Not unlike other jurisdictions, Ontario’s ambulance services have emerged from roots embedded in both healthcare and the private sector, evolving along a somewhat convoluted path into the current municipally controlled service delivery models. While the first municipally funded ambulance services appeared in Toronto as early as 1880, and were similarly well established in Berlin-Waterloo (now Kitchener-Waterloo) by 1903. Emergency Medical Services (EMS) were not municipal priorities in other parts of the province.
During the first half of the 20th century, it was not uncommon to see private ambulance services operating as sidelines for funeral homes, or even furniture stores, taxi and towing companies. While some would see providing ambulance service as a serious conflict of interest for the funeral director, their involvement was generally born out of a commitment to provide a much needed community service, not to mention that theirs was often the only equipment in town capable of comfortably transporting patients lying down. The funeral home was already staffed, the telephone answered 24 hours a day, and the staff’s education in the natural sciences was second only to that of the local physician.
In larger communities, a number of commercial ambulance services were often available, although no means existed to co-ordinate their efforts. There was no provincial funding for ambulance services, payment was on a full fee-for-service basis, and there were no uniform standards for patient care, training or equipment. No 9-1-1 telephone or centralized dispatch systems were yet in place, and a competitive element often affected quality of care provided. Unlike today, it was sometimes better to be the last ambulance arriving at the scene of a motor vehicle collision, rather than the first and fastest.
Arriving ambulances commonly blocked the ambulance ahead to prevent them from being able to transport patients. Thus, the last arriving ambulance was the only one assured of a paying customer. Despite the competition, there was no guarantee that the personnel aboard any of these ambulances were even marginally trained. No standard of training was prescribed, and one 1963 study revealed that only 141 of 181 operators contacted, even had staff with basic first aid training.
During the late 1960s, Dr. Norman McNally, then Director of the Emergency Health Services Division (EHS) of the Ontario Hospital Services Commission (forerunner of today’s Ministry of Health and Long Term Care), was charged with developing “a balanced and integrated system of ambulance services.” out of a “hodge podge” of 425 services of widely varying quality that existed around the province.
Under his direction, EHS set out to first standardize training levels among ambulance attendants, then improve vehicles and equipment. McNally’s stated goal was eliminating the private services, then consolidating them to gain benefits of scale, and placing them under the control of hospitals where stable funding, training and quality assurance could be maintained. Unfortunately, the cost of this worthwhile venture was grossly underestimated, and financial limitations negated the government’s wholesale purchase of all private ambulance services.
Licensed ambulance services could not be sold between operators, only back to the Ontario Hospital Services Commission (the Ministry of Health after 1971). The mid-1970s however, saw a reversal of this trend towards public consolidation, with a new emphasis on private sector involvement in the management and delivery of ambulance services. From 1973 on, service licences and assets were bought and sold as business undertakings.
What remained in place from the 1970s was an ever-evolving mix of approximately 175 publicly contracted (hospital and municipal), private, and directly operated (OPS) ambulance services, that were all fully funded and directed by the Ministry of Health. Some 40% of these services were operated by private individuals/corporations. Operations of the services were managed centrally through six Regional Offices of the Emergency Health Services Branch. Ambulances and major capital equipment were provided at no charge to the Operator, while other expenses were detailed in Ministry-approved line-by-line budgets, and then cash flowed automatically to the Operator. As any expenditure required prior Ministry approval before proceeding, there was little if any capital risk to the Operator.
Despite two government-initiated major reviews of EMS governance and structure, this rather eclectic mix of “private”, hospital, municipal and OPS ambulance services remained in place until the 1998 Local Services Realignment initiative of the Harris Conservative government.