Mr. Michael Dixon:

I express thanks to the Chairman and committee members for giving NASRA the opportunity to attend the joint committee to express its members' concerns about response times, key performance indicators and the resourcing of the national ambulance service. It is worth reflecting on the role of the paramedic and how it has evolved into what it is today.

Paramedics are officers of the State and often carry out their duty alongside their peers, such as members of An Garda Síochána, the Defence Forces and the fire service, and prison officers. Paramedics are also designated professionals in keeping with the Health Care Professionals Act 2006, although this status has yet to be acknowledged by the HSE.

The ambulance service today and the highly trained paramedics on which it relies have practically no relationship to the view we have of the ambulance service of the past. The service then was part of the transport department of the eight old area health boards with drivers carrying out duties which ranged from responding to accident and emergency calls in the community to transporting patients and the delivery of breakfasts from hospital kitchens to hospital wards.

The role of the paramedic has evolved immeasurably in recent years and it is paramedics themselves who have been the driving force behind the transition of members of the ambulance service into the professional practitioners they are today, governed by the professional standards and training laid down by Pre-Hospital Emergency Care Council. Central to their professionalism is the commitment of the paramedic in the pre-hospital setting to deliver the appropriate care required to the patient in a professional and prompt manner in order to stabilise and promote the recovery of the patient. The guiding principle here is that early intervention in life threatening circumstances improves the chances of survival of the patient which, in its own way, brings us to the issue of ambulance response times.

Some members are all too familiar from instances reported in their own constituencies of delayed ambulance response times. Nationally, this is an issue that has featured in the media on a regular basis, in particular in the past year or so. Members will also be aware that in some of these instances the consequences of delayed response from the ambulance services have been very tragic indeed and this is something that is felt and deeply regretted by every professional paramedic in the country. That said, I have to point out that we do not believe that any of these tragic incidents have been created, or contributed to, by the dedicated front-line paramedics of the National Ambulance Service.

It is worth looking at just what we mean when we talk about response times. The current set of response times, to which paramedics operate, have been set down by HIQA based primarily on international best practice. In Echo and Delta calls, which are classed as serious life threatening, we are currently tasked with achieving a response time in 85% of these calls of within seven minutes and 59 seconds. We know from previous HIQA statistics that the NAS has not been able to reach or achieve these targets. The HSE asked for these targets to be reduced and we have to ask why. From consultation with NASRA members, we believe the main reasons are the shortage of personnel, the shortage of infrastructure, the lack of accountability and the lack of funding.

Recently, the National Ambulance Service stated publicly that it aspires to the model of excellence of other ambulance services in jurisdictions, such as Northern Ireland and Scotland. It is a noble aspiration but NASRA would say it is totally unrealistic given the level of investment in the services here relative to these other jurisdictions. Northern Ireland, with a population of 1.7 million, has an ambulance service that employs just fewer than 1,200 staff. It has a range of just over 300 various vehicles deployed from 57 bases across the Six Counties and an annual budget of £62 million, or €78 million. In the case of Scotland, with a population of 5.3 million, the ambulance service employs more than 4,500 staff. It has a range of over 450 various vehicles, including a full-time air ambulance, deployed from just over 100 bases and an annual budget of £203.5 million, or €258 million.

In comparison, Ireland with a population of 4.6 million has an ambulance service that employs fewer than 1,600 staff. It has a range of various vehicles deployed from 87 bases, although not all of these are open 24-7, and an annual budget of €137.4million. When we examine these comparative levels of investment and the obvious lack of personnel, resources and infrastructure in our system, it is obvious that the National Ambulance Service can never achieve its aspiration of providing the ambulance services of Northern Ireland or Scotland or, indeed, the response times that would allow us conform to international best practice.

The HSE and the National Ambulance Service will argue that the resources available to the ambulance service here compare favourably with those available to these other jurisdictions. Unfortunately, NASRA has found that in dealing with these agencies, the reality on the ground is very much at variance with their view of the world. One example of this is how the HSE views the use of rapid response vehicles. These vehicles were introduced into the system to reduce response times in acknowledgement of key performance indicators, KPIs. Their purpose is that, in some cases, they arrive quicker than the ambulance. The jurisdictions to which we aspire, namely, Scotland and Northern Ireland, are at pains to point out that the rapid response vehicles are not intended as an alternative to an ambulance response but are there instead to complement the ambulance response.

In the Irish service, we deploy rapid response vehicles as an alternative to ambulance cover, which is clearly in breach of the intended use of this resource. NASRA maintains, and takes no satisfaction in this, that the key performance indicators can only at best be used as guidelines due to the fact there are gaps in the provision of ambulance cover across the State, mainly due to base closures, non-replacement of absent personnel, whole-time equivalent posts not being filled and a lack of investment across the services.

This under-resourcing of the National Ambulance Service is of great concern. Over the past number of years, the cuts to budgets have seen a remarkable decrease in investment in the provision of pre-hospital emergency care. Among the areas of the service which need to be urgently addressed are the ageing fleet of the National Ambulance Service; the emphasis on solo responder cars or rapid response vehicles in place of ambulances which cannot convey patients to hospital; the impact of roster changes and cutbacks on response times; the management of personnel in regard to staff illness, psychological or physical injury; the impact of the reconfiguration of hospitals across the country, resulting in the closure of smaller general hospital emergency departments in favour of centres of excellence and resulting in longer travelling times with a knock-on effect that the ambulance is lost to a location for longer periods; and the reinvestment of reconfiguration savings into supporting the expanded role of the NAS.

In responding earlier this year to a number of incidents, some of them with tragic outcomes resulting from delayed ambulance responses, NASRA said publically that the National Ambulance Service is "running on empty" in regard to staffing and resources. There have been further incidents since we made that statement and we have no reason to change our view that we do not have the personnel or vehicles on the ground to adequately meet the response time targets being demanded by HIQA.

Front-line paramedics as professionals, who show their dedication and commitment 24-7 and 365 days of the year, will always go the extra mile to serve the public and save lives. However, it would be wrong to see that dedication and commitment as either a limitless resource that can be taken for granted or that can maintain a service that is being asked to do more and more with less and less support and resources. We would be pleased to take any questions from members.