International Survey on Ambulance Services: Alternative Models

1. International Survey on Ambulance Services: Alternative Models Friday, October 28th, 2005 The Museum of History Hong Kong

2. The Lion Rock Institute • Independent public policy think tank • Dedicated to researching, generating and advocating public policy solutions for a freer and more prosperous Hong Kong • Also involved in education of policy makers and the general public • Importing the world’s best, exporting Hong Kong’s best practices to the world. • Three co-founders + 6 person Board of Advisors from Hong Kong and abroad • A new type of organisation in Hong Kong and growing.

3. Today’s Objectives • Generate awareness of alternative models, benefits and challenges. • Launch a discussion of what can be done to bring better ambulance service to Hong Kong, among the people who know the system best – you. • Raise the bar!

4. Could we be doing better? • Not the drivers, not the funding – it’s the system. • Ambulance Medical Priority Dispatch System? “20 years behind the USA” – CUHK AEMAU

5. Could we be doing better? (II) • Labour Disputes over working conditions “I’m not done my lunch!” • Excessive stress levels. • Cutbacks to funding.

6. Could we be doing better? (III) • 180 of 215 ambulances running (2003). • Calls expanding 5-7%/year. • Resource allocation – Disney over Mui Wo? • Standards below OECD norms.

7. Why Alternative Models? • Response times: Los Angeles 5-8 minutes, Chicago 4-6 minutes. • Higher percentage response compliance (normally over 95%). • Technology – More new technology and newer equipment in many alternative model systems. • Cost savings – Stockholm, Benoni (SA), San Mateo, Pinellas, Michigan, Ontario, more. • More savings means more development of people and staff. San Mateo increased paramedic staff from 60 to 220. BFES (SA) runs its own training school.

8. What Alternative Models? USA 2000 Journal of Emergency Medical Services (JEMS) survey + Co-ops in Canada!

9. AM: Problems? • Oversight – billing, inexperience by overseers. • Labour Disputes. (Netherlands retirement) • Change in government policies leads to confusion. (US Medicare and billing) • Minor, related to administration – no evidence of decline in quality of service.

10. Canada USA Belgium India Botswana The Netherlands Australia Denmark Sweden Norway South Africa Philippines And many more! Where? Soon, Hong Kong will be the alternative!

11. AM: Volunteer Services • India: Sri Gian Sthal Mandir sabha – provides ambulance service for widows in Ludhiana, India. • Pamilya Mo, Lingap Ko – Philippine National Red Cross and Rizal Commerical Banking Corporation – ambulance services for OFW. • Small town America, Canada, and even Hong Kong (St. John’s Ambulance pre-hospital care at events).

12. AM:Volunteer - Private - Government • Dunlip County, North Carolina – Volunteer service under pressure as people spend more time at work. Considering mixing volunteer efforts with private providers. • Netcare911– Ambulance and relief mission to Phuket led by South African private firm in coordination with government and volunteer groups.

13. AM: Mixed Public Private San Mateo County Hospital Advanced Life Support Services • San Mateo County (SMC) + American Medical Response • First response – fire agency paramedics. • Second response – Ambulance, medical supplies, equipment, training, clinical oversight. • Both fire and AMR share revenue and both suffer penalties. Benefits? • SMC increased certified and licensed paramedics from 60 to 220. • On time response: 98% for first response, 95% for second. • Excellent ambulance (private) and fire (public) staff relations.

14. AM: Mixed Public Private Billing • AMR taking over billing collection in many cities. • Increases % recovery at a lower price. Technology • Small Belgian ambulance company Van Damme partnered with government and Nokia to test new ASTRID communications technology. Dispatch Services • Benoni (South Africa) • Metrocare (New York) • Intergraph BEST (Melbourne)

15. AM: Mixed Public Private Ontario Air Ambulance Services Corporation • Government organised non-profit to coordinate air rescue operations. • Consolidating: Emergency Health Services Branch, the Sunnybrook and Women's College Health Sciences Centre and private air operators. Why?

16. AM: Mixed Public Private • One point of contact for the entire system with better co-ordination and quicker patient transfers. • Direct medical supervision reaching every part of the operations, ensuring safe, effective treatment of patients. • Dispatch and operations working together for more effective use of air ambulance resources. • Improved awareness for health care service providers, of available air ambulance services.

17. AM: Contractors • Denmark celebrating 100 years of private ambulance service in 2006 (Falck, 85% coverage). • Falck also in Sweden, Poland, Norway and growing. • United States and Canada – Classic growth and consolidation. • Rural/Metro – started as a fire service company, now provides ambulance services and billing. • Laidlaw of Canada absorbed American Medical Response (still named AMR).

18. AM: Managed Competition • Pinellas County (Florida) • Awarded contract to Sunstar after competitive budding with public and private providers. • Benefits? • Response times down by 30 seconds. • Non-emergency response compliance rose from 90% to 95%. • Equipment and software upgraded. • All ambulances replaced every 5 years. • Savings up to $21million over the next 7 years.

19. AM: Outsourcing - BFES Benoni Fire and Emergency Services (BFES) • Founded by fire chief Steven Barber in 1992. • Private investors. • Saved Benoni local authority about R21million over 7 years. • BFES college provides entry point to workforce for unskilled workers. • More flexible work conditions for employees.

20. AM: Outsourcing BFES Now? • Rescue Medics - Ambulance services • Forest Firefighting • Emergency Services Communications • Emergency Service Vehicles (manufacture and upgrade) • Emergency Services College • Many imitators in South Africa, bidding on contracts in the UK.

21. CETAM La Coopérative des technicians ambulanciers de la Montérégie Ambulance technicians created a cooperative to provide ambulance services Union and Caisse populaire assistance in launching Workers are owners Acquired 7 more companies Now serves 70 municipalities Could you all be owners some day? AM: Co-ops

22. US Experience – Best results with mixed services. Fire services first response, ALS and other ambulance services next response. South Africa – full outsourcing. Ontario – experimenting with non-profit corporation for Air Services. Quebec – Co-ops like CETAM and Urgences-Santé. Belgium, Denmark, Sweden, Norway – outsourcing for decades. Learning Experiences

23. Structure Is King Key design features: Flexible Production Strategy Peak-Load Staffing Event-Driven Deployment Performance-Based Contracting Competitive Bidding (public and private) Creativity in Contracting Lessons Learned!

24. Benefits of Alternative Models • Flexibility and lower stress for workers • Cost-savings allow investment in: • Training • Equipment • Modernisation • Improved Service Levels • Bonuses for performance • Innovation in service • Best combination of public and private provision

25. Are we being left behind? Can Hong Kong catch up to the world’s best and lead Asia?

26. Andrew WorkExecutive DirectorEmail: andrewwork@lionrockinstitute.org • 8th Floor Henley Building, 5 Queen’s Road Central, HK • Tel: (852) 2845 4544 • Fax: (852) 3015 2186