Overview

 
For over 35 years, the City of Carmel-by-the-Sea has benefited from shared fire services through various arrangements, most recently since 2012 with the City of Monterey. This collaborative model has proven operationally efficient, mutually advantageous, cost-effective, and has provided significant service-level improvements for Carmel-by-the-Sea residents.

 
On January 1, 2012, the City began operating its own ambulance service consisting of six (6) firefighter/paramedics, with oversight falling under the Public Safety Director/Chief of Police.  Although this model has been managed successfully, it has had its share of challenges, including maintaining staffing levels, high overtime, and our ability to keep the ambulance fully in service as required by the County who oversees our paramedic license.  

 
The city has benefited from having a public safety director with a unique knowledge of the licensing requirements to maintain an ambulance service which is not common in a Police Chief. However, during the Chief’s absence, a lack of administrative knowledge created compliance challenges with County and state licensing requirements. These challenges suggest it could be time to consider a new and more efficient model of management to retain a city controlled Fire/Ambulance service for our residents.   

 
201 Rights

 
The city's ability to legally operate/control an ambulance is an important component of any decision the city council makes.  Since 1930, the city has continuously maintained ambulance service in the village.  In 1980, California passed a law requiring standards for any agency who elected to manage its own ambulance service.  Part of this legislation involves a commonly used term, known as “201 Rights”.   

 
“201 rights" refer to a status granted to certain cities and fire districts in California that provided prehospital emergency medical services (EMS) before June 1, 1980. Cities with this 201 status are authorized to continue providing EMS at their existing levels until they cease operation. If a City ceases operating its own ambulance, service then falls under the county control for ambulance service (i.e.: American Medical Response, “AMR”). The city retains its 201 right to this day.  Should the city elect to contract out its ambulance service to Monterey Fire, it would not impact the city's “201 Rights”. 

 
Carmel-by-the-Sea’s long time dedication to providing city ambulance service has resulted in it being the last city to retain 201 rights in Monterey County. All other cities have relinquished their ambulance service and elected to utilize the county contracted service, currently provided by AMR.  

 
Ad Hoc Committee

 
With concerns over sustainability of the Carmel Fire/Ambulance, the city formed an Ad Hoc committee in 2020 to explore solutions to the management of the ambulance. The Ad Hoc Committee comprised of two council members and four residents who spent multiple meetings learning about the ambulance operation. Over the course of these meetings, they developed two important city goals for whatever decision was made. The specific goals established by the Ad Hoc were:

 
1.  Ensuring Carmel Retains its Ambulance Service (“201 Rights”) 
2.  Improving Service for the Residents

 
The Ad Hoc was particularly concerned with the potential for the City to lose its 201 right for ambulance service.  As previously stated, contracting ambulance service with Monterey Fire would not jeopardize these 201 rights.  What the Ad Hoc recognized could jeopardize 201 rights, was failure to meet County and State requirements of our paramedic license agreement, including continuous operation.   

 
Since 2012, the City has had staffing challenges which have both led to a growing number of incidents where the ambulance has been taken out of service. Additionally, with leadership changes in the Police Department, a number of other licensing requirements have also not been met, leading to the County recently notifying the city of potential license violations.

 
The Ad Hoc also learned that contracting with Monterey Fire would ensure that a paramedic always rode on both the Ambulance and the fire engine.  This would mean a paramedic was first to the site for all emergencies in the village, even if the fire truck arrived first, which often happens.  

 
Ultimately, the Ad Hoc Committee recommended that the City move forward with contracting ambulance services with Monterey Fire.  Firstly, to prevent the city from losing its 201 rights, which was goal number one.  Secondly, because it was learned that access to Monterey’s larger staffing resources would allow for an even higher level of service for the city’s residents, which was goal number 2.  

 
It was these Ad Hoc findings, which still hold true today, that necessitate considering changes to the ambulance management model.    

 
Changes to Ambulance Operation Model

 
The following are options for the council to consider which would allow the City to maintain 201 rights to ambulance service in the village.  In each of these options, the goals of the ad hoc would be met at varying levels.  The first option, which is contracting to Monterey Fire, is staff’s recommendation because it fully aligns with the recommendation from the city’s Ad Hoc Committee.  The other options would still allow the City to retain its 201 rights, at least in the short term, but are not recommended by staff.  more detailed cost comparisons, which include assumptions, are included as Attachment 1.     

 
Option 1 (Recommended):  Contract Ambulance Service to Monterey Fire

 
Total Cost (Salaries, Benefits, Admin., Supplies): $2.40 Million 

 
This contract model would ensure that Carmel-by-the-Sea’s ambulance was always staffed with two firefighters per shift: one firefighter/paramedic and one firefighter Emergency Medical Technician (EMT).  This would increase staffing flexibility, ensuring that a paramedic remains in the city and responds to every medical emergency in the village, even if the ambulance responds to a county call outside the city.   This enhanced staffing model, which includes access to a larger employee pool, would  allow for 24/7 ambulance coverage, eliminating service interruptions due to staffing shortages, and reduced overtime. Additionally, the integration with Monterey Fire’s system would provide operational benefits, such as maximizing resource utilization, enhanced fire protection services, and seamless coordination during major emergency events.  With this model both of the Ah Hoc committee goals are met.  

 
This model meets both the Ad Hoc’s goal of ensuring Carmel retains its 201 rights to operate an ambulance while improving services for residents.  In essence, the ambulance service would look the same as it does today, remaining in the Carmel Fire Station, fully staffed, with many of the same faces that work there today.  The only noticeable difference would be the patch on the arm of the staff which would say “Monterey Fire”.  

 
Monterey’s proposal leverages the proven benefits of shared governance, offering enhanced operational efficiencies, access to a depth of resources, and a higher level of service for the residents, businesses, and visitors of Carmel-by-the-Sea. Monterey Fire has a successful history of providing outstanding fire services to neighboring jurisdictions, including Carmel-by-the-Sea, Pacific Grove, and others. 

 
Option 2 (Not Recommended):  City Operational Model at Enhanced Level (Monterey Equivalent)

 
Total Cost (Salaries, Benefits, Admin., Supplies): $2.95 Million 

 
NOTE:  Cost to maintain current model with no enhancements = $2.14 Million

 
As identified in this report, this current model is not sustainable if the city wishes to retain 201 rights and uphold a service commitment to the residents.  Under the current operational model, Carmel-by-the-Sea staffs one ambulance with two paramedics who are responsible for emergency medical response both in the village and as a part of the county response as the closest available ambulance. The staffing model includes 6-full time Firefighter Paramedics to operate the ambulance 24/7/365.  Oversight of the operations falls under the Director of Public Safety (Chief of Police) and administrative assistance is done in part by both police department staff and finance. 

 
The cost reflected to maintain our current service model with enhancements includes the following changes to maintain the requirements of our paramedic license agreement with the state.  It also better aligns the cost with what Monterey is proposing in their service proposal in order to make a realistic comparison.   

•  Add two paramedics to reduce overtime and ensure adequate staffing to allow for vacations, sick time, and training.   

•  Add a management component, including a Fire Captain who can manage the operation including the oversight of required licensing requirements. (currently being done by the Public Safety Director)

 
Option 3 (Not Recommended):   Maintain City Operational Model - Add Paramedic on Fire Engine

Total Cost (Salaries, Benefits, Admin., Supplies): $2.21 Million

 
This option would keep the ambulance operating as is, with the exception of paying Monterey Fire to ensure that there was always a paramedic available to staff the fire engine under the existing fire services contract.  This option meets the second goal of the Ad Hoc, which was to improve service to the residents by having a paramedic respond to every medical in the village.  Staff contacted Monterey Fire, and the cost of this additional service would be approximately $70,000 per year. 

 
This option would partially meet the improved service goal established by the Ad Hoc Committee but the city would still be in jeopardy of losing 201 rights by not improving our staffing and management model.  As previously mentioned, Monterey County has recently identified that we aren’t meeting the obligation of our paramedic service agreement.  This option only results in our ability to provide a paramedic to our residents on every call, even when the ambulance is out of the city.   This model would not improve our overall ambulance service or create a management structure to ensure that the city retains its 201 rights.