Mr. Tony Gregg:

I should clarify the position regarding HIQA response times. Response times are clear. The response time for a life-threatening call is seven minutes and 59 seconds, which means an ambulance, rapid response vehicle or community first responder must arrive at the scene within seven minutes and 59 seconds. There appears to be some confusion at corporate level in understanding response times. As recently as last week, a rapid response vehicle in the north east responding to a call at St. Joseph's School in Drogheda was dispatched to the wrong school because there are two schools in the locality with the same name. The response of the Health Service Executive was interesting in that it suggested that because the life of the patient was not threatened, the incident did not fall within the response time category of 18 minutes and 59 seconds. This statement is incorrect and demonstrates a lack of understanding of response times at some level in the HSE.

Response times are clear, specific and in line with international best practice. They are not eight or 18 minutes but one second less in each case. These times are established and recognised as international practice. There is some confusion about ambulance response times. A community first responder can respond to a life threatening emergency once he or she has completed the basic life support training and is registered with the Pre-Hospital Emergency Care Council. The first responder may be a volunteer in the community, a rapid response vehicle, which is usually a car, jeep or motorcycle, or a traditional ambulance, which will have two paramedics on board and will be able to transport the patient to the hospital. At some level, the message has been sent that in life threatening emergencies the ambulance does not have to arrive until 18 minutes and 59 seconds have elapsed. That is only the case where the ambulance is the second responder. Once the community volunteer, rapid response vehicle or ambulance receives the call as a first responder, he or she is expected to arrive and deliver care first. Those are the ingredients for a first response. If the ambulance receives the call as the first responder, it must reach the destination within seven minutes and 59 seconds. The only time the ambulance is not required to meet the indicator of seven minutes and 59 seconds is if it is the second responder and is deployed in support of an already deployed first responder. I hope that offers clarity on the key performance indicators with regard to the responsibility of ambulances in respect of the response times of seven minutes and 59 seconds and 18 minutes and 59 seconds.

On rapid response vehicles, we draw comparisons with other jurisdictions. We are at pains to point out that the rapid response vehicles were introduced to the system to enhance or complement the existing deployment model of ambulance service provision, namely, a traditional ambulance with two paramedics and a range of equipment, including a stretcher, which can take a patient to a hospital. The rapid response vehicle is manned by one paramedic or advanced paramedic deployed to a scene by the ambulance service and should essentially provide a parallel response. However, these vehicles are being used as an alternative to an ambulance response. Deputy Kelleher referred to an unofficial policy of dropping ambulances and so forth. If a member of staff is injured or ill and does not turn up to work, only one paramedic is available and the ambulance is withdrawn from the system. The paramedic who turns up for work is then deployed in the rapid response vehicle and the ambulance is effectively removed from the system. As such, the rapid response vehicle is used as an alternative to the ambulance and we are left short of one ambulance resource.

That is a policy that the National Ambulance Service has engaged nationally. On the issue of the management of pressures experienced by paramedics, the impact of those pressures has been recognised and concerns have been raised with the ambulance service by the HSE occupational health department and also the critical incident stress management group - the psychologists who deal with the impact of events on paramedics.

Some members of the committee may be familiar with the Bob Clarke report, which was concluded in 1993. At that time, Mr. Bob Clarke described the relationship between the ambulance service management and staff as being hostile at best. That is probably the case at the moment.

With regard to shifts, the rapid response vehicle has been used as an alternative. In one station in Dublin, St. James's, 186 shifts have been dropped to the end of 2013. This strategy includes the closure of ambulance stations on an alternative basis. For example, a shift in Swords would not be covered on a Tuesday, a shift in Tallaght would not be covered on a Monday and a shift in Maynooth would not be covered on a Wednesday. Those shifts are actually being dropped from the system. The relief staff are brought in to cover those shifts that would normally be rostered by the staff on that particular roster. Due to the Haddington Road agreement, going from 40 hours to 39 hours, we lost those extra shifts. The impact of that is that the staff who cover short-term or long-term absences due to illness or injury are used to provide the minimum level of cover we normally had rostered prior to Haddington Road. That influences the decision to use the rapid response vehicle as an alternative, because we do not have the relief staff to cover for somebody who is ill or injured. Arsing from that, the ambulance is removed from the system and the rapid response vehicle is used as an alternative.

There was a reference to the downgrading of Ennis, County Clare. The position in Ennis is similar. The proposal is that the ambulance service will deploy the same system as has been established in Dublin at the three stations just mentioned. There are four stations in Ennis - Scariff, Ennistymon, Ennis and Kilrush. There is one ambulance in all of the stations except in Ennis, where there are three. The proposal is to close one of the other three stations for 12 hours on an alternative basis and that one of the three ambulances in Ennis will be deployed to cover those days of closure, thus minimising the level of resources in terms of deployment. So far as we can establish, response times to AS1 calls are 50:50. We get to 50% of cases on time and 50% beyond the time. Some 50% of AS1 calls are life-threatening emergencies in that region. We only reach 50% of cases. We propose to reduce the level of resources in Clare.

Do we believe the response times can be achieved? The response times are unrealistic due to the level of resources and the proposed changes in those areas. However, they are a reality, and we need to reach the time. What we do not accept is that 75% or 85% of calls can be collateral damage. Everybody has a right to an ambulance service within the parameters of those timeframes 100% of the time. Collateral damage in terms of people who do not survive beyond that 85% hit is unacceptable.

The role of paramedics has changed. We now deliver care guided by the pre-hospital emergency care council. As stated in our submission, we have gone from essentially delivering breakfasts in ambulances to hospitals, from delivering hospital patients to wards, to now delivering a world-class clinical intervention with best international practice at the scene. Mr. Michael Dixon will respond to the rest of the queries.