Mr. Dennis Keeley:

I thank the Chair and committee for today’s invitation and I welcome the opportunity to attend and discuss the issues facing the ambulance services. I am the chief fire officer with Dublin Fire Brigade and ambulance service. I am accompanied by my colleagues: Mr. Martin O’Reilly, district officer, and Mr. Richard Sheehan, senior executive communications officer. Dublin Fire Brigade provides the function of the fire authority for the four Dublin local authorities, namely, Dublin City Council, Dún Laoghaire-Rathdown County Council, South Dublin County Council and Fingal County Council. The brigade operates a 24-7 fire, rescue and emergency ambulance service from 12 full-time and two retained part-time stations. We also operate the east regional communications centre, an administrative headquarters, a fire prevention and enforcement section, a brigade training centre and a logistics workshop.

Dublin Fire Brigade, DFB, provides emergency cover to Dublin city and county, a region with a population of more than 1.43 million, which represents 28.5% of the population, and covering an area of 922 sq. km. In 2022, Dublin Fire Brigade processed in excess of 180,000 emergency fire and ambulance 999 or 112 calls. DFB responded to just over 81,000 medical incidents with in excess of 100,000 appliance movements mobilised to support ambulance incidents. Dublin Fire Brigade is particularly proactive with respect to safety and has achieved international accreditation, memoranda of understanding or both for all aspects of its service delivery, including ISO 9001 and ISO 45001 and recognition as an International Academies of Emergency Dispatchers, IAED, centre of excellence. The service is guided by the range of policies and procedures issued by the national directorate for fire and emergency management, which sets the national policy for fire authorities, the Pre-Hospital Emergency Care Council and the Health Information and Quality Authority. The objective of Dublin Fire Brigade is to respond and deal with fire and medical emergencies as statutorily obliged.

DFB has provided an ambulance service to the citizens of Dublin since 1892. All full-time firefighters are trained paramedics and rotate continually between firefighting and emergency medical services, EMS, duties. The east regional control centre, ERCC, receives and process 999 or 112 medical emergency calls for Dublin city and county. ProQA, the advanced medical priority dispatch system is used to code and assign a response priority to the emergency calls. The ERCC is accredited as a centre of excellence under the International Academies of Emergency Medical Dispatch. Dublin Fire Brigade normally operates a fleet of 12 emergency ambulances, each staffed by two paramedics available to respond 24 hours a day, 365 days per year. Since the early stages of the Covid-19 pandemic, an additional two emergency ambulances have been in operation, bringing our fleet up to 14 emergency ambulances. In addition, there are 21 front-line fire appliances crewed with up to 120 paramedics available to respond and support the emergency ambulance fleet as part of our fire-based EMS response. Our EMS training institution is accredited by the Pre-Hospital Emergency Care Council, PHECC, and supported by the Royal College of Surgeons in Ireland. Some 83 of our personnel provide advanced paramedic interventions.

In 2022 the following activity was recorded: 81,984 emergency medical incidents were managed, 52,165 patients were treated and transported to hospital, 4,387 critical medical incidents were managed, 453 cardiac arrests were managed, 148 ST-elevation myocardial infarction, STEMI, patients were transported to a primary percutaneous coronary intervention, PPCI, facility within 90 minutes of having an electrocardiogram, ECG and 483 positive stroke patients were transported to a facility that performs stroke thrombolysis.

Demand for ambulance services continues to grow. Computer-aided dispatch, CAD, activity is a measure of ambulance incidents created on the emergency response co-ordination centre, ERCC, CAD system. The annual figure for ambulance incidents created in 2017 was 114,543. In 2022, the number of ambulance incidents created was 148,974. This represents an increase of 30.06% in the annual number of incidents created since 2017.

Incident duration is measured from the time an ambulance is mobilised to an incident until the time it becomes available for the next incident. Duration time is calculated in minutes. Dublin Fire Brigade, DFB, has witnessed an increasing trend in incident duration times. In 2017, the average incident duration was 51 minutes. In 2022, the average incident duration was 64 minutes. Factors that influence that number are the offload turnaround time at hospitals and the fact that patient care is now more complex, with protracted interventions. Regarding offload turnaround time at hospitals, in 2022, the average offload or hospital turnaround time in Dublin hospitals was 39 minutes, with 16% of incidents having a turnaround time in excess of 60 minutes. It should be noted that in 2020, the comparable average turnaround time was 29 minutes, with 6% of ambulances experiencing offload delays in excess of 60 minutes.

Concerning patient care, clinical practice guidelines issued by the Pre-Hospital Emergency Care Council, PHECC, have led to an increased time on scene for paramedics involved in patient care. On queuing of incidents, when a resource is not available, an incident is placed in a queue until a resource becomes available to respond. Queuing of incidents is now systemic, with over 80% of incidents placed in a queue during peak hours, which now stretch from 0900 hours. to 2400 hours. Due to a surge in demand in November and December 2022, the highest number of incidents placed on a queue was recorded. The rise in queuing times for delta incidents is particularly worrying as they are deemed to be clinical status 1, or life-threatening conditions.

HIQA response standards set in 2012 identify the key performance indicators for emergency medical service, EMS, response at three clinical levels. A key area of concern is the ability to achieve the target for delta calls, with a requirement to reach 80% of all delta calls within 19 minutes. In January 2020, DFB had 12 emergency ambulances and 45% of all incidents that month were delta calls. DFB reached 58% of these incidents within the target timeframe. In the same month, 7% of incidents had a hospital turnaround time greater than one hour. In January 2023, DFB had 14 emergency ambulances. The overall number of incidents managed was similar to the same month in 2020 and 46% of all incidents that month were delta calls. DFB reached 40% of these incidents within the timeframe. In the same month, 17% of incidents had a hospital turnaround time greater than one hour.

On the ability to achieve the target for echo calls, which have a requirement to reach 75% of all echo calls within eight minutes, in January 2020, DFB had 12 emergency ambulances. 2% of all incidents that month were echo calls. DFB reached 59% of these incidents within the timeframe. In the same month, 7% of incidents had a hospital turnaround time greater that one hour. In January 2023, DFB had 14 emergency ambulances and the overall number of incidents managed was similar to the same month in 2020, with 2% of all incidents that month being echo calls. DFB reached 52% of these incidents within the timeframe. In the same month, 17% of incidents had a hospital turnaround time greater that one hour. These statistics point to a direct correlation between extended hospital turnaround times and the availability of ambulances to meet demand.

Agreed interagency activity measurement between DFB and the National Ambulance Service, NAS, has been in place since January 2017 and has been successful in identifying the high levels of activity as both organisations co-operate to maximise combined available resources. High levels of contact are a daily occurrence and, as per agreed protocols, DFB requests assistance from NAS as required. In 2022, DFB requested resources from NAS on more than 63,000 occasions. NAS indicated it could not provide a resource for 76% of these requests. These figures suggest the combined resources of NAS and DFB cannot meet current ambulance demand in Dublin city and county. In support of the Sláintecare implementation strategy, DFB actively engaged with NAS on a pilot basis to utilise fully alternative pathways through the National Emergency Operations Centre, NEOC, clinical hub. This provides an avenue for lower acuity calls to be transferred, triaged and treated via the clinical hub.

DFB has a quality and patient safety, QPS, committee chaired by the assistant chief for DFB emergency ambulance services. The fire brigade’s medical director and the managers of each section of the fire brigade also attend. The QPS agenda includes updates on capacity and demand, complaints and compliments, adverse clinical events, clinical audit, fleet and logistics, recruitment and training. This is the conduit to ensuring effective governance within our service. DFB and NAS have a joint operational working group which oversees day-to-day co-ordination and co-operation between both services. The managers of both control centres and the operational chiefs are represented at this forum. A collaborative approach to the issues that face both organisations in relation to capacity, demand offload delays at hospitals and alternative pathways are discussed and plans are developed to enhance overall service provision. DFB is actively engaging with NAS to utilise fully alternative pathways through the NEOC clinical hub. DFB and NAS have a medical director group which meets regularly to discuss clinical issues common to both organisations, for example, a common approach to the introduction of clinical guidelines, learning from adverse clinical events and clinical directives.

Response rates to our recruitment campaigns are very positive and to date attracting applicants to fill vacancies in the service has not presented a challenge. Attrition rates among our operational staff are low. In the past five years, less than 1% of operational staff chose to leave the service to pursue other careers. To date, the people who join our team remain with the team. DFB currently has a recruitment campaign in process and arrangements are in place in May 2023 for a class of recruits to commence training. In 2022, 108 personnel completed initial training and commenced operational duties. Ongoing training, career development and lifelong learning are important in DFB to ensure staff have the right skill sets to meet organisational objectives. Dublin Fire Brigade and Dublin City Council provide a very supportive educational scheme of assistance, giving our personnel access to and financial support for third level courses and development programmes.

Regarding the fleet, recent positive investment has dramatically reduced the age profile of our front-line fleet. Continuous review of the fleet profile and engagement with National Ambulance Service have seen good results in this area. Equipment management of ongoing replacement, maintenance and certification of EMS equipment is a continuous and detailed process. The costs associated with equipment purchase and maintenance are increasing. Supply chain issues are also impacting delivery times for some equipment and consumables. DFB recently tendered and awarded a contract for the provision of a new asset management system to improve the management of operational assets. The implementation of an electronic patient care reporting system could improve data gathering, management reports and monitoring of patient outcomes. Digital TETRA radios were installed in our fleet in 2021 to improve communications between our crews and the ERCC. The CAD system in Townsend Street is due to undergo a technical refresh to include new hardware, furniture, telephony system and TETRA radio functionality.

The Covid-19 pandemic is one of the biggest public health crises faced globally and its implications for our emergency ambulance services, which are already under pressure, have been quite significant. The professionalism of our paramedic staff has been especially commendable during the pandemic. DFB senior management worked very closely with our staff to ensure sufficient personal protective equipment, PPE, information, clinical guidance, risk assessments, procedures and training were maintained to allow continuity of services while affording the highest level of safety to our paramedics. Revised protocols and procedures introduced during the pandemic have contributed to increased incident duration times, further affecting performance levels. Examples include donning time for PPE, post-incident decontamination and increased hospital delays.

The current operating environment for our ambulance service remains challenging and can best be summarised as follows. Demand for ambulances is continually identified as being far in excess of DFB's capacity to meet HIQA performance standards. Demand is rising, thus exacerbating the situation. Treatment methodology is more complex. Incident duration times are getting longer. Offload hospital delays have increased. Incident queuing times are getting longer and delta cases are identified as being severely compromised by lack of resources. Ambulance unit hour utilisation rates in DFB are very high. Complaints, predominantly about ambulance response times, from the public are rising.

Despite the challenges outlined above, the management team in DFB is fully committed to the provision of high-quality pre-hospital emergency care and fully engaging with stakeholders to seek agreement on the development on a joint service model to enhance service delivery going forward. Discussions are ongoing to establish the foundations for the development of a revised model. We hope this could realise our vision for the service, which is to make Dublin a safer place to live, work and enjoy, by being a modern, community-focused, influential fire, emergency ambulance and rescue service.