Privately Owned, Publicly Funded: Quebec's Broken Ambulance System

Auditor general says private companies won't say how $360 million in taxpayer money is spent

by Hal Newman

Do you want to know the best kept secret in Quebec's health care system? 

Our network of ambulances is funded entirely by the state but belongs mostly to private interests who feel their finances aren’t subject to government oversight.

Last year, the Quebec government spent $633.7 million on ambulance providers. So, what do we get for two-thirds of a billion dollars? 

If you’re thinking we get a world-class prehospital care system, you can exhale now. We don’t. We have a fragmented, patchwork quilt of ambulance services which, for the most part, aren’t accountable to anyone. 

Of the $633.7 million, $143.9 million goes to Urgences-santé, the government-owned ambulance service which covers Montreal and Laval. Urgences-santé, as a public entity, is transparent with its use of funds. 

The remaining $489.8 million of taxpayers’ money was paid to private ambulance companies and co-operatives whose finances aren’t subject to provincial oversight. 

“The emergency prehospital system is almost entirely financed by the state but is controlled or is susceptible to being controlled by private interests,” Quebec’s auditor general wrote in a 2021 report. “Which is far from guaranteeing optimal use of resources and/or quality care focused on the patient.”  

Incredibly, according to the auditor-general, the financing of private ambulance companies is not based on the actual costs of providing the services. No one, at any level of the provincial government’s vast health and social services ministry, has any idea of the financial status of the private ambulance companies – or their profit margins. 

Under Article 30 of the loi sur le vérificateur général, the auditor-general requested access to verify the use of $360 million in funds distributed to three private ambulance companies. The auditor notes that at the time the report was published they had yet to receive a positive response. In fact, one of the companies categorically refused access to its financial document on the basis that the funds received were not subventions but were payment for services purchased.

“This goes against public interest and parliamentary oversight,” the report reads.

It’s no wonder the prehospital care system is — to use paramedic slang — circling the drain. 

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Don’t be surprised when Health Minister Christian Dubé announces that in lieu of a radical transformation of Quebec’s prehospital care system, his government will purchase and distribute thousands of automated external defibrillators. 

Shiny, happy band-aids with the potential to save some lives. But not the much-needed and long-overdue radical transformation of the system.

The CAQ spent more than $2 million putting together a committee to gather consensus on how to transform Quebec’s prehospital care system.

Among the long list of common-sense recommendations:

• Creating a helicopter medevac system.

• Creating a culture of public awareness and education for first aid; how to administer epinephrine and naloxone.

• Community care paramedics.

• Culturally adapted care for different regions and populations of Quebec.

• Treat and release; allowing paramedics to have more autonomy.

• Allowing paramedics to decide which care facility is the best destination for the patient.

Also on the list: 

• Expanding the network of publicly accessible automatic external defibrillators.

My prediction is that the Coalition Avenir Québec government will go with the shiny stuff and announce the purchase of a thousand publicly accessible defibrillators. It will make for excellent public relations when they’re distributed to towns and villages represented by CAQ MNAs in the regions. And perhaps the use of those devices will save a life or two.  

However, if anyone believes they’re going to announce the complete transformation of the prehospital care system you only need to look at the latest offer the CAQ made to paramedics who have been without a contract for more than two years.

It's not going to happen.

One of the committee’s priorities was “la valorisation” of the prehospital care system. Premier Legault can’t even bring himself to thank paramedics for their service throughout the pandemic. The latest offer from the CAQ government is a 2 percent increase. Does that sound like respect and appreciation for paramedics?

I asked Jean-François Gagné of the Fédération des employés du préhospitalier du Québec what the union wanted to see happen in the near future. His reply was so pragmatic and down-to-earth it caught me by surprise. 

“Respect for the profession. An adequate ambulance service to respond to emergency calls and provide quality of life at work for paramedics. Decision-making latitude in patient care and their orientations (destinations) in the network. Diversification of practice. The right patient transported by the right service to the right facility.” 

When I asked Gagné how negotiations were going, he said “We’ve only just begun talking with the Treasury Board so it’s still too early to see any trends. Our goals are to try to obtain decent working conditions and that would imply changes in the workload, type of schedule, and efficiency of the prehospital system. On the other end of the spectrum, we’re demanding respectable salary conditions for the exceptional work done by paramedics in the field.” 

Changing the type of schedules would be key to improving working conditions for many paramedics, to improving patient care and to radically improve response delays for high priority calls in many regions of Quebec.

Many paramedics work a schedule which requires them to be on-call 24 hours a day for seven consecutive days. Unlike paramedics who are working a set schedule and are in their ambulances waiting for urgent calls, on-call paramedics are each at home and waiting for calls. 

When they receive a call, the two paramedics must proceed to the station to retrieve the ambulance before leaving for the call. This practice generates additional delays of 5 to 10 minutes before the ambulance even begins its response to the call.

A Priority 0 call means that paramedics and (hopefully) first responders have been dispatched to a life-threatening emergency. In the case of a sudden cardiac arrest, the chances of survival drop by 10 per cent for every minute the victim doesn’t receive CPR or a shock from a defibrillator. Ten per cent for every minute. Do the math. 

In Montreal and Laval, paramedics from Urgences-santé work shifts on their ambulances and have an average response time of just over 9 minutes for a Priority 0 call. 

In Weedon (Estrie), paramedics are on-call and have an average response time of nearly 21 minutes for a Priority 0 call.

As Gagné said, “The most astounding part of the on-call schedules is that they were introduced as a temporary measure in 1989. We have a prehospital care system which prioritizes cost-savings over response time.” 

That patchwork quilt of private ambulance companies, cooperatives and Urgences-santé do not play well together. Their report card from kindergarten would have noted their inability or unwillingness to share. While the private companies are willing to send their medics to help one another out — e.g., paramedics from La Tuque headed out to Baie Trinité to fill-in for paramedics on summer vacation – they absolutely refuse to send their medics to assist at Urgences-santé in Montreal and Laval. 

It’s like a microcosm of the CAQ’s approach to governing Quebec. Prioritize the regions and hope that whatever happens to Montreal stays in Montreal. It’s not working out very well.

The paramedic shortage is impacting communities across the province. With no meaningful sharing of resources and no short-term solutions in sight, a scarcity of ambulances is likely to continue.

As part of the jigsaw puzzle that is a potential solution to a shortage of paramedics, students in CEGEP prehospital care programs are required to complete internships with maître-stagiaire paramedics who are specially trained for this process. 

After being on an administrative 'strike' which included limiting the number of stagiaires since June/July 2021, paramedics paused their pressure tactics and have begun filing required billing paperwork. 

Several paramedics told me that immediately after their labour action was paused, the ambulance companies restarted mandatory internships for the CEGEP students with the MSSS going as far as threatening to cut summer vacation quotas for paramedics if stagiaires were refused. 

That was too much for many maître-stagiaire paramedics who have chosen to resign from the program. This now leaves ambulance services in an even more precarious position with diminished numbers of paramedics willing to train the student medics.  

Keep in mind, the end of one 'strike' is the prelude to another more disruptive set of labour actions scheduled to begin on March 16th — just ahead of the March 22nd release of the Quebec budget. This according to a communiqué sent to paramedics by their union. 

Expect more of the same when the CAQ budget is announced. Paramedics leaving the profession in droves. Ongoing ambulance shortages. And a prehospital care system that is the envy of absolutely no one who is focused on providing meaningful patient care. 

Please note, after more than 40 years of being involved in emergency health services, waiting hopefully for the results of several committees appointed to improve the prehospital care system, watching as recommendation after recommendation was set aside in favour of preserving the status quo, I would love to be proven wrong. 

Sadly, I don’t expect any significant improvements. 

Only shiny, happy band-aids.