Ministry of Health and
Long-Term Care
Mr Daniel Burns, Deputy Minister
Ms Mary Kardos Burton, executive director, health care
programs
Mr Malcolm Bates, senior manager, patient care services,
emergency health services branch
Mr Fred Rusk, manager, air ambulance, patient care and program
standards section
Ms Allison Stuart, director, hospital programs
Subcommittee
report
STANDING COMMITTEE ON
PUBLIC ACCOUNTS
Chair /
Président
Mr John Gerretsen (Kingston and the Islands / Kingston et les
îles L)
Vice-Chair / Vice-Président
Mr John C. Cleary (Stormont-Dundas-Charlottenburgh L)
Mr John C. Cleary (Stormont-Dundas-Charlottenburgh L)
Mr John Gerretsen (Kingston and the Islands / Kingston et les
îles L)
Mr John Hastings (Etobicoke North / -Nord PC)
Ms Shelley Martel (Nickel Belt ND)
Mr Bart Maves (Niagara Falls PC)
Mrs Julia Munro (York North / -Nord PC)
Ms Marilyn Mushinski (Scarborough Centre / -Centre PC)
Mr Richard Patten (Ottawa Centre / -Centre L)
Substitutions / Membres remplaçants
Mr Brad Clark (Stoney Creek PC)
Mrs Lyn McLeod (Thunder Bay-Atikokan L)
Also taking part / Autres participants et
participantes
Mr Erik Peters, Provincial Auditor
Mr Nick Mishchenko, Office of the Provincial
Auditor
Clerk / Greffière
Ms Tonia Grannum
Staff / Personnel
Mr Ray McLellan, research officer, Research and Information
Services
The committee met at 1032 in committee room 1,
following a closed session.
SPECIAL REPORT, PROVINCIAL AUDITOR
MINISTRY OF HEALTH AND LONG-TERM CARE
Consideration of section
3.09, emergency health services.
The Chair (Mr John
Gerretsen): Good morning everyone. I'd like to call the
meeting to order. I'd like to welcome the delegation from the
Ministry of Health. Perhaps, Mr Burns, you could introduce the
people who will be making a presentation initially. We would hope
that you would keep your presentation to about 15 minutes and no
more, and then we'll throw it open to questioning from the
members of the committee.
Mr Daniel
Burns: Thank you, Mr Chairman, and good morning. Our
opening presentation will be made in part by myself and in part
by Mary Kardos Burton, the executive director in the health care
programs division, who is sitting just to my left. We have other
managerial and professional staff with us who work in various
aspects of this program .If it will be helpful to the committee
later on, they will be participating in the discussion phase of
this morning's meeting.
Let me begin by saying that
the ministry is committed to the enhancement of a health system
that reflects the government's vision for the future of health
services in the province, and that vision is of a system that
promotes wellness and improves health outcomes through
accessible, integrated, quality services for all Ontarians at
every stage of life, and as close to home as possible. It's
because of that commitment that the Ministry of Health and
Long-Term Care is also committed to being responsive to the
analysis and recommendations of the Provincial Auditor. Our
programs are large and extensive and the result of that is that
the Provincial Auditor works in our ministry every year. It's an
important part of our annual cycle of assessing the quality of
our work to work with the Provincial Auditor and respond to the
recommendations he makes.
Today, Mary Kardos Burton
will address the recommendations of the Provincial Auditor with
regard to emergency health services. But before she speaks, I
would like to take this opportunity to give you a brief history
of the government's recent initiatives concerning land ambulance
services. The Ambulance Act, as amended by the Services
Improvement Act, 1997, and the Tax Credits and Revenue Protection
Act, 1998, sets out the legislative framework for the funding and
delivery of land ambulance services under municipal
jurisdiction.
On January 1, 1998, each
upper-tier municipality became responsible for funding all costs
associated with the provision of land ambulance service within
its area. The legislation required the transfer of service from
the province to a designated municipality or delivery agent by
January 1, 2000. It's important to note that this was one part of
a much larger realignment of services between the province and
the municipalities.
On March 23, 1999, the
government announced its intention to extend the deadline for
municipalities to assume responsibility for land ambulance to
January 1, 2001. The government also announced that the province
would share the approved cost of land ambulance with
municipalities on a 50-50 ratio beginning January 1, 1999. To
date, 18 upper-tier municipalities have assumed responsibility
for ensuring the provision of land ambulance services in their
communities. The remaining 32 upper-tier municipalities will
assume responsibility by the legislated deadline of January 1,
2001.
The Ministry of Health and
Long-Term Care and the Association of Municipalities of Ontario
jointly established the land ambulance implementation steering
committee, LAISC, that has worked collaboratively to resolve
ambulance transition issues. Ministry consultations are ongoing
with municipal representatives at LAISC and directly with
municipalities. The province has approved a funding template for
cost-sharing land ambulance costs on a 50-50 basis. A standards
subcommittee of the land ambulance implementation steering
committee has been formed to review all standards related to
ambulance services, including response times. These initiatives
are a demonstration of the ministry's commitment to continue
working with municipalities to achieve a seamless transition of
responsibility for land ambulance services and to ensure that
safe and reliable ambulance services are available to
Ontarians.
That having been said,
members, I'm pleased to introduce Mary Kardos Burton, who will
address the specific recommendations of the Provincial Auditor
regarding emergency health
and provide you with a broader picture of ministry efforts
concerning this crucial health service.
Ms Mary Kardos
Burton: Thank you very much and good morning. I am
pleased to meet with the standing committee on public accounts
today and to present a response to the Provincial Auditor's
Report on Emergency Health Services.
Land ambulance services
contribute to the health and quality of life in hundreds of
municipalities and unorganized areas of this province. They
respond to more than 1.2 million calls a year. Last year,
approximately 67% of the calls were for emergencies. The air
ambulance program was established in 1977 to transport patients
who were inaccessible by land ambulance or in situations where
transport by land ambulance was dangerously time-consuming. Air
ambulances are also used to transfer medical teams and organs for
transplants. The ministry contracts with private operators of
helicopters and airplanes to provide these services.
Earlier this year, the
Provincial Auditor assessed the ministry's performance on
emergency health services, and I'm happy to say that the ministry
has made substantial progress in the full portfolio of areas
evaluated by the auditor. The first area is land ambulance. The
auditor recommended that the ministry ensure, after the
completion of realignment, an Ontario land ambulance program that
is seamless, accessible, accountable, integrated and responsive.
These are the principles that are outlined in the land ambulance
program and were endorsed by a land ambulance transition task
force.
The Ambulance Act clearly
establishes standards for ambulance operations. On assuming
responsibility for land ambulance services, upper-tier
municipalities sign a memorandum of agreement with the ministry.
As of December 11, 18 upper-tier municipalities had signed this
memorandum. Emergency health services branch field offices will
ensure the remaining sign by December 31.
The ministry will monitor the
transfer of responsibility through operational reviews,
inspections, investigations and central ambulance communications
centres. Services with patient care or public service
deficiencies will be quickly addressed.
Looking ahead, the
certification process is underway and will be completed for all
new operators by June 1, 2001. Ongoing operator reviews are
scheduled to ensure every station and service will be reviewed by
December 31, 2002. A database is being developed for availability
by this December. Ongoing non-compliance may lead to certificate
revocation.
In July 2001 the ministry,
through our field offices, will assess the impact of realignment.
If necessary, corrective measures will be taken in co-operation
with the affected municipalities. Preliminary discussions are
being held with field office staff on the monitoring of land
ambulance realignment. This field office contact report format,
to be available by this December, and database, to be developed
in the first half of 2001, will tie into the operational review
database.
1040
On ambulance dispatch, the
auditor suggested the ministry and municipalities work to ensure
that municipal boundaries do not impair the delivery of ambulance
services to patients or add significantly to costs. The ministry
is working closely with municipalities as they assume
responsibility for land ambulance services, including addressing
boundary issues through the EHS field offices. In addition,
central ambulance communications centres advisory committees have
been established to work with municipalities, monitoring service
delivery near and across municipal boundaries to ensure seamless
ambulance service.
To help guarantee that the
funds provided to municipalities are reasonable and equitable,
the auditor recommended that the ministry develop a process that
assesses relative needs and ensures equitable funding across the
province. The auditor also requested a definition of which costs
qualify for provincial funding. The ministry, with the land
ambulance implementation steering committee, has established a
subcommittee to review and make recommendations on standards and
costs. The subcommittee has finalized its joint report on
costs.
I'm pleased to report that
the government has approved a funding template which defines
approved land ambulance costs for purposes of provincial cost
sharing. The funding template was distributed to all
municipalities in October. This template will help ensure the
provision of funding is consistently approved in all areas. The
approved costs, by way of principle, are additional costs that
municipalities incurred, for example, costs of fuel and
insurance. The principle is also that the municipalities will be
funded for whatever number of vehicles and staff they had prior
to assumption.
Municipalities are preparing
budget submissions based on the approved costs template. Our
emergency health services head office will review all submissions
prior to final approval to ensure consistent application and use
of the template.
The subcommittee of the land
ambulance implementation steering committee met in November to
begin its review of standards, including the response time
standard. A key area of the auditor's report is response times.
To ensure ambulance response times meet the needs of patients
throughout the province, the auditor suggests that the ministry
and municipalities join to review current response time
requirements to determine if they are reasonable and consistent,
and to make adjustments where necessary. The ministry and
municipalities have agreed to jointly review current standards.
An LAISC subcommittee was formed to review standards, including
response time, and held its first meeting in October. The
response time review should be completed in the spring.
The auditor also recommended
the ministry take appropriate corrective action where specified
response time requirements are not met. The ministry is
continuing to monitor and analyze the response time of each
upper-tier municipality
and designated area to measure how well response standards are
being met.
On dispatch response times,
the auditor recommended the ministry establish dispatch response
times to better meet the needs of patients. Dispatch standards
will be incorporated into a performance agreement to be signed by
each dispatch centre and the ministry. Performance agreements for
central ambulance communications centres are planned for
implementation early in the new year.
The auditor recommended the
ministry monitor dispatch standards to see if they are being met.
Adherence to performance agreements will be closely monitored and
corrective action taken where necessary. In addition, extra
resources, including training and technical staff, are planned
for each dispatch centre to assist with standards compliance.
Also, the priority card index has been reviewed, and a new
computer-aided dispatch system will be implemented over the next
few years. Central ambulance communications centre reviews, with
field offices monitoring performance and reporting findings, will
commence early in the new year.
The auditor recommended the
ministry take timely corrective action where necessary if
dispatch standards were not being met. The ministry will take
timely corrective action. Measures are included in the
performance agreement, as mentioned earlier.
Turning to redirect
consideration and critical care bypass, the auditor recommended
the ministry analyze the impact of redirect consideration and
critical care bypass on ambulance services, including response
times for subsequent patients and, where necessary, take
corrective action. The ministry has established a working group
to review redirect consideration and critical care bypass,
including its impact on ambulance services. The recommendations
of this group are currently under review. In addition, in August
2000, the emergency health services branch circulated a new
standard for ambulance services which permits an ambulance, when
transporting a patient who is at risk of losing life or limb, to
override the RDC/CCB status of a hospital and advise that
hospital that the ambulance will be bringing in a critically ill
patient.
On dispatch priority, the
auditor recommended the ministry ensure that central ambulance
communication centres appropriately assess and prioritize patient
needs. The ministry is planning to add 10 dispatch training
coordinators across the province to further refine the priority
of calls. In addition, as mentioned earlier, a technical group,
the dispatch priority card index working group, has reviewed the
priority card index. A computer-aided dispatch system will be
implemented over the next few years.
On performance monitoring,
the auditor recommended the ministry research systems to analyze
operator performance, including its impact on patient outcomes,
and take corrective action where necessary to help ensure the
land ambulance system meets patient needs. The ministry now has a
fully defined and implemented certification process that focuses
primarily on patient care provided by operators. A review of the
certification criteria and process will occur annually.
Monitoring of patient care scientific data will be undertaken to
ensure that certification criteria are medically sound.
Regarding corrective action,
the certification process for ambulance operators under the
Ambulance Act provides for action where a contravention of
standards has occurred. Follow-up visits are conducted for each
applicant where a breach of one or more certification criteria is
found. Failure to meet these criteria will result in an applicant
or operator being denied certification to operate a service.
Failure on the part of an existing operator may lead to the loss
of the business enterprise.
A key component of
performance monitoring is service reviews. To ensure ambulance
operators meet ministry requirements, the auditor recommended the
ministry consider performing certification reviews without
advance notice to increase assurance of consistent quality of
practice. The ministry is putting in place an inspection process
based on random inspections without notice. Any follow-up visits
will be conducted with short or no notice, depending on the
nature of the certification breach.
The auditor recommended the
ministry have, on a timely basis, a coordinated follow-up of all
deficiencies identified during certification reviews. The
ministry will follow up on deficiencies.
The auditor recommended the
ministry clarify the circumstances when a formal investigation of
an operator is required and when a certificate is revoked. The
ministry reviews every complaint received to ensure requirements
are being met. Where there is substantial evidence they're not
being met, a formal investigation will be conducted. If a
complaint falls under some other jurisdiction, it will be
referred to the proper authority. Certificates will be considered
for revocation where a contradiction of Ambulance Act standards
exists.
To ensure emergency patient
needs are being effectively met, the auditor recommended the
ministry review central ambulance communications centres and base
hospitals within reasonable time frames. The ministry will
develop schedules to ensure that operational reviews are
conducted within reasonable time frames. In addition, continual
review of communications centres will take place within 2001.
Base hospital reviews are scheduled to be completed over a
three-year period, with nine reviews slated for 2001.
The auditor recommended the
ministry resolve all identified deficiencies on a timely basis.
Identified deficiencies are discussed with the operators/managers
and corrective action plans are developed. Corrective action
taken will be monitored. Announced and unannounced service
reviews and certification visits are being coordinated with field
office staff visits.
1050
A final component of
performance monitoring is complaints. The auditor recommended
that to better enable it to assess whether complaints are
satisfactorily resolved,
the ministry should establish clear lines of responsibility for
following up on deficiencies identified in investigation reports.
A process for investigating complaints received by or referred to
another jurisdiction relating to land ambulances has now been
developed for presentation to the land ambulance implementation
steering committee this month. Complaints and investigative
findings are reviewed with field offices on an ongoing basis. The
auditor has recommended that the ministry ensure that follow-ups
are completed and documented.
The Chair:
Are you about to wind up? I really think it's important for us to
get to the questioning as soon as possible.
Mrs Lyn McLeod
(Thunder Bay-Atikokan): It might be helpful, Mr Chair,
if there are points that add new data that are not already in the
ministry's written response in front of us, that might be
submitted, as opposed to rereading what is in the auditor's
report.
The Chair:
We have limited time this morning. Although I appreciate what
you're saying, we like to adhere to the 15-minute presentation
time as strictly as possible. Are there any comments you wanted
to make about the air ambulance service, since that is one main
area you haven't dealt with?
Ms Kardos
Burton: What I would raise in terms of the air ambulance
program, then, is just the points that the auditor raised. The
auditor recommended that the ministry better demonstrate, through
proper documentation, that air ambulances are used appropriately
and that the aircraft selected meet patient needs. We can discuss
through the course of this what we have done about that.
The Chair:
Why don't I throw out the questions at this point in time. We'll
have 20 minutes for each caucus and then we'll have about five
minutes left to discuss what else we should do with respect to
this matter. I'll start with the Liberal caucus.
Mrs McLeod:
We have a number of questions. I appreciate the fact, as the
deputy has said, that this realignment, including a cost
downloading-and I use that term advisedly-is part of a larger
context and was not something the Ministry of Health requested. I
think you've got a huge problem on your hands, and we're
extremely concerned about the potential dangerousness of the
situation as January 1 approaches. I consider this to be a really
serious set of issues that we're talking about today.
Let me start with resources.
We have a template that talks about the kinds of things that need
to be covered on a 50-50 basis. What we don't have is how much
money is going into it. To this point, to the best of my
knowledge-I'm looking to Mr Clark-we know there was the $25
million you mentioned at estimates that had been agreed upon,
which I think was primarily, if not exclusively, for capital. But
we also know the auditor has said that you need $100 million more
just to get to the 1996 response time, and that there is an
additional $64 million in one-time severance costs. That wouldn't
be part of the 50-50, but I assume that's already been committed
by the government.
In terms of the dollars that
are there to meet the 1996 standards, as a minimum standard, what
kinds of dollars have been committed to the municipalities?
Mr Burns:
Just on the final point that you've made, I think we indicated in
the presentation that the template for the base current costs was
dealt with in the last few months and we are now engaged in a
very detailed discussion about standards. It's really only with
that in hand that you can make a soundly based final judgment
about resources and timing, and that will take some further
months and some further discussion to complete.
Mrs McLeod:
That was going to be my second question, because I don't know how
you can determine what you're spending 50% of if you don't have a
standard in terms of response times that you're prepared to meet.
Obviously it is an operating cost in terms of the number of
ambulances and numbers of ambulance drivers/paramedics. We know
that the Fleuelling inquest recommended, for Toronto alone-I
think the implications of the Fleuelling inquest were something
like 118 new paramedics, if that's correct.
Ms Kardos
Burton: I think it's important to remember that there
are base costs that are spent on the ambulance program. We
currently spend approximately $280 million. There are additional
costs on top of that, some of which you mentioned, in terms of
severance costs, which we did pay in terms of this transfer. The
$30 million was for fuel insurance. These are the things I
mentioned earlier.
In terms of looking at
response times, particularly with the movement to municipalities,
it is important to look at response times and then discuss with
municipalities what their plans are for improving response
times.
Mrs McLeod:
I'm sorry to be so frustrated by this, but it is-what, December
13 today? Have I got my dates right? This takes effect on January
1. This is of critical importance to life in these communities,
and there are no standards in place. The Premier in the House
talks about a single standard that was put in place in 1996;
that's not, in fact, the case. What is still the standard in the
certification standards are the response times of the operators
that were in place in 1996, so it's not a single standard.
I don't know whether you're
looking to set a single standard for ambulance response times or
not, but what you're telling me today is that in the middle of
December, with the turnover to take place on January 1, you don't
know what standards are going to be in place until the spring,
and therefore you don't know how much money you're prepared to
provide in support for an ambulance service. I'm truly concerned
that it's not there now.
Ms Kardos
Burton: First of all, it's important to point out that
there are standards in place. As you mentioned, the response time
standard, just to be very clear, shall not be of a longer time
duration than the 90th percentile response time standard for
priority 4 emergency calls set by the operator who provided land
ambulance and emergency response service in the area in 1996.
That was a point in time
that the response time was decided then.
So there is an assessment in
terms of the municipalities. We've been working with the
municipalities. We've given each one of them their response time
information, so there is response time. Response time also
changes. It is not set in stone in terms of what a response time
is on a particular time. It varies across the province. It varies
in terms of urban areas and rural areas.
This is the current standard
that is in place, but we're working with the municipalities in
terms of-they are a partner-are the standards that we have in
place the ones that we will be continuing with or should we be
looking at other standards? But there are standards in place.
Right now, they know that these are the standards.
Mrs McLeod:
I understand that. So let me just take it right back, then. At a
minimum, starting January 1, are you committed to funding 50% of
the cost of meeting the 1996 standards? The auditor has indicated
in his report that that's at least $100 million more in annual
operating costs than is currently being spent on the ambulance
system.
Ms Kardos
Burton: We are committed to funding 50% of mutually
agreed upon standards.
Mrs McLeod:
So there will be at least $50 million more for operating to be
committed by the government in the next two weeks to
municipalities for ambulances to meet current standards?
Ms Kardos
Burton: I think we need to go through our review and
then determine what the actual costs there are.
Mrs McLeod:
How much money is on the table today? I'm going to push this,
because those municipalities cannot take this service and provide
it on January 1, three weeks from now, without having dollars.
How much money has the ministry committed to the municipalities
to run the ambulance service?
Ms Kardos
Burton: We have the $280 million that I mentioned
earlier. There is an additional $30 million. There are some
additional costs that the province has paid. The province
continues to pay 100% of the dispatch costs, which are
approximately $38 million.
The other point that I would
like to raise in terms of municipalities, and I think this is
very good news, is that some municipal councils have decided to
add additional funding in terms of meeting their own response
time standards.
Mrs McLeod:
I understand that. Is the ministry committed to funding 50% of
their additional costs?
Ms Kardos
Burton: The ministry is committed to funding 50% of
mutually agreed upon standards once we do our standards
review.
Mrs McLeod:
Once you have the standards. So those municipalities have gone on
their own-
Ms Kardos
Burton: They have.
Mrs McLeod:
-to put 100% of the additional costs in at this point in
time.
I've got too many questions,
obviously, because there are a lot of very, very critical issues
here. You said that 18 municipalities have signed and you expect
to have the others sign by January 1. I know there are reasons
for delay. In Kenora, for example, they don't have anybody to
deliver the service. They haven't been able to reach a local
agreement on delivery. What happens in the next two weeks in
Kenora?
Ms Kardos
Burton: Kenora has just recently taken a decision in
terms of delivering the service, I think. Our staff has been up
there in terms of looking at the certification. We expect that
this week the process will be finalized and that they will be
delivering the service January 1.
I have with me Malcolm Bates,
the senior manager. Perhaps he can speak more specifically about
the certification in Kenora.
1100
The Chair:
If everybody could move down one, then everybody will have their
own microphone. Go ahead, Mr Bates.
Mr Malcolm
Bates: Perhaps I can go back a second, because I think
you've raised an important question about standards in the sense
that there are numerous standards in place with respect to
patient care, vehicles, equipment, certification, communicable
diseases. Something in the vicinity of 27 standards are in place.
As Mary indicated, 18 municipalities have already assumed
responsibility, some as early as January 1 of this year. They are
working effectively under the standards that are currently in
place and they have been certified with respect to whether or not
they meet the standards on how their service is being
provided.
Kenora, as you bring up, is
going through a procedure at this particular point in time to
select a way they intend to provide service on January 1. As I
understand, they made a decision on the weekend. They did an
extensive review of how they wanted to do it and they came to the
conclusion that they would do it themselves in-house primarily,
although they do have two contracts already arranged.
We have been in the Kenora
district, working with DSSAB in Kenora to determine that they are
on-line. We fully expect that by this week or early next week,
they will have what they require as far as our satisfaction that
they will be able to provide the service beginning
January 1.
Mrs McLeod:
Are you satisfied that every municipality will be in a position
to maintain a continuous ambulance service as of January 1?
Mr Bates: We
are satisfied that they will be. We have checked and certified
all of the services that are currently being provided by the
municipalities and have worked with the other 31 that have not
yet assumed. They all have staff in place. They know what they're
doing. They're enthusiastic about it. The ones that have already
assumed are providing, as I say, excellent service at this
particular point.
Mrs McLeod:
Are they all prepared to meet the 1996 standards for their area,
whatever that might have been, without the additional funding committed from the
government yet?
Mr Bates: I
think as Mary indicated before, they're working with us with
respect to response times. We have a standards committee that is
looking at response times and other standards-not just response
time but other standards as well-and working closely with us. We
expect over the next few months that further resolution of
response times will come to pass.
Mrs McLeod:
I want to leave some time for my colleagues, so maybe just one
other area, particularly now, on dispatch response times. There
is some confusion in the report of the subcommittee that the
auditor has identified, and that is that there was a
recommendation that some municipalities should be allowed to run
the dispatch system but not forced to run it. Can you tell me if
there has been a final decision about who is going to run the
dispatch system?
Ms Kardos
Burton: As I said earlier, currently the province pays
100% of dispatch. Some municipalities run their own. Toronto, for
example, does run its own dispatch. During this last year we've
had requests from a number of the larger municipalities
particularly. They've requested that the government do pilots in
terms of running dispatch. We've been talking to them about
dispatch, but right now there has been no decision taken as to
changing dispatch governance.
Mrs McLeod:
So as long as there is no decision taken, the ministry continues
to be responsible for the dispatch system.
Ms Kardos
Burton: The ministry continues to be responsible.
Mrs McLeod:
Why has it been decided to take dispatch response times out of
regulations-I think they were under the Ambulance Act-and
negotiate individual dispatch response times with each of the
dispatch centres? Why not have a single standard for ambulance
dispatch response times across the province?
Mr Bates: At
the time the act was being reviewed, there was a question as to
what should be considered to be included in the act and what
could be taken out of the act. It was a review of the red tape
area, and the decision was made that ambulance standards could be
better utilized within a performance agreement. The Ambulance Act
requires an agreement to be signed between every agency that
receives funds directly from the province, and central dispatches
and dispatches are, of course, in that category because we're
funding 100% of dispatch. So performance standards will be
included in the performance agreement to be signed by dispatch
centres.
Mrs McLeod:
What possible advantage could the Red Tape Commission, or whoever
was running this-what possible advantage could there be in taking
a single standard out of the Ambulance Act and having different
standards for ambulance dispatch negotiated with each centre? How
does that solve any red tape problems? It seems to me that
increases red tape and it certainly creates inconsistencies. What
was the gain?
Mr Bates:
I'm sorry, I can't answer why they did that, but I can tell you
that the standards will in fact be consistent from one dispatch
centre to another. It will be a consistent performance agreement,
so the standards that are required will be the same.
Mrs McLeod:
So the government will still set a single standard and
incorporate that in every agreement?
Mr Bates:
That's correct.
Mrs McLeod:
But not be bound to it by the act?
Mr Bates:
The act in fact does bind, because the act refers to performance
agreements that must be signed.
Mrs
McLeod: I'm going to turn it over to my colleague. I
hope, Mr Chair, there will be time to get back at least to air
ambulance, as well as to redirect in critical care.
Mr John C. Cleary
(Stormont-Dundas-Charlottenburgh): You mentioned
agreements with upper-tier municipalities. How many
municipalities are going to be providing the service that are not
upper-tier municipalities?
Ms Kardos
Burton: I don't have the figures right in front of me.
There are upper-tier municipalities, but there are also the
DSSABs in the north, which are designated delivery agents. But I
don't have the actual figures right here in front of me.
Mr Cleary:
Not only in the north-
Ms Kardos
Burton: No, in the south too, right. I just don't have
the actual breakdown.
Mr Cleary:
Will we be able to get those figures?
Ms Kardos
Burton: Yes, we'll certainly look into that.
Mr Cleary:
The other thing I want to know: for municipalities that are
taking over the service, are you going to pay for their new
computers, software, uniforms, telephone systems and things like
that?
Ms Kardos
Burton: Our funding template does cover some
administrative costs, so we're working through that with
municipalities.
Mr Cleary:
What percentage?
Ms Kardos
Burton: It's up to 10%.
Mr Cleary:
What about records and things like that? Will they be transferred
to the municipality?
Ms Kardos
Burton: Is there anything you're thinking of
specifically?
Mr Cleary:
Yes. They want to get access to financial records for individual
ambulance buses to determine which or if any-
Ms Kardos
Burton: Certainly any information that the municipality
needs to do their job will be transferred to them. There are
certain protocols that we're still working through with the
municipalities in terms of some information and we're doing that
now.
Mrs
McLeod: Just to follow up on my colleague's questions,
why would there be any ambulance services being run by other than
the upper-tier municipality organization or, in the north, the
DSSABs?
Ms Kardos
Burton: We went through a process in terms of
designation, and it was whoever-
Mrs McLeod: I know the northern
situation extremely well. I didn't think it would be a problem in
the south as it is in the north, but apparently you're going to
have the same problems in some of the southern areas. It's tough
enough with ambulance service to try and figure out who's going
to be responsible for what portion of this cost when you're
crossing municipal boundaries, as the DSSABs do in the north. If
you've got a non-upper-tier municipality anywhere, including in
southern Ontario, that's trying to administer a service that
crosses municipal boundaries, how the heck are you going to
figure out who pays what portion of it?
Ms Kardos
Burton: Municipalities can come to agreements among
themselves.
Mrs
McLeod: Not lower-tier municipalities. If a lower-tier
municipality is running it, they can't charge it to the other
municipalities.
Mr Burns:
But the upper tier can. It's the upper-tier municipality's
responsibility to figure out how to do it best in their own
community, whether they want to do it-
Mrs
McLeod: Even when they're not running it, Deputy?
Mr Burns:
-whether they want to do it directly or whether they want to do
it by contract. If they want to do it by contact, a potential
contractor is another municipal entity.
Mrs
McLeod: Are you saying there's no situation in which the
upper-tier municipality is not still the contractor?
Mr Burns:
In the south?
Mr Bates:
Excuse me. I think you may be referring to a situation in which a
separated city, such as Cornwall, was selected as the designated
delivery agent. Is that correct?
Mr Cleary:
Yes.
1110
Mr Bates:
Of course, in that particular instance they would have all the
requirements and responsibilities of a delivery agent. They were
selected through a proposal system. If the upper tier and the
separated city both wished to operate the ambulance service, the
possibility was that either one could do it, and a selection
process was put in place. In the instance of Cornwall, Cornwall's
proposal was selected and they were named as a designated
delivery agent for the provision of ambulance service.
Mrs
McLeod: And they will now levy charges against the
upper-tier municipality?
Mr Burns:
Just on the language, I don't think they're levying a charge;
they're contracting to provide the service in that particular
piece of geography.
Mrs
McLeod: All right. We'll come back to that later.
The Chair:
You've got a minute and a half left.
Mrs
McLeod: Given the fact that there are no standards, that
there is no agreement on what 50-50 cost-sharing is, that
municipalities are opting, on their own, to put additional
resources in, there is a municipal charge that's going to be
levied in some way, and it is going to be difficult to know who
does what.
Just to touch on air
ambulance before I use up my time, the fact that air ambulance
systems are not in compliance, according to the auditor's report,
44% of the time with a dedicated air ambulance is a tremendous
concern. It was shocking. I don't understand that. I don't
understand why the preferred air ambulance system is in the air
within the 10 minutes 68% of the time and the dedicated air
ambulance is not. We understand that no data has been collected
that can explain that. Do you have any sense of why the air
ambulance is not in compliance with the standard that has been
set?
Ms Kardos
Burton: I'd like to introduce Fred Rusk, who's our
manager of air ambulance for the province.
Mr Fred
Rusk: I can answer that very simply. The standards that
were in place are the reaction-time standards for all air
ambulances.
Mrs
McLeod: How quickly they're in the air?
Mr Rusk:
That's correct. We've had discussions with the air operators, and
in fact we've revised the standard. Because of the number of
issues that can come before them, the biggest one being weather,
the next largest one being approval from air traffic control to
depart and whether they have to wait for additional equipment or
medical teams, we've discussed with them the change in the
standard. The change is this: the reaction time for them now is
from the time they receive the request from the call and the
captain accepts that request-because, as you can appreciate, the
captain must be fully cognizant of the weather situations for
them to depart. I'm sure you can appreciate-
Mrs
McLeod: I'm sorry to interrupt, but my time's up. It's
not a question of the change in standards, because there are
differences. Weather is one that affects both the preferred and
dedicated air ambulances equally.
Mr Rusk:
But here's what we've done. Instead of being in the air, we've
said it's to be ready to receive air traffic control clearance.
For the dedicated program, it's 10 minutes-
Mrs
McLeod: But they're not in compliance.
Mr Rusk:
The new compliance has just been put into place.
The Chair:
OK. We'll have to leave it at that. Ms Martel.
Ms Shelley Martel
(Nickel Belt): I'd like to go back and begin with the
dispatch response times. I want to be clear in terms of the
change of having the regulation taken out of the Ambulance Act,
now to be incorporated in individual performance agreements. You
said, and I want to be clear, that the ministry is still going to
have a single provincial standard and that same standard will be
incorporated in each individual agreement.
Mr Bates:
That's correct.
Ms Martel:
And the standard is unchanged or changed as of the time of the
audit?
Mr Bates:
At this point in time, it is unchanged, but of course it is
subject to discussion with the standards committee that has been
established.
Ms Martel: But even if there is a
change, it will be a consistent change incorporated into each
agreement?
Mr Bates:
Yes.
Ms Martel:
OK. Tell me, if a decision is made by the ministry to allow
dispatch to be carried out not only by Toronto but by other
communities, are you going to be similarly funding those dispatch
centres in terms of the additional resources that you outlined in
the audit that would be required? Is there a commitment that if
there is a download of dispatch centres, provincial money will
flow for extra resources, training, technical staff etc?
Mr Burns:
We're going through this process step by step. So the first thing
is to determine what people think the next standard regime should
be and then what the next dispatch and response-time regime
should be. Then, at that point, we will look at whether we've got
resource questions or not. If we do, we will of course address
them. But we've got a fair amount of discussion to go through
before we get to that point.
Ms Martel:
But you've already indicated in your response to the auditor that
there are resource questions, because you've outlined in your
response that considerable extra resources, including training
and technical staff, will be implemented in each dispatch centre
to assist with standard compliance. So that's a problem now,
correct? You know you need additional resources right now.
Mr Burns:
The activities that are related to the existing base program of
course include training, recruitment, ensuring that we've got the
right kind of service delivery mechanisms in place, and we
continue to look at all those things, because we're still
responsible for managing the service.
Ms Martel:
I was looking at the word "extra" specifically, deputy, to assume
that there had been some additional costs that had been
identified that you were going to cover.
Ms Kardos
Burton: Yes, we have made a commitment to provide
additional resources on dispatch.
Ms Martel:
But at this time, because you don't know if a new governance
model will be adopted, you can't comment on whether or not you
would also provide the extra resources to municipalities if they
took over dispatch.
Mr Burns:
If they're required at the end of the day, the province will do
what we need to do to make sure the system is funded. I'm simply
not predicting what the final outcome will be of all the
discussions.
Ms Martel:
The auditor commented that although the ministry was aware that
dispatch time requirements were not being met, there was very
little corrective action that was going to be taken. What are you
going to do to ensure in the new performance standards that
you're going to implement with dispatch centres that that's going
to be corrected?
Mr Bates:
There are going to be what we call operational reviews conducted
on a regular basis with dispatch centres. There are seven of them
scheduled for the forthcoming year. The operational review, for
your information, is a review that is conducted by peers within
the ambulance system. With respect to dispatch, a team composed
of maybe another dispatch manager, dispatchers themselves from
other centres and perhaps a dispatch training officer would go
into a dispatch centre and, according to a format that has been
developed, review the dispatch centre from top to bottom and be
able to determine whether or not they're meeting the requirements
of the performance agreement and providing the type of dispatch
service that is required.
Ms Martel:
I understand that seven are scheduled in 2001. That would leave
you with about 10 or 11. That wouldn't happen on an annual basis;
is that correct? Is there a similar smaller process that's going
to be implemented in the other dispatch centres?
Mr Bates:
You are correct in that there are 19 central ambulance
communications centres, and yes, as far as random inspections go,
if that's what you're referring to, we will have random
inspections. We'll have a specialized inspector who will be
looking at dispatch centres, as we have specialized inspectors
for land ambulance service and air ambulance service.
Ms Martel:
Do you know when you'll have the specialized inspector in place?
Because the auditor finished his work in about February or March
of 2000, so we're-
Mr Bates:
I can't tell you precisely, because they're in the process of
being hired, if you will; there's a hiring process that's
ongoing. That may take two to three months.
Ms Martel:
Have the random inspections begun, and are they more regular in
terms of occurrence or frequency than what the auditor noted
during the course of the audit?
Mr Bates:
They will be, that's correct.
Ms Martel:
When will that start?
Mr Bates:
As soon as these particular people are hired.
Ms Martel:
Is it one single inspector?
Mr Bates:
No. As I mentioned, it's a specialized person, someone who knows
exactly what takes place and can go through a tape. Because in
doing an investigation or an inspection of a dispatch centre, a
considerable amount of technical knowledge is required. You must
be able to go through the tapes, because every conversation,
every dialogue in a dispatch centre is taped. A specialist type
of approach is required. However, all inspectors and
investigators will be taking part in this.
Ms Martel:
Let me ask you a question about ambulance response time. The
auditor had recommended a review of current response times. The
ministry's response was that they had conducted a comprehensive
review of response times and you were sharing that data with
municipalities. I'm assuming this was done after the auditor
finished his work. Would that be correct?
Ms Kardos
Burton: In terms of the comprehensive review, last
spring the way we shared the data with municipalities was by way
of a CD-ROM and all municipalities got the data. It was May-June,
last spring, that they
got the data. We sent out the information and then our regional
offices actually met with municipalities to talk to them in terms
of interpreting that data because people needed some time to
actually work through it and review the data.
1120
Ms Martel:
Did the auditor have a look at this comprehensive review? Because
it would certainly have fallen under their investigation of
ambulance response times.
Mr Bates:
The information was available, but I don't know if the auditor
specifically did or not.
Mr Nick
Mishchenko: The statistics were available, but at the
time we did our audit, there had been no review of those
statistics. The information, I believe, had been shared with the
municipalities and the operators, but I don't believe there was
any what I would call review of that.
Ms Martel:
Review by your office?
Mr
Mishchenko: We were aware of the statistics-that's how
we know that over 60% of the operators did not meet standards-but
there was no review, that we're aware of, of that information and
any action taken by the ministry at the time that we did our
audit.
Ms Martel:
So are you suggesting that the ministry response doesn't really
reply to your recommendation? Page 169.
Mr Brad Clark
(Stoney Creek): What is meant by "review"?
Mr
Mishchenko: I think it would be more appropriate to ask
the ministry what they meant by "review." We're not sure, because
that was the response to our-we're not sure what they mean by
"review."
Interjection.
The Chair:
Mr Clark, your turn will come.
Mr Erik
Peters: Are you referring to the sentence where "The
ministry and municipalities will jointly review ... "? That was
the future tense.
Ms Martel:
The next paragraph.
The Chair:
What page are we on?
Ms Martel:
Page 169. Let me just try and be helpful. The recommendation from
the auditor with respect to what you found on ambulance times,
which is that they were being met, was to "review current
response time requirements for reasonableness and consistency
and, where necessary, make adjustments; and take appropriate ...
action." The ministry's response was that they "will jointly
review standards." The next paragraph talks about "a
comprehensive review of response times and is now providing
municipalities with access." This is the ministry's response to
your recommendation, and I'm still trying to figure out if it was
an appropriate response.
Mr Peters:
It is appropriate because of the word "now," because the response
was framed after we did the audit. So as a result-the way the
process works is that we make our recommendations and the
ministry then responds. The ministry very clearly has responded
that they're "now"-which means probably in the summer of
2000-"providing" this information to the municipalities.
Ms Martel:
So your concern was that the data be provided to the
municipalities?
Mr Peters:
That's right.
Ms Martel:
And in terms of that being provided to the municipalities at this
point, are there any other changes, either positive or negative,
in terms of response times that have been identified? Or is the
information already contained in what the auditor had
reviewed?
Ms Kardos
Burton: I think I mentioned in my earlier comments that
response times do change. The information that we gave out was in
approximately May or June, confirming the time, but we are
working with municipalities on an ongoing basis in terms of
response times.
Ms Martel:
Is this something that can be tabled with the committee?
Ms Kardos
Burton: I can look into that. I'd certainly be happy to
look into that.
Ms Martel:
That would be helpful.
In terms of your ongoing
dialogue with municipalities, I'm assuming it has to do with how
they are going to deal with inadequate response times where those
exist in individual communities. Is that correct?
Mr Bates:
If I could refer you back to page 168 of the auditor's report,
which I think is an interesting aspect that the auditor points
out, it's the third paragraph down and it states, "In December
1999, the LAISC"-that's the land ambulance implementation
steering committee-"stated that 1996 response times might not be
the ideal standard. Its costing subcommittee also noted that
service and response times in similar jurisdictions were uneven
across the province. For example, one municipality was concerned
that its 1996 response times were 50% longer than those of a
similar-sized jurisdiction."
That's one of the things
that the land ambulance implementation steering committee is
looking at. I think it's a relevant part of response times. How
do you measure response times? What is the ideal way? Because
there are conflicting opinions as to how you should do it. For
instance, one might say it should be measured in terms of rural
areas, urban areas and suburban areas, or something along those
lines. That's the sort of dialogue we are involved in and expect
to be more involved in with the standards subcommittee in the
future.
Ms Martel:
All right, but if the ministry and the auditor have already
identified that the 1996 standard, whether or not it's
appropriate, is not being met in many communities, and you have
this committee that's now trying to determine what other standard
might be more appropriate, I have a serious concern about what
we're going to finally arrive at and what is the cost to
municipalities to take us there or to get themselves there.
Ms Kardos
Burton: I think there are two points to that. In terms
of the committee and what we're looking at, we're initially
looking at the plans of municipalities in terms of how they would
meet response time, because you're right, that is the current
standard.
Ms Martel:
For 1996.
Ms Kardos
Burton: Right. However, the committee has also
identified that in the future, and because we're partners in this, we would look
at whether in fact the standard that's in place now will be the
standard for the future. So the first part of the task is not
just response time, but part of the task of the committee is to
look at what are the plans to meet them.
Ms Martel:
Have you given a commitment to the municipalities that if the
standards change-first, there are many not meeting the 1996-and
if there's a second change around a different standard, there
will also be funding arrangements established with them and costs
to be picked up?
Ms Kardos
Burton: We've committed to 50% of mutually agreed-upon
standards.
Ms Martel:
Can you give me a clear idea with respect to the template of what
the costs are which are covered?
Ms Kardos
Burton: Yes. The costs in the funding template are
varied in terms of what they are, but the first one is vehicle
purchases. It's purchase of replacement vehicles that would meet
the legislated standards; administrative vehicles which would be
of a similar type. So vehicle purchase is the first one.
I won't go through the
whole details. I think you just want the highlights. The items
are: the operation, maintenance and repair of vehicles; patient
care equipment and supply purchases repair and maintenance;
paramedic staffing-just on the paramedic staffing, what the
template says is that it's the same type and hours of paramedic
staff in place at the time of assumption-paramedic training;
administrative costs; severance; taxes; insurance; WSIB; any ER,
which is new experimental experience rating assessments;
ambulance stations; inter-facility transfers; base hospital
costs; and first response teams.
Ms Martel:
Can I go back to your staffing? You said as it was-
The Chair:
Excuse me, is that template a public document? Can it be tabled
with the committee? It is? OK, fine. Thank you. Sorry.
Ms Martel:
Can I go back to the staffing, the 50% as of the time of
assumption? If it's clear that the municipalities were already
not meeting the 1996 standard and that had to do with staffing,
why wouldn't the ministry be covering the cost to at least get
them to the standard? Shouldn't that have been a responsibility
of the ministry before the service was downloaded?
Ms Kardos
Burton: To meet the response time? Some have said
that.
Ms Martel:
Can I ask why the ministry wouldn't do that? I think more than
some have said that. In my own community, the mayor has just come
forward saying that he needs $4 million to do this properly.
Mr Burns:
First, just to recall, we're doing this in three steps: the
present situation; then we're dealing with the standards review;
and the dispatch arrangements in the future. It's not surprising
that people on the other side of the discussion would like as
much resource as they could get to support the program, so we
have a bit of that kind of debate going on. What we've agreed,
among ourselves, to do for now is to deal with our existing base
operations, because the answer to the question that you've just
raised means answering some other questions before you could
really get to the full answer.
Ms Martel:
I would have assumed, though, that it would have just been a
question of equity or a question of principles. If you're going
to download something on to municipalities, they should be up to
the current provincial standard, and we know many are not. The
auditor identified that.
We've got a situation
where, I think, not a few communities but probably many are not
in that position. That's why I'd like to see the individual data
as per municipality and what additional costs the municipalities
going to have to bear to bring them up to a standard that should
have been in place before the service was downloaded.
1130
Ms Kardos
Burton: As we've already said, I think it's important to
focus on what we are doing in terms of the future. We've got a
commitment to work with the municipalities on the standards and
see what the plans are. There are a number of ways one can look
at how you can reduce response time and the mechanisms to do
that. We've got a commitment that the municipalities, through
this standards committee, are prepared to do that.
Ms Martel:
I'm going to assume it was a political decision and not yours, so
we'll leave it there.
Let me ask what
municipalities are left to be signed-I missed that. You have 18
upper-tier that have and about 31 or so that have to signed?
Ms Kardos
Burton: There are 31.
Ms Martel:
OK. I'd like to ask you about the redirect and critical care
bypass. The auditor made it clear that the ministry would have to
analyze the impact of redirect and critical care bypass on
ambulance services, and the ministry's response was to talk about
the 10-point plan the minister implemented at the end of
1999.
I want to know how
comfortable you are feeling with respect to the 1999 plan, in
terms of its being effective or not to deal with the critical
care bypass problems in the Toronto ambulance service.
Ms Kardos
Burton: I'd like to introduce Allison Stuart, the
director of our hospital programs, who will address that.
Ms Allison
Stuart: In terms of RDC/CCB and the comments in the
auditor's report about it, they were based on information made
available in the 1997 report of the OHA region 3 working group.
Since that time, the OHA and the ministry have worked very
closely in terms of the recommendations. The minister immediately
indicated her commitment to responding to all the recommendations
that applied to the ministry and put around $225 million into the
system.
Since that time, additional
funds have been put in that assisted the hospitals. There was
around a $90-million infusion in 1998 and an additional infusion
of $97 million to fast-track the redevelopment of 56 emergency
departments. There was $187 million put into alternate funding
arrangements for emergency physicians. There was $23 million put in to fund the 10-point
plan that was specific to the Toronto and near GTA area.
Then more recently, in the
summer of 2000, the emergency services strategy was announced,
which included $46 million for 463 new permanent beds in Toronto
and 210 transitional beds in the GTA, and $16.8 million to add
450 additional flex-beds across the province, 100 new discharge
planner positions across the province and six new emergency
co-ordination positions, so that there would be emergency
co-ordinators in each of the regions we work with-we have the
province divided into regions-and of course, the flu vaccination
campaign.
Ms Martel:
If I might then, why is it, after all that, that the OHA released
a report in September 2000 where they said that GTA emergency
rooms on critical care bypass or redirect are up 66% from last
year?
We know, if you compare the
1999-2000 statistics for the month of August alone, the number of
hours that hospitals in the GTA were on redirect or critical care
bypass in 1999 was 3,760, and in 2000 it was 4,861. The problem
is not getting better.
Ms Stuart:
The issue of pressures in emergency departments is really
reflective of pressures that are experienced throughout the
system, and to a certain extent the emergency departments become
the heat sink for this. While there certainly have been major
commitments to improve the system; for example, in terms of
addition of long-term-care beds, because the acute care hospitals
have reported-and there's no question-that they have patients who
could be better cared for in long-term-care settings and would be
more comfortable in long-term-care settings-
Ms Martel:
But this was just with respect to emergency rooms.
The Chair:
We'll have to leave it at that, Ms Martel. Government
members?
Mr Clark:
I will be done very quickly, and then my colleagues can have an
opportunity. The first question I'm going to ask is, why would
CCBs be declared if a hospital wasn't at capacity?
Ms Stuart:
I can't speak to the findings of the OHA region 3 task force
report in 1997. I can say that currently when hospitals indicate
they are on redirect consideration or critical care bypass, it's
because they've exceeded the number of electronic monitors that
monitor heart rates and so on that they have available to use on
patients, they have exceeded the critical care beds they have
available in the hospital and don't have any other beds available
to serve patients in critical care beds or they don't have enough
staff to manage any additional patients. We're all aware that
those three issues interplay, one with the other, to make for
pressures in emergency departments.
Mr Clark:
How was the funding template arrived at? The municipalities that
were on the LAISC committee sat down and had consultations with
the government, negotiated back and forth and arrived at a
funding template that cost the provincial government an
additional $30 million. Where did the decision on that funding
template from LAISC go from there? Who ultimately had an
opportunity to approve this funding template?
Ms Kardos
Burton: Once an agreement was reached in terms of where
we were moving, any decisions taken by the land ambulance
implementation steering committee-first AMO has to go to its
board in terms of support, and the province has to go to the
government for support.
Mr Clark:
So AMO supported the funding template and where they are right
now.
In terms of standards and
response times, there has been a lot of discussion about response
times and the fact that some municipalities across the province
can't meet current response times and that the government wasn't
meeting current response times. There has been lots of
discussion: the auditor has mentioned $100 million, and another
figure that has been mentioned is $50 million. In discussions
with the municipalities, if they had the money tomorrow, could
they meet their response times? Hypothetically, if the government
were to provide them with the money tomorrow, could they meet the
response times? Better yet, how quickly could they meet the
response times?
Mr Bates:
I think some changes could be made to improve response times. But
there is a reality that sets in, and that is that significant
extra vehicles would be required-ambulances require six to 12 to
15 months to be constructed-and the number of paramedics that
would be required would also be substantial. I think it would
take approximately a year and a half to two years before
sufficient paramedics from the community colleges could be
provided for the type of change you're referring to. So there is
a time element.
Mr Clark:
Who provided us with the information that it would take 12 to 24
months for the municipalities to meet the standards, based on
their capital needs requirements and personnel requirements?
Ms Kardos
Burton: I think the municipalities also raised that
issue, in terms of the fact that they recognized the human
resources and vehicle limitations.
Mr Clark:
So the municipalities actually brought it to our attention that
even if we were to fund them tomorrow and state that they could
go ahead and begin meeting the 1996 standards, it was not
physically feasible because they would have to order all the
ambulances that are required and get the personnel trained, and
it would take 12 to 24 months.
1140
Ms Kardos
Burton: I think I can confidently say that the
municipalities recognize the time limitations that there are.
Mr Clark:
The auditor's statement in terms of "review current response time
requirements," you had stated to this committee that the response
time in the database was provided to the municipalities in April
or May 1999, or was it 2000? When was that provided?
Ms Kardos
Burton: It was 2000.
Mr Clark:
Was the auditor aware of the database being provided to the
municipalities?
Ms Kardos Burton: Yes, I believe
he was.
Mr Bates:
We would have to say he was, but I think you'd have to
substantiate that from the auditor himself.
Mr Peters:
Our fieldwork was substantially completed by March. At that time
we were writing the report and we were dealing with our
recommendations and the response thereto. This was provided to us
as part of the response of that and we discussed the
response.
Mr Clark:
You were aware before you wrote the document or after you wrote
the document?
Mr Peters:
We were aware as we were writing the report that this was
happening. The fieldwork was completed; we didn't-
Mr Clark:
But your document is silent on the fact that the Ministry of
Health was actually in discussions and reviewing response times
with the municipalities.
Mr Peters:
That was provided to us by the ministry and that's why we asked
them to-they did write it into our report so it would be made
available to the Legislature, together with our report.
Mr Clark:
Was this report complete when you found out that the
municipalities and the province were currently reviewing, as of
March and April, response times? There's no indication anywhere
in your document under ambulance response times that the
municipalities and the Ministry of Health were sitting down and
review-ing the response times and that municipalities indeed had
been provided with the response times. Your statement is simply
to review it. They were already doing it.
Mr Peters:
Mr Clark, we have to become clear on the word "review." What we
were aware of at that particular time was that the ministry had
provided raw data to the municipalities for a joint assessment
between the ministry and the responsibility. That was an ongoing
process as we were finalizing the report. I would not categorize
that, from our perspective, as a review at that time.
Mr Clark:
Then you're going to have to help me out here. Could you provide
us with a definition of the word "review."
Mr Peters:
A review would be to take a look at the data. What we were made
aware of was that communication had taken place-
Mr Clark:
I'm sorry, you just said a review would be to be made aware of
the data?
Mr Peters:
No, a review was start-let me count back. What we were aware of
was that the ministry had provided the data. Our recommendation
was that the review should take place and at the time we wrote
our report, the review had not taken place. The first step had
been taken: information had been provided to start a review.
Mr Clark:
As I understand it, the LAISC committee was already in the
process of reviewing the numbers with the municipalities. So did
you know that or didn't you know that? This is very important to
me because it states here that you're stating that we should be
reviewing it, where in fact the municipalities were already
reviewing it with the province and it's not in your document that
that was underway.
Mr
Mishchenko: At the time that we completed our audit and
subsequent discussions with the ministry, we were aware that raw
data had been provided to the municipalities. But at that point
in time, to our knowledge, there had been no reviews of that. Our
recommendation specifically states "review current response time
requirements for reasonableness and consistency and, where
necessary, make adjustments." At that point in time, that process
had not taken place. I'm not sure where that stands today. We
understand it is still in process.
Mr Clark:
One last question, over here now. In terms of the issue of the
response times themselves, the 1996 standard has been referred to
many times: 90 percentile. How significant a variance for that
ambulance standard could that be across the province?
Mr Bates:
I think you can look at some significant-depending upon how you
define "significant." But certainly, in certain parts of the
province that are very rural, you can expect that response time
will be lengthy, versus the more urban areas of the province,
where response time can be expected to be, for instance, less
than 10 minutes.
Mr Clark:
Is it not true that the municipalities have asked us to consider
developing evidence-based standards for ambulance response times
as well as all the standards for ambulance provision of services
across the province? They want it based on evidence as opposed to
just grabbing a figure out of the air in 1996 standards. In your
community, if you had a half-hour response time in 1996, as long
as you meet that 90% of the time, you're in compliance. Isn't it
true that the municipalities want to look at a comprehensive
review of the standards?
Mr Bates:
That is true. In fact, that is what we mentioned previously, I
believe, where we drew attention to the Provincial Auditor's
report, who did in fact say that. So as I understand it, the
standards committee has looked at it and will be looking
extensively at that particular aspect of response-time
standards.
Mr Clark:
So it's the government's commitment to get municipalities to the
1996 standards while they're also negotiating with them in terms
of looking at evidence-based standard models?
Mr Bates:
I believe that is the case, yes.
Mr John Hastings
(Etobicoke North): Thank you very much, folks, for
coming in today. What I'd like to revisit is the Ambulance Act
and the rationale for re-examining it back in 1996 and prior to
that. I guess I'd divide the time-frames: "régime ancien,"
"régime nouveau". Roughly how long have you been involved,
Mr Bates, in this whole area of emergency health care?
Mr Bates:
I don't like to admit it, but 18 years.
Mr
Hastings: OK. Would it be true that in the 1990s, in the
1980s, in the 1970s, in the 1960s, even before your time, there
probably are records over at MOH that would indicate there were
redirects in Metropolitan Toronto?
Mr Bates:
Yes.
Mr
Hastings: Back 20 years ago?
Mr Bates:
I'm not sure if there are records, but I would have to say you're
probably correct.
Mr Hastings: It was a concept that
was around, if you looked in different reference libraries,
looked at hospital records, that sort of thing?
Mr Bates:
As I understand, the concept came about in the 1980s, when there
was a question of creating an emergency health services system,
which is what we have at the present time. That is, ambulance
services were basically ambulance services remote in the past and
the idea was to put it together as an emergency health system
including the hospital system, of course, so bringing all the
aspects of emergency health together. That was the impetus that
took place in the 1980s, and the Ambulance Act recognized that
and the operational methodologies that were taken into place
recognized that. The types of vehicles recognized that. The
central ambulance communication centres recognized that. All of
the emergency health system was geared toward that, making it in
fact a total system.
Mr
Hastings: Would it be safe to assume that there were
inquests back in the 1980s regarding redirects and the whole
situation that we've seen out of the most recent Fleuelling
inquest?
Mr Bates:
Well, I can certainly tell you there were inquests. I don't know
if the inquests were specifically related to redirect at that
particular point in time, but certainly the ambulance system was
in effect then, and you might expect that similar types of
circumstances took place, I think.
Mr
Hastings: My point to all these questions is that there
is an underlying thesis around here that somehow the old system,
the old centralized, top-down management that was certainly
pretty evident when I talked to people who were the private
ambulance service providers, needed a little bit of improvement
in terms of how they were treated, in terms of how the overheads
were dealt with, in terms of their professionalism-everything. In
other words, the point is that our members opposite consistently
point out that the old Ambulance Act and everything about it was
simply fantastic. There were no problems, hardly, just maybe a
little more money, and there was no problem with the way it was
centralized, the way everybody was dealt with in those days. You
were there.
1150
Mr Bates:
I was there, yes. It doesn't matter which era, there are
difficulties; there's no question about it.
If you're trying to say,
and I don't know, that the Ambulance Act as it changed in the
last few years has made significant changes, I think I would have
to say that from a quality-based standard, the Ambulance Act now
contains some very significant assurances, such as the
certification process, such as the standards which we have
here.
I would have to say to you
that, from a quality viewpoint, the Ambulance Act is much more
geared toward maintenance and the continuation of the quality of
ambulance provision.
Mr
Hastings: Do you believe we're on the right road in
terms of the improvements made through amendments to the
Ambulance Act, in terms of a different service delivery
methodology, when we get all these issues worked out in the next
two or three years?
Mr Bates:
That's a difficult question to answer at this particular point in
time.
Mr
Hastings: OK, thank you.
The Chair:
We have three minutes left. Mrs Munro?
Mrs Julia Munro
(York North): Much of our discussion has centred
obviously around the question of standards and the maintenance of
standards. I have two quick questions. Could you give us an idea
today how many private ambulance operators there are in the
province?
Mr Bates:
I believe-and you can't hold me to specifics, if you don't mind,
because there are still some private ambulance operators now in
effect that as of the official transfer date of January 1 will
change. I believe there will be in the vicinity of 20 to 25
private ambulance operators, depending upon how you define
it.
There will be contractors
such as hospitals which could also be considered to be
semi-privates, if you will, because they're now in a private
enterprise type of effort. When you have a contract with a
municipality, you have to adhere to that and it's the same type
of contract that a private enterprise or any other operator would
have to adhere to. If you were to count those, then probably
there will be 35 contract-type operators in the province as of
January 1.
Mrs Munro:
But I think we could probably describe even those examples you've
provided as public sector in the sense that yes, they may be
contracted but they would, if they were associated with hospitals
obviously, be viewed that way.
That leads me to my second
question, because obviously the whole issue of paramedic training
and the support that's provided becomes very important. I just
wondered what the government's role is or has been in that area
as well with paramedic training.
Mr Bates:
In the past, the government has been totally immersed in
paramedic training and has been the principal enterprise, if you
will, with respect to ensuring that training is done.
There are two types of
training basically. There is continuing medical education and
then there is, of course, initial training. Initial training of
paramedics has taken place through the community college system.
We work very closely with the community college system and when
an individual graduates from a community college, he or she must
pass a provincial certification examination that emergency health
services set.
There are also
organizations that provide advanced paramedic training above and
beyond community college. The Michener Institute, for instance,
has provided that in the past several years, that we have paid
for as part of the Ontario Pre-Hospital Advanced Life Support
study, which is a very important study when it comes to paramedic
training. It is designed to look at the effectiveness of advanced
paramedic skills. It's a seven-year study. We're now in the fifth
year. We expect to have,
of course, the resolution within the next two years. It looks at
advanced paramedics and tiered response provisions in 20
communities across the province and is going to determine, as I
say, the effectiveness of paramedic acts such as defibrillation,
intubation and so on.
Continuing medical
education, on the other hand, is something that is provided as
well. There are three types of paramedics: primary-care,
advanced-care and critical-care paramedics. Now, depending on the
level-there's more complex education and training required for a
critical-care paramedic than there is for a primary-care
paramedic. It varies anywhere from 16 hours a year for primary
care to 96 hours a year for the advanced-care paramedic. That is
ongoing. We have been providing that type of training through the
base hospitals and through our training officers in the province.
That will continue, although municipalities will become more
involved as they assume responsibility for the training aspects
of paramedics in the future.
The Chair:
OK, sir, we'll have to leave it at that for now. We're already
over the 20 minutes that was allowed to each caucus.
Before we break, there are
just a couple of comments that Mr Peters wanted to make, and then
I want your direction with respect to the subcommittee's
report.
Mr Peters:
My comments are largely aimed to help the researcher who has to
write a report on this to get some clarification of the
record.
The emergency services
working group final report: I believe it may have been in the
record that it's 1997; I think it was April 1998. Can I have
confirmation of that? Is that correct?
Mr Burns:
Yes.
Mr Peters:
Also, the date of the emergency care 10-point plan: I think the
press announcement, at least that we have, was dated December 20,
1999.
Mr Burns:
Yes.
Mr Peters:
I'll make everybody confused.
The last one is regarding
the review. There was an agreement between the ministry and
ourselves at the time we wrote the report. The exact wording was,
"The ministry and municipalities will jointly review the
standards." So it was future tense at that particular time.
The last point is that we
did report on problems in the ambulance area in 1996, when we
brought to the legislators' attention quite a number of problems.
It was not a perfect system.
The very last point is that
I would really like to appreciate and put on the record the
amount of work that was committed to be done by the ministry and
the update that they have provided.
The Chair:
Thank you very much.
SUBCOMMITTEE REPORT
The Chair:
We have the subcommittee report. It basically suggests that the
committee meet next December 21 to continue with the emergency
health services. Is this what you wish to do at that point in
time?
Mrs
McLeod: I don't have a problem if the committee wants to
reconvene next Thursday, but I'm just wondering, given the
January 1 date, is the committee meeting in January? Would we be
able to discuss this in January?
The Chair:
No. The committee will not be meeting, subject to the House
leaders' approval, until the last week of February, first week of
March.
Would somebody like to move
the subcommittee report? Julia, would you like to move it?
Mrs Munro:
Sure. I move that the committee meet on Thursday, December 21,
2000, to continue with Section 3.09 (Emergency Health Services)
of the special report of the Provincial Auditor if required or to
receive a briefing by the Provincial Auditor on the general audit
process and the 2000 Annual Report of the Provincial Auditor.
The Chair:
OK. So what's the wish of the committee?
Ms Martel:
I'd like us to continue with the Ministry of Health next
week.
The Chair:
Is there agreement on that? There's general agreement on that,
then. OK, good.
Mrs
McLeod: Does that mean that we proceed to the emergency
health services, then, or to the health recommendations
throughout the auditor's report?
Ms Martel:
The auditor's report.
The Chair:
To the auditor's report, the emergency health services, because
that was agreed to by the committee beforehand. So, we'll
continue with that next week. Is there a need for an in-camera
briefing at 10 o'clock? If not, we'll start with that at 10
o'clock, and hopefully we can finish it next week.
If times permits, there was
also something handed out with respect to the proposed amendments
to the Audit Act that Mr Patten asked for at the last meeting.
There is some information here that we may want to discuss either
at the end of next week to see what we want to do with that or
when we get back together in February. Agreed? Agreed.
