Dr. Geoff King:

The general issues resonate elsewhere. I would make two points. The legal requirements needing to be changed will change with initiatives 1 and 2. There are some advantages to coming last. We are the only regulator in the world that registered three levels of professional: EMT paramedics, advanced paramedics and UK-registered paramedics. Other places do not do that. We have had the tight regulations and the laws changed. Practitioners in Ireland must practise at the sharp end. They need to be working for an organisation approved by us, whether it is private, voluntary or statutory, they need to be registered on our register, and they need to be acting under our guidelines and under the medicines regulation. That is a triple-lock mechanism that no one else has. In terms of the sharp end, we are getting there. Do we have enough? We want more but we are getting there. I am very happy with the sharp end.

On the nuances, the professional always makes the decision. I remember when I had just graduated I was told by the hospital that there was a ship at sea and they needed someone to go out to treat a person who had had a heart attack. We found out that a team of sailors had been resuscitating the person. It was somebody who was cold. We did not tell them that what they had done was stupid. We told them that we thought he had passed. We did 20 minutes resuscitation and we finished. If that is done professionally, discretion is used and there is good training, that will happen. The bigger risk to me is if someone is doing that because they are scared of litigation whereas the employee should be scared of litigation if somebody is 40 years old and healthy and could survive and one has one's people deployed on a cold body. That is where the litigation would be.

That aside, I would not be genuine if I did not say that those are the two biggest issues for me at the sharp end. We are even setting up a retrieval service and the HSE has asked me to lead on that. We have a neonatal service that everyone knows brings in sick patients. Every other country has had these wall to wall for ten to 15 years, but we will be going 24-7 with neonatal and probably before the end of the year. We also have money to establish these for adults in Cork and Galway, seven days a week daytime, and in Dublin. We are also setting it up in paediatrics. Before long, not only are we getting the pre-hospital sharp end, we are getting the in-hospital process.

There is too much discussion about response times. The ones in the law are flawed and meaningless. The biggest risk to patients currently, and we have only snapshot data, is what happens between hospitals.

The second point is that this country's system is logjammed. If one goes to any hospital in the country - Dublin or elsewhere - one has the wrong patients in the wrong places and they cannot move. There are people in one hospital who need to be in another because they cannot be looked after in the hospital they are in. They miss the window. When they are being transported, they are at greater risk of a bad outcome and dying than those in the community making a 999 call. That is where I see the risk. That is in the mix for consideration under the service plan. It was in the mix last year. The bid to support it did not get up.We are not talking about the sharp end. We want EMTs with only four to six weeks training. It is a low level of staff cost and a low level of ambulance cost. In terms of this year, if it does not come out now, if we do not get them this year, I will be thinking that next year the same thing will happen. Everybody will be logjammed. The system will be stuck. I am very nervous about how it will come out in the process this year, but I will be around every year from here and the issue of providing a sufficient number of ambulances will be constantly to the forefront until it is fixed.

We have a legacy where the thinking was that if someone was in a hospital they were safe and that if they were in the community and they ring 999, they were not safe but the opposite is the case. If someone is in a hospital or between hospitals, in my view they are at greatest risk. In terms of the system here, I agree with every bit of the reconfiguration of acute services, including the grouping of places and linking those. Every bit of it is sound, but if the ambulances are not put in to do it, it cannot be unlocked and these people will not end up where they need to be. If the members visit any hospital - Letterkenny, Monaghan, which I have visited, and down to the Beara Peninsula - everyone will tell them they have somebody who needs to be in another hospital because if he is not, he will not get his pPCI and will instead get open surgery or medication. They are out of their depth where this person is concerned but the right hospital does not have a bed while there is a person in the right hospital which the original hospital wants back. It is logjammed. That will be the case every year until it is fixed. It would be disingenuous of me if I said otherwise.

My priorities and what we are working on are the two issues to which I referred. They do not need a change in the law. They just need consensus, we will get there, and the committee members can help. Until the other issue is resourced, that is it.