A twitter query related to a news article ( http://t.co/aVV4yM0 ) from @Modc30 this morning got me thinking again about how the EMS system works. I don't think there is a "one size fits all" solution to better care. I do however think that there are some core ideas that can help add capability, skill and cost savings in to EMS programs. A key issue is "geography based logistics". The FD has a lock on this key factor in many areas due to the positioning of assets to complete their core (firefighting) mission. This logistics (supply caching, vehicle care/upkeep, personnel staging) and deployment (dispatch, coordination of tactics with related FD assets on some calls) infrastructure is a difficult cost to overcome if it were to be replicated by private industry.
That said a leaner and more independent EMS would come from lighter vehicles with highly trained personnel who have the authority (and skill/training) to bring efficiency to medical response. I believe that if lawyers, medical directors and government could see that transport policy and it's legal requirements are some of the greatest impediments to efficient care we would be able to implement a better system. My thought is a system that would rely on a professional, highly trained staff. Raising the training bar, both initial and recurrent to create a new class of medical professionals. These standards of top level technical training and professionalism will do much to inspire confidence of both the general public and it's elected Representatives. These pros must be given the authority to make a wide range of decisions in the implementation of patient care. By making accurate and timely assessments of those requesting care and being able to make wider ranges of decisions about the next step in care rather than being forced to follow an inefficient but legally satisfying policy. This is where much fiscal waste in the health care arena could be wiped out. This strategy will require the winning of hearts and minds not easily swayed, but it is not impossible. EMS is a fairly young business as it is today. The last vestiges of the founding leadership is slowly drifting away, to be replaced by a ever more capable, less resistant to change group of professionals that are assuming positions of influence.
Back to the FD issue, I discussed the logistic and deployment benefits of FD based EMS, but why do we need firefighter/paramedics. Is there value to be had in co-locating EMS with fire and sharing the comms and dispatch but running the EMS side of the house as a separate "business". I envision staging the required number of lean, "quick response" vehicles (Mid-size SUV) with the equipment on board necessary to complete 80 to 90% of calls. Staffed by an EMS professional who has a sole core career focus on the medical profession. All backed up by a government or private transport vehicle service that is called when deemed necessary by the professional medic. I see the EMS community as a stand alone, professional, highly trained group attached to the fire service as a logistical platform. The EMS profession should be just that, people dedicated to the practice of pre-hospital care with the skills and authority to make critical decisions. To this end I believe that you must engage in a full time career path as a medical pro and not a an additional duty to a career in fire.
I don't believe that private industry can find sustainable profit in a system that relies on building support infrastructure. However a privately operated medical service co-located with FD may be a workable and profitable solution. In some cases a dedicated "medical corps" administrated by a public sector entity may be a better fit. Systems like this are in place in other parts of the world. As a disclaimer, I' m a devout capitalist, but health care rarely (if ever) allows the patient to be a true consumer. Many of the core fundamentals of business practice are out the window when you are dealing with safety, health, life and limb. You can't shop around at the time service is required. You take what you can get when crisis strikes. The mechanisms to provide for competitive cost/benefit need to be preplanned.
Private industry is (no matter how public service oriented the mission statement) a business, and as such they will stretch efficiency to risk ratios to remain profitable. At the end of the day the, no matter which public/private solution you choose, the costs are passed to the community. I see benefits to a FD based EMS system, but mostly from a logistics basis. I see benefit to a stand alone EMS system as a rapid, cost-efficient way to provide pre-hospital care. Somewhere in this jumble of ideas is a solution that is tailored to the specific needs and desires of the communities being served. The next generation of EMS will no doubt look much different than today, there will be competing thoughts, plans and ideas. I encourage all public safety professionals to never forget that, public or private, the mission you have is bigger than yourselves or your agency. You are in the business of life, and that requires a commitment to excellence in all you do. God bless the FF, EMS and other public safety professionals who undertake and embrace these careers. The future is now, take action, devise strategy to meet these challenges, be active in shaping EMS and most of all... Stay safe!
-Chuck W.
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