With paramedics spread thin, Honolulu dusts off a possible solution
Honolulu’s paramedics and emergency medical technicians are burned out from working so much overtime in an agency that is perpetually understaffed, sometimes to the point that ambulances sit idle because there’s no one to drive them.
It’s a familiar problem, with a familiar proposed solution: Merge the city’s Department of Emergency Services with the Fire Department to pool resources, simplify dispatching and provide better, more cost-effective medical care.
City leaders have contemplated this at least three times — in the 1990s, in the early 2000s and again around 2011. That time, the city hired a consultant for $175,000 to make a recommendation. The consultant said merging fire and emergency services, which at the time included the city’s lifeguards, was the way to go. But it didn’t happen.
More than a decade later, a merger is back on the table. In December, the City Council passed a resolution calling for a new task force to consider a merger. Council member Val Okimoto said she introduced the resolution in response to complaints from current and former EMS workers about understaffing and low morale.
“If we don’t start making changes now, we’re never going to address it,” Okimoto said. “I fear that in 10, 20, 30 years, we’re still looking at the same thing, saying, ‘Oh, we didn’t fix it.’”
If prior efforts are any indication, addressing those complaints will not be quick or easy.
Ambulance Service ‘Close To A Breaking Point’
For more than 30 years, Honolulu officials have been talking about what to do about the city’s strapped ambulance system.
“It can best be characterized by a staff of highly motivated and dedicated employees who are proud of the care they deliver,” wrote an auditor in 1992, as quoted by a consultant’s report a couple decades later. “However, they are working in a system that is highly inefficient and operating in some parts of the island at close to a breaking point.”
The auditor recommended more preventative maintenance for ambulances, increasing fees to fund EMS and varying workers’ schedules and placements, among other things.
Attilio Leonardi, who served as fire chief from 1998 to 2006, told Civil Beat the idea of merging the departments came up “maybe three or four times” between when he started in 1971 and his retirement.
In 1994, after an independent consultant recommended considering a merger, council member John Henry Felix kickstarted a task force to study the issue. Two years later, he tried to get the council to put a charter amendment combining the departments before voters. The council voted it down.
In 2005, Leonardi floated the idea again, according to a story published in the Honolulu Star-Bulletin. It didn’t go anywhere.
Leonardi said he was open to a merger back then, but he recognized that it could be difficult to accommodate the stringent, distinct training requirements of paramedics and firefighters in one department.
Consultants: One Department Would Be Better, Cheaper
Several years later, the idea gained traction again and the city hired Emergency Services Consulting International to study the issue. Its 222-page report described problems that sound a lot like what’s happening today and outlined how a merger would solve them.
Ambulances in urban areas were used heavily, leading to staff burnout, and the department depended on employees working overtime to meet demand, the consultants wrote. There were few opportunities for career advancement, and the department had to compete with federal fire departments for staff.
The city had created a complex dispatching system to manage calls to the two departments, the consultants found. The city’s primary 911 center didn’t dispatch ambulances directly; instead, its operators transferred calls to the Department of Emergency Services. Sometimes, when there weren’t enough ambulances, people waited on hold.
And with ambulances and fire trucks dispatched separately, the consultants found that there was no process in place to assess the performance of the city’s emergency response system as a whole. The two departments measured their response times in different ways, with the fire department starting the clock when a unit was dispatched and EMS starting it when its dispatcher picked up the phone. The separate systems meant there was no way to establish how long it took for the first unit, regardless of which department sent it, to arrive on the scene.
By combining the departments, the consultants wrote, the workload could be spread between more responders, vehicles, stations and dispatchers. A centralized dispatching system would reduce delays.
Some firefighters and paramedics would be cross-trained; applicants open to such training would be prioritized for hiring. Firefighters who received additional medical training could respond to calls on their own, lightening the workload for paramedics.
“In our opinion, the merger of the organizations has the capacity to resolve some of the critical issues facing the Division of Emergency Medical Services as well as to position the merged organization to meet future challenges,” including the needs of an aging population, the consultants wrote.
They predicted that the combined department could operate with fewer employees and that it could save the city at least $10 million over five years. Honolulu Emergency Services Department Director Jim Ireland disputed that figure at the time, saying the extra training and certification would require the city to pay employees more.
The merger became an issue in the 2012 mayor’s race, with Kirk Caldwell building it into his platform as he campaigned against former Gov. Ben Cayetano and incumbent Peter Carlisle. One sticking point was how to deal with the fact that EMS workers were represented by United Public Workers, while firefighters were represented by the Hawai‘i Firefighters Association.
The report itself became controversial, with paramedics contending it was slanted toward the fire department because the consulting firm was tied to the International Association of Fire Chiefs.
The city’s Ethics Commission investigated whether the contract had been awarded improperly because a city official had changed how he scored the competing offers. The state health department weighed in too, saying it should have a say in the decision since it funded the city’s ambulance service at the time.
Caldwell won the election, but the merger never went through. Ember Shinn, managing director of the city at the time, said that was due in part to resistance from the EMS union, the heads of the two departments — Caldwell replaced Ireland and the fire chief — and questions about how the move would impact the state’s funding for ambulance service. The effort fizzled out, Shinn said, “even though Mayor Caldwell was in favor of it, and probably remained in favor throughout his two terms.”
Another Task Force Gearing Up
The city may be headed down the same path again.
Mike Formby, the city’s current managing director, said the merger issue has been on his radar since at least the first year of Mayor Rick Blangiardi’s administration, in 2021. But first he wanted to figure out how to move the city’s lifeguards from EMS and into their own department.
In December, more than a dozen people who said they were current or former EMS workers testified in favor of creating the task force to study the merger.
Caldwell told Civil Beat that a merger would probably be easier today because the state no longer oversees Honolulu’s EMS system. “But I think the biggest issue is still going to be the union issue,” he said.
UPW state director Kalani Werner testified on the task force resolution last December, saying he supported creating the task force but was wary about the effects on his workforce.
“While UPW supports improving emergency services on Oahu, and perhaps, improving the working conditions of our EMS members, we are concerned with the loss of positions that may come as a result of a possible integration,” he wrote. “This is a longstanding concern that has been voiced by UPW when the prospect of the integration of EMS into the Fire Department has been considered in years past.”
Even if the city does decide to pursue a merger, it doesn’t appear to be an immediate solution to the problems facing the city’s ambulance service.
More than four months after the council called for the task force, it hasn’t met. Formby said last week that he has 12 names for the task force and was thinking about adding a few more.
It will include representatives from both departments, both unions, human resources and the budget department. Formby said he expects the group to start meeting in June or July.
By then, it will have been six or seven months since the council acted, but Formby said that doesn’t concern him. “I’m not bound by the date that the resolution was passed,” he said. “I’m bound by a process that will come up with an objective, evidence-based decision-making process.”
The city has allocated about $250,000 in the upcoming budget year, which starts in July, for a possible consultant.
And if the city eventually decides to move forward with the merger? Back in 2011, the consultant said that process would take three to five years.
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This story was originally published by Honolulu Civil Beat and distributed through a partnership with The Associated Press.