After learning in greater detail about the experiences of Indigenous children who were forcibly removed from their families and placed in residential schools, and the impacts on them and their families, Canadians have spent the last year revisiting their own thoughts and feelings about this country’s true history and their individual role in advancing reconciliation.^{1Today we reflect on the dark realities that lead to reconciliation https://thehub.ca/2021-09-30/karen-restoule-today-we-reflect-on-the-dark-realities-that-lead-to-reconciliation/} Many people have been left with mixed emotions and a greater motivation to challenge their own long-held beliefs about Indigenous peoples and Canada, as a whole. As a result, there has been hesitation in deciding how to engage with key annual celebrations like National Indigenous Peoples Day and Canada Day. How do we celebrate the positive points of our relationship and reconcile the darker shades of our shared history? 

Today, as we recognize National Indigenous Peoples Day, June 21, let’s go beyond celebrating the unique heritage and diverse cultures of Indigenous peoples. Let’s challenge our assumptions and commit to learning about the unique and outstanding contributions of Indigenous peoples in forming the strong foundational fabric of our country and be inspired by the principles of the original Indigenous-European relationships.

There is a commonly held stereotype that Indigenous peoples have always lived in small, secluded communities, never leaving their patch of land for anything. This couldn’t be further from fact. Prior to Indigenous-European contact, Indigenous peoples throughout these lands had expansive and established trade networks that gave way to the movement of goods and the people who moved them. 

As Indigenous leader Manny Jules recounted to a crowd in 2008 in his role as Chief Commissioner of the First Nations Tax Commission: “There used to be millions of us. Although there were no population counts, best estimates suggest that there were at least 40 million of us in the Western Hemisphere in 1491. […] Market economies are not foreign to us. We created them ourselves. We traded goods over hundreds of miles. How could corn be used all throughout the Americas before contact, if we did not trade? How could pipestone end up in our territory before contact when it only comes from Pipestone, Minnesota, if we did not trade?”^{2First Nations Trade, Specialization, and Market Institutions: A Historical Survey of First Nation Market Culture https://ir.lib.uwo.ca/cgi/viewcontent.cgi?article=1372&context=aprci}

Following contact, Indigenous Nations continued to have strong trade relations with European explorers as migration progressed. Research reveals that First Nations held all of the elements that are linked to a successful market culture in the periods prior to and immediately following contact, including specializations ranging from furs to wheat, iron to tobacco, and others. 

Extensive trade networks continued to grow throughout the 16^th century and over the course of the next 200-plus years as European colonies continued to expand into the New World. The French and the English formed alliances with Indigenous Nations in an effort to secure commercial interests, and these groups pushed through conflict and war. 

Leading legal scholar John Borrows notes in his 2005 article, “Indigenous Legal Traditions in Canada”,^{3Indigenous Legal Traditions in Canada https://openscholarship.wustl.edu/cgi/viewcontent.cgi?article=1380&context=law_journal_law_policy} that diplomacy was also factored into these trade relationships, whereby the legal customs, traditions, and cultural protocols of Indigenous Nations were observed and respected by European explorers and colonies. In the early 1700s, the French entered into Treaties with the Anishinabek of the Great Lakes by using Anishinabek forms, wampum belts, and ceremonies. European fur traders are said to have conducted commercial transactions in accordance with Indigenous traditions as well, by the giving of gifts, the extension of credit, and the standards of trade based on Indigenous legal principles. Marriages between Indigenous women and European men were conducted according to Indigenous legal traditions. The traces left behind by these interactions over hundreds of years following first contact continue to influence Canada’s fabric today, through symbols, historical celebrations, trade routes, harvesting traditions, traditional clothing apparel, and otherwise.

There was a fundamental shift in the mid-1700s when Britain, through the Treaty of Paris of 1763, ended 150-plus years of war.^{4First Nations in Canada https://www.rcaanc-cirnac.gc.ca/eng/1307460755710/1536862806124} This was quickly followed up by the issuance of the Royal Proclamation of 1763 which, among other points in relation to France and Spain, helped Britain to achieve certainty and stability with Indigenous Nations. It laid out specific protocols for all dealings with Indigenous Nations, making the Crown the primary point of contact between Indigenous Nations and all colonies. While the Royal Proclamation of 1763 aimed to control the western expansion of the colonies, it made clear the parameters on land and trade: only the Crown could purchase land from Indigenous Nations and no settlement or trade could be completed without the permission of the Indian Department. 

The impacts of this legal instrument went beyond ending a war and establishing a fiduciary relationship, it extinguished a rich, mutually respectful, and mutually beneficial relationship that could have built off the early successes and led to a foundation for a different kind of country—a stronger, more collaborative, and more prosperous Canada. 

Today, as we celebrate National Indigenous Peoples Day, and prepare for Canada Day celebrations next week, let’s consider the power of acknowledging the ugly and shiny parts of our shared history. Let’s be inspired by the successes of the original relationship between Indigenous peoples and Europeans that governed these lands for more than 200 years. Let’s commit to a better future, a Canada that is shaped by our foundational relationship of co-existence, collaboration, ambition, competitiveness, and great innovation.

Few voters had first-hand experience with hallway medicine or Canada’s world-famous wait times before the pandemic. Lockdowns changed everything. Health policy failure moved from fear-filled headlines into a tangible crisis everyone could feel.

Failure begs for better policy, or new policy to fill gaps. Planners and policy writers jump to offer solutions: surgicenters, funding reallocation, redesigned models of care, and so on.

New policy, however, cannot fix old policy, unless we know why the old failed in the first place. Most policy fails on implementation, not from bad design. Furthermore, we cannot fill policy gaps unless we understand why gaps exist. Gaps form around constraints and incentives, not from a lack of creativity. The policy environment dictates viable policy options. 

How a system functions has more to do with how its governed than with the policy ideas in play. Implementation failure, constraints, and incentives all fall under the larger umbrella of governance. Governance and policy overlap, but they are different. 

To fix health care, we need to start with governance: how do we make decisions? Who gets to make them? If we do not, a new policy will deliver the same old results.

Policy to the rescue

Take surgicenters as an example. Surgeons and specialists join together to build a non-hospital, outpatient surgical facility. Each centre offers a specific basket of specialty care, for example eye, orthopedic, or endoscopy services. Surgicenters can offer comfort, convenience, quality, and efficiency that hospitals struggle to match. 

Surgicenters exist around the world. They are not new. In Canada, we have been trying to move care out of hospitals for decades. We want to save money and shorten waitlists. Why aren’t Canadian cities littered with surgicenters? 

Current incentives and constraints make surgicenters impractical and onerous. Currently, hospitals supply nursing care, equipment, and use of the facility. Physicians use everything but do not pay for it, making non-hospital facilities a tough sell. On top of this, billing rules, regulation of independent health facilities, licensing for necessary lab and imaging services, as well a basket of other restrictions all weave together into a policy environment intolerant of (publicly funded) independent facilities. 

We do not need a policy about surgicenters. We need research on why surgicenters do not exist in the first place and what to do about it. 

Thomas Sowell, American economist and author, said once, “The most important decision about every decision is who gets to make the decision.” 

Sowell expanded this in his book, Knowledge and Decisions: “The most fundamental question is not what decision to make but who is to make it—through what processes and under what incentives and constraints, and with what feedback mechanisms to correct the decision if it proves to be wrong.”^{1Knowledge And Decisions, p. xxii https://www.amazon.ca/Knowledge-Decisions-Thomas-Sowell/dp/0465037380?keywords=knowledge+and+decisions+thomas+sowell&qid=1655309944&sprefix=knowledge+and+de,aps,120&sr=8-1&linkCode=sl1&tag=shawnwhatleym-20&linkId=d571f2389079717bc2c2ab4c6586d10f&language=en_CA&ref_=as_li_ss_tl}

Before making a change, every hospital administrator must ask, “Who needs to be in the room?” Spectacular new policy will fail in even more spectacular fashion if you ignore governance. Informal governance can matter even more. Decision makers are often not the ones listed on the organizational chart: colleagues influence through personality without title or position. 

Governance eats policy for breakfast

Peter Drucker, the legendary management consultant, once said, “Culture eats strategy for breakfast.”^{2“Peter Drucker (1909-2005) was one of the most widely-known and influential thinkers on management, whose work continues to be used by managers worldwide. He was a prolific author, and among the first (after Taylor and Fayol) to depict management as a distinct function and being a manager as a distinct responsibility. His writing showed real understanding of and sympathy for the difficulties and demands faced by managers.” https://www.bl.uk/people/peter-drucker} We can say the same about health policy: governance eats policy for breakfast.

Dr. Dave Williams, a former astronaut and leader at NASA, served as CEO at Southlake Regional in Newmarket. He said, “It’s not clear who runs the hospital.” He was making an observation, not a complaint. “Compared to what I’m used to, it’s challenging to get things done.” 

Without clarity and fidelity to best practices, governance will drift. Sowell, again, sums this up:

Even within democratic nations, the locus of decision making has drifted away from the individual, the family, and voluntary associations of various sorts, and toward government. And within government, it has moved away from elected officials subject to voter feedback, and toward more insulated governmental institutions, such as bureaucracies and the appointed judiciary.

Is this a problem in Canada? Brian Lee Crowley, managing director of the Macdonald-Laurier Institute, thinks so. Governance drift leads to central design—a temptation for all political parties.

In his book, Gardeners and Designers: Understanding the Great Fault Line in Canadian Politics, Crowley dilates on how gardeners approach governance.^{3Gardeners vs. Designers: Understanding the Great Fault Line in Canadian Politics https://amzn.to/3aWW80R} A gardener prepares the soil, removes waste, provides support, and tends to progress. Gardeners celebrate the surprise inherent in what grows and blooms. They do not manage growth for a specific policy outcome they designed in advance.

Designers dream about how to make health care better. Gardeners ask the more important question: how can we get good ideas to grow? A gardening approach to governance leaves plenty of essential (gardening) work for government. It empowers those closest to the problem and leaves design, experimentation, and implementation to them. 

We cannot try to “fix” health care with new policy. Without good governance, new policy will struggle with implementation like all the old policy. We need to do first things first. Governance eats policy for breakfast.