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See: Niagara to bring ambulance services in house for press release (www.cupe.ca/www/57/ART3f1862904ea99).

Presentation to Niagara Regional Council, Health Sub-Committee
Ambulance Services: why the Region should assume delivery
Monday, July 14th, 2003

We are representatives of CUPE Local 7100, which represents nearly 600 employees at the Hotel Dieu hospital, including 196 in the paramedic unit (193 paramedics and 3 clerical workers).

In addition to primary and advanced care paramedics, we also have specially trained paramedic units, such as first response vehicles, the marine unit, bicycle medics, tactical medics, high angle rescue medics, and critical incident stress medics.

As you know, on December 31st, 2004, the current contract for ambulance services, held by Hotel Dieu hospital, will expire. It is our understanding that Hotel Dieu will not be applying to continue holding the contract for ambulance services beyond that date.

As you review the options available in terms of how to best deliver ambulance services in the Niagara region, we would like you to consider the perspective of ambulance paramedics.

We are very familiar with the particular challenges posed by the regional geography – our paramedics cover over 400 square km and a population base of 403,500 people. We also know that Niagara has the third largest senior population in all of Canada, and a higher proportion (16.2%) than the entire province of Ontario (12.6%) of the population aged over 65 years. The senior population is projected to increase by 4.3% between now and 2008 (Source: KPMG Consulting).

As frontline health care workers, it is our view that the best possible option for delivery of the service is for the Region to take it over. By taking on direct operation of ambulance services, the Region can ensure a more efficient service, higher levels of service and a more stable work force.

If Niagara Region decides to take on direct service provision, it will be following the provincial trend. When the provincial government first downloaded ambulance services on January 1, 2001, 22 municipalities out of 50 took on direct delivery of ambulance services, and that reflected an increase in public delivery from the period prior to the downloading.

The trend across Ontario since the province first began downloading ambulance services to upper tier municipalities (UTMs) has been toward more and more direct municipal service delivery. Twenty-two (22) out of thirty-nine (39) UTMs in southern, southeastern and southwestern Ontario are the exclusive service operators. At least two more have made the decision to take over the service – the County of Frontenac and Northumberland County will assume operations on January 1, 2004.

Some examples of recent changes are: Kawartha Lakes assumed the service on January 1, 2003, Haldimand Country on February 1, 2002; Norfolk County on November 1, 2001; Oxford County on January 1, 2002. Some took the service back from hospital operation, others from private corporations, and some from a combination of both. No municipality has gone from direct service delivery to contracting another agency or private corporation to operate ambulance services since January 1, 2001.

One of the biggest problems facing all ambulance services in Ontario is the critical shortage of paramedics. It is a challenge for any municipality to attract qualified workers, particularly those who are interested in remaining in the community for long-term periods of service. One of the rationales identified by other UTMs in their deciding to take over direct operations of ambulance services, is that municipally-run ambulance services provide stability. A contract that flips every few years, by contrast, creates a dynamic where the service is not viewed as stable by prospective health care professionals.

Every time the contract comes up for bid, paramedics worry about losing their pensions and benefits, and about their salaries going down – with good reason. Each time a service is contracted out, staff are likely to be replaced, and existing paramedics may have to reapply for their jobs and start all over again with a new employer, if they get hired. This makes paramedics more inclined to seek employment with one of the municipally-run services elsewhere in the province.

With staffing levels in Niagara critically low, we obviously want to attract paramedics who are interested in staying here for a long time. Having the Region assume delivery is one way to assist recruitment, and to avoid the high levels of burnout, low morale, and staff turnover that plague ambulance services like those in the U.S., which operate on a private contract model.

One of the biggest factors affecting whether the Region will take over the service is, of course, cost. The study commissioned by Niagara Region in 1999 concluded that the direct delivery option was the lowest cost option (but then recommended against that option for other reasons). This should give the Region much comfort on the question of cost effectiveness.

There are several factors which contribute to making direct service delivery the most cost-effective option.

When the service is delivered by an outside operator, that organization must charge the municipality for its additional management costs. Private contractors cost more by duplicating services that are already provided by the Region, in particular administrative services. Why should the community have to pay a private contractor to set up finance and human resource departments when the Region already has those services in place? The same applies to vehicle maintenance and repair – the Region already supplies those services for other municipal vehicles, and extending the service to our ambulances is cheaper than paying an outsider to do it.

Outside service providers will charge the municipality either administrative/management fees or some profit margin in order to improve their own revenue flows. These are funds that can be put directly into the provision of ambulance services if the Region is the operator. For instance, Northumberland County will use the fee paid to the private operator to cover the transition costs of bringing the service in-house.

In 1995, the U.S. Department of Health and Human Services reported that the average cost billed for ambulance services was $500. The average cost for public ambulance services in Ontario at that time was $200. It is certain that a great deal of that difference can be attributed to the prevalence of private operators in the U.S. Also related to financial considerations is the question of fraud and abuse. The American private, for-profit ambulance system is rife with over-billing and bid-rigging. This is one of the key reasons this model was abandoned in Ontario 25 years ago. In the fully publicly operated and administered system we have in most Ontario municipalities now, this problem is non-existent, because there is no profit to be generated.

The best way to maintain accountability is for the Region to run the service, so that we have full control over how public dollars are spent.

Another key reason for the Region to assume the service is to build confidence in our system. The outbreak of Severe Acute Respiratory Syndrome (SARS) in the Toronto area has taught us a great deal about the importance of a fully accountable public system, not to mention the value of frontline health care workers.

In preventing the spread of infectious disease, direct communication among various medical departments and teams is crucial. For instance, emergency medical services workers should be closely linked to public health departments. This is much more likely to happen if the paramedic service is housed within the Region than if it has been contracted out.

Following the recent SARS outbreak in Taiwan, links were made between contracting out of services and the rapid spread of the disease. The head of Taiwan’s disease control agency has acknowledged that contracting out of various health care services there weakened infection control measures, because the movements and protective equipment of health care workers could not be tightly controlled during the outbreak. (Source: www.taipeitimes.com/chnews/2003/06/10/story/2003054672 Taipei Times).

Furthermore, the Toronto experience of SARS showed us the importance of having some flexibility in the system. Toronto’s paramedic service was stretched to maximum capacity during both recent SARS outbreaks, with hundreds of paramedics under house quarantine at the peak period. They were able to keep the service running despite those challenges. In the event of such a crisis in Niagara, we would not want to be functioning under a private contractor who is more interested in cutting corners to maximize profits. We would want to be working for an ambulance service that has ongoing safe delivery of public health care as its only priority.

We hope to spend the next year and a half working with you to make the ambulance service one that can easily be assumed by the Region at the start of 2005.

On behalf of our members, we thank you for the opportunity to make submissions.

Steve Palmer
CUPE 7100 president

Larry Butters
CUPE 7100 vice-president and paramedic