Paramedic Services in Canada: Structure, Privatization, Unionization and other issues

Governance and Funding:  While police and fire services are usually municipal services, Emergency Medical Services (EMS) are typically controlled by provincial governments.  In Ontario, regional municipal governments have responsibility for delivering and funding EMS.  But even in Ontario the province plays a key role, strictly regulating EMS, providing funding for 50% of the approved land ambulance costs, and paying 100% of the approved costs for air ambulance, dispatch, base hospitals, First Nation EMS, and for territories without municipal government.

Delivery:  Like police and fire services, EMS is predominantly a publicly provided service in Canada.  

But businesses have now made some significant in-roads into EMS, primarily Medavie, a private corporation based in the Maritimes that describes itself as not-for-profit. 

Medavie goes back over 70 years, with its roots in health insurance.  It still operates Medavie Blue Cross with 1,900 employees. 

It now also operates the Medavie EMS Group of Companies and is aggressively expanding its EMS operations into new territories.  In 1997 it began operating EMS in Nova Scotia through a contract with the provincial government.  It expanded into the operation of Island EMS in Prince Edward Island, also through an exclusive contract with the provincial government. 

Ambulance New Brunswick, a provincial crown corporation, employs the province’s paramedics and EMS communications officers.  But Medavie manages EMS on behalf of Ambulance New Brunswick.

Medavie operates Prairie EMS in Fort Saskatchewan, Elk Point, Two Hills, Lamont, Andrew and Vermilion Alberta.  Now (starting May 1, 2015) they are moving into the St. Paul, Alberta. 

In Ontario, Medavie operate three services.  They started with Muskoka in 2009 and later added Chatham-Kent, and in January 2014 Elgin County. 

Also in January 2014, Medavie entered Saskatchewan via the purchase of MD Ambulance which serves the Saskatoon health region with 150 employees, 28,000 patient trips, and 21 vehicles. Medavie EMS has now also moved into Massachusetts.

Despite the in-roads by Medavie into Ontario, municipal governments usually directly deliver EMS in Ontario.  First Nation communities also provide some services as do some hospitals under contract with municipal government.  Air ambulance services are provided by ORNGE, a provincial crown corporation which recently became entangled in scandals driven by the partial privatization of its operations.  EMS communication services are sometimes provided by EMS services (e.g.in Toronto, Ottawa, Niagara, Kenora, and North Bay) but are still provided by the provincial government employees in most other areas. 

·    In B.C., EMS air, land, and communication services are provided by the B.C. Ambulance Service, a provincial organization. 

·    In Alberta, land ambulance has been the responsibility of the provincial health authority, Alberta Health Services (AHS), since April 2009.  AHS deliver most EMS, but contracts some work to a handful of for-profit or municipal EMS operators.  AHS also contracts 12 fixed-wing aircraft to provide air ambulance services.

·   In Saskatchewan, land ambulance services fall under the regional health authorities.  The health regions directly provide EMS, but also contract other EMS providers. 

·    In Newfoundland, the four regional health authorities are funded by the province to provide air and land ambulance services. 

·    In Quebec, Urgence-santé, a non-profit organization with a board appointed by the provincial government, provides EMS to Montreal and Laval and responds to 40%-50% of Quebec’s EMS calls.  Outside of Montreal and Laval, private companies and cooperatives provide EMS. 

·   In Manitoba, land ambulance services are delivered by regional health authorities or other service providers contracted by a regional health authority (e.g., municipalities or First Nation communities).  Shock Trauma Air Rescue Society (STARS), a charitable, non-profit organization, provides emergency medical air transport for critically ill and injured patients.  

Issues:

Pensions:  CUPE paramedics helped win changes to the federal Income Tax Act that extended the definition of “public safety occupations” to include paramedics.  Previously the category was restricted to police officers, firefighters, correctional officers, air traffic controllers, and commercial airline pilots.  Public safety occupations are eligible for a normal retirement age of 60 (“NRA 60”) rather than the more common “NRA 65” pension.  Getting employers and pension plans to implement this has proven challenging in the current environment, given that NRA 60 plans are typically more expensive.  In Ontario, a proposal was made in April to the municipal pension plan (OMERS) simply to allow an employer to provide NRA 60 benefits to paramedics under the pension plan.  But the employers defeated this proposal.  The B.C. Public Service Pension Plan confers enhanced early retirement benefits on members of the British Columbia Ambulance Service, as negotiated by CUPE Local 873 in 1995. The provision allows paramedics to retire as early as age 55 without penalty or reduction where the member has age plus years of contributory service equal to 80.

Health and Safety:  Concern about EMS health and safety issues has sky-rocketed.  CUPE EMS members have been closely involved in a legislative campaign in Ontario to ensure EMS staff have access to workers compensation when Post Traumatic Stress Disorder (PTSD) occurs.  Health and Safety problems with lifting of patients and equipment, road side safety, violence, and cube van design are also significant issues for EMS staff. 

Appropriate Oversight:  With increasing responsibilities, there has been increasing oversight of EMS.  There is significant concern that there are too many (conflicting) levels of oversight of EMS staff by employers, provincial governments, base hospitals, and others.  These levels of oversight do not always allow due process for EMS staff and EMS staff sometimes face double, or even triple, jeopardy from the different levels of EMS oversight.

Firefighting and EMS:  As austerity cuts into municipal budgets, fire fighting has sometimes unfortunately been hit with cuts. Moreover, better buildings have mitigated fire calls.  Some  have advocated expanding the fire industry into emergency medicine, creating some concerns.  

Free and fair collective bargaining:  The number of EMS staff allowed by law to strike is often tightly restricted, reducing their bargaining power.  At the same time, some employers are trying to change the laws governing interest arbitration to bias that process against employees who are required by law to settle contract disputes through interest arbitration.  Police and fire typically settle disputes through interest arbitration.

Private patient transfers:  CUPE and other unions have been able to achieve significant wage increases for EMS staff.  At the same time, the demand for EMS has grown, as well as the skill and qualifications of EMS staff.  Health care restructuring has also increased inter-facility patient transfers.  These changes have encouraged the rapid growth in the private, for-profit patient transfer business.  Public oversight of the private transfer companies is often lacking and the service provided by these private companies is often inadequate.  The workers in this industry are often non-unionized and poorly paid. 

EMS shortages:  “Offload delays,” where paramedics must remain at emergency rooms while they wait to hand off patients to hospital staff, are common, often driven by hospital under funding.  Demand for EMS is increasing.  As a result, long waits for EMS sometimes occurs.  Indeed, on occasion, no ambulances are available to respond to 911 calls in certain areas. 

Community Paramedicine:  There is increasing interest in using paramedics in non-emergency situations, notably by visiting patients like frail seniors with multiple chronic conditions in their homes to prevent illnesses or accidents from occurring.  A key goal is to reduce 911 calls and hospital admissions.  These programs allow paramedics to apply their skills beyond the traditional role of emergency response.  For example:

• Visits to the homes of seniors known to call emergency services frequently, to provide services such as ensuring they are taking their medications as prescribed.

• Educating seniors in their homes about chronic disease management and helping to connect them to the appropriate local supports as needed.

Bargaining:  CUPE is the largest union of EMS staff in Canada, representing over 8,000 workers in the industry.  For about three-quarters of these members, this is through EMS-only locals, with the other quarter in broader municipal or health care locals.

CUPE represents all EMS staff in B.C., New Brunswick, PEI, most EMS staff in Ontario, and some EMS staff in Alberta, Saskatchewan, and Newfoundland.  Other unions with EMS members include:  the International Union of Operating Engineers, Confédération des syndicats nationaux, some affiliates of the National Union of Public and General Employees, UNIFOR, the International Association of Fire Fighters, and the Service Employees International Union.   

CUPE also has some police officers and firefighters in the Maritimes and some police administrative staff in BC and Quebec.  Many other police are represented by police associations, and many other firefighters are represented by the International Association of Fire Fighters.

In New Brunswick and B.C., CUPE EMS locals bargain as part of a broader health bargaining group.  In B.C., the government has recently placed the members of EMS CUPE local 873 in the Facilities Bargaining unit with approximately 47,000 workers employed in hospitals and other health facilities.  In New Brunswick, the CUPE EMS local bargains as part of the CUPE hospital group.  

In some cases in Ontario, EMS workers are part of broader municipal or hospital bargaining unit (e.g. Toronto, Ottawa, York, Durham, Sudbury, and North Bay).  In other cases, Ontario EMS members are in EMS-only units (e.g. Niagara, Windsor-Essex, Renfrew County, Sault Ste. Marie, Hastings, and Cornwall).  In Alberta, CUPE EMS locals are in stand-alone bargaining units, including units for three municipal EMS employers (St. Paul and District, Town of Vegreville, Beaver County) and one for-profit EMS employer (Associated Ambulance).  Some CUPE EMS staff are found in broader health authority bargaining units in Saskatchewan and Newfoundland and Labrador. 

Typically, EMS staff have a very limited right to strike by law.  In some cases interest arbitration is used to settle bargaining disputes.  Changes were made to the Labour Act of PEI in December 2010 in which the government legislated away the right to strike for paramedics and replaced it with interest arbitration.  Hospital paramedics in Ontario are also required to use interest arbitration.  Some municipal EMS providers in Ontario also use interest arbitration through voluntary agreement of the union and employer. 

CUPE Local 1764 (representing Region of Durham “inside” workers) was forced to go on strike during this past summer to deal with an attempt by the employer to reduce paramedic sick leave.  CUPE paramedics in PEI had an interest arbitration hearing with Kevin Burkett on July 4.  In May of 2014, an agreement for B.C. Health Facilities was reached which continues separate provisions for EMS staff.  The main issues at the Facilities table were job security, protection of benefits, health and safety and changes to the ambulance service.

Community Allies and Success Stories:  There is widespread community concern about EMS response times.  The public understands that adequate EMS is vital for their health.  As a result, community concerns sometimes drive service growth in the sector.  For example, in New Brunswick in October 2013, the employer announced the layoff of six paramedics in a rural area, Grand Lake.  But through work with local municipalities, rallies, street-side meetings with local community members, refusals to do unsafe work, and meetings with local politicians, Local 4848 was able to reverse the cuts to services and stop all the layoffs.  The prestige of EMS in the community can help command significant media attention.

In Ontario, despite significant government austerity, we have achieved some growth in the staffing of EMS (3% growth in staffed hours per 1000 population over the last two reported years).  Need, however, is growing at a rapid pace.

Photo:Fryderyk Supinsk