Second Generation health care puts a squeeze on space in the Downtown Eastside

Vancouver Coastal Health has initiated an overhaul of services in the Downtown Eastside, revising how it spends more than $55 million a year and, in many cases, sparking extreme anxiety.

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      David Ogilvie has created artwork since his childhood, but it wasn’t until he was 66 years old that he sold his first drawing. At a café on Main Street, the artist gave credit to Gallery Gachet, a space on Cordova Street near Columbia.

      “The modest success that I’ve gained has been at least partly due to them,” Ogilvie said. He recounted that in 2015, Gallery Gachet gave him his first proper exhibition and, soon after, the Capilano Review made an offer for a series of his work.

      Ogilvie said it can be hard to explain the difference this made in his life, and similarly difficult to explain the health benefits that Gallery Gachet provides to the Downtown Eastside. But he argued that its impact on mental health in the community is significant.

      “Without Gallery Gachet, I don’t think I would have gotten this far,” he said. “I might not have made it at all.”

      For 22 years, the gallery has operated with support from the provincial health ministry. But in September 2015, Vancouver Coastal Health (VCH), the regional care provider in charge of that money, eliminated Gallery Gachet’s $132,000 in annual funding.

      The cut was the first of many moves VCH has begun as part of its “Second Generation” strategy for health care in the Downtown Eastside. The plan is described by VCH as no less than a “system transformation”. As the name Second Generation suggests, it represents the most significant revision of health care in the Downtown Eastside since VCH’s inception in 2001.

      Already five years in the making, Second Generation entered an implementation phase last February. That is scheduled to continue through to October, with an official launch planned for the following month.

      What’s at stake is almost $60 million that VCH spends every year on the health of Vancouver’s most marginalized residents, those of the Downtown Eastside.

      A September 3 VCH media release lists a host of new mental-health and addictions services planned as part of Second Generation. That document and related materials describe a renewed emphasis on clinical services and integrated care delivered with a low-barriers approach that is heavy on peer involvement. The release warns that programs not falling within this focus on clinical applications may be discontinued.

      “VCH contracts without a clear health mandate or those offering stand-alone services without formal connections to health care services may not be renewed,” it reads.

      Critics of the plan argue that such a tight focus on medical and psychiatric programs will come at the expense of services that, though less formal, are no less beneficial.

      Ted Bruce was interim executive director of the Portland Hotel Society for 14 months before he retired in August 2015.

      “There is a need for clinical services but there is also a need to balance the clinical services we provide with some of those other, softer, support systems, which are just as important,” he told the Straight.

      Portland operates Insite, North America’s first supervised-injection facility, plus 19 social-housing projects throughout the Downtown Eastside.

      “What’s important to any population—and, particularly, these folks—is social inclusion, the ability to build community amongst themselves, and the ability to support each other,” Bruce explained. “The kind of programming that has long-term vision—of not just a clinical service but services that build inclusiveness and community—it’s a very important. But that’s often what is not happening when there is an emphasis only on the clinical.”

      Bruce stopped short of direct criticism of Second Generation but added: “There are some things that VCH needs to think long and hard about.”

      VCH’s chief medical health officer, Dr. Patricia Daly, is quoted in the September release acknowledging that the transition may encounter resistance.

      “This is just the beginning of a long-term strategy for change in the Downtown Eastside that will evolve over time,” she said. “We know not everyone will agree with the changes being made, but as health care providers we know that services in the Downtown Eastside can be improved”.

      Services expanded
      New services
      Funding withdrawn
      Services modified

      Three organizations lost in the shuffle

      Gallery Gachet was the first nonprofit to lose funding.

      On April 7, VCH announced that a second organization would be dropped in the shuffle: the Drug User Resource Centre (DURC), a drop-in across the street from Oppenheimer Park that the Portland Hotel Society has run since 2003. DURC previously received $634,000 a year from VCH.

      On May 13, in an email to the Straight, VCH named a third: ARA Mental Health, which offers advocacy services for people with mental-health challenges in a building at Pender and Beatty streets. The organization, founded in 1996, has received about $220,000 in annual government funding the past few years.

      VCH has extended support to both DURC and ARA to continue operating while they seek new sources of funding, but only through to the end of this summer.

      To be sure, VCH services in the Downtown Eastside are expanding by a number of measures. The clearest of these is funding. VCH has said it is increasing what it spends in the neighbourhood by $4 million a year, bringing the annual total to $59 million. There are also extended service hours coming to a number of existing clinics and an entirely new addictions-treatment centre tentatively planned for Powell Street.

      Of course, Gallery Gachet’s take on Second Generation focuses on the money it lost to allow for those programs to expand.

      “The pattern that I would say seems to be becoming clear,” said Cecily Nicholson, the organization’s financial administrator, “is that there is a lack of attention to preventative means, social, and tertiary services—services that are not directly clinical but are also completely necessary.”

      David Ogilvie began volunteering at Gallery Gachet after the organization helped him get his first paid job as an artist.
      Travis Lupick

      She described Ogilvie’s story as typical of the gallery’s membership, many of whom struggle with mental-health challenges.

      “Like the fellow who just brought in his sculpture last week,” Nicholson said. “These are people who are isolated in SROs—very poor housing conditions—but with wall-to-wall art in their rooms. And they have not been able to share it. That is a common narrative.”

      She warned that as VCH moves to fill gaps in its system, it is this population that’s at risk of falling through new cracks that open up.

      A state of extreme anxiety

      For this article, the Straight spoke with some two dozen people employed by VCH-funded nonprofits and the clients for whom those organizations provide care.

      Several people who have spoken to the Straight on a regular basis in the past refused to go on the record for an interview about Second Generation. They cited fears of placing funding in jeopardy. Some pointed to nondisclosure agreements that are now routinely built into contracts with VCH and even applications for VCH contracts.

      Those and other conversations revealed a community in a state of extreme anxiety for the changes that are coming.

      Coco Culbertson is in charge of housing, community, and peer development for the Portland Hotel Society, one of the few nonprofits that was willing to comment on the record for this story.

      She noted that it is still early days in the rollout of Second Generation, and she stressed that service providers don’t yet fully understand how the plan will change health care in the Downtown Eastside.

      “It remains to be seen,” she said. “And I think it’s important we stay in discussion with VCH.”

      At the same time, Culbertson expressed concern for a focus on clinical services coming at the expense of community programs that she maintained—although perhaps not involving a psychiatrist in a lab coat—do improve people’s health.

      “From the PHS Community Services Society’s perspective, nonclinical, nonmedicalized, and noninstitutional approaches to care are at the heart of what we do and why we’ve been successful in engaging thousands of people every day in the Downtown Eastside,” Culbertson said. “I would hope that VCH will continue to value those interventions.”

      Marion Allaart is executive director of the Vancouver Area Network of Drug Users (Vandu), a nonprofit founded in 1998 that was instrumental in the fight for Insite. Asked about Second Generation, Allaart’s response was representative of other nonprofit employees who only spoke off the record.

      “We’ve been expecting them to come for us for a long time,” Allaart told the Straight.

      Service improvements throughout the community

      VCH’s mental-health and addictions programs in the Downtown Eastside are overseen by Andrew MacFarlane, operations director of community health services (inner city–east). In a wide-ranging interview at VCH headquarters at West 6th Avenue and Cambie Street, he began by outlining the problems that VCH aims to address with Second Generation.

      Andrew MacFarlane, Vancouver Coastal Health's director of mental health and substance use, and Natasha Golbeck, director of strategy deployment, say a revised strategy for the Downtown Eastside benefits from peer involvement and integrated care.
      Travis Lupick

      “We’ve, historically, not been great about being low-barrier and accessible for vulnerable people,” MacFarlane said. “Between 9 a.m. and 4 p.m. doesn’t work for a lot of people that have chaos in their lives.”

      To that end, MacFarlane said, VCH is extending service hours and expanding programs at three existing clinics: at 59 West Pender Street, 569 Powell Street, and 330 Heatley Street.

      At those locations, he said, doors will soon be open 12 hours a day, seven days a week.

      A second complaint VCH heard in its consultation phase for Second Generation was of a system heavily burdened by its complicated structure, where services are isolated from one another in ways that prevent many mentally ill people from receiving care.

      “We had programs that were really siloed,” MacFarlane said. “If you saw a mental-health clinician somewhere, then you had to walk somewhere else to a primary-care doctor, who may or may not be in the loop on what is happening with your mental-health treatment.”

      To address that problem, new “integrated health-care teams” will deploy at those three locations and others to offer more holistic care, he continued.

      “We have a model that we’re implementing that is about having one care team that is really interdisciplinary with a single care coordinator at the centre of it,” MacFarlane said. “Each client will have a designated care coordinator, which will provide a single point of contact for other care providers and agencies.”

      Second Generation will also bring a whole new point of access to the Downtown Eastside: the Railtown Centre for Addictions (a working title that could change). VCH declined to reveal a location for the building but multiple sources told the Straight it will likely open on Powell Street east of Oppenheimer Park. VCH will run the centre itself (as opposed to contracting it to a nonprofit). It is scheduled to open this fall.

      MacFarlane described the Railtown Centre as a low-barriers medical hub for people with addiction issues.

      “This includes an interdisciplinary team, an on-site physician, pharmacist, nurses, and evidence-based psychosocial supports such as social workers, counsellors, peers, and financial workers,” he said.

      He noted it will also involve a drop-in component that, crucially, will allow people to connect with addictions services without having to make an appointment or work their way up a wait list.

      Through all of that, MacFarlane maintained that harm-reduction programs such as needle exchanges will continue to be a “core competency” of VCH’s work in the Downtown Eastside.

      He said that Insite, the city’s only low-barrier supervised-injection facility, has already seen its hours shifted to open earlier in the morning. MacFarlane added that VCH also hopes to soon see supervised injection occur at additional locations. “We are actively pursuing approval to go ahead with that,” he said.

      Feedback falling on deaf ears?

      For Second Generation, VCH conducted an extensive consultation process that lasted longer than two years.

      It commissioned three lengthy papers that presented Downtown Eastside residents’ views on what they want for the community. Today, VCH points to those documents as evidence the Second Generation rollout is following the advice of the people it serves.

      At the daily street market on the unit block of East Hastings Street, the Straight asked one of those papers’ authors, Ann Livingston, if Second Generation’s implementation fits with the community feedback she presented in her report.

      “Hell, no,” she replied. “I don’t think they’ve looked at it at all.”

      Ann Livingston worked with Vancouver Coastal Health during the consultation phase of its Second Generation strategy but now says the organization is failing to implement the recommendations she included in her report.
      Travis Lupick

      Livingston, a cofounder of Vandu, argued that Gallery Gachet and DURC, though not perfect, made people feel welcome and a part of decisions related to their care.

      “The things that make the most difference in people’s lives is being welcomed, having autonomy, and having power,” Livingston explained. “Trauma-informed services should be accessible. People should feel welcome. They shouldn’t have to buzz to get in; they shouldn’t have to be a client; they shouldn’t have to give their name….That’s a model for trauma-informed services. But that seems to have been dropped.”

      Support for change

      Livingston and other Downtown Eastside residents interviewed for this story also raised serious questions about the first big winner in the funding shuffle that’s come with Second Generation: Lookout Emergency Aid Society. She criticized the group’s record on harm reduction in Surrey, where it previously operated as Keys Housing and Health Solutions under the direction of Fraser Health Authority. Livingston took issue with restrictive hours for harm-reduction programs and a past requirement for needle exchange to happen on a one-for-one basis (since abolished).

      When DURC lost $634,000 in annual funding from VCH, Lookout gained about $200,000 to allow it to extend hours and expand services at a drop-in centre called LivingRoom, located on Powell Street just east of Oppenheimer Park.

      In a telephone interview, Lookout’s executive director, Shayne Williams, defended the organization’s harm-reduction services in both Surrey and Vancouver. He said harm reduction will also be a big part of expanded programs at LivingRoom, though he added it was too early to say exactly what shape those will take.

      Williams did, however, note the new LivingRoom will fit with VCH’s stated emphasis on clinical applications. “It certainly won’t be hardcore clinical,” he said. “But the focus will be to be proactive. To help folks get connections to care, to VCH services, to other, more clinical services, and to be that kind of entry point for folks.”

      LivingRoom, operated by Lookout Emergency Aid Society, has had its funding increased to $1 million a year as part of Vancouver Coastal Health's Second Generation strategy for the Downtown Eastside.
      Travis Lupick

      Stephen Finlay is executive director of ARA Mental Health. Despite VCH eliminating funding for his organization, he was largely supportive of Second Generation.

      “For many years, everybody has complained—and rightly so—that clients get shuffled from door to door,” he began. “Vancouver Coastal Health listened to that. And they are trying to set up this service so that there is less of that.”

      Discussing cuts to his organizations and others like Gallery Gachet and DURC, Finlay alluded to an issue larger than VCH. He pointed out that the health-care provider no longer receives annual budget increases like it once did.

      Budgetary constraints

      A review of VCH’s annual reports shows Finlay is correct.

      In 2009, the B.C. Ministry of Health gave VCH a seven-percent increase to its total operating budget. Since then, there’s been a downward trend in the amount of annual increases. In 2010 and 2011, the increase was three percent each year, then four percent in 2012, two percent in 2013, and three percent in 2014. Then, in 2015, provincial contributions to VCH were reduced by one percent from the previous year.

      Since 2010, the change in ministry funding for VCH has averaged plus–two percent per year, barely keeping up with inflation, let alone costs associated with new technologies and aging baby boomers.

      Asked if this situation has put a squeeze on services in the Downtown Eastside, VCH’s director of strategy deployment, Natasha Golbeck, remained upbeat.

      “We’re always challenged in health care to do more with less and to be increasingly efficient and thoughtful about where we spend resources,” she said. “We are not doing more with less; we’re doing more with more.”

      Pressed on whether or not VCH is preparing to eliminate funding for other programs beyond Gallery Gachet, DURC, and ARA Mental Health, Golbeck responded: “The things that are going to be lost have already been lost. At this point, we have made the reallocations that we’ve needed to make.”

      The Ministry of Health did not make a representative available for an interview. Quoted in a VCH media release, minister Terry Lake threw his weight behind the Second Generation.

      “Change is never easy, but we know it’s desperately needed in the Downtown Eastside,” he said. “Many residents increasingly struggle with chronic conditions and changing addiction issues, but a lack of integration between health services creates barriers to accessing treatment. I applaud Vancouver Coastal Health for making the changes needed to improve patient care in this neighbourhood.”

      Losing space

      DURC, expected to close by the end of the summer, is a low-barriers community centre that serves as a safe space for alcoholics and people addicted to hard drugs, including stimulants such as methamphetamine and crack cocaine. It offers laundry and showers plus harm-reduction services such as a crack-pipe vending machine and a managed-alcohol program that lets severe alcoholics brew their own beer.

      Portland Hotel Society

      Each Friday afternoon, the managed-alcohol program convenes at DURC for a regular meeting called the “Drinkers Lounge”. What’s said there is usually confidential (as with Alcoholics Anonymous meetings), but the group permitted the Straight to attend on April 29 on the condition that names be withheld.

      Participants explained how the program saves people from drinking Listerine and hand sanitizer across the street in Oppenheimer Park. The homebrew they make at DURC is safer, and the Friday meetings allow DURC to connect members to health services, including detox and rehab.

      The April 29 meeting began with a roll call of the 35 people in attendance. Next there was a round of happy birthdays, followed by a reading of the group’s rules and mandate. To conclude the meeting’s opening, people were asked to stand for a moment of silence and invited to recite the names of friends or family who had recently passed away or gone missing. One by one, 16 names were called out.

      Moving to an open discussion, the topic of the day was DURC’s pending closure and VCH’s reallocation of funds to the Lookout drop-in centre called LivingRoom.

      “Where are we going to go?” asked a man in the back. “The City of Vancouver doesn’t want us on the streets around here. They don’t want us in the park. They’re doing this to get rid of us.”

      Liz Evans founded the Portland Hotel Society in 1993 and served on the organization’s executive management team for 20 years before she resigned in 2014. She declined to speak specifically on Second Generation, but expressed concern for marginalized people losing the spaces where they feel comfortable.

      “If you’re living in a tiny SRO room, 120 square feet, where all you have that’s yours is a sink and a fridge, then having a café to sit in is meaningful,” she said. “And it just feels like space is being lost.”

      On May 6, the Portland Hotel Society’s interim executive director abruptly stepped down. Pending the appointment of a new leader, Coco Culbertson is acting as a spokesperson for the organization.

      She voiced concerns about the pace with which the Downtown Eastside is changing but maintained that it has learned to take care of itself.

      “This community has always had a strong voice when it gets together,” Culbertson said.

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