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Alberta Federation of Labour The Alberta Federation of Labour is pleased to have the opportunity to make a submission to the MLA Review examining the delivery of ambulance service in the province of Alberta. The Federation is comprised of most of the province’s major unions; representing 80,000 unionized workers and their families in Alberta. Our members are affected by changes to the provision, delivery and legislation of emergency medical services in many ways. As workers who provide these types of medical services, as well as those Albertans requiring emergency medical attention, our members contribute to and benefit from well-funded, accessible ambulance operations. Delivery of Ground Ambulance Services: Governance Model Under the current legislation, the authority to administer ambulance services has been granted to the municipalities. Within the province’s Municipal Government Act, cities, towns, villages and counties have the power to establish ambulance services and to determine the level of those services. As a result of this governance model, differences in the delivery of and access to ambulance services are apparent across the many municipal jurisdictions. In rural and smaller municipalities, the public infrastructure may be either unavailable or unable to sustain the provision of an ambulance service. This has led many of these municipalities to contract-out the service to private companies. In contracting out a public service to a private service provider, a municipality relinquishes some of its ability to ensure adequate service and access levels. In urban centres, a varied approach has been taken in establishing and administering emergency medical services. In these jurisdictions, ambulance services have been separately established, created as amalgamated services and merged with municipal fire departments, or formed as a service under contract with a Regional Health Authority (RHA). Under these types of arrangements, emergency response professionals often work collaboratively in meeting the emergency medical needs of patients. The levels of access and service are generally higher in these areas. By legislating municipalities the power to establish and administer emergency medical services, specifically ground ambulance services, the province has created jurisdictional inequity. Staffing, response time, accessibility, and generally, the level of service one receives will depend, in large part, on where one lives. In order for the province’s healthcare system, and the services provided under that system to be ‘universal,’ Albertans should have the same levels of access to those services, regardless of where, geographically, in the province they are located. The Federation believes that in order for there to be jurisdictional equity with respect to ambulance services, the current governance model should be reformed to establish the following:
Existing Standards for Emergency Medical Services: Level of Service The standards contained within the Ambulance Services Act sets forth a "floor" or minimum for which ambulance service is run in the province. Like any minimum standards, there is an inherent danger that standards pertaining to ambulance service may be set to a point so low that the line separating ‘adequate’ service and ‘inadequate’ service is blurred. This creates a situation where patient care and access may be negatively impacted due to some ambulance operators choosing only to meet the minimum regulations. This is not to say that ambulance operators are haphazardly choosing to offer inferior levels of service, but rather that they may have little choice but to offer lower levels of ground ambulance service because that is all that they can afford. Many municipalities have established higher levels of service because of population requirements, so it seems that it may be necessary to review the current legislation to ensure all municipalities are legislated to provide service at somewhat higher levels. RECOMMENDATION: The Federation recommends a review of the Ambulance Services Act to ensure the standards pertaining to ambulance operators, ambulance attendants and ambulance equipment are strengthened. RECOMMENDATION: The Federation recommends that the province determine the level of ambulance service required in each jurisdiction. Medical Direction The current legislation has created an important role for medical directors in the administration of ambulance services. By guiding and directing ambulance operations, medical directors play a large role in shaping the type of emergency medical services patients are able to access. The medical protocols, which are given to these directors as resources, play an equally important role. The difficulty lies in the fact that medical directors are under no legal obligation to implement and meet these provincially derived guidelines. Medical directors are given the power to adapt and change protocols without having to justify these decisions. Adaptations to these protocols may affect the provision of ambulance services. RECOMMENDATION: The Federation recommends that medical protocol guidelines become a set of legislated standards. Further, the Federation recommends that medical directors be legally obligated to implement and observe any and all legislated medical protocol guidelines for ground ambulance service. Communication and Dispatching Ambulance dispatchers are increasingly called upon to provide emergency medical advice and direction to callers. Jurisdictions without the staff able or available to provide this type of service are, in some respect, failing to provide a ‘complete’ ambulance service. Ambulance dispatchers also provide an important link between ambulance attendants and patients. Differences between the dispatching systems across the provincial jurisdictions create difficulties in providing seamless, effective communication between the receivers and providers of emergency medical attention. RECOMMENDATION: The Federation recommends that regional dispatching centres be established in the province of Alberta. It is further recommended that these dispatching centres ensure all communication and dispatching personnel are trained and skilled in providing on-line medical advice and instruction. Patient Access As stated previously, the geographical and jurisdictional differences in ambulance service adversely affect Albertans living in areas not complemented by a well-established emergency medical service. In order for there to be parity in patient access, the size and scope of a jurisdiction’s ambulance service should be based on a criteria that includes:
RECOMMENDATION: The Federation recommends that the province reassess ambulance service needs using the following criteria: geographical area, population density and population growth, emergency medical call frequency, and distance to the nearest emergency medical facility.
Over the years, municipalities have seen their responsibility for the provision of public services increase. While the public services municipalities provide has increased, the levels of funding available to provide theses services has remained relatively unchanged. Simply, municipalities have to do more, with relatively much less. Despite this, many municipalities have continued to provide as good an ambulance service as they can reasonably afford. Because of the differences in ambulance service between the various jurisdictions, it is difficult to make specific suggestions for improvement. The ambulance needs of each jurisdiction is driven, in large part, by the population it serves. Inefficiencies in rural areas cannot be improved by using the same methods employed to fix problems in urban centres. It may be beneficial for the province to consult with the various municipalities, and undertake an appropriate analysis of ambulance service levels and delivery models. RECOMMENDATION: The Federation recommends that the province consults with the municipalities, and undertake an appropriate analysis of ambulance service delivery, and the use of ambulance and emergency medical resources. We believe that one way to alleviate some of the strain placed on ambulance service resources is to increase the amount of provincial spending dedicated to areas that include community-based health services, interfacility transfers, and public health initiatives and education. By increasing the resources in these areas, one allows for ambulance services to focus on providing emergency medical attention to those requiring it. RECOMMENDATION: The Federation recommends that the province increase its spending in the areas of community-based health services, interfacility transfers, and public health initiatives and education.
Ambulance services derive their funding from a variety of sources. Whether funding is through municipal grants, through Alberta Health and Wellness, the Federal government, user fees, third party insurance, or a combination, the funding and fee schedule is neither homogeneous nor simple in any jurisdiction. Despite ambulance service being an integral part of a well-functioning provincial healthcare system, more times than not, it is both the municipalities delivering the ambulance service and those patients requiring the emergency medical attention, who bear the brunt of the funding burden. Ambulance providers are able to set fees by whichever means they feel necessary, basing costs on level of service, equipment and supplies used, as well as distance travelled. These costs are different in each municipality. For someone who is in need of emergency medical attention, a cost-benefit analysis is generally not something that would be undertaken prior to calling for an ambulance. Instead, a patient must hope that Alberta Health and Wellness, or one of a few other government agencies will cover their trip. Barring this, a patient must then rely upon third party insurance. Should the patient not have this type of medical benefit, any ambulance fees will result in out-of-pocket costs for the patient. There are problems with this scenario:
Source of Funding To ensure Albertans have equal access to ambulance service, there should be one source of funding. This funding should come from the provincial budget areas dedicated to Health and Wellness. RECOMMENDATION: The Federation recommends that funding for ambulance service in Alberta becomes the responsibility of the provincial government. Rate for Ground Ambulance Service To ensure equitable ambulance rates, there should be a single rate for the use of ground ambulance service, only when Alberta Health and Wellness or the Federal government does not cover fees for ambulance services. Ambulance providers and operators should not be allowed to charge any additional fees to clients of other government-sponsored programs. RECOMMENDATION: The Federation recommends that a single rate for ground ambulance services be established in the province of Alberta. User Fees User fees should not be levied for those patients accessing ambulance services in the province. By implementing user fees, some Albertans will be denied access to ground ambulance services. Medically Necessary and Medically Unnecessary The Federation acknowledges the importance of ensuring that all Albertans who need ambulance services are able to access it in a timely manner. The Federation also understands the need to ensure Albertans are not burdening the system with unnecessary requests for ambulance services. To deter the unnecessary use of ambulance service in the province, the Federation is recommending the following: Medically Necessary: Patients for whom ambulance service is medically necessary will have the entirety of their ambulance costs covered by the Province of Alberta’s Department of Health and Wellness or the applicable Federal Government agency. Medically Unnecessary: Patients for whom ambulance service is deemed medically unnecessary will be responsible for the cost of ambulance services. This cost will represent the single rate established by the province for ground ambulance service. RECOMMENDATION: The Federation recommends that the province establish guidelines for ambulance services that will define what will be deemed to be "Medically Necessary" and "Medically Unnecessary." Designation of Emergency Medical Services as an Essential Service In most cases, ambulance workers (paramedics and emergency medical technicians) are represented by unions, and as such are afforded the right to bargain collectively. Unfortunately, the provincial government is now considering changes that would see all ambulance functions designated as "essential services." This would mean that unionized emergency medical workers would no longer have the right to strike. The AFL is strenuously opposed to these changes for several reasons. First, we oppose removing the right to strike from emergency medical personnel because such a move would undermine their rights as workers and citizens. We believe that the right to bargain collectively is a fundamental democratic right that must be enjoyed by all working people. However, collective bargaining without the right to strike is meaningless – it shifts the power balance decisively in favour of employers. So, if the government removes the right to strike, they are also effectively infringing on the right to bargain collectively. It is our submission that these kinds of restrictions cannot be justified in a truly democratic society. Second, we oppose any move to outlaw strikes because it will inevitably undermine the bargaining process and poison relations between employers and workers. When workers have the right to strike there is a clear incentive for both parties to compromise and work towards agreement at the bargaining table. The workers compromise in order to avoid loosing wages – and employers compromise in order to avoid loosing profits and/or the ability to provide certain services. However, in situations where workers do not have the right to strike, the employer has no real incentive to bargain in good faith. This is exactly what happened during the recent paramedics’ strike in Edmonton. When the provincial government announced in March that it was considering expanding the "essential service" designation to cover ambulance workers, negotiations came to screeching halt. One union official described what happened in this way:
These comments summarize one of the central problems with so-called "essential service" legislation. Without the right to strike, workers are rendered virtually powerless and bargaining turns from a process of negotiation into a parade of ultimatums, threats and "final offers" from management. The whole point of bargaining is to reach an agreement that is acceptable to both parties – but under a system that relies on strike-bans and binding arbitration, the final agreement is almost never acceptable to workers. The result is festering resentment and lowered morale among employees and a poisoned relationship with management. Paramedics in Edmonton are now talking about feeling "under-valued" and "brushed off" by the City. These are exactly the kinds of frustrations that can be expected to spread across the province if the right to strike is denied to all emergency medical workers. The third and final objection that we will raise to expanding the "essential service" designation has to do with protecting the public good. People familiar with contract negotiation – especially those in the public sector – know that monetary items like wages and pensions are not the only issues brought to the table. Often, workers are more concerned about things like work load, staffing and access to the best possible equipment. All of these things have a profound impact on the quality of service provided to the public. Unfortunately, in a system where the employers refuse to bargain, these issues are unlikely to be addressed. Once again, the recent paramedics’ strike in Edmonton provides a good example of the problem. The paramedics wanted to talk about inadequate staffing levels and the shortage of ambulances on Edmonton streets – especially when compared to Calgary. But because the City was refusing to bargain in good faith, these issues were never addressed. Clearly, the public would have benefited from an open and frank discussion between management and the union on these issues. For example, if the union had been able to win a promise of more ambulances, the quality of service available to Edmontonians would have improved. But that didn’t happen – largely because the City was relying on a strike-ban and binding arbitration to force a deal on the paramedics. This was a clear example of how removing the right to strike is not in the public interest. Of course, supporters of revising Alberta’s essential service designation will say that removing the right to strike from ambulance workers is a matter of public safety. But, with all due respect, we see that argument as nothing more than a red herring. The reality is that more than 98 percent of contract negotiations in Alberta are settled without strikes – and there is no reason to believe that those numbers would be any different with ambulance workers. What’s important is the prospect of strike – it compels both parties to bargain even if a strike never actually materializes. Furthermore, even in the unlikely event of a strike, experience shows that there is no serious risk to patients or the public. That’s because unions regularly work out agreement with employers to provide skeleton or emergency staffing during strikes. For example, when a military Hercules went down during an Edmonton ambulance strike in the mid 80s, the striking paramedics immediately put down their picket signs and went back to work for the duration of the emergency. A similar commitment regarding emergency service was made during the more recent paramedics’ strike. That’s not to say, of course, that strikes by paramedics won’t disrupt ambulance service – it’s obvious that they will. All we’re saying is that the benefits of maintaining the right to strike (in terms of defending basic democratic rights, fostering better labour relations and protecting the public good) far outweigh the drawbacks. RECOMMENDATION: With all this in mind, we urge the provincial government to fully recognize the collective bargaining rights of ambulance workers in Alberta. That means recognizing both their right to bargain and their right to withdraw their labour. We further encourage the government to eliminate all so-called "essential service" clauses from its labour laws (both the Labour Relations Code and the Public Service Employees Relations Act) and grant all organized workers in Alberta the right to strike. Concluding Remarks We would like to thank the MLA Review of Ambulance Service Delivery for requesting the Alberta Federation of Labour provide comments and recommendations. We hope that our input will assist in shaping the future delivery and governance of ambulance operations in the province. Respectfully submitted, Alberta Federation of Labour |