In the view of many, the Auditor General’s Report was revealing, welcome, and finally placed some issues in public view. All those news stories about long waits and ambulance no-shows seem to have firm foundation.
For decades the local ambulance service across the province was a mix of hospital-operated vehicles, Saint John Ambulance services, and systems in rural communities of volunteer-based services and services run by local businessmen or funeral directors! With this hybrid, there was a variety of levels of service from highly professional and efficient to fairly rough. There were some concerns with standards of service brought to government’s attention that in the mid-1990’s staff in the department of health commenced working on a plan that would provide standardization across the province.
In those days, local ambulance services operated on one-year contracts and could easily have been cancelled if performance was a problem. One seasoned operator, who served on a government advisory committee, observed that there were regulations in place but no regulatory capacity; nothing happened to those operators whose standards were problematic.
Operators who failed to meet the standards were still able to get contracts renewed with nothing happening to them. There was nothing more than admonition where there should have been discipline and contract forfeiture.
In December 2007 a new system was introduced; out with the old, in with the new. Ambulance NB was created with the promise of consistent standards, a “one size fits all”. Except that is not the way it has played out. Never, with the pre-2007 system, did we have the level of issues in the press that have appeared in recent years.
So rather than fix that which was wrong, government chose to go to the opposite extreme of a highly-expensive model built on a base of modern rolling stock and improved standards of training for personnel. As with other provinces, the EMT designation was given birth and has now become well respected and understood in the province and across the continent. EMTs and Advanced-EMT training does codify and standardize a level of skill and professionalism not seen in the pre-2007 system.
Just prior to the dramatic change, the cost of ambulance service was $35 million per annum; that would be $43.94 million today. But the budget now is $110 million. New Brunswickers must ask the simple question: is the province receiving $76 million annually in improved service standards and reliability? Listening to those in rural New Brunswick, you would think not. That the service in urban centres is superb goes without saying, although it gives the appearance of being expensive with two vehicles and three staff often responding to routine calls.
In February 2020, the NB government introduced what it hoped was the first phase of health and long-term care reform and it backfired dramatically. Amongst the central reasons for the push-back was the reputation of urban hospitals for having exorbitantly long wait times in the Emergency Departments and the rural ambulance system lack of reliability in terms of long response times and erratic service availability. Fix those problems and you make a giant step in getting acceptance of key elements of health care reform.
In the rural areas, apparently ambulances often have no staff or they have a shortage of fluently bilingual staff. What are the reasons for that? There have been stories of “trucks sitting idle” with staffed vehicles having to come from urban centres to do pick up patients.
In chatting with informed sources on the ground, there seem to be, in some places, issues of supervision and local management. Ambulance staff are like all other employees: they want to be valued, recognized, challenged, treated fairly. One EMT in a northern community, upset with management, left to take a cleaning job at lower pay rate because he could not handle the atmosphere.
Then there is the very contentious issue of the requirement for bilingual staff and the difficulty in recruiting and retaining people who are fluently bilingual. This, in the eyes of people with experience in the field, is a huge distraction. The Mayor of Belledune, who operated ambulances for many years and was involved in government advisory committees prior to 2007, agreed with other experienced first responders in observing that when people are in a true medical emergency (defined as “imminent danger to life or limb”), language spoken takes on a secondary level of importance. In reality, the accident or cardiac emergency or stroke victim simply needs to be quickly stabilized and transported to the nearest full-service emergency department for definitive care as quickly as possible. From onset to arrival at the Emergency department, the “golden hour principle” must be always respected.
In the words of some with experience, language preference has been a real distraction from resolving the real issues of managing an excellent pre-hospital emergency transportation system. It is possible to learn sufficient conversational French or English to enable the on-site stabilization and transportation to be accomplished with minimal difficulty. One seasoned first responder told me that it was common to encounter persons who spoke Russian, Mandarin, and many other foreign languages but “you just do the best you can”.
Those who insist on the right to be transported by fluently bilingual EMTs are honestly missing the point of what an excellent emergency medical transportation system is all about.
With all the issues that have been publicized in recent years, it comes as no surprise that, again, the governance model is criticized by the AG. In any organization of consequence, when the governance model lacks clarity on who is accountable for performance and to whom that person is accountable, you have a formula for disaster. So why do we wonder at the disparity between urban and rural service?
Bonus payments is, yet, another matter that may take many by surprise. Normally, the payment of bonuses follows satisfactory performance, meeting legitimate and measurable performance targets. It would seem that those outside urban centres would want an explanation of how exemplary performance has been determined and by whom?
The public believes that Medavie is a not-for-profit organization but the corporate behavior seems to suggest otherwise. The AG highlighted the bonus system which has come under fire. Then in March 2019 the Moncton Stadium was renamed Stade Bleu Medavie on receipt by UdeM of a donation of $1 million. Normally, not-for-profits do not donate to other not- for-profits, a long-established ethical principle. Medavie has a charitable foundation whose purpose is to “support programs and initiatives aimed at addressing some of our country’s most pressing physical and mental health care challenges, according to the website”.
As with all else in New Brunswick, the urban model of Health Care Service provision does not work in rural New Brunswick. In Rural Western New York State, by contrast, you will see highly professional ambulance systems in the cities being complemented in the rural areas by the volunteer fire service in which case the volunteers have acceptable, state of the art First Responder Training. And in the fire- fighting system in NB, the same principle applies in which volunteers are very well trained with weekly training updates and can be at a fire in minutes.
Could we not re-think this rural Ambulance system and put away our biases and ill-conceived notions and just fix it? Thirteen years is enough!
Ken McGeorge,BS,DHA,CHE is a retired career health care CEO, part time consultant, and columnist with Brunswick News; he is the author of Health Care Reform in New Brunswick and may be reached at firstname.lastname@example.org or www.kenmcgeorge.com
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.