.

I was talking to one of the people the other day, a young woman who is 52 now. She’s been living with Parkinson’s for 20 years — the same age as her daughter. She was diagnosed the week after she gave birth, and she said that when she was diagnosed, it looked like they were going to come out with the cure within ten years.

Well, from where she’s standing, the cure looks further away now, because they’ve discovered that Parkinson’s is not simply a movement disorder clinic. It is now regarded as an all-systems disorder clinic because it doesn’t affect just your movement. It affects your breathing, your digestion. People get constipation, which causes, in my case, two hernias. I had a hernia operation last year, and I’m going to have another one in a couple of weeks.

Because Parkinson B.C. has done such a fabulous job with providing information…. I’d really like to see them get some help, because I think they sometimes feel like they might be the lone voice. I went into the hospital prepared for the fact that people knew very little about Parkinson’s, and it was absolutely true. I’d taken the kit with me that Parkinson B.C. provided so that the nurses and the doctors and anaesthesiologists knew that I had to have my medication on time every time.

I’m taking medication every two hours or less right now, which presents its own set of problems because protein interferes with the absorption or the ability of the Sinemet to get across the blood-brain barrier — the dopamine. If protein and dopamine arrive at the blood-brain barrier at the same time, protein always wins. Now, what they recommend is that you eat your meals one hour after or two hours before your dose. So do you want to think about how you could do that when you’re taking medication every hour and a half to two hours? Consequently, I’ve lost 80 pounds. There are quite a few people in our exercise group who’ve also lost weight. These are just some of the little things on the side.

I was diagnosed eight years ago, when I was 61. The neurologist I saw then thought I’d had it for about five years. The current neurologist I’m seeing, who has quite a lot of knowledge about Parkinson’s, figures I had had it for 15 years when I was diagnosed.

It would be really nice if there were more neurologists who are specialists or at least have some specialty in Parkinson’s. There are no neurologists on Vancouver Island that have a specialty in Parkinson’s. There are two that have a specialty in multiple sclerosis, there are three that have specialties in strokes, but there’s nobody that specializes in Parkinson’s. Consequently, we have very little…. Well, I guess Parkinson’s B.C. and Headway in Victoria provide us any information that we can get.

Everybody’s Parkinson’s is different. I was talking to my neurologist last week, and I apparently have a very quickly progressing type of Parkinson’s. Apparently, people who don’t have a tremor…. Jean mentioned it’s 30 percent of people with Parkinson’s who don’t have a tremor. We’re more susceptible to having this very fast progressing Parkinson’s. It has an enormous effect on our families, because this disease is unrelenting.

I really would appreciate if there was some kind of recognition of the need for an organization or a department that could be available to give information to people with Parkinson’s, because we really don’t have anywhere to turn. There was a nurse available from UBC, from the movement disorder clinic. She was available by phone. You could phone and ask her questions about your medication. Parkinson’s B.C. looks after most of the other areas, but they are unable to look after things like medication and any health issues. This woman at UBC is about to retire. There’s nobody to replace her, which means we have nobody to phone and ask.

Another young woman who’s just joined our exercise group is 42 and has a two-year-old and a seven-year old. She’s just been diagnosed, and she was really frustrated. She said: “Who do I phone to ask about this disease? Who can I talk to?” She’s got to wait 18 months before she gets to see a neurologist. That’s ridiculous.

The issues with dopamine. I experienced the dyskinesia that Jean talked about, because I’m in the third stage. That means that when I’m off, I go absolutely rigid. It’s really, really difficult to breathe. So I panic. When the medication works, it goes too far the other way.

The young woman of 52 that I told you about is at the point where her dyskinesia is so bad that sometimes her feet end up around the back of her neck. You can imagine what it’s like living with that, and she’s been living like that for a long time. I think you will find that people with Parkinson’s, on the whole, are remarkably stoic. They don’t blubber like I’m blubbering.

We’ve got this really good exercise program here. I know that Jean and PSBC have done a fantastic job of training as many physiotherapists and personal trainers as they can to teach these special exercise classes.

I’ve just taken up boxing, which is quite exciting. That’s supposed to be really good for us. A young man in Victoria offered to teach us boxing. I exercise probably six days a week.

My husband leads a walking group. It’s a program that was sponsored by Parkinson B.C. called Step by Step. It’s a 12-week walking program, and it has to be led by somebody who does not have the disease.

We’ve had a very successful group of people who’ve come out every week. They often feel really, really terrible, but they come out, and they’ve done absolutely marvel-
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lous things, because exercising does help. It does make you feel better. I think the socialization aspect has a lot do with it — and the ability to laugh at yourself.

L. Larson (Chair): Thank you so much, Paddi, for being here, for the courage to be here and for telling us what you’re living with and what your life is like. It takes a lot of courage to do that, and we appreciate that.

P. Wood: Have some kind of organization where there is somebody that we could phone to ask questions about our medication, because we all experience a lot of problems with our medication. It sounded like the magic bullet, and I guess it was when there was nothing else. But the on-off periods that occur…. Some people are allergic to the medication, and there’s nobody to phone and ask.

I’ve told you how long we have to wait to see a neurologist here. Fortunately, I had found a neurologist who is absolutely fantastic, and he will phone me, if necessary. But I’m one out of 69 people in that position. Everybody else thinks I’m very lucky because: “How come this guy will phone you and give you the information you need?”

Not for me, particularly, but for all of the other people that are really suffering….

J. Blake: …for people with Parkinson’s disease as well as for medical and allied health professionals across the province.

It really is mind-boggling that we have the wait-list that you’re talking about. What’s on the horizon here? I mean, it just seems to me ridiculous that we’re talking about three years for somebody to wait.

J. Blake: It’s probably a multi-pronged solution, but one of things right away would be to see if we could recruit additional movement disorder specialists. That would be one thing. Or it could be looking at a different way of providing that support.

We’ve just engaged a little bit with Providence Health Care, as I mentioned earlier — the RACE program, the rapid access to consultation with an expert. So that’s a possibility.

But again, there needs to be some funding that’s pumped in, because it means that these movement disorder specialists who are already doing clinical care or research…. Usually they have to do neuro coverage at Vancouver General Hospital as well, so the actual proportion of their time that gets spent in seeing patients with Parkinson’s gets decreased through all of those other responsibilities.

P. Wood: The neurologist I see has just cut back his office hours from three days to two days because he’s got so many other responsibilities.

When Jean was talking about the three-year wait for deep brain stimulation, that’s once you’ve been referred to somebody who does the deep brain stimulation. There’s a two-year wait to see a neurologist before that. So it’s five years. The number of people that are not eligible by the time the five years has gone by is phenomenal.

D. Plecas: No. The people who, right now, are on that wait-list. How many people would that amount to?

P. Wood: In our group of exercise people…. That’s all I can speak for, because they’re people with Parkinson’s that I see regularly. There are at least ten people out of 69 — and probably more, because they don’t talk about it. People don’t talk about not being able to manage. They just give you the impression that they’re managing, and they’re not — at all.

D. Barnett: I’d just like to thank you very much. I have two very dear friends with Parkinson’s. The one friend, fortunately, lives in the Cariboo and has had great results with a neurologist in Kamloops.

He just spent six months in Kamloops hospital due to falling down and doing some major damage to himself. Finally, they could do the surgery, but only after he had healed to a point — because of the medication that you have to take, etc. So he’s come a long ways.

Back to the brain stimulation surgery…. You have to qualify first before you even start your two- to three- to five-year process, and your disease has to be to a certain level before they will even let you qualify.

I have another friend that did have the surgery. She went to Toronto, and she had the surgery there. Then, of course, when her battery…. Every so many years, your battery also needs to be replaced. Because she didn’t have the surgery here they weren’t going to replace her battery, which would have killed her. Fortunately, I got some help for her, and we got her a new battery. As long as she’s
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got that, it’s amazing, simply amazing how mobile she is.

So I understand it completely, and I agree that there should be some place that you can phone for help because it is a different type of disease that many people don’t understand.

J. Blake: Just to speak to the numbers a little bit. If you look on page 3 and 4 of the print package, there’s some information there about the wait-lists and the numbers of people.

L. Larson (Chair): Thank you very much Jean. We really appreciate you coming today. Thank you Paddi and Brian for being here as well. We will certainly take everything you’ve told us to heart, and we will put in the recommendations. That’s all we can do. We are a committee that listens to you and then puts in a report to the Legislature, so that is what we will do. Thank you very much.

We’ll move right into our next presentation. Welcome Geoffrey Sing from the Cridge Centre for the Family. We’ll let you leap in as soon as you’re ready.

G. Sing: Good afternoon and thank you very much for this opportunity to speak to you. Importantly, just thank you for your commitment to this process. I was looking at your schedule for the next eight days, and it’s quite challenging, so thank you very much for taking your time out of your summer break.

I am with the Cridge Centre for the Family, but the area that I wanted to share about was brain injury. My focus will be work that we do here in greater Victoria, but I do have some knowledge about what’s going on within the province in the area of brain injury, so I should hopefully field your questions or concerns big picture–wise as well.

Just some basic stats about brain injury. In Canada alone, there are about 165,000. We extrapolate those numbers into B.C…. I’m sorry. I didn’t prepare those notes for you. I’m just going to read off my notes and then take your questions.

We look at B.C. There are 22,000 new brain injuries per year. We look at that per day. That’s 60 new brain injuries per day. We compare that to breast cancer or AIDS or spinal cord injury or multiple sclerosis. That’s more than those four combined by four times. So the significance and number of brain injuries is quite staggering.

Brain injury is the leading cause of disability and death worldwide. The leading causes — I’m sure you’re familiar — are: motor vehicle crash, work-related, assault or violence, sports, recreation, falls.

Who are the survivors? Stereotypical survivors are adolescents, young males. Stereotypical survivors: a 19- to 25-year-old male, crossing what we call the stupid line, doing something silly. These people are invulnerable. The numbers for male to female are about 2 to 1. The guys are stupid. They’re drinking and driving. They’re getting into fights. They’re doing silly things. Dr. Plecas knows this. We figure that brain injury in the prison population is probably about 60 percent to 80 percent.

Divorce after brain injury is well over 90 percent. Just recently, I read an article about intimate partner violence. Females suffering brain injury because of intimate partner violence is probably about 60 percent to 92 percent — domestic violence. It’s a little bit of a downward spiral. Many of those are survivors, and they have anger issues or are struggling with various aspects of life, and it results in domestic violence.

Brain injury, we know, is cumulative. You have a three times greater chance of suffering a second, subsequent brain injury after your first one. One of the saddest parts about brain injury is probably…. The stats are saying 90 percent of the brain injuries are preventable, so there’s one aspect about prevention issues that we want to be part of. Part of my sharing today is just some of the things we hope might be included in future consideration.

Present situation. I feel for you, because you’re probably going to hear a number of stories this week about the challenges of being part of the health care system. I just listened to this poor couple here and the numbers with Parkinson’s.

The process to receive services for survivors. They go through the acute care system, and then there’s some rehabilitation. Within acute care, that’s the sprint. You’ve heard stories. Just this weekend, up in Courtenay, a young lady had to be air-evacked with injuries, and she’s probably got a brain injury.

There was a serious crash. Just the other day, I had a call from a family: serious crash on the Malahat, young woman in a coma, and they don’t know what to do. So they’re going to be in the sprint in the acute care. They want Johnny or Susy to get well, to come out of their coma and get home.

After that, we look at the marathon of support with the brain injury, of living with brain injury. For survivors coming out of acute care, they have to apply for services for support. The challenge there is we’re looking at a six- to eight-month wait-list. What we’re advocating is for earlier intervention. I’m sure you’re going to hear this: either we invest now or we pay later.

I’m going to share a little bit about what the Cridge Centre does. I’m looking at how we can try and address the issues of how we can create a cost-effective system of primary community care built around interdisciplinary teams and how we can enhance the effectiveness of addiction recovery programs.

At the Cridge Centre, we run a continuum of care for housing. We have a group home for ten men. That’s at A.

We have the middle stage. We have an apartment building where we have survivors living on their own,
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and they would come and reside there for three years maximum and then move on to independent living. It’s not just housing we provide. We provide employment opportunities. Survivors need somewhere to live and something to do.

The need for the future, for what we’re concerned, is…. This is where I was putting on my hat with the big picture. I was talking to colleagues — Carol Paetkau in Fraser Valley and a couple of other leaders in the Lower Mainland — and their identified need is…. “We have an increased need for one-to-one and family support.”

One of the challenges that we have…. When we have that long wait-list, if we don’t intervene right away….

I’ll give you an example of one of the clients that we’re supporting. He suffered a car crash in 2014. In 2015, ICBC ended their services. They applied for services with the brain injury program. They waited, and we didn’t get approval to support them until March of 2016. So there was probably about a year or a year and a half without support.

One of the challenges that we’re encountering now is that…. This couple had seven children, and now we’ve just found out they’ve all been apprehended. Our thinking is that if we were there early, supporting this gentleman who has survived a brain injury and his spouse and their children, I don’t think we’d have the challenging outcome that we have right now with the apprehension of the children. So it’s getting involved now as opposed to later.

Another area of priority need is that we need affordable housing and support. I know this is a little bit of a challenge. Our funding comes through the Ministry of Health, but where we’re having difficulties and challenges is that there are different ministries that we were hoping the Ministry of Health would be able to talk to and be able to access this affordable housing.

We, as the Cridge, are trying to develop more housing for survivors. Sometimes Health is in a little bit of a silo, the ministry for social services is in a little bit of a silo, and the Solicitor General’s ministry is in a little bit of a silo. Perhaps the various ministries could work together to try and pool more funds. What we’re seeing is a social decline, like the apprehension of seven children. Now we have social services involved, right? What’s that going to be costing in terms of trying to support those children?

I skipped over the challenge of a brain injury. You break your arm. You’ve got a cast, and everybody knows you have a broken arm. I gave you one quote there, about the parent’s challenge of having a loved one, a son or a daughter, living with a brain injury. It’s the undiagnosed. We call ourselves the walking wounded. We look okay, people assume we’re okay, but there are some challenges.

I’m going to talk about our position paper, which I shared with you. I know you guys get a ton of reading. I’m sorry about that. But this position paper…. If we look at brain injury and homelessness, we’re talking about some of the social issues again. The stats are that 52 percent of those who are homeless have a brain injury. A worse stat is that of those who are brain-injured and homeless, 70 percent of them had a brain injury and then became homeless.

We look at the challenges that we’re having on the courthouse and Legislature lawns. I’m telling you. A number of those people are survivors of a brain injury. And trust me. No one goes out wanting to be homeless. It’s coming back to intervening to support the survivors when they need that support, before it’s too late.

I’ll share some stats that we have in the position paper with you. Our role from the Cridge is…. We call it we’re working ourselves out of a job. We’re always going to have new survivors of brain injury.

If we look at acute care costs, it’s $1,500 a day. Again, Dr. Plecas would know this. Federal prison costs $320 a day. We look at MacDonald House, our group home — $253 a day. Our apartment building, what we call independent living with assistance — $80 per day. Then we move those survivors along towards independent living with support. It’s about $120 a month.

We need flow-through from the acute care to the community, and we need to intervene with survivors early and now. If we don’t, it’s going to cost us more. We have the social cost. We have the criminal justice system. We have the housing. How much have we put into this unfortunate situation of the tent city? We could be investing for survivors, helping them to live in the community and be contributing members. We have employment with the employment programs.

I gave you two pictures here about the investment aspect. Joseph Centis. This is 2005. I’m sorry it’s a little bit old, but this impacted the Cridge. You may or may not know the story about Joseph Centis. He was living up in Nanaimo. He was married and had five children. He was living with his mom in an apartment building, sleeping on an old couch. We had a bed available at MacDonald House. We met with the family and met with him and said: “You’d be a good fit. Come live with us.” That opportunity was there. Unfortunately, they chose not to because they didn’t want to separate the family. Their hope was that the family would work it out for Joseph and the entire family.

Then we saw the negative cycle start. She filed for divorce and sole custody of the children and of the family’s possessions. They were quite wealthy. He was a very successful plumber but then suffered a brain injury. So filing for divorce, the children, custody, the property. He got so angry. He went out and murdered his wife. It was in the
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news. He shot her. She was gassing up the vehicle when he shot her in the back.

So what do we have? We have a murdered person, five children in custody now and a person…. He ended up being convicted of first degree murder, and he’s in jail for the rest of his life. Perhaps if we would have had supports up in Nanaimo, housing supports and such, we wouldn’t have this type of tragedy on our hands.

Ours, from the Cridge perspective, is that we know survivors can do well after a brain injury. We just need to be able to support them. We need the opportunity to provide that opportunity to them. It’s not all doom and gloom. We’ve had success for our survivors. I want to give you a good story to end your day here.

We had a gentleman, Robin…. Actually, we touch upon it in this paper. He had a brain injury from a viral infection, and he was in a coma for two months. He was married and had a child. He came out of his coma. Unfortunately, the marriage broke down. He moved into Mary Cridge Manor, our program of independent living with assistance. He resided there. With the right support, he’s now back at university. He’s taking social work. He’s living on his own after three years of Mary Cridge Manor. He’s on a dragon boat team. It’s been successful. They’re gold-medal winners in dragon boating.

His line to us is that his goal is to be a taxpayer. As opposed to being someone receiving services, he wants to contribute. That’s what our goal was for the survivors. It’s a win-win for everybody, right? More support for survivors. Better success for survivors and taxpayers for us.

Yes, we have a few minutes for questions. We want to have a chance to ask you a few things. We’ve only got about five minutes or so left.

D. Plecas: Geoffrey, thank you for all that you do. I know you do so much. You’re a saint.

The wait-list issue. We just keep hearing this. Wait-list, wait-list, wait-list. I guess my question would be is: somehow, there got to be a wait-list. What do you see on the horizon for making that go away? I guess something led to it. If something isn’t done to intervene here, we would expect that wait-list to grow even larger.

G. Sing: I think, Dr. Plecas, there are two areas. There’s no doubt there’s no bottomless pit of money for us to use. I think it’s incumbent on the health authorities that support brain injury to look at how those funds are being used and identify what is working. We’re subcontractors of the ministry. Giving us the funds to identify what needs to be done and giving us that opportunity, as opposed to putting…. Allowing survivors to choose and get out, sometimes eliminating the middle man in terms of the health authority….

Don’t get me wrong. I’m not slamming it. I’m trying definitely not to criticize it. We take some clients on from the personal services initiatives, which supports people with FASD and autism. These clients are able to apply for services, get approved for the services, and then they choose who their agency is. It’s quite a bit smoother for them.

I think part of it is the recognition that there does have to be a little more investment in the brain injury community. I don’t have the stats for you, in terms of the numbers. But relative to what we receive — the brain injury program versus some of the other disability programs — it’s a fraction of what we get. We’d like to see an increase.

The one that kind of concerned me was the fact that we have these young people who think they’re invincible taking these incredible risks — the extreme sports they do, flying off buildings and just wild things. We have bicycle laws. We have them wear their bicycle helmets.

We seem to be a risk-taking society. What can we do to prevent these things? It’s easier to prevent them than to fix them. It just seems to be such a huge problem in society.

G. Sing: Dr. Bing, I couldn’t agree with you more. Ninety percent of the brain injuries are preventable. I think there could be more investment in prevention issues. I mentioned a line about “Don’t cross the stupid line.” That was an advertising program about eight years ago. People just need to be pounded about these prevention issues. Because how many times do we see…?

We have the helmet laws for cyclists, and people don’t wear them. I was around when that law was brought in probably about 20 years ago, and the arguments we would get…. Like: “It’s my body. I can do what I want with it.” Then our line: “Well, go to G. F. Strong and see what it’s like to be severely impaired for the rest of your life and if you enjoy that.”

I think the prevention issues are crucial, and prevention campaigns need to continue on. Like the seatbelt laws. We need to bring greater awareness. Right now there’s a big push in sports like football and the concussions, the CTE that’s happening. Yes, we — and perhaps from a government perspective — need to continue to support that, because we need to bring greater awareness about what may happen without protecting your head or taking these risks.
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D. Barnett: Do we have any statistics available as to how many injuries have happened due to the increase of bike riding without helmets, or any of those statistics? Are they available anywhere? Do you know?

D. Barnett: Not very well. Because it would be very interesting to see, actually, how many are on bikes that are not wearing their helmets, that are doing things that are unsafe, when we spent all this money making beautiful trails and things. I would like to see the stats. I wonder where we could find those.

L. Larson (Chair): I’m not sure, but I’m sure they exist because every time a head injury or whatever would come in, it would be recorded, right? So I’m sure there are stats around.

Thank you very much. Thank you, Geoffrey, for coming. We really appreciate you being here and your presentation. Everybody was madly writing notes, as usual, so that’s a good thing. Thank you very much.

Access to on-line versions of the report of proceedings (Hansard)
and webcasts of committee proceedings is available on the Internet.

6) Ts’ewulhtun Health Centre	Danièle Behn Smith
7) University of British Columbia, Department of Family Practice, Centre for Rural Health Research	Dr. Stefan Grzybowski
8) Pacifica Housing Advisory Association	Dean Fortin

Chair:	Linda Larson (Boundary-Similkameen BC Liberal)
Deputy Chair:	Judy Darcy (New Westminster NDP)
Members:	Donna Barnett (Cariboo-Chilcotin BC Liberal)
	Dr. Doug Bing (Maple Ridge–Pitt Meadows BC Liberal)
	Marc Dalton (Maple Ridge–Mission BC Liberal)
	Sue Hammell (Surrey–Green Timbers NDP)
	Dr. Darryl Plecas (Abbotsford South BC Liberal)
	Selina Robinson (Coquitlam-Maillardville NDP)
	Dr. Jane Jae Kyung Shin (Burnaby-Lougheed NDP)
	Sam Sullivan (Vancouver–False Creek BC Liberal)
Clerk:	Susan Sourial

1) Canadian Centre on Substance Abuse	Rita Notarandrea
2) BC Health Coalition; Support Our Health Care Society	Edward Staples
3) Victoria Cool Aid Society; Canadian Association of Community Health Centres	Grey Showler
4) British Columbia Council for Recovery Excellence	Marshall Smith
5) First Nations Health Council	Grand Chief Doug Kelly

9) Parkinson Society British Columbia	Jean Blake
	Brian Wood
	Paddi Wood
10) The Cridge Centre for the Family	Geoffrey Sing

REPORT OF PROCEEDINGS(Hansard)

SELECT STANDING COMMITTEE ON HEALTH

REPORT OF PROCEEDINGS
(Hansard)

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HEALTH