Q&A with Bill Metcalf

This spring, Bill Metcalf, chief and CEO of the North County Fire Protection District in Fallbrook, CA, was named the 2012 recipient of the James O. Page EMS Achievement Award, which is given to a leader who has influenced fire service EMS on a national scale.

Metcalf began his career in 1974 for the Anne Arundel County (MD) Fire Department, where firefighters had basic EMT training and answered both fire and medical calls. “If it was a medical call, we jumped in the ambulance; if it was a fire call, we jumped on the fire truck,” he says. “Early on I figured out I enjoyed helping people more than I enjoyed squirting water at a dumpster.”

In 1979, Metcalf graduated from the first paramedic class in Maryland; soon after, he became involved in a grant project to expand the ranks of volunteer paramedics in the state, which remains one of his proudest achievements. Other career highlights include developing the curriculum for the nation’s first paramedic bachelor’s degree program at the University of Maryland Baltimore County and working as director of EMS for the Colorado Department of Public Health. He was elected to serve as second vice president for the IAFC during the 2010–2011 term, is currently first vice president, and will become president in August 2013.

In July at the Pinnacle EMS Leadership Forum, Metcalf participated in a panel that included leaders from the three largest private ambulance providers with a discussion on areas that divide but also unite EMS agencies of different stripes. He continued the conversation with Best Practices in EMS. The following excerpted interview can be found in its entirety at emergencybestpractices.com.

What are the biggest issues facing EMS today?
I divide that question into external and internal threats. Externally, one of the real challenges is that we talk about ourselves as a public safety service, yet we have created a system that is based on a different financial model. Financially, we have tied ourselves to healthcare.

If we’re going to use the healthcare system to pay for emergency service, that means we are subject to the healthcare debate—and, recently, the reduction in dollars available to pay for health care. But if we are going to be a true public safety service, we have to be ready whether or not people use the service. If your financial model is based on fee for service, you are setting yourself up for failure almost from the beginning.
In order for EMS to continue to develop and grow, we need to find an alternative or at least a hybrid model for funding EMS that combines a component of fee for service but provides a steady revenue source, or at least one that is less subject to peaks and valleys.

Do any systems come close to having that steady source of money to support EMS?
Medic One, which provides ALS in the Seattle area, is funded in part by a special tax, and they also bill for services provided. If we’re going to move EMS forward and continue to grow and develop and enhance EMS, you have to not only pay your day-to-day cost of doing business, but you have to have money and resources to do research and to try innovative things. If you’re in a pure fee for service system where every nickel is rung out of the system for delivering service, there is very little ability to be innovative and try different things. One of the things that could be done with a national pot of money or even regional pot is to encourage innovation, encourage people to try new things and do research to find out what works and what doesn’t.

My system is also something of a hybrid. We estimate the total cost of providing advanced life support is $2.5 or $3 million, but we generate $1.4 million in billings. The rest of that is funded or subsidized by general funding, which comes from property tax revenue in the district.

The fire service has suffered unprecedented cuts and there has been considerable push back to the unions by city managers trying to manage budgets and pension costs. Do you see this as a long-term trend?

It is going to be long-term. Those of us who have been in this business for a while have seen peaks and valleys in the economy that can affect our budgets. What has happened this time is there has been a change in public attitude that has gone with it.

Whether it’s valid or not, public employees are one of the scapegoats, and in particular, firefighters are being used as poster children for all the bad things about government employees. Much of that is based on bad behavior in a very few places, and all of us are paying the price. What the fire service in general needs is a conscious strategy about how we are going to educate people about what is reality. All departments are different, many pension systems are different, and just because firefighters in a big city somewhere else are abusing the system doesn’t mean it’s happening in your town.

To help local departments deal with that, the IAFC has put together an Image Task Force, which has two goals. One is to develop a set of resources for local departments that are under attack, and to help the leadership with how to respond once they’re already in the crosshairs. The second is to develop a set of tools for departments that are not yet in the crosshairs on how to educate the community about what they do.

Do you have any tips for what fire department leaders should be doing to protect their image and reputation within their communities?

Developing positive relationships with your community needs to be an ongoing effort that you do from day one, not something you start after you’ve got a problem. My little recipe for success is to be very engaged in the community. I’m a member of the Rotary Club. I attend all the Chamber of Commerce mixers. I’m very visible in the community, and so is my public information officer. I’ve spent the time developing positive relationships with the media in the community, so they give us the courtesy that if they are going to run a negative story, we have the opportunity to respond.

But that is not something that happened overnight; I started doing it as soon as I came to this job. I think we’re all guilty in the fire service and in EMS that we sit around the station and the building and talk to each other. Everybody says, ‘I don’t want to do politics.’ Unfortunately, you do have to do it; that’s part of the job. Once you’re in the crosshairs, you need to have a message that you’re ready with. You can’t be making it up as you go along.

Is it the IAFC’s position that the fire service is the best, most economical way to provide EMS?
Yes, that is the position of the IAFC. That was arrived at out of the debates that have come out of communities across the country that have attacked the fire service as not being an effective way to deliver EMS. And that is not true. There are many examples of prehospital emergency care being delivered in a very cost-effective manner by the fire service across the country. Done right and done well, the fire service is very capable of providing first-class, exemplary emergency medical services.

There are strong arguments that we can be a highly effective model because we get multiple uses out of resources, and we can have dual-role or multiple-role people on an apparatus. But there is another side of the argument, which is that people who do one thing and do it well are going to do it better. That is the whole principle of a trauma center, for example. There are arguments on both sides.

Ultimately, it’s a community-level decision. There are some places that have extraordinary systems based around the fire service, some are based around hospitals, and some use private ambulance companies. There are outstanding examples of all different models.

Jenifer Goodwin is associate editor of the monthly newsletter Best Practices in Emergency Services.