SPECIAL REPORT, PROVINCIAL AUDITOR
MINISTRY OF HEALTH AND LONG-TERM CARE

SUBCOMMITTEE REPORT

CONTENTS

Thursday 14 December 2000

Special report, Provincial Auditor

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.

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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.

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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.

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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.

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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 Bates: Adjoining upper-tier municipalities? Yes.

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.

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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.

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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.

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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.

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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.

Meeting adjourned.

The committee adjourned at 1200.