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This clearly puts the doctors involved in a conflict of interest. In a health system experiencing a significant shortage of practitioners, medical resources are drained from public hospital-based "free" care and into private purses. It also ties health care quality and accessibility to a patient's wealth - precisely what the Canada Health Act tries to prevent. For example, Montreal Children's Hospital - one of Montreal's two pediatric university hospitals - has decided to stop offering many medically necessary services. Instead, it will direct some patients to a new outpatient clinic. There, parents may be billed for such services as dermatology, endocrinology, general pediatrics and other important specialized care.

This steady disintegration of the principles of health care could soon be irreversible. Premier Philippe Couillard's new Bill 20 will legalize direct patient billing for medically necessary services provided outside of hospitals. The provincial government is confident that Ottawa won't intervene to enforce the Canada Health Act in Quebec (the federal government hasn't intervened in the past decade). Bill 20 makes legal practices that were grey-zone breaches in the universal public health system. This is creates a parallel, legal private health-care system subsidized by public health insurance. This could be the final blow to health care in Quebec. An unhealthy coalition - the Couillard government, private clinic owners, medical federations, private insurers and even some hospital administrators - is irresistibly pushing to decrease the care offered in public institutions and to increase the market share of direct payment and privately insured services. The only chance to save health care in Quebec is direct intervention by the federal government. Prime Minister Justin Trudeau and federal Health Minister Jane Philpott must enforce the Canadian Health Act in Quebec, even cutting federal health transfers until the province conforms.

Doing anything less will mean access to care according to a Quebec patient's wealth, rather than their needs. Astrid Brousselle is a professor in the Community Health Department, and researcher at the Centre de recherche de l'Hopital Charles-LeMoyne, Universite de Sherbrooke and Canada Research Chair in Evaluation and Health System Improvement. Damien Contandriopoulos is a professor in Nursing and a researcher at the Public Health Research Institute at University of Montreal (IRSPUM). CIHR Research Chair in Applied Public Health.

According to the registry, 527 patients were billed a total of $40,775 between Feb. 15 and Aug. 2015. Respondents noted feeling indignant about the injustice of having to pay amounts they considered exorbitant for medical care. Some said they couldn't afford to pay - they needed the money for groceries or rent. User fees for insured medical services covered by the provincial health insurance board are illegal. But there's a grey zone, and for years many physicians and clinics have quietly been applying extra, arbitrary or excessive fees for exams and medications covered in hospitals. Led by the clinic's Comité de lutte en santé, the registry also showed that rates for medical services levied on patients varied among professionals, the clinic's co-ordinator Luc Leblanc said Sunday.

"It's a two-tiered system. One for those who can pay and one for those who can't," he said. Data analysis shows the average amount demanded by family doctors was $63, and the average for specialists was $91. The biggest category is medications or anaesthetics, followed by administrative charges like photocopies or filling forms. Adopted last week, Quebec Health Minister Gaétan Barrette's Bill 20 included a set of amendments to legalize fees charged to patients in clinics for insured services, commonly called "accessory fees." The list of regulated ancillary fees will come later, after the government hires an independent accounting firm to determine real costs.

But Leblanc noted the public wasn't consulted because "initially Bill 20 made no mention of the possibility of accessory fees," Leblanc said. And there are no prior government studies or surveys to determine the scope or impact of current fees on patients, he added. The introduction of user fees is a serious threat to universal care, critics said, including the Canadian Medical Association, Quebec Medical Association, Canadian Doctors for Medicare, and Médecins québécois pour le régime publique (MQRP), who asked Barrette to hold offon regulating fees in October.

Charging patients at doctors offices and clinics for medically necessary care isn't acceptable, said Isabelle Leblanc, president of the pro-medicare group, Médécins québécois pour le régime publique. It strikes at the heart of the principle that access to health care should be based on need rather than ability to pay, she added. The clinic's health committee is calling on Barrette to suspend extra fees and on the new federal Health Minister Jane Philpott "to act immediately to force Quebec to respect the Canada Health Act," said Louis Blouin of the committee. The committee is continuing to document billing in its online registry. It can be found on the Pointe-Saint-Charles clinic website cfidelman@montrealgazette.com twitter.com/HealthIssues

Now, medicine, especially socialized medicine, is a snakes-and-ladders game of priorities and timing. Given the fact that resources are limited, doctors find ways to move urgent patients up to get the care they need. But that care is delayed by other demands, by shortages of doctors, by shortages of beds.

On the east coast of Newfoundland, a report identified a series of problems with paramedic services, including the fact that there are just not enough paramedics to provide the service, and there are long periods of time when no paramedics or ambulances are available for calls. T

Figures compiled in CIHI’s database over 40 years show the share spent on physicians hit an all-time high in 1988, then slowly declined until 2007, when it turned around, growing at about 2.2% annually. It now accounts for 15.5%, comparable to levels seen in the late 1980s. Hospital spending has decreased from 45% of total health spending in the mid-1970s to just under 30% today, whereas drug spending has been increasing since the mid-1980s to account for just under 16% of spending.

“The guild has done a great job of protecting our income,” Dr. David Naylor said, referring to medical associations’ success in negotiations with governments. “But wouldn’t you expect [the share of spending on physicians] to drop a little?” Naylor, past president of the University of Toronto and chair of the Advisory Panel on Healthcare Innovation, spoke at a panel discussion on the CIHI findings, held Oct. 29 in Ottawa.

He said the “constancy of focus on doctors, drugs and hospitals … speaks to the stasis in the system. If anything, it’s in a state of arrested development.” While overall health spending has gone up in dollar terms, amounting to $6105 per capita in 2015, it has declined as a proportion of gross domestic product (GDP). After the 2008–2009 recession, health spending fell from 11.6% of to an estimated 10.9% of GDP today. When inflation and population growth are taken into account, health spending also shows a decline.

The first half of this movie seems similar to what happened in the 1990s,” said Don Drummond, an economist at Queen’s University. He said that in the 1990s, government austerity led to a decline in health spending, but a return to a good economy resulted in health spending growing “much faster than economic growth.”

In regard to the similar spending decline after 2011, Drummond asked “did we create efficiencies or just cut off the money and create pressure?” Drummond and Naylor clearly think that efficiencies are lacking. The solution, said Naylor, is integrating services, including home care and virtual care. “There’s not a single province that has taken steps in that direction.”

CMA President Cindy Forbes agreed. “We need integrated, appropriate and high-quality care.” She gave the example of a patient in an acute care hospital discharged to community care and later moving to palliative care. “The patient goes through three different systems. They all have their own budgets and caregivers. These silos have to be broken down so it’s one system.”

She stressed the need for a national seniors’ strategy to address a population that is aging and living longer, often with complex, multiple diseases. Integrated services could address the patients needing an alternative level of care who currently occupy 20% of beds in acute care hospitals, she said. “They are not ‘bed blockers,’” she said. “They are waiting for long-term or home care.”

Naylor also thinks changing the way physicians are paid is part of the solution. “The fee schedule is full of perverse incentives. It doesn’t create ‘integrative quarterbacks.’ There should be rewards for good prescribing and shorter hospital stays.”

Wide variations in the price tag for health care among provinces and territories also stood out in the data. Costs in Canada’s provinces range from $5665 per person per year in Quebec to $7036 in Newfoundland and Labrador. (In the territories, costs are much higher.) Seven provinces devote more than 40% of their budget to health, of which two devote more than 45%.

Demographics and geography account for some of the variation, according to Brent Diverty, CIHI’s vice-president of programs, especially costs to transport critical cases from remote areas. However, panellists expressed concern about inequalities in quality of care and access.

“People who are covered for a drug in one province are not covered in another,” pointed out Forbes. “Especially cancer drugs, which are expensive.”

Naylor added, “There’s a huge challenge for the [federal/provincial/territorial ministers] to understand this variation. We need to unbundle why these disparities occur. How do we get to a common higher ground as Canadians?”

There is a strong case to be made for a return to the original 50/50 funding arrangement, which is one of the key reasons the provinces signed on to Medicare in the first place but which has steadily been eroded in the decades since. There is also a fair criticism that increased funding - from $124 billion in 2003 to $207 billion in 2012 - should have been used more deliberately to attempt to achieve the intended change in system performance or health outcomes for Canadians. So as the health ministers meet in Vancouver, how can they bend the curve toward a less costly and more effective health care system? How can they ensure the funds invested this time around will buy real improvements in health?

Some of the directions for this can be found in the Prime Minister's mandate letter to the Minister of Health, which included an exhortation to "support the delivery of more and better home care services." Investment in quality home care has been shown to improve patient experience while easing pressure on acute and long-term facilities.

The letter also encouraged Minister Philpott to "encourage the adoption of new digital health technology." If done right, electronic medical and health records can greatly expand our ability to effectively treat individuals and the population. A third major element described in the mandate letter was a call to "improve access to necessary prescription medications" by "joining with provincial and territorial governments to buy drugs in bulk," and "exploring the need for a national formulary." This falls short of a national pharmacare program, but does not close the door to the possibility.

Canada is the only nation with a universal health care system that doesn't include drug coverage; one in five Canadians reports being unable to afford to take necessary medications as prescribed. A national pharmacare program would eliminate that problem while saving Canadians approximately $6 billion per year in excess costs. Half measures in this area will not achieve the desired savings or accessibility. The directives from Trudeau to Philpott are helpful, but there are two key ingredients missing. The first is that the flow of health care funds needs to be connected to clearly articulated goals. Indiscriminately increasing fund transfers with no accountability for how they will be used is a recipe for continually increasing costs without improving the quality and accessibility of care. The second is that all levels of government need to move toward a Health in All Policies approach that understands all areas of government - policies affecting income, education, housing, food security, for example - impact health outcomes. Health care is the greatest cost driver in provincial governments, but it isn't the area in which spending has the greatest impact on health - and it's not where those costs can best be controlled.

The decisions emerging from this upcoming summit could change the landscape of health care policy in Canada. Ryan Meili is a family physician in Saskatoon, vicechair of Canadian Doctors for Medicare, an expert with EvidenceNetwork.ca and founder of Upstream: Institute for A Healthy Society.

But Saskatchewan's Health Minister Dustin Duncan seems to believe that a novel feature in their "model" will make it palatable: MRI providers will be required to provide a "public" MRI for each private MRI sold. There is great fog around this stipulation. MRI clinics in Alberta and British Columbia provide a menu of services, just like an auto repair shop. Of course, it is difficult to identify prices for Canadian MRIs because their websites, while advertising "competitive" prices, ask you to contact them. The United States is more "competitive." For example, Ohio law requires hospitals to publish their prices. The website for medcentral.org lists more than 40 items in its MRI price list.

Here is my question: If a Saskatchewan MRI provider does a foot scan for a private patient, does it then have to do a foot scan for a public patient? How will this be monitored? Also, when does the public patient get her foot scan? If a paying patient is standing in the door, does the MRI provider say, "Sorry, you have to wait till we provide the public foot scan that we owe?" How is this monitored? Does the government pay for the patient from the public list? If so, at what price?

Is this simply a revenue guarantee in disguise? Undoubtedly Bill 179 provides for wide ministerial discretion. Can we bank on the minister being discreet? This model is bizarre. If the provincial government is seeking ways to provide more MRIs without having to incur the upfront capital costs and to remove the operating costs from its budget, then just negotiate MRI fees in the physician fee schedule, as currently occurs with other imaging services.

However, it might quickly become obvious that the private modality cannot compete with cost effective public provision. Glen Beck is emeritus professor of health economics at the University of Saskatchewan.

Wait times and coverage vary widely between and even within provinces, with only one in six hospitals offering surgical abortions and access is most difficult for women living in rural communities - including First Nations reserves - who may have to travel long distances to get an abortion. Prince Edward Island does not provide any abortion services at all, although it does cover the cost of the procedure for provincial residents who obtain an abortion at a hospital in Moncton, N.B., where no referral is needed, or in Halifax, where women need to be referred by a P.E.I. doctor.

Philpott was not available for an interview Tuesday to elaborate on what she has in mind, and spokesman Patrick Gaebel was unable to add many details. Prime Minister Justin Trudeau said last year that all Liberal MPs would have to vote along pro-choice party lines, but the campaign platform and his ministerial mandate letter to Philpott did not mention anything about improving access to abortion services.

Ontario's doctors are dedicated to protecting high-quality, patient-focused care. A large number of patients in Kitchener are joining Ontario's doctors in expressing concern with the provincial government's cuts to health care. The number of patients adding their voice is growing daily as more people learn about the almost seven per cent in cuts to the funding for all of the necessary care that physicians provide and the government's decision to arbitrarily cap that funding in a way that doesn't account for growth in the system.

Doctors and patients in both the community and hospitals are seeing the negative impact of the Ontario government's unilateral cuts to medical care, which include difficulties accessing a family doctor, growing waiting lists for specialists and surgical treatment, community clinics on the brink of closure and new medical graduates who are looking at leaving the province.

Ontario's population is growing and, with a greater number of people living longer, medical care will be needed more than ever. That is why doctors want to work with government to find solutions that make our health-care system sustainable and able to meet the needs of all patients in Ontario. In fact, Ontario's doctors have a history of helping government find the savings they need, while protecting access to patient care.

Michael Hurley's concerns about the health-care system should be directed squarely at the Ministry of Health and Long-Term Care, which has the responsibility of fully funding all aspects of the health-care system. The most recent figures show that the Ontario government spends less on health per person than 10 other provinces and territories in Canada.

Ontario's doctors are committed to advocating for patients and our focus will always be on ensuring that everyone in the province has access to high-quality care. Dr. Mike Toth President, Ontario Medical Association Toronto

Ms. Rius said there were six problem areas - from MSF's perspective - in the early leaked versions of the TPP. Three have been eliminated in the final text, although she said some of those were "absurd" in the first place. Among them was a provision that would have made it illegal to oppose a patent before it was granted and another that would have forced governments to allow surgical techniques to be patented. There are three key remaining problem provisions, according to the MSF analysis. One would allow pharmaceutical companies to "evergreen" their product patents, essentially making small changes to a drug's use to extend its protection from competition. Another would extend patent protection if there are delays in regulatory approval of a new product.

For generic drug makers, she said, the TPP will create additional legal barriers that will get in the way of making new products, and that will stunt the industry. The TPP will actually raise drug prices, especially in developing countries, she said, and this "will affect our capacity, and the capacity of the ministries of health with whom we work, to scale up treatment programs and reach as many people as needed."

More broadly, allowing greater monopoly protection for brand-name drug makers will diminish innovation at other firms, Ms. Rius said. "If you are trying to develop a pediatric formulation of a product, if you are trying to combine different pills into one pill, ... if you are trying to improve a medicine and create a second generation, all of that technology and knowledge is going to be protected by secondary patents." The final text of the sweeping trade pact, which has been in the works for eight years, was released in early November. Canada is one of 12 countries that have negotiated the pact, although it was the former Conservative government that signed on. Prime Minister Justin Trudeau said his government will wait for parliamentary hearings on the TPP before deciding on ratification. Each country has to ratify the agreement before it comes into effect.

A third would allow developers of certain advanced drugs - called biologics - to keep their clinical data private for up to eight years. That would make it much tougher for competitors to create similar drugs, or at least delay that from happening. This "data exclusivity" rule would be new for some of the countries that are part of the TPP group, although Canada already has a similar provision in place. Indeed, many of the provisions of the TPP are already part of the Canadian scene, at least in some form, said trade lawyer Larry Herman, of Herman & Associates in Toronto. The former Conservative government had said the TPP was "in line" with Canada's existing patent laws, and this appears to be true from his read of that part of the text, Mr. Herman said.

Still, he said, from a global perspective "there is no doubt that the agreement increases patent protection and enhances the monopoly rights of the patent owner." From the perspective of Canada's generic drug industry, the TPP has to be looked at in conjunction with the Comprehensive Economic and Trade Agreement (CETA) between Canada and the European Union, said Jim Keon, president of the Canadian Generic Pharmaceutical Association.

CETA, which has not yet taken effect, would extend patent protection for drugs and cut into the business of Canadian generic drug makers - thus boosting drug costs - Mr. Keon said. But it also contains some specific protection for the generic industry to mitigate that impact. It is not clear yet whether the TPP will allow those mitigating measures to be implemented in Canada, he said. And because of the immense complexity of the TPP, "you've got all sorts of potential for misinterpretation here," Mr. Keon added.

ows, such as looming job losses in the Saskatoon Health Region as it tackles a projected deficit of almost $50 million.

the government has faced complaints about poor care of seniors in the province’s nursing homes and stubbornly long ER wait times.

And the $40-million lean management process that is supposed to deliver efficiencies and improve services to patients remains controversial. Critics — including some health care-workers — say the supposed benefits have been overstated by health bureaucrats and politicians and the money would have been better spent on frontline care.

$11 million has been spent on the salaries of 120 health workers employed to promote lean, according to the NDP Opposition.

"All provinces and cities will likely be saying, 'We think we can play a role here and we want to have a chance to do so.' " Manitoba Premier Greg Selinger added that his province would like to welcome up to 8 per cent of the Syrian asylum seekers - about twice Manitoba's proportion of the overall Canadian population. "We know that Manitobans want to do their part in welcoming these innocent victims of war [and helping them] find a better life," he said.

In a conference call with reporters, Immigration Minister John McCallum said he's aware that officials in places from Victoria to Halifax are working to rejuvenate their population. "We would like to see these refugees spread fairly evenly across the country. We do not want to concentrate them all in three or four big cities," he said, adding that Ottawa does not "control exactly where they will go." Mr. McCallum said the government will be leasing planes from Royal Jordanian Airways to fly many of the refugees to Canada, stating the first trip could occur as early as next week.

"We want to have a certain number built up before we begin the process," Mr. McCallum said, adding the government will soon be able to process 500 cases a day at a centre in Jordan. Still, there have been concerns about whether small-town Canada can handle government-sponsored Syrian refugees, who will be the most vulnerable and traumatized newcomers. Governments are preparing an assessment checklist that can help them determine whether smaller towns have the necessary minimum services such as health, mental-health and education workers.

Chris Friesen, of the Immigrant Services Society of B.C., said that "if those key elements are not in the community," resettlement groups and governments will have to consider whether these support services can be added over time. The alternative is sending these refugees to the 36 longstanding refugee-resettlement centres across Canada. Resettlement groups say they are still waiting to be given the names of the private sponsors who will welcome 10,000 refugees in coming months, to assist them in successfully integrating the newcomers into Canadian society. "A number of these private sponsors will be doing this for the first time and it's critically important for them to have support around them ...," Mr. Friesen said.

He added that Syrians will have a challenge adapting to welfarerate housing. "You're coming from a middle-class family with a nice house in Damascus. Managing expectations may at times be challenging," Mr. Friesen said. Another issue is seeing how many refugees Ottawa plans on bringing to Canada in 2016, not only from Syria but other countries, as well. The "immigration levels" are normally released every fall, and refugee groups say they need to see overall projections to accurately plan for all the newcomers.

"The government has been consistent in promising [Syrian refugees] will be over and above pre-existing refugee targets for other regions," Mr. Friesen said.

What is especially disturbing, said Amy Ma, co-chair of the central users' committee, is that the above-ground parking lot was constructed 30 years ago, and so there is no justification for charging such a high fee. In contrast, the MUHC is charging the same rate for its new underground parking lot that opened at the superhospital's Glen site in April, arguing that the higher fees are necessary to pay back a $266-million loan for the lot's construction. "Recently, I was talking to a parent who had to bring her child to the newly opened external clinic of the Children's at 5100 de Maisonneuve," Ma said. "In addition to having to pay $25 for an allergy shot, she also had to pay $25 for parking. The $25 for parking ... is just mind-boggling because it's not even a brand-new, multi-storied parking garage.

"It's definitely going to add yet another barrier in terms of access to care," Ma added. In September, Quebec's ombudsman vowed to investigate "excessive" parking fees at the $1.3-billion superhospital following a formal complaint by the users' committee. The MUHC levies patients and visitors $25 after 90 minutes of parking - the highest rate of any hospital in the province. On Aug. 1, the MUHC also "harmonized" its parking rates to $25 after 90 minutes at the Montreal General and Montreal Neurological hospitals. Previously, the rates were $19 after 90 minutes.

Despite this harmonization, the users' committee found that a patient who parked at the Montreal General and the Glen site on the same day was charged $50. The ombudsman warned that such doubledipping is "abusive and shows a lack of inter-hospital coordination." A report by the ombudsman's office on Oct. 27 recommended that the MUHC "revise" its parking rates by Monday so that the fees "do not hinder the right of an individual to access to health care." The ombudsman's delegate, Léa Préfontaine, did not recommend by how much the rates should be lowered.

A week before the report, the MUHC lowered the maximum rate for express parking at the superhospital to $30 from $50 for cars parked between 61 minutes and 24 hours. But the $25 fee for general parking has not been changed. In fact, the hospital network raised the fees for employee parking by $120 a year, going from a monthly rate of $105 to $115. What's unusual about the parking at 5100 de Maisonneuve is that it does not fall under the jurisdiction of the MUHC, since it's a private facility. On Oct. 13, the Brunswick Medical Group opened "The Children's Clinic" at that address. The clinic is staffed by doctors from the Montreal Children's Hospital that is part of the superhospital complex.

Parents who go there must present their children's medicare card before each consultation. If a child is in need of an allergy or blood test, the parent is offered one on the spot for a fee, or can go to the hospital and wait for one that would be covered under medicare. Shortly after the Montreal Gazette reported that children were being charged fees for tests at the private clinic, Health Minister Gaétan Barrette ordered the MUHC to remove its signs from the building. He also demanded that the MUHC cancel as soon as possible a 30-year lease it signed with the Royal Victoria Hospital Foundation regarding the property.

an Popple, a spokesperson for the MUHC, confirmed that the hospital network is managing the parking lot at 5100 de Maisonneuve through a private company. Popple added that the "MUHC plans to announce modifications to its parking policy over the coming week," but declined to provide details. aderfel@montrealgazette.com twitter.com/Aaron_Derfel

DAVE SIDAWAY, MONTREAL GAZETTE / The parking at 5100 de Maisonneuve Blvd. does not fall under the jurisdiction of the MUHC.

Ms. Carter's efforts are just part of a broad effort of Canadians to welcome refugees from Syria. But her work also highlights the ad hoc preparation that is taking place while the federal government scrambles to meet its commitment to bring 25,000 refugees to Canada in the next three months. The Immigrant Services Society of B.C. expects about 400 refugees, half government assisted and half privately sponsored, to resettle in the province by the end of December. Governmentassisted refugees will be placed in the lower mainland, but privately sponsored refugees will head to the communities where their sponsors are based - Victoria, Kelowna, Duncan and Prince George are preparing to greet refugee families before the end of the year.

No more than 20 refugees will likely arrive in the region where Ms. Carter and her team of volunteer professionals are ready to help. Other communities may not be as well served - there is an element of good fortune that the Victoria region happens to have an experienced volunteer corp of therapists at the ready. Ms. Carter just spent four years with the Centre for Victims of Torture in Jordan, where she worked with hundreds of Syrian refugees. Before that, she specialized in trauma support with Medecins sans frontieres (Doctors Without Borders). From that experience, she knows the counsellors themselves will need ongoing support to deal with the topics they'll be processing. "Many of these refugees have gone through incredible trauma," she said. "The stories are very difficult to hear, even for experienced counsellors."

And, after 25 years working in child and mental-health services in Victoria, she knows the system is already strained and would not be able to cope with the urgent needs of the new arrivals. "Mental-health services for adults and children are very, very sparse. Often Canadian children have to wait for months to get into our mental-health system. I'm very concerned that the refugees, when they come to Canada, most of them of have a lot of PTSD symptoms and they are going to need assistance and there was really nothing set up."

Victoria Mayor Lisa Helps is coordinating efforts among immigration support groups, the region's school districts, postsecondary institutions and other levels of government to welcome an unknown number of refugees in the next three months to southern Vancouver Island. "We are rolling out the welcome wagon, recognizing that it looks different for refugees from a war zone," she said in an interview. The biggest challenge, she said, will be finding a place for the new families to live: Victoria has one of the lowest vacancy rates for rental housing in the province, and low-rent housing is particularly squeezed.

"We want to provide a welcoming new home. It will take a heroic effort." These stories are emerging across the country - Canadians pushing aside security fears and making the near-impossible happen.

And on Dec. 2, Ambulance NB administrators across the province received new directions on how to fill vacant shifts. If a person calls in sick, or someone has requested vacation time and they must be replaced, the manager in charge of scheduling that shift would offer the shift to anyone with bilingual qualifications in the person's station, typically first part-time or casual employees. Unfortunately, there is a shortage of bilingual part-time or casual employees in many parts of the province. So the next group to receive offers is bilingual full-time employees, who would be called in for an overtime shift. If nobody is available, the offer is extended to bilingual paramedics from other jurisdictions.

That's not fair to the many dedicated unilingual paramedics across the province, says Trent Piercy, a paramedic with Ambulance NB and the secretary for paramedics' union CUPE Local 4848. "They are going to get offers, but it's going to come after that process has been exhausted," he said. Piercy said he understands that Ambulance NB has a legal obligation to offer service in both official languages.

But he said that if an ambulance arrives at the scene of an accident, makes the offer of service in both languages and learns that it can't provide care in the language requested, he believes Ambulance NB is still meeting its legal requirement if those unilingual paramedics request another crew with bilingual capabilities to respond to the scene. While they wait for them to arrive, he said, they can use existing translation services until that backup arrives.

"If we have another crew coming, is that not offering the service? If we offer translation, or have somebody come from one of our crews to translate on a call, is that not offering the service? Other avenues, I don't think, have been explored enough." Piercy said Ambulance NB has set a goal to have 60 per cent of its paramedics be able to offer service in both official languages. He believes that only about 35 per cent of the province's paramedics are currently bilingual. "It's going to take a very, very long time to get up there and the costs are going to go up," he said. The paramedics' union has filed a grievance about new hiring practices introduced in August 2014, which place new weight behind a candidate's linguistic abilities.

After having already expressed frustration with the challenges posed by those changes, he said, the provincial ambulance service has now made it more difficult for unilingual paramedics to find meaningful employment in the province, rather than trying to work through a long list of suggestions submitted by the union as potential alternatives to the new scheduling protocols. The union suggested finding ways to screen calls by language, making it possible to send ambulances with bilingual staff to scenes where a specific language is requested, and to explore translation equipment for use in provincial ambulances. Other ideas involved lowering the language requirements to a conversational level of French or English, alter the deployment protocols to keep unilingual ambulances away from areas that might require them to provide care in their weaker language, or improve language training resources for existing paramedics. Currently Ambulance NB has offered to cover the costs of distance-education language training from the Université de Moncton or Rosetta Stone, though the employee must complete the work on his or her own time.

But Piercy said so far the provincial service hasn't been willing to commit to exploring any of these ideas. "We will continue to work with stakeholders to find solutions that will best meet the needs of our patients and employees, while respecting our legal obligation," he said. The Daily Gleaner requested an interview with Katherine d'Entremont, the commissioner of official languages for New Brunswick, but was informed she declined to comment on this story.

While speaking with the paper about Ambulance NB's push to improve its language capabilities in August 2014, d'Entremont said the legal obligation to provide service in both official languages has been in place since before Ambulance NB launched in 2007. Back then, she said it wasn't her job to tell the provincial ambulance service or the Department of Health how the organization should reach its language goals, but simply to make recommendations on how to address deficiencies identified by the public. "I'm interested in the results of a plan as opposed to the means to get there," she said at the time. "My mandate is very specific in this regard. So once I've made recommendations, the rest is up to the institutions concerned."

Both Dominic Cardy, leader of the New Democratic Party of New Brunswick, and Kris Austin, leader of the People's Alliance of New Brunswick party, attended a rally co-ordinated by frustrated paramedics in Fredericton this week. Afterwards, Austin said he feels the way Ambulance NB is bolstering its language capabilities is flawed, saying that it unnecessarily punishes many qualified francophone and anglophone paramedics by freezing them out in favour of the smaller complement of bilingual professionals. The newspaper asked the Department of Health if Health Minister Victor Boudreau wanted to comment on the paramedic protests, but was told he was unavailable.

Jason Malinowski, an emergency physician in Barry’s Bay, Ontario, says that the requirement for a doctor to agree to accept a patient can lead to dramatic delays in some cases. “Doctors are sometimes in the operating room and can’t get back to us quickly,” he says. “But I’ve assessed the person and it’s very clear they need to be treated somewhere else.”