Introduction
Members of the Canadian Union of Public Employees play a valuable role in our province’s existing Emergency Medical Services system as Emergency Medical Responders, First Responders, clericals, and as emergency workers in blended positions such as LPN/EMTs. These workers, along with the over 12,000 CUPE members working in health care in Saskatchewan, recognize the need for reform of our EMS system.
The Saskatchewan EMS Development Project is an important and long overdue step toward development of a province-wide, patient-centred and coordinated EMS plan. We congratulate the Saskatchewan government for undertaking this important study and commend the report’s authors for their thorough research.
We agree with many of the report’s broader recommendations for improvement of our current patchwork of private and public Emergency Medical Services: Saskatchewan residents should have access to emergency ambulance service twenty-four hours a day, seven days a week; and this service requires provincial coordination, a provincial ambulance fleet and a state-of-the-art dispatch system. We also support the creation of 200-250 new emergency medical positions; the expansion of First Responder programs; minimum staffing requirements for ambulances; and increased opportunities for training and certification.
However, we find that in some key areas the recommendations are preoccupied with costs instead of public health. At other times they are too intent on protecting the interests of the “multiple EMS providers” – that is, private ambulance companies – regardless of cost. The authors often advocate for privatizing parts of a new EMS infrastructure without any rationale.
The Canadian Union of Public Employees offers the following comments in response to the Saskatchewan EMS Development Project Report:
EMS Development Project Guidelines
The reality of fewer hospitals in rural Saskatchewan means that a growing number of residents are at greater risk in a medical emergency. This means it’s critical that all Saskatchewan residents have twenty-four hour access to ambulance service. It’s also important that the most advanced treatments possible are available, both on the scene and during transport to the nearest emergency department. As well, there is a growing dependence on medical transport for patient access of specialized diagnostic and surgical procedures.
When emergency and medical transport becomes this integral to our health and this indispensable to our health care delivery system, equity of access becomes a critical issue. The only fair and equitable approach to EMS is to create a fully public system.
Regrettably, the EMS Development Project’s limited mandate prevented its co-leaders from exploring the potential of a fully public Emergency Medical Services system. The result is a report in which protection of private interests becomes the sub-text of several key recommendations. This is the report’s major failure. A study, which at the outset must protect 113 private ambulance service providers, will not achieve the best possible, most objective results.
CUPE believes that the best way to provide equitable, efficient ambulance service – particularly when patients are distant from an emergency ward – is through a government funded, publicly coordinated and publicly delivered ambulance service. We urge Saskatchewan Health to expand the Saskatchewan EMS Development Project to include study of the benefits of a fully public EMS system.
Emergency Dispatch
We agree that the current fragmented network of ambulance dispatches should be replaced with a more centralized system that employs more sophisticated technology and is staffed twenty-four hours a day, seven days a week with trained personnel. However we disagree with the report’s recommendation that only one such dispatch centre be established for the province.
While we recognize that more than one dispatch centre is a significant capital investment, we view the risk associated with dependence on one system as too great. In the event of even minor system problems, the ability to respond to emergencies may be affected. In the case of a disaster, a single dispatch system could be completely disabled, leaving the province without back-up ambulance dispatch during a crisis. We recommend that a minimum of two dispatch centres be established to serve the province.
We disagree with the recommendation that the management and operation of the state-of-the-art dispatch system, built with public funds, be contracted out. The dispatch will obviously play a critical role in the delivery of Emergency Medical Services and medical transportation activities. Public administration is one of the five principles of Medicare. Public accountability will be compromised if an outsourcer is responsible for the staffing, training and supervision of dispatch employees. Direct public control of the day-to-day operations is the best approach to providing consistent, high quality dispatch services and maintaining a high degree of accountability.
Responsibility for these dispatch centres could be left with the managing health districts – in the case of two dispatches, Regina and Saskatoon. This would be in keeping with Saskatchewan Health’s divestiture of provider responsibilities and would eliminate the unnecessary and separate organizational layer that the inclusion of an outsourcer would create.
Provincial Ambulance Fleet
CUPE supports the recommendation for creation of a provincial ambulance fleet to ensure that all ambulances are safe, reliable, and outfitted with the best life-saving equipment. Other benefits of a provincial fleet are lower acquisition costs, potential fuel discounts, reduced maintenance costs and the need for fewer ambulances.
However, we disagree with the report’s recommendation that provincial fleet management be tendered and that there be a continued role for private ambulance services in a provincial fleet program. We also question why the province should supply back-up and replacement ambulances to ambulance companies which choose to opt out of a fleet program so they do not lose “the financial benefits of a shared back-up fleet.” Once again, the report’s authors appear more concerned with protecting profit margins, than public health.
If the province establishes a provincial ambulance fleet, then Saskatchewan residents should reap the benefits, including the above economies of scale achievable with a provincial fleet.
Furthermore, as the report acknowledges, for-profit ambulance services protect their margins by operating their ambulances in excess of their useful life, therefore compromising the safety of patients and workers. This strategy illustrates perfectly why there is no room for profit in the delivery of EMS or any other health care service. Patient and worker safety is argument enough for a publicly owned and maintained provincial fleet.
The Organization of Ambulance Services
Many of the current problems, redundancies and inequities of EMS arise from the fact that each of the thirty-two health districts is responsible for maintaining its own EMS system. We support the recommendation that eight managing health districts should be funded to provide Emergency Medical Services for the entire province.
We also agree that Saskatchewan Health should develop performance requirements in its agreements with the managing health districts with respect to response time targets, financial accountability, personnel levels, as well as a process for evaluating EMS plan implementation.
However, we fail to see how the new administrative staff proposed to oversee EMS in each of the managing health districts will be able to meet the expectations of Saskatchewan Health if districts contract private ambulance services. As a contracting agency – not an employer – the managing health district would be unable to hire, fire, schedule and discipline Emergency Medical Services employees and would therefore have very limited control over EMS plan quality. Control and accountability are further complicated if a managing health district has contracts with several separate private ambulance services and must get each to conform to the same standards.
This proposed organization of the ambulance system would be more effective if ambulance services were publicly delivered through the managing health districts. A public system would give the managing health districts’ administrators more direct control over front-line ambulance workers and the quality of ambulance service. This arrangement would effectively remove another administrative tier – the private ambulance management – from the EMS structure.
There are also cost efficiencies associated with having emergency medical personnel employed directly by the health district, particularly in sparsely populated areas where emergencies are less frequent. For example, employees of a health district working as Licensed Practical Nurses, Special Care Aides or maintenance workers can be cross-trained as Emergency Medical Responders or Technicians, or First Responders. They can perform duties within the health district while they are on call to provide Emergency Medical Services.
These “blended” positions, which already exist in some health districts, are cost-effective because they ensure that employees are fully utilized during their hours of work. Blended positions eliminate the downtime associated with full-time ambulance work.
Medical Taxis
The report recommends that managing health districts secure formal arrangements with medical taxis for the transport of patients to medical appointments, diagnostic tests and for other medical reasons. The proposed agreements would include conditions with regard to performance levels, quality of drivers, safety of vehicles, responsiveness and availability.
We recommend that the managing health districts operate these medical taxi services. Maintaining minimum quality, safety and reliability standards is possible only if the health district is the employer and has the ability to directly supervise, hire, fire and discipline. Medical taxis could also be acquired and maintained at a cost savings through the provincial fleet program. Medical taxi drivers could hold blended positions within the health districts.
All Inclusive Rates for Ambulance Transportation
There is currently a huge variation in how ambulance services are charged to users with base rates ranging from $95 to $250, and kilometre rates from $0.75 to $2.25. This is not surprising since private ambulance services within any given community will have a monopoly and patients requiring emergency or medical transport are not in a position to shop around.
We appreciate the report’s authors’ efforts to recommend another, more equitable means for setting ambulance fees. Under the proposed fee schedule, users in life-threatening or serious situations will subsidize non-emergent users, and urban users will subsidize users living in rural and remote areas. As this recommendation proves, there is no fair way to distribute the cost of ambulance service. No matter how fees are set, a segment of the population will be burdened unfairly with the expense. The fairest way to distribute the cost of EMS is to publicly fund it.
Conclusion
Saskatchewan residents are more dependent than ever on emergency and medical transport to access needed health care services. When Emergency Medical Services becomes this integral to our health and health care delivery system, it has no place in the private sector.
The people of Saskatchewan deserve the best possible EMS system – the recommendations of the EMS Development Project will not deliver. Our EMS system will remain fragmented, uncoordinated, inequitable and less accountable, so long as it must protect the interests of the over 100 existing private service providers.
To their credit the co-leaders of the EMS Development Project have gone to great pains in their report to Saskatchewan Health to emphasize the need for provincial standards with respect to virtually every aspect of a new EMS system, from the wages paid to EMS personnel and the user fees charged, to staffing and performance levels, and vehicle safety. However, their recommendations for outsourcing and contracting out will limit the power of Saskatchewan health care employers to achieve these improvements.
In her address last May to delegates of CUPE’s Health Care Conference, Saskatchewan’s Minister of Health, the Honourable Pat Atkinson, stated that, “for-profit health care does not represent our best interests.” Why then must we accept private sector involvement in emergency medical care?
The Honourable Minister also commented about the need to develop a “renewed vision of publicly funded and publicly administered health care that continues to offer quality care, good access to services and patient choice.” The Minister stressed that this process would require strong leadership and that we must find the “courage to…undertake a ’daring experiment’ to keep the ideals of Tommy Douglas alive and well.”
To date, this government’s approach to developing a provincial EMS plan falls well short of the Honourable Minister’s described process and vision by yielding to pressures from for-profit stakeholders. If the Saskatchewan government is truly committed to a model of health care that “keeps the ideals of Tommy Douglas alive and well,” it will find the courage to implement an Emergency Medical Services system that is publicly funded and delivered.
Summary of CUPE Recommendations:
The Canadian Union of Public Employees believes the best way to provide equitable, efficient, patient-centred Emergency Medical Services and medical transport is through a government funded, publicly coordinated and delivered ambulance service. We recommend the following:
- The mandate of the Emergency Medical Services Development Project should be expanded to include the study and development of a fully public EMS plan.
- Our current fragmented dispatch system should be replaced with a more centralized, technologically sophisticated, twenty-four hour service that includes at least two dispatch centres. Selected health districts would operate these centres.
- A publicly managed and operated provincial ambulance fleet should be established to ensure that all ambulances are safe, reliable and outfitted with the best life-saving equipment.
- Eight managing health districts should be funded to deliver Emergency Medical Services to the province. Saskatchewan Health should enter into agreements with these districts to establish response time targets, financial accountability, and personnel levels. EMS personnel would be employees of the health district.
- the districts should create more “blended” positions that include EMT, EMR or First Responder duties and the duties of other health district job classifications in order to eliminate the downtime associated with full-time ambulance work.
- The managing health districts should provide medical taxi services. Taxis would be acquired/leased and maintained along with ambulances in the provincial fleet program.
- User fees for emergency and medical transport should be eliminated.