In a two-volume report entitled Paramedicine in Ontario: Consideration of the Application for the Regulation of Paramedics under the Regulated Health Professions Act, 1991 released on March 10, 2014, the Health Professions Regulatory Advisory Council (HPRAC) recommended to the Ministry of Health and Long-Term Care (MOHLTC) that paramedics in Ontario not be regulated under the Regulated Health Professions Act, 1991 (RHPA). HPRAC is the provincial body whose role it is to assess applications for health profession regulation under the RHPA against certain criteria and make recommendations to the MOHLTC.

The first of those criteria requires that applicants for self-regulation meet a “risk of harm” threshold – meaning they must provide clear evidence that there is risk to the public in the practice of the profession. If the threshold is not met, the review process ends and HPRAC does not recommend self-regulation. In this particular case, HPRAC concluded that while paramedic practice did pose some inherent risks to patients, on the whole, the practice did not meet the required harm threshold. Further, HPRAC opined that the current system of oversight for paramedics sufficiently mitigates any potential risks to patients.


Paramedics are an integral part of Ontario’s health system. They provide pre-hospital emergency medical services (EMS) and care and transport acutely ill patients from the community to hospitals.   As noted by HPRAC, the current oversight regime for paramedics consists of four key stakeholders:

  • the MOHLTC which governs the ambulance system and paramedics through the Ambulance Act and its regulations and standards and policies;
  • the MOHLTC’s Emergency Health Services Branch that has the day-to-day responsibility for administering and enforcing the Ambulance Act;
  • the regional base hospitals and physicians who provide leadership and direction to paramedics on the medical aspects of pre-hospital emergency care; and
  • the municipal EMS service providers who employ paramedics and are also responsible for ensuring that employee paramedics meet certain practice standards.

In addition, paramedic associations such as the Ontario Paramedic Association (OPA) that submitted the application for regulation, and the Canadian Paramedic Association (CPA), the national association for the practice, also play a role.

Entry-to-practice requirements for paramedics include passing a mandatory provincial exam set by the MOHLTC and being certified by a medical director of the base hospital with which the paramedic will work. Additionally, paramedics are required to complete continuing education (CE) courses to maintain their skills and must be recertified every year.

The call for regulation

In March 2013, the OPA submitted an application for the regulation of paramedics in Ontario under the RHPA. The OPA’s application seemed less about the regulation of paramedics per se and more about the regulation of non-ambulance care. The OPA focused on so-called “unlicensed” areas of quasi-paramedic practice such as community paramedicine and non-urgent patient transfer services provided by private companies (HPRAC described these non-urgent patient transfer services as the “NET industry” but it has also been referred to as the Non-Emergency Ambulance Transfer (NEAT) industry). NET service providers either employ people with no paramedic training or people with paramedic training who operate outside of the regulatory framework prescribed by the Ambulance Act. Similarly, in community paramedicine, the OPA’s concern was that trained paramedics could be called upon to work outside their scope of expertise and without any oversight from a physician either at a base hospital or otherwise. Community paramedicine has been endorsed by the MOHLTC (see here for more information).

The OPA’s concerns about the qualifications, training and oversight of these quasi-paramedic services as well as a desire to counteract the public perception that these services are regulated in the same way as EMS, formed much of the basis of its risk of harm arguments in favour of self-regulation.

HPRAC’s decision and recommendations

In response, HPRAC concluded that the NET industry is already regulated – by the Ministry of Transportation under part x.2 (Medical Transport Services) of the Highway Traffic Act (HTA) (essentially, municipalities currently set the standards). HPRAC was persuaded that the government was committed to future, increased regulation in the interest of patient safety, namely as a result of the introduction of Bill 151 into the Legislature late in 2013. Bill 151 received Second Reading on February 20, and if passed, would amend the HTA to impose new rules and standards on the NET industry including the need for all personnel to have certain prescribed qualifications and transferring the oversight of the industry to the Ministry of Transport. As such, the non-emergency transport industry did not form part of HPRAC’s consideration with respect to the regulation of paramedics.

Though HPRAC concluded that the OPA’s application did not pass the risk of harm threshold and that the change from indirect regulation by government to direct self-regulation would not be in the public interest, it did recognize that paramedicine is becoming more than simply the delivery of ambulance services. It suggested that when assessing how best to meet the needs of the evolving profession, the MOHLTC consider:

  • the introduction of title protection for paramedics such that the designation is restricted to those who meet the entry-to-practice requirements, maintain CE and other certification requirements;
  • mandatory affiliation with a base hospital so that anyone working in the quasi-paramedic role including community paramedics and performing controlled acts operated within the base hospital program;
  • a standardized complaints process; and
  • enhanced interprofessional care opportunities for paramedics.

It will now be up to the MOHLTC to consider HPRAC’s recommendations and to decide if and how to incorporate into a framework for paramedicine.