International Survey on Ambulance Services: Alternative Models

Friday, October 28th, 2005 The Museum of History Hong Kong

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 worlds best, exporting Hong Kongs 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.

Todays 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!

Could we be doing better?

Not the drivers, not the funding its the system.

Ambulance Medical Priority Dispatch System? 20 years behind the USA CUHK AEMAU

Could we be doing better? (II)

Labour Disputes over working conditions Im not done my lunch! Excessive stress levels.

Cutbacks to funding.

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.

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.

What Alternative Models?

USA
Private For-Profit Fire depts. using multi-role personnel Third-service agencies Private nonprofit agencies Fire depts. using single-role person Public Utility Model Hospital based Services Volunteer 34.5% 34% 12% 5% 5% 5% 3% 1%
2000 Journal of Emergency Medical Services (JEMS) survey

+ Co-ops in Canada!

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.

Where?
Canada USA

Denmark

Sweden
Norway South Africa Philippines And many more!

Belgium
India Botswana The Netherlands Australia

Soon, Hong Kong will be the alternative!

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. Johns Ambulance prehospital care at events).

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.

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.

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)

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?

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.

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).

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.

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.

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.

AM: Co-ops
CETAM
La Cooprative des technicians ambulanciers de la Montrgie

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?

Learning Experiences
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-Sant.

Belgium, Denmark, Sweden, Norway outsourcing for decades.

Lessons Learned!
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

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

Are we being left behind?

Can Hong Kong catch up to the worlds best and lead Asia?

 Andrew Work Executive Director Email: andrewwork@lionrockinstitute.org 8th Floor Henley Building, 5 Queens Road Central, HK Tel: (852) 2845 4544 Fax: (852) 3015 2186