Le 23 novembre dernier, la Division des services ambulanciers du SEFPO a présenté la soumission ci-dessous au Comité permanent des affaires gouvernementales pour donner suite au projet de loi 160, la Loi de 2017 renforçant la qualité et la responsabilité pour les patients.
Pour télécharger une version imprimable de la soumission (en anglais), cliquez ici.
A submission of the Ambulance Division, Ontario Public Service Employees Union, to the Standing Committee on General Government regarding Bill 160 , the Strengthening Quality and Accountability for Patients Act
The Ontario Public Service Employees Union (OPSEU) represents 130,000 members across Ontario including more than 3,000 paramedics. We are deeply concerned about changes proposed in Bill 160, the Strengthening Quality and Accountability for Patients Act. An omnibus bill with sweeping implications, Bill 160 would repeal, amend or enact more than 40 pieces of legislation. Most of the provisions of Bill 160 have undergone no public consultation. Now, it is being fast-tracked with only four days of public hearings, solely in Toronto. While we are concerned about the implications of several schedules as proposed under this legislation, this submission will focus on our concerns pertaining to Schedule 1 – amendments to the Ambulance Act (the act).
If enacted, these amendments would have a significant effect on the work of emergency medical service providers everywhere in the province. The proposed changes would give paramedics alternative options for on-scene medical treatment (namely “treat and release” and “treat and refer”), as well as more flexibility in determining where a patient is taken to receive care (i.e., an “alternative destination” other than a hospital). The changes, however, would also open the door to the use of the fire-medic model, a costly and dangerous proposal that would allow firefighters certified as paramedics to respond to emergency medical calls.
Background: the pitfalls of the fire-medic model
Issue #1: Safety
OPSEU is concerned about the safety implications of the fire-medic model for both patients and staff. One Ontario study suggests that increasing the use of firetrucks for emergency response may actually put citizens at greater risk as more large vehicles are on the roads.
Many fire departments operate on a 24-hour shift schedule. As primary care paramedics working for a land ambulance service, these employees would be accustomed to 12-hour shifts, with eight to 11 hours off in between. Under the proposed model, as fire-medics, they would be required to work 24-hour shifts, at the same level of responsibility and accountability. OPSEU questions the ability of an employee working 24 hours to be able to make split-second decisions and conduct assessments and drug calculations that are accurate and safe. The union is opposed to putting employees – and patients – in such high-risk situations.
Issue #2: Costs
OPSEU has repeatedly warned that where an ambulance is required, it is a waste of resources and a duplication of costs to send both paramedics and firefighters. The cost of expanded fire response is an increased cost placed on already-overstretched municipalities who bear 100 per cent of the cost of providing fire services. In the fire-medic model, municipalities also pay an extra cost for the additional wear and tear on firefighting equipment.
Issue #3: Employment standards
Paramedics are not exempt from the hours of work, daily rest period, time off between shifts, and weekly/bi-weekly rest period provisions of the Employment Standards Act. Firefighters are exempt from all of the above. Where the act sets minimum standards and rules for land ambulance service, these standards and rules must not be ignored or exempted.
Issue #4: Patient outcomes
There is no Ontario-relevant evidence to support fire as first response for any CTAS 1 (highest urgency) patient other than sudden cardiac arrest (which comprises approximately one to two per cent of all EMS calls). No Ontario studies provide medical evidence that fire response makes a significant difference in patient morbidity and mortality.
It is important to note that expanded fire involvement does not fix any of the issues that exist with the current dispatch system, hospital offload delays, or current community demands. The province should focus its attention on addressing these issues.
Bill 160: New exemptions and directives would facilitate use of the fire-medic model
The OPSEU Ambulance Division has been vocal about the pitfalls of the fire-medic model and has called for positive changes to our emergency medical services that will improve patient care. Yet the provincial government has chosen to move forward – despite an utter lack of evidence and support – to implement the model. Currently, Bill 160 is being used to clear the path for pilot projects by introducing exemptions into the Ambulance Act. Section 8 subsection (3) of Bill 160 states that:
Subsection 22 (1) of the [Ambulance] Act is amended by adding the following clause: (f) exempting any class of persons, services, conveyances, vehicles or equipment from any provision of this Act or the regulations and attaching any conditions to any such exemption, including exemptions for the purpose of pilot projects.
OPSEU is deeply concerned by this move to expand the powers of the Lieutenant Governor in Council to allow exemptions. This is particularly concerning because the standards established in the Ambulance Act exist for a reason: to ensure the highest level of patient care and safety. Exemptions move away from established and expected standards and could place patient care and safety at risk.
Schedule 1 also introduces a new section 7.0.1, which gives the Minister of Health and Long-Term Care the power to issue operational or policy directives to the operator of a land ambulance service, where the minister considers it to be in the public interest to do so. Operators must comply with these directives, which may be general or particular in application – they could be directives around alternative destinations, treat and release or treat and refer. In fact, the example provided in the legislation is a directive regarding “responsibilities to facilitate the adoption of treatment models for persons with lower acuity conditions.” Currently, the Fire Protection and Prevention Act (FPPA) states that firefighters can perform “fire protective services” which can include “rescue and emergency services.” The permissive language of “emergency services” has allowed firefighters to perform some medical tasks; “persons with low acuity conditions” could easily fit into this definition.
This change – along with the introduction of the exemption clause – makes the government’s intentions clear. What remains unclear is how the government plans to implement this plan in practice. To date, no municipality has agreed to run a pilot project; the Association of Municipalities of Ontario (AMO) remains vehemently opposed to this costly and dangerous plan.
Schedule 9: the creation of “community health facilities” impacts the delivery of Emergency Medical Services
While we have several concerns about the liability and safety implications resulting from the proposed changes under Schedule 1, these changes are particularly troubling within the broader context of expanding private clinics and hospitals, as proposed via the Oversight of Health Facilities and Devices Act (OHFDA) under Schedule 9. This legislation would facilitate the use of privatized clinics for patient care, and further cuts to public community hospitals as a result.
The minister would have the power to issue directives for the provision of fire-medic emergency medical services, with the newly rebranded “community health facilities” functioning as “alternative destinations” under section 7.0.1. This is dangerous. The Schedule 1 amendment addressing directives for alternative destinations must clarify that all alternative destinations to which paramedics would transport patients must be non-profit, public facilities, and only in clearly defined circumstances.
Ministerial power to establish new user-fees
Despite assurances of no additional costs to patients, Schedule 1 would add a new section 22.2(1) to the act, which states that:
The Minister may, by regulation, establish fees that may be charged for each class or kind of service provided by the operator of each class of ambulance services, may determine the methods and times for payment of such fees, may determine by whom such fees may be charged and may determine the classes of persons to whom the fees may be charged.
This would give the minister the power to establish fees and to determine who may charge the fees and who may be charged. This amendment has the potential of increasing costs for EMS users. Currently, EMS operators may charge up to $45; the amendment places added power into the hands of the minister, who may now establish new fees for service. As previously stated, no municipalities have agreed to initiate a pilot project. We have anticipated that some form of incentive would be designed by the province to entice the municipalities into compliance with their mandate – regardless of cost, no doubt. Under section 22.2(1) the Minister could allow the “delivery agents” (municipalities) to charge fees as a local revenue-raising tool; this would give them the capacity to cover the extra cost of the fire-medic model, but could also be used as a general revenue-raising tool. We are concerned that this will be used as a bargaining chip to entice the municipalities. Any new fees charged would be in addition to potential municipal tax increases that result from the additional cost pressures placed on municipalities who operate fire-medic services.
In addition to our concerns, we have made it very clear that OPSEU’s Ambulance Division would only support legislative amendments under the following criteria:
- The “treat and release” and/or “treat and refer” of any patient would only be performed by a paramedic and with that patient’s full consent. Otherwise, the patient would be required to complete a “refusal of services” or be transported immediately to hospital.
- Patients would only be transported by paramedics to “alternative destinations” with the patient’s full consent. Otherwise, the patient would be required to complete a “refusal of services” or be transported to hospital.
- All alternative destinations to which paramedics would transport patients must be publicly funded facilities.
- Paramedics working in community paramedic programs would only respond to patients identified through the 911 system. The purpose of these programs is to augment and improve existing emergency services, and to ensure that all patients receive the right care, by the right professional. Community paramedic programs should not encroach on other workers’ rights or responsibilities.
- Where patients meet the established criteria for “treat and release” or “treat and refer,” but do not pursue the prescribed follow-up, paramedics and communications officers cannot be held responsible.
It is important to note that all the unions representing paramedics are united in our opposition to the fire-medic model. Together, we are resolved to ensure that any changes to the Ambulance Act and its regulations actually improve emergency medical services and remain in the best interest of patient care and safety.
Despite repeated warnings about the high costs and dangers of implementing a fire-medic model in Ontario, the government is moving forward with this plan, as evidenced by the proposed changes to the Ambulance Act under Schedule 1 of Bill 160. Exemptions and ministerial directives have been established to facilitate pilot projects that introduce this problematic model. This is particularly disconcerting considering the broader implications of the Bill, and as previously stated, OPSEU’s Ambulance Division would only support the transport of patients to fully public, non-profit facilities. Additionally, there are proposed changes to the Ambulance Act that would facilitate the proliferation of patient user fees. OPSEU is concerned that section 22.2(1) has been included as a revenue-raising incentive for municipalities, who to date have been starkly opposed to the introduction of the fire-medic model.
Bill 160 facilitates the introduction of a potentially costly and dangerous scheme. Support for the plan is virtually non-existent, and the government has failed to outline any practical implementation strategy. There exist many outstanding questions around liability and safety issues, including ones that the government may not yet have considered.
OPSEU’s Ambulance Division is focused on changes that will improve the EMS system. We continue to call on the Ontario government to improve the system in the following ways:
- by funding ambulance services to meet demand that is growing by six per cent a year;
- by providing our 911 dispatch system with better tools to prioritize calls and deliver the right care, at the right time;
- by increasing the number of single-paramedic response units, backed up by ambulances, to reduce the response time in emergencies;
- by building a registry for life-saving defibrillators and supporting more public defibrillators and CPR training; and
- by expanding community paramedic programs that deliver non-emergency, in-home services and help reduce the number of 911 calls.