March 30, 1998

 To:Emergency and Protective Services Committee

 From:Alan F. Speed, Fire Chief, Toronto Fire Services

Ron Kelusky, Acting General Manager, Toronto Ambulance Services

 Subject:Fire/Ambulance Services Consolidation Options

 Purpose:

 To present to Toronto Council a qualitative assessment of the major options available with respect to the possible integration of components of Toronto=s Fire and Ambulance Services.

 Funding Sources, Financial Implications and Impact Statement:

 There are no immediate financial implications on the present operating or capital budgets of either of the two services. However, the current consolidation initiatives taking place between the fire and ambulance services are expected to yield longer term financial savings and service delivery efficiencies.

 The initiatives which are planned and which have already been undertaken in this area are precedential for the corporation, and for emergency services in Ontario. A very successful historical working relationship between fire and ambulance services in Toronto is being enhanced, while unique service delivery characteristics are being maintained. In the end, it is the public who will benefit from these efforts.

 Recommendations:

 It is recommended that:

 (1)this report be received for information; and

 (2)it is the respectful opinion of both the Chief of the Toronto Fire Services and the Acting General Manger of the Toronto Ambulance Services that Model One - Strategic Partnership - described herein continue to be adopted as the consolidation model of choice in any discussions or planning about integration of fire and ambulance services.

   Council Reference/Background/History:

 At the first meeting of the City of Toronto=s Emergency and Protective Services Committee held January 13, 1998, a decision was made to establish working sub-committees so that contact could be established with particular services - for the purposes of dealing with specific service issues -on a more frequent basis than the regularly scheduled monthly meetings of the E&PS Committee.

 At the Fire and Ambulance Sub-Committee meeting held on January 30, 1998, a request was made of the Chief of the Toronto Fire Services and the Acting General Manager of the Toronto Ambulance Services to prepare a joint report outlining the potential options for greater integration - including possible full amalgamation - of the two emergency services.

 The Experience of Other Jurisdictions:

 A timely comparison for the possibility of full amalgamation exists in the City of Edmonton (note that because of the differences in health care systems, comparisons with jurisdictions in the United States are not equitable). In 1993, the City of Edmonton directed that its fire service undergo amalgamation with its ambulance service, based on dual, cross-trained emergency providers (i.e. firefighters performing ambulance work, and vice versa). Prior to that point, both services were run separately.

 After four years of operation, a number of problems were identified. These included training problems, >cultural= problems, labour relations problems, workload problems, accountability problems, and management discord. In 1997, an independent review was commissioned and concluded that the amalgamation should never have taken place. Further, it identified that fire and ambulance services are too different to be conducive to amalgamation.

 Today the Edmonton fire and ambulance services operate as two distinct disciplines, but under the same administrative umbrella. This is very similar to the model that the Toronto Fire and Ambulance Services are striving to achieve within the Works and Emergency Services cluster.

 Comments and/or Discussion and/or Justification:

 The Toronto Fire and the Toronto Ambulance Services have a decades long history of providing top quality and efficient emergency service to the residents of the City of Toronto. Both services have developed and grown as uniquely separate entities, mirroring the operating and organizational practices of almost all other fire and ambulance services in Canada. At the same time, both services have established agreements of cooperation with respect to certain aspects of their respective service delivery. >Tiered response= - where fire service resources are responded (along with the police service) to potentially life-threatening medical calls - is the most prominent example of this degree of cooperation. Through >tiered response= those citizens of Toronto suffering from serious illness or injury receive the benefit of the closest, medically capable resource available, be it police, fire or ambulance.

  But while both organizations are classed as >emergency services=, beyond that shared title both are very different. While their service delivery may intersect on specific calls, their operating mandates - and the organizational structures which have been constructed around them - remain very distinct. To date, this approach, and its differences, has served the public exceptionally well.

 Service Overview - Operating Mandate - Toronto Fire:

 The Toronto Fire Services are responsible for maintaining life and safety through comprehensive fire protection and fire prevention programs. The overall objective of the fire department is to provide the community with the optimum level of protection from fire and other related public safety hazards.

 Because fire fighters are usually the first responders to most types of emergencies, the Toronto Fire Services have evolved into a total rescue service that involves many diverse functions: fire suppression and rescue (auto extrication, water and ice, machinery, high angle, confined space, trench, and heavy urban search and rescue), pre-hospital emergency medical services, hazardous materials control, response to terrorist incidents, emergency planning, preparedness and response.

 Toronto Fire fulfills its legislative responsibilities under the authority given by the Fire Protection and Prevention Act of Ontario.

 Service Overview - Operating Mandate - Toronto Ambulance:

 The Toronto Ambulance Service is responsible for the provision of emergency care and transportation to those individuals who experience sudden injury or illness. It=s primary focus is medical. In actual fact, ambulance service in Ontario is, in the first instance, viewed as simply an extension of the health care system, as comprehensive out-of-hospital health care. Toronto Ambulance also provides non-emergency care and transportation, as directed by provincial legislation.

 Its service activities are exclusively geared to the response to, and treatment of, all out-of-hospital medical and trauma calls. It also maintains and deploys disaster resources to any large scale incident in the City and, as may be needed, to elsewhere in the Greater Toronto Area. It provides specialized medical support to other agencies, as required (e.g. to the Emergency Task Force of the Toronto Police).

 Toronto Ambulance fulfills its legislative responsibilities through the Ambulance Act of Ontario and its regulations, as well as through the Mental Health Act, the Health Insurance Act and the Health Facilities Act. Medical oversight exists through the College of Physicians and Surgeons, by way of designated >base hospital= medical control.

 Service Similarities:

 As indicated, both the fire and ambulance services are >emergency services=. Often times, the public perception is that they are quite similar in their service delivery, since both will appear and work together at the same type of emergency call. At such calls, the responders of each service work as a team, undertaking clearly defined roles and responsibilities, roles which complement one another.

Apart from those operational situations, the similarities of the two services are found in their administrative and organizational functions. For example, both operate communications centres (and both are linked to the 911 system), both maintain and service some of their fleet vehicles, both provide training programs, both maintain equipment and supply inventories, and both require financial and human resource support services.

 Service Differences:

 Beyond the public perceptions described above, the differences between the fire and ambulance services are pronounced, and are not just limited to the differences in their operating mandates and activities, or to the differences in the legislation which governs them. On a basic level, paramedics are not trained to fight fires, just as firefighters are not trained to initiate intravenous therapy.

 Each organization=s service priorities have shaped the systems and infrastructure which sustain them. From the inside out, and at almost all levels, this accounts for the differences.

 For example, Toronto=s Fire Services utilizes a >station-based= deployment model. This involves the strategic geographical placement of 80 fire stations throughout the city. Fire apparatus situated in these locations are then able to achieve optimal response times, by being geographically and strategically located in order to meet the established standard. The location of fire stations, then, is critical to fire service response time performance.

 Toronto Ambulance, on the other hand, relies less on >station-based= deployment than it does on >mobile= deployment. Stations, in most cases, are simply the start and finish points for ambulance crews in the course of their shifts. Response time performance is strongly linked to having a fleet that is fluid. This also contributes to greater system efficiency in as much as many more ambulances and many more stations would be necessary if Toronto Ambulance were to count on a station-based model for achieving response time standards.

 The >mobile= deployment utilized by Toronto Ambulance also reflects the >multi-point= and medically seamless nature of its service delivery. When an ambulance responds to a call, it may have to transport a patient to a hospital which is outside the community in which the call took place (e.g. a patient picked up in North York may well be transported to a hospital downtown). When that ambulance is clear, it may be reassigned to transport another patient to a hospital in Scarborough.

It is very common for ambulances to move freely across the whole of the city. Their response parameters are determined much more by patient need and hospital resources than they are by the location of stations.

 On the reverse, it would be very impractical and not at all cost effective to apply the same >mobile= approach to fire vehicles. Fire service is generally considered a >two-point= service in that a fire vehicle will respond to a call and, when the call is complete, return to its home station. Being station-based is much more critical to maintaining response time efficiency.

  Service Consolidation Options:

 Toronto Fire and Toronto Ambulance have carefully evaluated two options for consolidating service delivery. They are presented below as models.

 Model One - Strategic Partnership:

 In this model, Toronto=s Fire and Ambulance Services will continue on a course that has already been mapped out since the beginning of the formation of the new City of Toronto. Both services are actively exploring opportunities for administrative alliances which will result in greater efficiencies and cost savings.

 The Strategic Partnership Model recognizes and respects the distinctiveness of each organization=s operating functions. At the front-line level, therefore, there will be no noticeable effect on service. In the areas of administration and support services, however, changes are being and will be effected.

 The most substantive of these is already well underway. The Toronto Fire Service is locating its headquarters at the existing headquarters facility of Toronto Ambulance, and has already established some of its main staff offices there.

 Other viable opportunities for cost and support service sharing may possibly involve:

• shared communications systems/facilities
• shared vehicle maintenance facilities and resources
• shared equipment and supply facilities and, where possible, common bulk purchases
• shared station use
• common IT purchases and applications, where appropriate
• administrative services (e.g. financial, human resource)
• joint medical training (e.g. cardiac defibrillators)
• shared mapping systems
• joint bidding for external revenue opportunities

 A comparison of the significant advantages/disadvantages of the Strategic Partnership Model is as follows:

 Model Two - Full Amalgamation:

 This model would see the fire and ambulance services becoming one single service. Within the new structure, decisions would have to be made with respect to how fire vs. medical services would be provided, and as to who would provide them.

 Options might include placing paramedics on fire vehicles, or placing an ambulance in each of the current eighty fire stations.

 In the first scenario, both a fire apparatus and a fire service ambulance would respond to all emergency medical calls currently received by the Ambulance Service. This amounts to approximately 200,000 calls involving road response, an increase over the present fire service medical response volume of approximately 50,000 calls. Where required, the firefighter/paramedics would accompany the patient to hospital in the ambulance, requiring their fire vehicle to be placed out of service or to operate with two fewer staff members. For minor cases, the ambulance=s basic life support crew might transport unaccompanied.

 Note that this option would require a significant increase in vehicle and staff resources - with attendant increase in cost - and a transport system with a guaranteed response time. In cases where a fire service ambulance transported a patient, there would have to be appropriate station or area coverage backfill. The amount of backfill would be increased whenever the ambulance was engaged in cross-community transports, to a hospital outside of the area in which the call originated (e.g. from Etobicoke to Scarborough) - in those situations the ambulance might be away from its home base for extended periods of time.

 Straight response to and from a medical call would normally see a fire vehicle and crew committed for 20 to 30 minutes. On calls where part of the crew was committed to transport, this time would lengthen to at least an hour or more (based on present ambulance service call completion times).

   In the event paramedics were assigned to pumpers, they, too, would have to be backfilled whenever they accompanied a patient during ambulance transport to a hospital. Again, in cases of distant transport destinations, the time - and therefore the cost - associated with backfill would be significant. If a decision was made to limit the amount of backfill, then ultimately fire service response times might begin to increase above current standards, as more and more vehicle resources were pulled for backfill duty from stations further away.

 In the second scenario, fire trucks would cease responding to medical emergencies unless extrication, technical rescue or forcible entry was likely to be needed. Each of eighty fire stations would be equipped with an Advanced Life Support ambulance and two paramedics who would respond to all medical emergencies in the station=s area. As outlined above, sufficient ambulance backfill resources would be required to ensure that the station=s area remained adequately covered. In effect, many more than eighty ambulances would be necessary in order to guarantee sufficient backfill so that response time performance could be maintained. The number of additional vehicle resources would, in part, be determined by the number of times an ambulance engaged in cross-community transports. Again, an increase in costs would be a very real factor in this service delivery model.

 In either of these or other scenarios, issues of training, possible cross-training, medical control, deployment, performance standards, communications procedures, etc. would all have to be addressed. Also the equalization of salary differences and the harmonization of collective agreements and legislation would be a major consideration.

 A comparison of the significant advantages/disadvantages of the >Full Amalgamation= model is as follows:

  In addition to the above, there are some very legitimate reasons why full amalgamation should not be pursued at this point. They include:

 Consultant Perspective:

 In 1996, the (then) Metro Toronto Corporation hired the consulting firm of Ernst & Young - at a cost of $500,000 - to conduct a review of Toronto Ambulance in order to determine how well it was measuring up to industry standards and best practices. When evaluating alternative delivery options, it concluded that the Toronto Ambulance service should remain operationally separate from fire service.

 It also provided Toronto Ambulance with a number or recommendations which will result in service improvements, through an implementation plan expected to carry through to the year 2001.

 >Who Does What= Sub-Panel on Emergency Services:

 The >Who Does What= panel, in its review of service delivery in the GTA, examined a full range of opportunities for the integration, in whole or in part, of emergency services. It recommended in November, 1996, that full integration at the front-line service delivery level was not a viable option at that time. It noted that Aeach service has a separate legislative framework, statutory requirements, financing arrangements, labour relations framework, culture and traditions, job skills, training needs and infrastructure needs@. It recommended that opportunities for the sharing of resources and support services be pursued instead.

 Budget Restraint and Effect on Performance:

 The six collective fire departments which now make up the Toronto Fire Services have undergone considerable budget restraint over the last six years. During a period where all municipalities have been affected by notable financial pressure, fire service budgets have either been flatlined or reduced. Through serious service and administrative rationalizations, an acceptable level of fire service delivery has been maintained in most municipalities.

 Similarly, Toronto Ambulance has seen the equivalent of a 15% reduction in its operating budget since 1991. In spite of this it has been able, through aggressive restructuring and reorganization of its operating practices, to actually improve its service performance, a trend which is continuing.

 The introduction of full amalgamation into the two services would likely have a deleterious effect on the continuity of the efforts that each organization has invested in becoming more efficient while coping with ongoing expenditure reductions.

 Achieving Integrity of Current Fire Service Amalgamation:

 The Toronto Fire Services has the extremely challenging task of consolidating the six previous municipal fire services into one single fire service. This will not be an overnight process. Significant planning has been involved, and while there is imperative to consolidate as soon as possible, each step must be conducted carefully and properly. The impact on staff of the changes associated with fire service consolidation can not be understated. The changes also come at a time when there is a momentous change in municipal structure, and in some of the processes which will govern fire service.

 To introduce an ambulance service amalgamation into these initiatives would be to jeopardize the success of both consolidation efforts. A more prudent approach would be to allow the fire service to effectively complete its own integration, and to revisit the potential for further alignment with ambulance services, if feasible, at a later date.

 Other Factors Which May Impact Ambulance Service:

 The timing of the possibility of full amalgamation of fire service with ambulance service is highly unfavourable in light of the uncertainty of the present health care system environment.

 The full effects of health services restructuring are unknown. The continued closure of hospital emergency departments, and the overall increase in patient care demands, make it very difficult to forecast with any accuracy the emergency pre-hospital needs and demands for both the near and distant future. Any amalgamation would have to consider service volume changes, and related resource requirements.

 In addition, while Toronto=s Ambulance Service is now being exclusively funded and operated by the City of Toronto, it still has legislative and service linkages with the Province. There have been a number of discussions with respect to Toronto Ambulance assuming limited service partnerships with parts of the GTA, on a cost-recovery or cost-recovery plus basis (e.g. vehicle and equipment purchases, disaster resources, training). These discussions have also included the possibility of Toronto Ambulance assuming control of the operations of some of the GTA ambulance dispatch functions. Any amalgamation may serve to undermine or preclude these initiatives.

 Lastly, health care rationalization is becoming increasingly focussed on community based care and service. In this context, ambulance service is being seen not just as an access point to the emergency care or hospital system, but as part of a greater health care continuum. It is widely expected that in the future, ambulance services will play a role much larger than simply providing emergency care and transportation to the community.

 Conclusions:

 It has been suggested on more than one occasion that a full marriage of fire and ambulance services is a natural and logical path to follow. While this may appear to be so on the surface, the reality is that both are very different and very operationally distinct organizations.

 The Toronto Fire Service is currently undergoing its own significant amalgamation of the six fire services from the previous Toronto area municipalities, a process which will take some time to complete. Likewise, Toronto Ambulance is in the middle of implementing a number of consultant determined recommendations which will assist it in becoming a more efficient and cost effective department.

 In the meantime, both services are engaging in a strategic partnership, seeking out common areas for cost savings and further service and organizational efficiencies. One of these is the move to a shared headquarters facility, and another is the participation in a joint station facilities study. While this is taking place administratively, the cooperative operational practices of tiered response continue to go on. On specific emergency medical calls, both services continue to respond together, working as a team in the best interests of patient care.

 The Chief of Toronto Fire Services and the Acting General Manager of Toronto Ambulance Services - and senior staff - are unanimous in their endorsement that both services maintain the present course of strategic alliance. Full amalgamation may be an option to be reconsidered at a later time, but at present there are many convincing reasons why it should not take place, and why it might, in fact, jeopardize the ultimate effectiveness of both services.

 The Toronto Fire and the Toronto Ambulance Services have, as separate entities, enjoyed a successful history of providing emergency service to the citizens of, and visitors to, the City of Toronto. It is fully expected that this high quality of service will continue, even in light of the pressures being faced through consolidation and transition.

 Toronto continues to enjoy the best fire and ambulance services in all of North America. Through strategic partnerships they will become even stronger.

 Contact Name:

 Alan Speed

Phone: 397-4300 Fax: 397-4325

 Ron Kelusky

Phone: 397-9240 Fax: 392-2115

Alan F. SpeedRon Kelusky

Fire ChiefActing General Manager

Toronto Fire ServicesToronto Ambulance Services

 Barry Gutteridge

Commissioner, Works and Emergency Services