Jerry Buttimer (Cork South Central, Fine Gael)
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I remind members, delegates and those in the Visitors Gallery that mobile phones should be switched off or left in flight mode for the duration of the meeting to avoid interference with the broadcasting of the proceedings.

The purpose of the meeting is to discuss ambulance response times. Concerns have been expressed about a number of instances involving the national ambulance service. HIQA was due to carry out a review of the ambulance service in the second quarter of the year. However, at a recent meeting with the Minister for Health, Deputy James Reilly, he confirmed that he had spoken to the chairman and CEO of HIQA and that they had agreed to fast-track the review in order that all relevant factors might be investigated. The joint committee took the decision to receive an update on the national ambulance service from a number of parties. In that regard, we will get the perspectives of presenters from the National Ambulance Service Representative Association, NASRA, SIPTU and the HSE. We will have three sessions, for the first of which I welcome the representatives of NASRA Mr. Michael Dixon, national chairman, and Mr. Tony Gregg, national secretary. I thank them for attending. There will be a 45 minute window and I will be strict on time because the room is needed for a later meeting.

By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of evidence they are to give to the committee. If they are directed by it to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable.

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.

Jerry Buttimer (Cork South Central, Fine Gael)
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I welcome members of the McQuillan family and offer them our deepest sympathy. I thank them for being here.

Billy Kelleher (Cork North Central, Fianna Fail)
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Will Mr. Dixon shed some light on the HIQA guidelines for the first responder to be at a location within seven minutes 59 seconds? He said the rapid response vehicles are meant to complement the ambulances rather than replace them. Is it the case that the rapid response vehicle is sometimes the only vehicle dispatched to a very serious traumas, such as a heart attack? Does that happen regularly or only when there is a shortage of ambulances? Is it almost an unofficial policy that rapid response vehicles are used not only as the first responders, but also as emergency vehicles?

Mr. Dixon referred to staffing and a lack of resources and made comparisons with Northern Ireland and Scotland. One could argue that we do not have the vehicles or the staff and Mr. Dixon went on to say that management does not seem to appreciate the pressures under which staff work. Is there any form of communication between the front-line paramedics, ambulance drivers and others and management to deal with the shortage of resources in terms of vehicles, the shortage of personnel and the stress and pressure under which people must work to try to deliver emergency care?

In regard to the reconfiguration of hospitals throughout the country, the biggest concern people have when there is a downgrading of an emergency department in their communities is whether there will be an adequate ambulance service put in place. When hospitals emergency departments are downgraded, are there any formal discussions in terms of the delivery or enhancement of an ambulatory service? Is there any mechanism in place to ensure that is the case as opposed to just downgrading the emergency department and hoping there will be no difficulties in a particular area?

I refer to some of the very serious incidents which have been highlighted and the tragedies that have unfolded because of the inability of the emergency services to respond in a timely fashion due to the lack of resources.

Are the witnesses satisfied with the investigations into those complaints by the National Ambulance Service, NAS? In other words, when something happens and it is brought to the attention of the NAS, are the witnesses satisfied that the service investigates the matter correctly, liaising with the families involved and giving an explanation as to why there was not a timely response, as per the HIQA recommendations and guidelines?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Go raibh maith agat. I wish to apologise to the spokespeople from the National Ambulance Service Representative Association, NASRA, because I missed the earlier part of their oral presentation. However, I had a chance to go through the documentation in advance of this meeting. At the outset I want to pay tribute to all who work in our ambulance and emergency services. I would also like to make it very clear that when we express concern over response times, we are doing so while being mindful of the overall causes of those concerns and the incidences of which we speak. It is in no way to reflect in a questioning or negative way on the excellent dedicated ambulance crews, some of whom I have had personal experience with in the very recent past and I cannot speak highly enough of them.

Paramedics have yet to receive the proper recognition that their work deserves. Inadequate resources allocated to the service by successive governments places paramedics under enormous pressure on both a personal and professional level. I acknowledge that it is not all about resources and that ways of working must also be addressed. Indeed, they have been addressed and improvements have been made, which have been acknowledged by front-line staff. However, there is a limit. One cannot always say that it is not always about resources. It comes to a point when it is mostly about the resourcing of the service. It is clear to me that there is a crisis in terms of the current inadequate allocation to the NAS. I agree with NASRA when it says that targets are not being met because of a shortage of personnel, infrastructure and funding. No amount of rearranging things on the plate will change the fact that we have an inadequate provision. A comparison of the situation north and south of the Border shows that there are 57 ambulance bases in the six-county area of our island but only 87 for the entire 26-county area. Regarding the area in which I live, namely, the north east, including the counties of Cavan, Monaghan, Louth and Meath, we are expected to be able to survive on an ambulance cover available at any one time of the order of 12. I know that people will say that there are 30 ambulances. I read a most ridiculous article recently where a Member of these Houses said there were 180 ambulances driving around the aforementioned four counties. I wonder where they are being kept. I can say for sure that at any one time we have an available fleet of 12 ambulances covering this huge area. That simply is not adequate and I can attest to that fact on the basis of personal experience.

Does NASRA believe that the HIQA key performance indicator response times are realistic, given the level of resources currently available to the ambulance service, including personnel and equipment? The impact, from a personal and professional point of view, on ambulance personnel must be of concern to members of this committee. What is the impact on ambulance personnel of working to those response times, knowing that they are going to miss the targets, that they are just not achievable, sometimes with very tragic consequences? That must have a human toll and an impact on individual staff.

What are the implications for the emergency services on the ground of cutbacks introduced in recent years, including the cuts in rostered hours, for example, as highlighted in the NASRA document? How has the role and responsibility of the front-line paramedic changed? Is that role acknowledged by health service management? I certainly want to acknowledge it, as do my colleagues here. Indeed, I am sure this committee would be unanimous in offering, if not heaping, praise on those who work as first responders in some of the most difficult situations.

Jerry Buttimer (Cork South Central, Fine Gael)
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In the absence of Deputy Healy and Senator van Turnhout, I now call Deputy Clare Daly.

Clare Daly (Dublin North, Socialist Party)
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I would like to apologise for being late but I was in the Dáil for Leader's Questions. A lot of our remarks will be saved for management who, in my opinion, bear the responsibility for the way in which the service is being operated, rather than the staff at the front line. I appreciate the role of the staff organisations in highlighting a lot of the difficulties which the changes have caused for their members and the broader consequences of same.

While I do not want to put the witnesses on the spot, I wish to use an example which I will also be using with management later. There is a family in the Visitors Gallery today who were victims of the cutbacks; the family of Wayne McQuillan from Drogheda. Wayne was stabbed in Drogheda on New Year's Eve last and an ambulance arrived at the scene 32 minutes after the initial call was made. A few minutes before that, local gardaí decided to put him into a Garda car and drive him to Our Lady of Lourdes Hospital. The tragic sequence of events in that case is an example of the consequences of the cuts. This young man was stabbed at approximately 1.40 a.m. and an ambulance was called for within minutes. The ambulance was dispatched from Ardee, approximately 20 miles away. The ambulance was called seven or eight times before gardaí decided to drive him to the hospital. Wayne's parents are now having to deal with losing their son as well as with the thought that, were it not for the cuts, he might not have died. Very bravely, they are trying to turn their own personal tragedy into something positive. They do not want this to happen to another family. It is very important that we point out that the cutbacks have real-life consequences. It is the McQuillan's impression that it is not just a case of the ambulance cuts per se but also that the old system that was in place was far more effective in terms of responding to crises. What is the opinion of the witnesses of that analysis?

We heard of a case last week of difficulties in dealing with a traffic collision in Portlaoise. The airways in Kildare were awash with commentary over the weekend about the fact that there was no ambulance cover in Athy because management refused to provide overtime cover due the cutbacks. Is that the case? In Portlaoise, it appears to be the case that a staff member was out on long-term sick leave and a second ambulance was called away to Kildare. The stretching of resources appears to be having serious consequences. Is it a regular occurrence that the service is grappling with low numbers of staff while trying to keep budgets in check, resulting in management decisions which are leading to serious situations?

Several other Deputies have referred to the situation in Northern Ireland and I would also cite the example of Scotland, which has only a marginally higher population than ours but which has four times more ambulance personnel.

Scotland, which is not awash with cash, has twice as many ambulances. I presume we need to be heading towards that as well. Maybe I will leave it at that.

Peter Fitzpatrick (Louth, Fine Gael)
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I welcome the members of the McQuillan family from my own county of Louth. I heard about the tragic death on New Year's Eve. It would be one's worst nightmare as a father. I apologise to the family for what happened their son.

I would like to pick up on the suggestion that we do not have enough appreciation for paramedics. I had a bit of an incident approximately two years ago, as a result of which I have nothing but admiration for paramedics. I congratulate them on the absolutely fantastic job they are doing. It has been mentioned that paramedics work closely with the Garda Síochána, the Defence Forces, the fire service and the Prison Service. They do a really professional job. By providing early intervention in life-threatening circumstances, they definitely improve a person's chances of surviving. Paramedics do an excellent job on the front line.

The current targets for paramedic response times are set by HIQA. The response time of 7 minutes and 59 seconds for Echo and Delta calls - those relating to serious life-threatening situations - is achieved in 85% of cases. I know HIQA is trying to improve that again this year. The shortage of personnel has been mentioned by a few speakers. As far I know, some 1,692 people are employed in this sector. The Government has given a commitment to allocate an additional 43 posts in 2014. Reference has also been made to a lack of funding. I attended a meeting of this committee at which we discussed the budget with the Minister. In 2013, an additional €8 million was allocated to national ambulance services. An increase of €3.6 million is being provided for in 2014. Is that enough?

We have heard a great deal about the different staffing and other allocations in Northern Ireland and Scotland. The bottom line is that this country needs an ambulance service that has good response times. Nobody in this room would deny that. The McQuillan family will be particularly aware of that. We are all on their side. It is important that we all work together. It is easy for people outside the Government to criticise the ways things are at the moment. I hope that all members of this committee will work together by talking to the Minister and pushing as hard as we can to help the ambulance service.

It seems from what Mr. Dixon said about rapid response vehicles that paramedics are not happy with the service that is being provided at the moment. I understand that an additional 25 vehicles were allocated recently. He also spoke about "the impact of roster changes and cutbacks on response times". He referred to the belief that the National Ambulance Service is "running on empty". I do not like that phrase because it suggests that something is lacking at the moment. I wish we could hear a little more about that. Not many people realise that between 275,000 and 280,000 emergency calls are received every year. The average monthly figure is approximately 23,000. In December 2013, that figure increased to 25,000.

We all realise that the members of the National Ambulance Service Representative Association have a tough job. We are here to listen to them. If we can help them in any way, it will be well worth it if it means that just one extra life is saved.

Regina Doherty (Meath East, Fine Gael)
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I thank the witnesses for attending today's meeting. I acknowledge and welcome those who are present in the Gallery.

The statistics that Mr. Dixon mentioned by way of comparison obviously make for stark and compelling reading. I would like to drill into them. When he mentioned that Northern Ireland has 1,200 staff, Scotland has 4,500 staff and Ireland has 1,600 staff, was he comparing like with like? Are they all the same kind of staff? Are there different staff categories in Scotland that we do not have, or are known by a different name here? Can I get that information from Mr. Dixon? I have asked for it from other bodies previously. It appears that they do not have it, which is very odd. I would also like to ask for a breakdown of the different figures that were provided for vehicles. We were told that there are 350 vehicles in Northern Ireland and 450 vehicles in Scotland. It appears that we have 265 vehicles. Is a breakdown of those figures available somewhere? Is there a spreadsheet that sets out simply that they have ten type A vehicles but we have just two type A vehicles?

I am looking for a clear and simple analysis of the difference between the per capita resources we have and the per capita resources that other countries have. These figures also need to be broken down to the next level. The HIQA standards to which the paramedics need to adhere, which are obviously difficult, are based on best practice. Our target achievement rate, in the cases of Echo and Delta calls, is 85%. The rate we are currently achieving is between 68% and 70%. How are Scotland and Northern Ireland performing with regard to their targets, which are also set on the basis of best practice? Are they much better than we are? Do they have different targets or variable targets? Is it simply the case that they hit better targets because they have better resources?

During the presentation, Mr. Dixon said that the HSE asked HIQA to lessen the targets. On what basis was that done? The presentation does not say what that was based on. They did not say what it was based on. I know the witnesses have firm ideas about what is causing us not to hit the targets. Why did the HSE ask HIQA to relax the targets? Has the National Ambulance Service Representative Association contacted HIQA, on foot of the HIQA reports that came out recently and in the medium past, to make representations regarding what it considers to be causing the difficulties of its members? If it has made such representations, what kind of response has been received from HIQA?

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I apologise for my late arrival. I was taking Leaders' Questions in the Chamber. I welcome the representatives of the National Ambulance Service Representative Association. I also welcome the people in the Gallery, particularly the members of the McQuillan family from Drogheda. I sympathise with them on their sad loss.

I would like to ask a few questions about the ambulance service nationally. How does the number of staff in Ireland compare with the number of staff in other jurisdictions? Mr. Dixon might have answered that question before I arrived. He has provided details regarding the number of vehicles. Can he comment on the condition of the vehicles and say whether he believes they are fit for purpose? Are different rostering systems used in different areas? Are additional staff or ambulances needed, depending on the type of terrain being covered? Some ambulance bases are close to motorways or national primary routes, whereas others have to cover rural hilly areas.

I would like the witnesses to comment on how cutbacks have affected ambulance services. My understanding, as a representative of Tipperary South, is that cutbacks are having significant effects. For instance, the three ambulance stations in south Tipperary have to cover Kilkenny, Carlow, Wexford, New Ross, Waterford and Dungarvan on an ongoing, daily basis. This is not something that happens just once a week. The Dungarvan ambulance might be pulled to cover Youghal, which has lost an ambulance. It is now proposed to reduce ambulance coverage in south Tipperary. This is to be done to give coverage to other areas which have been affected by the cutbacks. Do the witnesses agree that this is the case? Is this happening in other areas throughout the country? It seems to me that the various cuts that have taken place have affected the service to the extent that Peter is being robbed to pay Paul on an ongoing basis. I would like the witnesses to deal with this matter, in particular.

Sandra McLellan (Cork East, Sinn Fein)
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I welcome the witnesses and thank them for their presentation. I also welcome those who are in the Gallery. I thank Mr. Dixon for outlining the concerns of the members of the National Ambulance Service Representative Association.

While a number of the issues have been addressed, we heard a long list of areas that need to be urgently addressed. These include the ageing fleet in the National Ambulance Service, the emphasis on solo responder cars, the impact of roster changes and cutbacks on response times and the management of personnel in respect of staff illness and psychological or physical injury. Are these matters being addressed? Is the National Ambulance Service Representative Association in negotiations on having them addressed and, if so, has any progress been made?

Michael Healy-Rae (Kerry South, Independent)
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I welcome the witnesses and acknowledge those in attendance in the Visitors Gallery. Last year, I stated in the Dáil that changes in emergency call-outs, in County Kerry in particular, would lead to deaths. Unfortunately, I have since been proved right as they resulted directly in the death of Mrs. Elizabeth Riordan from Direen, Cahirciveen, who fell ill in Tralee town within sight of Kerry General Hospital. An ambulance was called because the lady was choking but she died while waiting for it to arrive. Staff in the ambulance control centre directed an ambulance from Listowel to the scene, whereas those waiting at the house were given the impression that an ambulance was being dispatched from Tralee. Mrs. Riordan's husband listened for a siren but by the time the ambulance came, it was too late. His wife died two days later in hospital as a direct result of the loss of local knowledge when the call centre in County Kerry was centralised to the dispatch centre in Townsend Street, Dublin.

Are the witnesses satisfied and confident that the facility in Townsend Street is fit for purpose? Why was an external safety audit of the building not carried out? Is it true that while an internal safety audit was carried out by the Health Service Executive, no external audit of the facility has been carried out? All businesses can be subject to an audit at any time, including by an external body, which will check whether the business premises is fit for purpose? Are the witnesses satisfied in respect of the operations being run out of Townsend Street that the necessary systems, mechanisms and technology are in place? The control centre was certainly not fit for purpose when it commenced operations.

In another case, the control centre received a call from an address in County Kerry but dispatched an ambulance to an identical address 55 miles away in County Cork. These frightening events led directly to the death of at least one person. Is it any wonder that we, as public representatives, raise concerns on behalf of the people we represent? When we did so before these events took place we were told by those operating the service in County Kerry that such cases would occur if local knowledge was lost. Deputies from other areas received similar warnings. The problem can be traced to simple matters such as the pronunciation of various townlands and the accents of people from different areas. This is common sense.

Mr. Tony Gregg:

We have been asked wide-ranging and varied questions. If we miss anything, perhaps the Chairman will prompt us and we will ensure the relevant matters are addressed. I understand we have 15 minutes to respond.

Jerry Buttimer (Cork South Central, Fine Gael)
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Times are approximate.

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.

Mr. Michael Dixon:

I think Mr. Gregg has covered almost everything in his response. There are a few things of which we should be mindful. What we are dealing with here is people's lives. As we have seen in the past 12 months, people's lives have been lost. There is no way at any stage that we can attribute this either to the ambulance service or to the incidents that took place. One of the most important issues is to look at the bigger picture of the reconstruction of the hospital network and the changes that have been introduced. If we wish to advance the service, one issue that has been highlighted is the closure of accident and emergency units in smaller hospitals in various counties. These were a vital cog in the provision of care because they were centres of definitive care. They have the X-rays, the doctors on the scene and the surgery facilities. To remove them is to remove a very critical part of emergency care. If the reconfiguration is designed to be best practice and what we have then is centres of excellence, the longer distances we have to travel create bigger gaps in the system. The only way we can secure those gaps is through further investment in the ambulance service. One provision we sought is that the saving made by the reconfiguration of closures of smaller accident and emergency departments be invested in the ambulance service. The ambulance service is the conduit. That is the health service as it stands. Paramedics are at the front line and are first on the scene. They require the support of the committee and the Health Service Executive to order to give the general public the service it requires.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. Michael Dixon and Mr. Tony Gregg for their attendance and for making their presentation.

Jerry Buttimer (Cork South Central, Fine Gael)
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We will begin session two. I remind those in the Public Gallery, witnesses and members of the committee that all mobile telephones should be switched off. I apologise for starting late, but the committee had to deal with some private business. The time allowed for this session is 45 minutes.

I welcome Mr. Paul Bell, Mr. Sean Nolan, Mr. Brendan O'Brien and Mr. Gerry Harris, all from SIPTU. I also welcome Mr. Peter Ray, chairman of the Irish Ambulance Representative Council, Mr. Glen Ellis from the Dublin Fire Brigade and Mr. Fintan Ferrick, supervisor from the National Ambulance Service. They are all very welcome and I thank them for attending.

Before we commence, I remind all here of the rules of privilege. By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of the evidence they are to give this committee. However, if they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise nor make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.

Mr. Paul P. Bell:

On behalf of SIPTU, I thank the Chairman and the members of the committee for acceding to our request to convene this forum to bring clarity to issues arising in the delivery of ambulance services as provided by the HSE National Ambulance Service and Dublin Fire Brigade Ambulance Service. In representing members of these vital services, we want to share our concerns about the effect which adverse public comment is having on the morale of our members who provide front-line ambulance services throughout the Republic of Ireland and the concerns our members have about the perceived lack of public confidence in a vital life-saving service on which every citizen of the State must rely.

As committee members are aware, both from their work in this forum and in their individual constituencies, public concern has grown as a consequence of several high profile cases in which ambulance response to a specific incident or event has been flagged in the media as a matter of concern. We are here today not to apportion blame in incidents where the ambulance service has failed to meet the published Health Information and Quality Authority recommendations, but to assist the Oireachtas Joint Committee on Health and Children to examine all factors involved in delivery to the public and to establish the growing challenges confronting this front-line service and the professional ambulance personnel committed to providing it.

Ambulance professionals in both the HSE National Ambulance Service and Dublin Fire Brigade Ambulance Service have a proven tradition of putting the care of the patient first, and this ethos has been well demonstrated by their commitment in developing the service from a casualty transport service to a sophisticated, first point of control, medical intervention. This has required the strategic educational development of personnel, whereby ambulance professionals are trained to the level of emergency medical technician, paramedic and advanced paramedic, all of whom are equipped to deliver the earliest possible medical intervention, thereby giving the patient or casualty the best possible medical outcome. Our members are also committed to the bachelor of science degree programme in pre-hospital emergency medicine supported by University College Dublin.

Those who deliver front-line emergency ambulance services are deeply affected when a failure to deliver the best medical intervention or meet the recommended response times are linked to an adverse outcome for a patient as many of our members, both in the HSE National Ambulance and Dublin Fire Brigade services, live in the communities in which they are deployed to serve. Despite restrictions on resources in these difficult times, ambulance professionals continue to develop their skill set and the service in the interests of the public. It is important to note that the development and professionalisation of the ambulance service has evolved since 2001, and has been overseen and regulated by the Pre-Hospital Emergency Care Council, PHECC. The PHECC is also the licensing authority for all qualified ambulance personnel.

To assist the committee in its work we will give a brief overview of the resources which the ambulance service utilises and deploys in its daily work. The overall operational budget for the ambulance service for 2014 is €138.5 million, of which €9.2 million is issued to Dublin City Council for the provision of Dublin Fire Brigade Ambulance Service. In regard to human resources, the HSE National Ambulance Service has 1,615 personnel across professional grades in the Republic, of which approximately 390 are advanced paramedics. There is a staff ceiling of 1,670. Recruitment and training of 25 paramedics is ongoing, advanced paramedic training is ongoing internally and recruitment of 43 control staff is ongoing.

The Dublin Fire Brigade Ambulance Service employs 110 personnel across all grades of ambulance professionals, inclusive of 40 advanced paramedics. The service receives backup support from 840 paramedical first response firefighters, backed up by 21 paramedic first response fire appliances and two emergency fire appliances, offering a rapid first response deployment to any pre-hospital emergency. The HSE National Ambulance Service provides the following supports to the public throughout the State: emergency ambulance service; intermediate care transport; mobile intensive care ambulance and neonatal intensive care ambulances.

In regard to HIQA recommendations and international comparisons, our members, both in the HSE National Ambulance Service and the Dublin Fire Brigade Ambulance Service are committed to attaining best international standards and have no issue with HIQA as the monitoring agency reviewing and enforcing standards. However, we ask the committee to note that the HIQA response time recommendations, as set out in its publication dated 19 January 2011, Pre-Hospital Emergency Care Key Performance Indicators for Emergency Response Times, sets out the following recommendations: first response to patient within 7 minutes 59 seconds; and patient carrying vehicle within 18 minutes 59 seconds. These critical key performance indicators are set as recommendations. However, it is the public perception that these response times are mandatory and when a call is not responded to within these timeframe recommendations, the ambulance service is called into question, regardless of whether the patient or clinical outcome is positive.

It is our understanding that HIQA was advised in 2010 by the Pre-Hospital Emergency Care Council and the ambulance authority that its stated recommendation on response times could not be met at the frequency demanded. This required that response times would incrementally move from 75% to 90% of all life-threatening calls, also known by the code names, ECHO, which relates to respiratory and cardiac related emergencies, and DELTA, which relates to life-threatening non-cardiac related emergencies.

It is our understanding that the PHECC communicated its reservations to HIQA on the reasons the response times could not be met on the following grounds: release of ambulances from accident and emergency departments and patient hand-over; geographic location of ambulance facilities; rural versus urban response time variations; road conditions; weather conditions; vehicle availability; crew availability; increases in call volume; and demographics and population.

The following are examples of response time data. From 1 January 2011 HIQA stated its expectation that the recommended response times would incrementally progress from a 75% to a 90% success rate. For the purpose of assisting the work of the committee, we suggest that the data as provided by HSE be noted. The following data include all emergency and urgent calls received by HSE National Ambulance Service and the Dublin Fire Brigade Ambulance Service. These figures include the emergency calls volume and response times for ECHO and DELTA emergency calls: call volume, 267,039; emergency calls, 209,694; urgent calls, 57,345; ECHO calls, 2,772; and DELTA calls, 79,155. The HIQA recommended target time response for ECHO calls is 18 minutes 59 seconds at 80% for urban and rural calls. The ambulance service success rate for patient transport carrying vehicles was 68%. The HIQA recommended time response for DELTA calls is 18 minutes and 59 seconds or 80% for urban and rural calls. The ambulance success rate for patient transport carrying vehicles is 63%. The 2013 emergency call volume and response times were: call volume, 280,572; emergency calls, 230,433; urgent calls, 50,139; ECHO calls, 2,916; and DELTA calls, 85,670. The HIQA recommended response time for ECHO calls was 80%. The ambulance service patient carrying vehicle success rate was 68%. The HIQA recommended response time for DELTA calls is 18 minutes and 59 seconds at 80%. The ambulance service patient carrying success rate was 63%. I call on the committee to note the increase in calls volume for 2013.

Let us consider the HIQA recommended targeted emergency response times. As stated, HIQA's published pre-hospital emergency care performance indicators for emergency response times on 11 January 2011 and set out the targeted recommended response times for first response and patient-carrying vehicle ambulances. It is our clear understanding that the adopted recommended response times were considered appropriate by HIQA having reviewed best international practice and having considered the operation and standards of ambulance services in the United Kingdom. Reports from ambulance services in neighbouring jurisdictions and throughout the globe are contained in the HIQA document.

However, among the concerns expressed by our members in the HSE National Ambulance Service and the Dublin Fire Brigade Ambulance Service was the fact that no capacity review study was undertaken by HIQA, the Department of Health or the HSE at any time in the history of the ambulance service. We believe that such a review should have been commissioned prior to the adoption of the response time recommendations being issued to examine the ambulance service and resources at its disposal, especially considering the reconfiguration of hospital services throughout the State which has put greater demands on the nation's ambulance services, including the resources and the skill set of professional ambulance personnel. This point is made on the basis that our members are keen to achieve best international standards to provide the best service possible to the public and achieve the optimum outcomes for the citizens of our country. We are conscious that HIQA is about to commence a scheduled review of the performance of ambulance services, as initially proposed in 2011, and this is welcomed as a positive opportunity by our members.

Let us consider the international comparisons. As the committee is aware, in recent times there has been much public and media commentary about the quality and efficiency of ambulance services in neighbouring jurisdictions. To assist the committee, we will outline the resources of two neighbouring ambulance services, both of which were referred to in the HIQA report and this submission and both of which are obliged to meet the same response times as the Irish ambulance services, with the exception of ambulance response times in the Scottish highlands.

The population of Northern Ireland 1.8 million. It has no population centre greater than 500,000. The geographic area is 13,843 sq. km. The Northern Ireland Ambulance Service budget stands at €77 million. There are 1,100 staff, the call volume is 40,000, there are 59 ambulance stations and there is a fleet of 313. Now let us consider the Scottish Ambulance Service. The population of Scotland is 5.2 million, with no population centre greater than 600,000. The geographic area is 78,387 sq. km.

Jerry Buttimer (Cork South Central, Fine Gael)
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Can you finish your presentation now, Mr. Bell? Please bring it to a conclusion.

Mr. Paul P. Bell:

I apologise, but I believe we need to go through these figures, with due respect to everyone.

Jerry Buttimer (Cork South Central, Fine Gael)
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We are 11 minutes into the presentation.

Mr. Paul P. Bell:

The data presented are sourced from ambulance authorities and government websites. Irish ambulance service professionals are committed to service of the public. While the debate on performance indicators continues to rage in our neighbouring jurisdictions following the outcome of the Mid-Staffordshire NHS Foundation Trust investigations, which determined that clinical and patient outcome became secondary to time targets or time-measured key performance indicators, our members will continue to strive to meet the HIQA time response recommendations.

As I set out in my opening remarks, SIPTU, as the recognised representative organisation within the HSE National Ambulance Service and Dublin Fire Brigade Ambulance Service, wishes to work towards a position whereby public confidence is restored to this vital front-line service and to restore morale among the professionals committed to providing this dynamic and evolving service. The first steps can be taken today by this Oireachtas committee, working in partnership with all stakeholders committed to achieving the highest standards. As the oversight body charged with the oversight of the health service, HIQA should be invited to participate in this process having initially set the key performance indicators for emergency ambulance services. As stated, HIQA is due to commence a review of the ambulance service and we believe it should be made known to the committee and the public. As the key statutory regulator and licensing authority for all ambulance professionals and services, the PHECC should be invited to participate in the process and any subsequent review aimed at bringing the State's ambulance services to best international standard.

In order that a proper discussion can take place on the resources required for the State's ambulance services it is imperative a capacity review of the service takes place and that such a review be conducted by an expert organisation from outside the jurisdiction. Such a review, if acceded to, would also require transparent terms of reference which should have stakeholder involvement. Stakeholders could include patient advocacy groups, clinicians and ambulance professionals via their recognised representative organisations. SIPTU members are committed to working with all processes which will advance the ambulance service. The significant advances made by our members in the past 15 years, driven from the ground up, bear testament to our credibility in the area of improving the ambulance service through the development of ambulance personnel and services. I thank the Chairman and committee members for their consideration of this submission.

Jerry Buttimer (Cork South Central, Fine Gael)
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Thank you very much, Mr. Bell. I call Deputy Billy Kelleher.

Billy Kelleher (Cork North Central, Fianna Fail)
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I welcome the presentation by the ambulance services. No one is criticising the staff at the coalface of the ambulance service. We should be clear about that. We are here to try to shed some light on the challenges facing front-line services, to see where there are deficiencies and if we can highlight and throw some light on that, as well as determine where additional resources are required.

We recognise the fact that resources are always an issue in every service. However, at the same time, there seems to be a good deal of disquiet among the public about the ambulance service. Given the reconfiguration of hospitals groups, the small hospital framework and the downgrading of emergency departments and the amalgamation of others, pressure has been put on the services which had not necessarily been anticipated. Moreover, the issues that have been highlighted by other speakers relating to major incidents raise questions about the responsiveness of the ambulance service. This is why we are having these meetings. It is not a criticism of front-line staff.

The deputation stated that HIQA or some other body should have carried out a capacity review in advance of bringing forward the key response indicators of 7 minutes and 59 seconds and 18 minutes and 59 seconds. Does the deputation recognise that HIQA has probably set out best international best practice in terms of the performance indicators and call-out times? Rather than addressing these issues, what we should be addressing are the resources to ensure we can meet the key performance indicators. That is why we are here today.

Some confusion exists. If an ECHO or DELTA call comes in, the first responder is meant to be there in 7 minutes and 59 seconds. That would be either a community responder, emergency vehicle or an ambulance. If the ambulance is the first responder, then it should be there in 7 minutes and 59 seconds. If it is the second responder, then it should be there within 18 minutes and 59 seconds.

When we question the National Ambulance Service and speak to individuals who have complained about response times, we get varying views. I would like to have this clarified once and for all: is the National Ambulance Service obliged under HIQA guidelines to have a community responder, an emergency response vehicle or an ambulance, if it is the first responder, within seven minutes and 59 seconds? If there is a first responder that is not an ambulance, is the ambulance obliged to go as a second responder within 18 minutes and 59 seconds?

We have heard all too often that the emergency response vehicle is being used to supplement, rather than complement, the ambulance. That seems to cause a great deal of confusion. I believe the National Ambulance Service almost has a policy to use emergency response vehicles as the first and only responder. I seek clarity on that issue.

There is no doubt that a cursory look at the resources available to the National Ambulance Service to provide a quality service shows that they are not available, when compared with those available in Northern Ireland or Scotland. Instead of talking about HIQA’s response times, we should be talking about the need to ensure proper resources are in place.

Is the relationship between SIPTU members and management confrontational? Do individuals have issues about how they may relay their concerns? Is the union able to advocate for its members? Are there rostering difficulties and are relief teams being used to supplement, as opposed to complement, the service team on duty? Is there an inherent break-down between members at the coal face and management in addressing the rostering of personnel throughout the country? That is critically important when we are reconfiguring hospitals throughout the country. Is there enough discussion between key front-line personnel who try to deliver the service? They seem to be under inordinate pressure and stress. When I speak to individual members of the service, they say they work excessive hours and travel long distances.

While I understand the pressure on emergency departments in hospitals, from time to time ambulances are lined up outside emergency departments, unable to discharge patients. How can this issue be addressed? I can understand that in traumatic cases the patient is rushed in, but I cannot understand why a scarce resource is simply parked outside an emergency department. Has SIPTU put forward any proposal to deal with this, or discussed the issue with the National Ambulance Service or the Pre-Hospital Emergency Care Council? What is its view on how to address this impediment to ensuring a smooth discharge from the ambulance and its release to do its work?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I welcome our guests from SIPTU. I join Deputy Billy Kelleher and the Chairman in acknowledging that the National Ambulance Service is a pillar of the health service. Lives depend on what it does. I take the opportunity, as I did when the National Ambulance Service Representative Association, NASRA, attended the committee, to pay tribute to the ambulance personnel who are also members of SIPTU.

I thank Mr. Bell for his presentation, in which he raised several points. I have lived all my life four miles from the Border and the comparisons made in the presentation leap off the page. Mr. Bell refers to a staffing level of 1,100 north of the Border. However, he makes the important point that there is a staff ceiling here of 1,670 - currently the figure is 1,615, excluding the Dublin Fire Service. Was this figure arrived at during the recruitment embargo? When was the ceiling set? We understand reconfiguration, greater efficiencies and effectiveness are crucial, but when everything is moved about, one comes to the logical conclusion that under-resourcing is at the core of the difficulties.

In respect of the comparison with the service north of the Border, without even considering the position in Scotland, there is under-resourcing in terms of equipment and personnel. The number of ambulances available is a major concern. I cited a figure for NASRA and Mr. Bell has personal knowledge of the north east, coming, as I understand, from County Louth. Some incredible figures for the level of ambulance cover in the region have been suggested recently. I suggested a figure of 12, but it may be a little higher. I understand there are approximately 30 vehicles, but they are not all in operation at the same time and not all ambulances. Will Mr. Bell throw some light on the complement of vehicles and personnel in the north east?

I arrived a little late for NASRA's presentation, but I join the Chairman and others in welcoming the McQuillan family and the other guests in the Visitors Gallery. I am very conscious of the great hurt and pain people have suffered as a result of the loss of a loved one, but, as I said, under-resourcing puts ambulance personnel in a very difficult position. They must know that the key performance indicator response times are sometimes unachievable because of the distance involved, when ambulances in closer proximity are already being utilised in making various deliveries and other responses. What is the impact on ambulance personnel? Light is rarely shone on the fact that ambulance crews are under enormous physical, emotional and psychological stress because they know that they will not arrive in time and are responding in very difficult circumstances. Do the delegates agree that we need to see significant investment in the ambulance fleet? I distinguish between the ambulance fleet and other vehicles because ambulances are critical and at the core of what is needed. The ceiling needs to be removed. We need adequate personnel to be appointed to the National Ambulance Service.

Jerry Buttimer (Cork South Central, Fine Gael)
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Before I call Deputy Seamus Healy, I remind members that there will be a division on the Order of Business in the Dáil. Four members of the joint committee wish to speak, as well as Deputies Seamus Healy and Clare Daly and two non-committee members, making a total of eight speakers. This session is due to end at 5.20 p.m. and I want to be fair to everybody.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I welcome the SIPTU representatives and thank Mr. Bell for his very informative presentation. I worked in the hospital sector for many years.

A family member of mine was an ambulance driver initially and then progressed to being a paramedic and an advanced paramedic. I am well aware of the work done by the ambulance service. While the public might be concerned at times about particular incidents, there is a very high level of respect for the ambulance service among public representatives and the public in general. Like the members of the delegation, our job in this committee is to help to ensure that we have a first-class quality ambulance service for the public. I particularly welcome the proposal in the presentation for a capacity review study because this is the key element. The HSE is currently carrying out a national review of ambulance services but this is a case of putting the cart before the horse. The first principle must be to establish by means of a capacity review the current level of resources, what resources should be made available and what additional resources are necessary. For instance, as I said to the previous delegation, a review of the ambulance service is being carried out in south Tipperary. The HSE has not undertaken a capacity review before making proposals for reductions in the service at the Cashel ambulance base and the transfer of a vehicle and a roster to Carlow. In my view, this is part and parcel of cuts to the service and a case of robbing Peter to pay Paul, whereby ambulances from south Tipperary are being pulled out to cover Kilkenny, Carlow, Waterford, Wexford and other areas. I welcome the proposal for a capacity review which should be the key element of the proposals from this committee.

I have a question about the SIPTU representatives' contact with the national management of the ambulance service. Are negotiations or consultations under way about the review that appears to be ongoing throughout the country and in south Tipperary and the south east in particular? Have the delegates any information about the situation in south Tipperary and the south east? There is absolute opposition to any changes in the rosters either at the Cashel base or the Clonmel base because we believe that it will be impossible to have minimum response times with the proposed reductions in the resources in south Tipperary.

My understanding was that the Haddington Road agreement gave a guarantee that existing roster patterns would be maintained. I am of the view that the current review and proposals by the HSE would be a breach of that agreement.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is it agreed to take the questions from seven members together as there will be a vote in the Dáil on the Order of Business? Agreed.

Regina Doherty (Meath East, Fine Gael)
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I thank the delegates for their attendance. I will ask the same questions I asked the previous delegation and to which I did not get answers. It is worrying that Mr. Bell's statistics differ from the statistics provided in the last case. This information is key to the capacity review. The reason for this meeting today is to ensure that the service has the capacity to do the job which we, as ordinary people living in Ratoath or Ballyfermot, or where ever else, all expect it to do. I refer to the staff numbers compared to the numbers in Northern Ireland and in Scotland. Why have those services so many more staff? Do those services have different grading structures compared with the Irish service? The ambulance vehicles are exactly the same. The previous delegation did not have information on the total number of vehicles. If I add up the total provided by this delegation, I note there are 479 vehicles in Ireland compared with only 450 in Scotland. That does not add up, in my view. Is there a definitive spreadsheet available that will show Northern Ireland has ten of these things and we only have eight but that is all right because the population matches up? There has to be a spreadsheet somewhere, owned by someone who makes these decisions to resource the services. If we were to have that information, we could then understand that ten more are needed or that the current capacity is acceptable. I have a question about targets. All our targets are based on best international practice. We are at 68% to 70% with regard to Echo and Delta calls. How does this measure against how Northern Ireland and Scotland achieve their targets, notwithstanding the Ireland has 50% fewer vehicles than they have? Is that information available?

Robert Dowds (Dublin Mid West, Labour)
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I thank Mr. Bell and the other delegates for attending the meeting and I commend the vital work in the national interest of the ambulance service staff. There is no point in going over the same ground covered by previous speakers. To what extent are ambulances held up at hospitals because they cannot get access to a bed for the patient? This has been a serious problem and I ask to what extent it continues to be a serious problem. I refer to the Hallowe'en period and I ask if the work of the ambulance service is disrupted by anti-social behaviour.

Peter Fitzpatrick (Louth, Fine Gael)
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I welcome the delegates. I will not repeat what I said in the first session. We are dealing with people's lives and with the closure of accident and emergency departments. I come from County Louth where the Louth county hospital in Dundalk was closed in 2010. This has resulted in ambulances travelling longer distances. Mr. Bell referred to the paramedics who are members of his trade union. He stated that his members are also committed to the bachelor of science degree programme in pre-hospital emergency medicine supported by UCD. Is this provided to all paramedical staff? He stated that the staff ceiling is 1,670. I do not think that is a small number but the HSE has stated that at the end of 2013 the ceiling was 1,692. There seems to be a difference in those figures. Both sides agree that the allocation for 2014 is an extra 43 staff.

Given that he is from County Louth, I have a few questions for Mr. Bell. There has been much criticism in County Louth of the ambulance service in Drogheda which has a catchment area of more than 80,000 people. The people in County Louth are looking for an improvement in response times. Are the response times different in County Louth from other areas? They are looking for an increased number of ambulances. Is there a shortage of ambulances in County Louth? They say they need more paramedical personnel. Is there a shortage? Is County Louth getting a fair share in the allocation of funding? They want a spare stand-by ambulance and they complain that the gardaí transported a patient to the hospital on New Year's Eve because no ambulance was on call. I ask for answers to those questions.

Clare Daly (Dublin North, Socialist Party)
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In the opening remarks Mr. Bell stated that his members were concerned with the effect on morale of adverse public comment.

The problem does not really relate to adverse public comment, rather it arises on foot of the large number of fatalities which have occurred and which have perhaps resulted in people not only dealing with the tragedy but also inquiring as to what might have been the outcome if the ambulance service was better structured or financed. What I am saying in this regard is in no way meant to be a reflection on those who work at the coalface and for whom everybody has the height of respect.

I have three brief questions. I do not believe there should be a debate on response times. Are the response times only a guideline or are they meant to be reflective of international best practice? I am a new member of the committee and remain confused about that matter. It seems that the times reflect international best practice. If that is the case, that should be our starting point and there should be no further debate. What we should be concentrating on is how we can achieve these times. It is clear that we are a long way from achieving them. I do not have a difficulty with HIQA stating these are the response times. If they are reflective of best practice, we should try to achieve them. I would like some clarity to be provided on the matter.

We have been informed that if somebody is sick and cover is not available, an ambulance will not be sent. It appears, therefore, that the problem is not one of vehicles but rather that there are not sufficient staff available. Ambulances are being taken out of circulation and we are relying on other rapid response vehicles as an alternative. That is strange because ambulances are far better equipped for dealing with various situations than the other vehicles to which I refer. Do our guests agree that this is an accurate assessment?

Have studies been conducted of staffing levels? Mr. Bell has stated some recruitment is taking place. How do numbers in the service now compare to those which obtained previously? Is a comparison valid in the light of the changed nature of the job done by paramedics? Any comparison would probably not be inaccurate. When all emergency response workers are factored in, are we still far behind where we should be? Should our targets be higher in the light of the greater responsibilities which obtain?

Denis Naughten (Roscommon-South Leitrim, Independent)
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I also have three brief questions, the first two of which relate to the national performance standards published by HIQA. Is Mr. Bell in a position to explain why the target of under eight minutes for first responders is not published in the annual report? If it is not measured, how do we know whether targets are being achieved? The HIQA target of 85% which relates to the patient transport vehicle arriving within 19 minutes and is published was achieved in north Leinster in June and July last year. It was also achieved in the south in March and November. However, it was not achieved in these areas in every other month of the year. In the west and Dublin the target was never achieved. What can be done to ensure this target is achieved?

The National Ambulance Service has indicated that there are three official accident black spots, all of which are in the west, namely, in Mulranny, County Mayo, Tuam, County Galway and Loughglynn, County Roscommon. Neither additional ambulances nor extra ambulance personnel are being allocated to any of these three locations this year. If such resources were allocated, could they make a significant difference in the context of dealing with the appalling response times in the west?

Gerald Nash (Louth, Labour)
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I thank the Chairman for allowing me, as a non-member of the joint committee, to ask questions on this issue of huge importance nationally and to people in my community. If I understood what he had said correctly, Mr. Bell appeared to indicate that a capacity review to inform the development of the ambulance service had never been undertaken. One would not organise a business or make an investment on that basis, not to mention try to run a service the purpose of which is to save people's lives. It is a terrible indictment of the health service and successive Administrations if no such review ever took place. If one cannot measure what is required, one must plan the system in a vacuum. That is simply not acceptable.

My second point relates to response times. Does SIPTU have a view on how they have evolved? Were the response times in 2007 and 2008 better than those which obtain or have demonstrable improvements taken place in the interim? Is it the case that it is not possible to compare like with like in this regard? In other words, are the metrics which obtain now different?

According to the HSE's submission, with which the committee will deal, some 43 additional staff are to be engaged this year. Does SIPTU have a view on how such staff should be deployed? Is it clear where they are going to be deployed? Will they be deployed at the new ambulance control centres in Tallaght and Ballyshannon or will they be individual paramedics who will be deployed to various locations?

I would appreciate it if SIPTU would outline its views on community responders, probably an underdeveloped feature of the service. These responders appear to be involved in the service in some parts of the country but not in others. I would appreciate it if our guests from SIPTU would outline its views on working with community responders from an operational point of view. How do full-time professional paramedics react to working with community responders?

Jerry Buttimer (Cork South Central, Fine Gael)
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There are up 15 to 20 minutes available for replies on this matter. If Mr. Bell wishes to involve some of his colleagues in the discussion, he should, please, do so.

Mr. Paul P. Bell:

I will do my best to respond to all of the points raised. I will then defer to my colleagues from the fire service.

Jerry Buttimer (Cork South Central, Fine Gael)
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This session is due to conclude at 5.35 p.m.

Mr. Paul P. Bell:

No problem. The first matter with which I will deal is the capacity review. I can understand why Deputies Seamus Healy and Peter Fitzpatrick raised issues relating to their individual constituencies. What would a capacity review involve? The first thing we need to know is whether all ambulance services are deployed in the correct locations. In that context, consideration would have to be given to geographic spread and demographics. The second aspect is that key performance indicators have to form part of the overall capacity review in order to understand whether they are achievable. The point we have made is that before the recommendations contained in the HIQA report were published, it was very clearly understood that they were recommendations. There was a question about whether the National Ambulance Service-----

Jerry Buttimer (Cork South Central, Fine Gael)
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I apologise for interrupting, but a vote is taking place in the Dáil. I suggest we suspend proceedings to allow members to attend. Is that agreed? Agreed. We will suspend proceedings at 5.20 p.m.

Mr. Paul P. Bell:

The capacity review is absolutely paramount.

Deputy Billy Kelleher referred to accident and emergency departments. Ambulances can be caught at these departments for between three and 16 hours. That is a fact.

Jerry Buttimer (Cork South Central, Fine Gael)
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I apologise for interrupting, but where are they caught for three to 16 hours?

Mr. Paul P. Bell:

Our colleagues from Dublin Fire Brigade can provide statistics which show that an ambulance was caught at one hospital for 16 hours. This was because the patient could not be signed over to the accident and emergency department. That occurred a number of years ago. However, we still have an issue with the release of ambulances. It is not unusual to see a number of emergency ambulances sitting outside accident and emergency departments.

Deputy Regina Doherty asked about the number of vehicles available. A total of 265 emergency ambulances, 56 rapid response vehicles, 64 officer response vehicles, six motorbikes and 54 intermediate care vehicles are available. We believe intermediate care vehicles represent the future of the service. Again, a capacity review would identify this and indicate where the shortcomings were. The demands being placed on the ambulance service would also be identified and it could be properly reported how the ambulance service - both Dublin Fire Brigade which is part of Dublin City Council and the national ambulance service - would respond to these challenges.

In the context of the organisation dealing with ambulance management, our members engage with management on a regular basis on issues of concern in responding to patients and delivering a service to the community. We have overall national agreements which are aimed at ensuring we can reach local agreements to make the ambulance service work as it should. This is done through negotiation.

The real challenges lie in other areas. In the context of intermediate care vehicles, people have been recruited into the service, but more are needed in order that emergency ambulances can be made more readily available. A programme has been agreed with the union and personnel are being recruited into the service.

The ceiling has been set not by way of the moratorium as the ambulance service is one of those services that has managed to recruit staff through the efforts of management in negotiating with the Department of Public Expenditure and Reform or the Department of Health. The same applies to Dublin Fire Brigade.

Jerry Buttimer (Cork South Central, Fine Gael)
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As a vote has been called in the Dáil, I propose the suspension of the sitting. We will resume at the conclusion of the vote. I apologise to our guests for the interruption of business.

Jerry Buttimer (Cork South Central, Fine Gael)
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We will resume in public session. Mr. Bell is in possession and has 12 minutes remaining.

Mr. Paul P. Bell:

I will ask my colleague, Mr. Glen Ellis from Dublin Fire Brigade, to address the committee first, to be followed by my colleague, Mr. Peter Ray.

Mr. Glen Ellis:

I thank the Chairman for the opportunity to speak on behalf of the SIPTU branch in Dublin Fire Brigade. One of the key points we would like to get across is that since 1987 for the city of Dublin we have only had an increase of one resource in the ambulance service, having regard to the increase in the population and in housing around the city of Dublin. This was the Swords ambulance service, which was brought into play by Dublin City Council more than three years ago. The population has grown and our number of turnouts has also grown. We have been able to maintain an appropriate dual role, a dual-based EMS system, which is recognised as an appropriate, or even an increased, level of care in the country.

To return to the target response time of 7 minutes 59 seconds, we would ask why these figures have stopped being published. For the city of Dublin, it does not truly reflect the response, as such. I will give an example of what I mean by that. If Dublin Fire Brigade control centre receives an Echo call and a Dublin Fire Brigade engine is resourced to attend this incident and on arrival the fire crew, who are trained paramedics, do not feel an ambulance is required for whatever reason, the ambulance is cancelled and the call is logged as an Echo response. It goes into the statistics, and because no patient-carrying vehicle was required within the 18 minute 59 second target response time, it accrues a negative number on the overall numbers. Similarly, if Dublin Fire Brigade receives a call where a HSE National Ambulance Service ambulance is the patient-carrying vehicle that attends the call, we will have a negative number on time that is published through the HSE time stamps. We have statistics that indicate that, of the calls received from January to December 2011, some 58% were attended by the fire service first, with paramedics on fire trucks in attendance, until the arrival of the vehicle. Again, in respect of 2012, we are led to believe that we are meeting up to 68% of the key performance indicators, KPIs. Under the current KPIs, the target periods of 7 minutes 59 seconds and 18 minutes 59 seconds - on which my colleague, Mr Bell will also speak - are also accepted internationally but along with those figures there have been findings following clinical reviews in the relevant ambulance service. I would point to a report of a review of the West Midlands Ambulance Service in London in 2009 which indicated that if these target figures are to be used, considerable staffing and resources need to be increased to achieve these KPIs. It reverts to the point that no review was carried out to identify if the resources were available to achieve these KPIs.

In regard to the delays, my colleagues and I in Dublin Fire Brigade have faced ongoing delays, including up to today, of anything ranging from three to four hours weekly in certain emergency departments and have experienced delays of 16 hours, 14 hours and ten and a half hours waiting on trolleys to become available. Our colleagues in the nursing service in emergency departments are struggling to produce beds or find areas where our patients can go, which in turn has a knock-on effect on the ambulance service in that a vehicle is not available to attend life threatening emergencies.

Mr. Peter Ray:

In regard to the target period of seven and a half minutes, in the UK service, which is a comparable quality service across the globe, this target has been examined in a different light in regard to patient outcomes. The target period of seven minutes 59 seconds emanated in 1979 but that was a different day and age. As that target was in operation in the UK it was transposed here. It was a convenient mechanism to apply here, but for today's ambulance service, there is no scientific basis for it because what is called a critical intervention period for a patient in hospital is well outside the eight minutes period. Patient outcomes is what is being examined currently in all developing services.

On the question raised regarding a second vehicle that might arrive at the scene of an incident, that is a patient-carrying vehicle that would arrive within the target period of 17 minutes 59 seconds minutes rather than a second vehicle.

A first responder might get to the scene within the target response time of 7 minutes 59 seconds because they live in the community; it could be a next door neighbour or whatever. The second vehicle could be an RRV instead of a patient-carrying vehicle. The target for a patient-carrying vehicle is 17 minutes 59 seconds.

Regarding the vehicles, a question was raised about the figures supplied. All the vehicles would not be on duty at the one time. In other services the figures supplied would be vehicles that are on duty at the time. The numbers supplied by the Health Service Executive, HSE, to us are on the actual fleet. Some of them might be parked but the numbers that might be on duty would be considerably reduced from those figures. Also, there is a cohort - the officer response vehicles - that would be a resource to call upon out of hours; they are not actually on duty.

Queuing of ambulances is a worldwide problem. It is not unique to the Irish set-up. A number of jurisdictions have examined different ways of trying to tackle it. I am sure if there was to be a capacity review it would examine what might be deployed in other jurisdictions to try to resolve that problem but it is not unique to the situation in Ireland. It happens in the Australian, American and United Kingdom ambulance services. I hope we would not end up with the Australian experience because they use ramping, which involves putting people into a 40 foot container. In the Australian services it is like a second room but it is kitted out with staff etc. They call it ramping because of the ramp up into it.

Regarding the degree programme, the Irish Ambulance Representative Council, under the auspices of SIPTU, has always welcomed the continued professional development of the service for the staff in terms of education. The BSc programme will be coming down the tracks. There are a number of hurdles that University College Dublin and other educational establishments must overcome but, essentially, people entering the service now will have a BSc degree in line with all other health care professionals, that is, nursing and all the other paramedical personnel. It is a very important development education-wise. It brings us into a new plain, and we welcome it in that regard.

Mention was made of the pressures on staff, critical interests, the stress management programme, etc. That area needs investment because staff are constantly under pressure from local management to try to meet these targets. I will hand over now to Mr. Bell.

Mr. Paul P. Bell:

To answer the two points made, outcomes in the Northern Ireland Ambulance Service and outcomes in the Scottish Ambulance Service are more successful than those in the Irish ambulance service.

Regina Doherty (Meath East, Fine Gael)
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Much more.

Mr. Paul P. Bell:

Yes, but that is because their services were structured in such a way as to meet this key performance indicator. However, a debate is taking place in the United Kingdom to the effect that clinical outcomes and patient outcomes should now be examined. That is because of what happened in mid-Staffordshire. That debate is raging on. It comes from a different era. As Mr. Ray said, ambulance professionals now can give much more direct medical intervention, and they will continue to improve that service in rapid deployment.

The issue we have had is that the regulatory authorities, namely, the pre-hospital emergency care council and HIQA, should be discussing what it is possible to meet. In terms of HIQA, we believe there should have been some discussion about having the capacity to review and to say whether we can meet these key performance indicators. The problem is now that members of the public and those waiting for ambulance services have an understanding of two key times and, as my professional colleagues described earlier to the committee, they relate to specific emergency life-threatening calls. The two other main players are the regulatory authority, which is the pre-hospital emergency care council, and HIQA.

Some of the questions being put to us today are being asked well after the fact. We believe the capacity review, which will cover a number of clear, defined areas for public representatives such as the members, professionals such as the representatives, and the general public, will clearly understand what is achievable and what is best.

I put it to the committee that if our colleagues in an ambulance service save a life today but that call was responded to in 21 minutes, that will be deemed a bad call. If they respond and achieve the key performance indicator and the patient has an adverse outcome, because of the way the structure is set that is a good call. We find that unacceptable. Our members are determined to have the best patient outcomes, whether people live in the city or in rural settings. We want to see the development of a capacity review that takes all of that into account as well as, more importantly, quality and patient outcomes. That is what we are about. Key performance indicators have their place but the professional ambulance services across the globe, be they in the United Kingdom, Scandinavia or elsewhere, are now having the discussion about best clinical and patient outcomes. That is the way we want to go.

Jerry Buttimer (Cork South Central, Fine Gael)
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We will suspend until the beginning of our third session. On behalf of the committee I thank all of our witnesses for participating. I thank the representatives for their professionalism and commitment. On a personal level, I had an incident in the family before Christmas and the response was phenomenal.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank everyone for their patience. I remind people that mobile phones should be switched off or put in aeroplane mode. This the third and final session in today's meeting on ambulance response times. I welcome, from the HSE, Ms Laverne McGuinness, chief operations officer and deputy director general, Mr. Martin Dunne, director of the National Ambulance Service, and Dr. Cathal O'Donnell, medical director of the National Ambulance Service. They are all welcome and I thank them for their attendance.

Before we commence, I remind witnesses they are protected by absolute privilege in respect of the evidence they are to give this committee. However, if they are directed by the committee to cease giving evidence in respect of a particular matter and continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise nor make charges against any person or persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice and ruling of the Chair to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.

Deputy Kelleher has asked that his apologies be conveyed, and his place will be taken by Deputy Calleary. Deputy Ó Caoláin also is obliged to depart for the Dáil Chamber. Apologies have also been received from Deputies Catherine Byrne and Ciara Conway and Senator Henry. I invite Ms McGuinness to make her opening statement.

Ms Laverne McGuinness:

I thank the Chairman and members for the invitation to attend the committee meeting today. I am joined by my colleagues Mr. Martin Dunne, who is director of the National Ambulance Service, and Dr. Cathal O’Donnell, who is the medical director of the National Ambulance Service and a consultant in emergency medicine. Before beginning the statement, I wish to acknowledge the presence of the McQuillan family and to extend the HSE's sympathy to the family on the loss of their son.

The joint committee requested information regarding the National Ambulance Service and response times and the HSE already has provided a detailed briefing. In my opening remarks, therefore, I will focus on the key areas of investment in 2013 and 2014 and on improvements in emergency response times. The primary role of the ambulance service is to deliver a responsive emergency service to the public in pre-hospital emergency care situations, with patient care at the heart of this service. Care begins immediately at the time the call is received right through to the safe transportation and hand-over of the patient to the receiving hospital. Each year, the National Ambulance Service receives between 275,000 and 280,000 emergency calls, which amounts to approximately 23,000 emergency calls each month. During 2013 the National Ambulance Service experienced an increase of approximately 1,000 emergency calls each month over the year, and in December the total number of emergency calls exceeded 25,000. Analysis of the overall data indicates that there has been an increase of approximately 10% in all emergency calls from January 2013 to December 2013.

The National Ambulance Service has a budget of €137.7 million in 2014. There has been significant investment in the ambulance service in recent years with the aim of developing a modern, high-quality National Ambulance Service that is safe, responsive and fit for purpose. Responding to emergency calls within the target response time is a key objective of the ambulance service, and the target set for 2013 was that 70% of clinical status 1 ECHO incidents - that is, those incidents in which patients are suffering from a life-threatening emergency such as cardiac or respiratory arrest - should be responded to by a patient-carrying vehicle in 18 minutes and 59 seconds or less. National performance for 2013 was 69.5%, while some regions achieved rates as high as 79%. As for clinical status 1 DELTA incidents - that is, those dealing with other non-cardiac life-threatening emergencies - the target set in 2013 was that 68% of incidents should be responded to by a patient-carrying vehicle in 18 minutes and 59 seconds or less. The performance for 2013 was 64.1%, with some regions achieving 67.87%. In 2013 a total of 88,644 category 1 calls, both ECHO and DELTA, were received, which amounted to between 7,300 and 7,500 each month. During 2013, the volume of ECHO and DELTA calls alone increased by an average of 1,000 per month. Despite this increase in volume of 1,000 per month, the ambulance service responded to a higher number of these calls within the 18 minute and 59 seconds target. Had the volume of calls remained the same, we would have seen an even more significant improvement in response times.

A performance improvement action plan has been put in place to improve our response times and patient outcomes, and we have increased our target for ECHO and DELTA response times in 2014 from 70% to 80%. These actions include monitoring and improving processes in respect of call taking, allocation and dispatch, monitoring and improving crew mobilisation times, appropriate targeting of emergency vehicles, appropriate targeting of intermediate care resources and monitoring and improving emergency department turnaround times. The delivery of these improvements will be facilitated greatly by the new financial investments made in 2013 and 2014. To ensure successful implementation of these items, a three-year national ambulance strategy is currently being finalised.

I will turn to some of the significant areas of investment. The development of a single national ambulance control centre operating over two sites, namely, Tallaght and Ballyshannon, is a key priority for the health service. Between 2013 and 2014, the health service invested €26.2 million in the development of a single national control centre which will operate over the aforementioned two sites. Of this €26.2 million, capital funding amounts to €14.2 million, which includes €7.6 million invested in ICT, for example, for the digital, voice recognition and call-aided dispatch technology system and an integrated command and control system. This €26.2 million also includes €8 million in revenue funding.

The process of rationalising the number of ambulance control rooms across the country is in line with international best practice. The single control centre will contribute to the provision of optimal pre-hospital emergency services to the public by ensuring that all emergency call-taking and despatch is carried out on one system in order that the nearest available emergency resource is despatched to each incident, regardless of any former geographic boundaries. It is expected that the new national control centre will open in 2015.

Cork, Tralee and Navan control centres' functions have already migrated to the National Ambulance Service Control Centre at Townsend Street during 2013 and control operations for the former east, which is, Dublin, Wicklow and Kildare, migrated onto the same computer system as Townsend Street and went live for both voice and data on the national digital radio system.

One of the other investment is in intermediate care vehicles and services. In 2013, capital funding of €3.25 million was used to purchase an additional 25 intermediate care vehicles to allow us further optimise the deployment of resources. The intermediate care service is specifically focused on the delivery of inter-hospital transfers and low acuity work to ensure emergency ambulances are available to respond to emergencies as they arise. To date, 73.4 operatives have been appointed across the country in Cork, Galway, Sligo, Letterkenny, south Dublin, Waterford, Kilkenny and Castlebar.

In 2013, in order to support the implementation of additional intermediate care services, the National Ambulance Service procured 25 additional vehicles at a capital cost of €3 million. Preliminary analysis of the data for 2013 shows that the investment made in respect of our intermediate care services is already showing some positive results. This preliminary data, especially for December, indicates that intermediate care vehicles are taking over much of the non-emergency work that would normally have been managed by our emergency ambulance vehicles. This investment allows emergency vehicles to be freed up, thereby enabling improvements in emergency response times, to deal with the increased volume of emergency calls being received.

The emergency aeromedical service was established as a pilot service in June 2012. The service involves the Air Corps providing aeromedical support to the HSE National Ambulance Service. Based in Custume Barracks, Athlone, the Air Corps is providing a dedicated helicopter and personnel to fly and maintain the aircraft.

The emergency aeromedical service has completed 458 missions since its inception to year end 2013. The Irish Coast Guard supplies services to the National Ambulance Service as a primary responder for search and rescue missions and as a secondary responder for aeromedical services. In 2013, the Irish Coast Guard completed 276 missions.

These are just some of the key investments that have taken place within the National Ambulance Service over the past two years. As part of the three-year national ambulance strategy, the health service will be conducting a national capacity review setting out the requirements of the ambulance service over the next number of years.

This concludes my opening statement and together with my colleagues, I am happy to answer any questions that the committee may have.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Ms McGuinness. I thank Deputy Calleary for allowing Deputy Ó Caoláin to go first as he is to speak in the Dáil.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I welcome Ms McGuinness and her colleagues from the National Ambulance Service.

I seek a brief clarification. When she shared with us the details on the performance levels within the set response times, she spoke of ECHO and DELTA calls in relation to a response time of 18 minutes and 59 seconds. Perhaps there is a small contradiction here with one of the earlier presentations which spoke of ECHO and DELTA calls classed as "serious life threatening" and where the ambulance service is tasked with achieving a response time in 85% of these calls within seven minutes 59 seconds? Could she explain clearly the difference between the seven minutes 59 seconds and the 18 minutes 59 seconds and the designations of ECHO and DELTA? Both refer to serious life threatening matters. Even Ms McGuinness, in her presentation, spoke of "life threatening emergencies" in two preceding paragraphs.

In a recent meeting at which Ms McGuinness herself may have been present, as a result of a personal experience - not my own but another experience known to me - where an ambulance was called out and could not locate the address, there were a number of contributing factors and there was no fault due to the ambulance personnel. It was a cardiac situation and the patient did not survive. However, I raised the issue of Sat Nav or some other such guidance system within the ambulance fleet and I was told that such would not be considered in advance of the introduction of the new postal codes. This was a response given here by colleagues of Ms McGuinness, if not herself - I cannot be certain as to whose contribution it was at the time. Dr. O'Donnell or Mr. Dunne also might like to comment on this.

I have had the matter raised with me by ambulance personnel who picked up on a report of the matter. All of them, of whom there have been a few, reflected that, in their opinion as ambulance personnel being called out in these situations, it would be an additional aid to getting to the call-out point quickly. I am concerned at the period of time we may have to wait for the introduction of these postal codes. Whatever is the cost, and I do not know what it might be, where lives are at stake serious consideration should be given to it. I would ask Ms McGuinness to further comment on that.

Looking back on my own notes, in November last Dr. Geoff King, the director of the Pre-Hospital Emergency Care Council, came before this committee. In the course of Dr. King's contribution, according to my notes, he stated that there was a need for more ambulances within the National Ambulance Service. I would like to know whether Dr. O'Donnell agrees with Dr. King's assessment and if he quantify that in any way. I would ask for a response from Ms McGuinness as well. I reflected to SIPTU, immediately before the Chairman went to NASRA earlier, that my sense of it is we can do all the moving about we like in trying to create greater efficiencies, but, ultimately, if one comes to the bottom line repeatedly, no matter how often one moves the pieces around on the table, it is a no brainer. We need further resourcing of the National Ambulance Service. It is not only based on comparisons with the neighbouring jurisdiction north of the Border, although these are quite stark, or Scotland with a comparable population base. Ambulance crews and personnel across the country, not only in my north-east area, are time and time again reflecting on the enormous strain that they bear, particularly given the inadequate cover available in terms of ambulances and personnel. I did not get a full explanation from the SIPTU team, but I understand that there is a ceiling on the number of personnel within the National Ambulance Service of 1,670. Could they explain why that ceiling applies and how flexible it might be? Surely, if more ambulance personnel are needed - I am quite convinced they are - that ceiling needs to be lifted. I will leave it at that.

I apologise to our guests. I am not able to wait for their responses, but my colleague, Deputy McLellan, will advise me of same.

Dara Calleary (Mayo, Fianna Fail)
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I apologise to Ms McGuinness. On the last occasion I substituted at a health committee, we had a row. I hope we are not going to have one now, but I am not convinced.

First, I have a couple of general questions which are area specific.

The ambulance service staff on the ground are doing a fantastic job under considerable pressure. That came across in the presentations from SIPTU and the group before it. What is the difference between a paramedic and an emergency medical technician? How many people in the service are trained and doing the duties of paramedics but paid according to the rate applicable to an emergency medical technician?

SIPTU raised the issue of emergency room delays and stated ambulances are parked up at emergency rooms. It cited the case of a 16-hour delay in trying to get a trolley. One representative spoke about this being an international problem. Is there an Ireland-specific problem? What protocol is in place?

The HSE said in its presentation there was a quite significant volume increase in 2013, by an average of 1,000 per month. Is there any specific reason for that? Is it the international experience? Are there any particular conditions resulting in the trend?

Now comes the row, perhaps. I was made aware of a delay in a call-out in Ballina the third week of October. I emailed the service in Galway and got a very prompt response; I had it within days. The time of the call was 10.41 p.m. The ambulance was mobile at 10.44 p.m. and at the scene at 12.10 a.m. It left the scene a 12.29 a.m. and was at the hospital at 1.02 a.m. The delegation defined the primary role of the ambulance service as delivering a responsible emergency service to the public. In the case in question, where does that fit in? I subsequently submitted a parliamentary question to obtain further detail and it took two months for me to receive a response. It was only half a response. I raised my frustration over this in a Topical Issue debate and Minister of State Deputy Kathleen Lynch, in fairness to her, very kindly intervened and got a response. The response I got contradicts some of what the delegates have told us. The HSE would say that the appropriate targeting of emergency vehicles is involved. It has also made the point that, in terms of the establishment of the new control centres, geographical boundaries are no longer what they were. I understand that on the night of the call in question, the Ballina-based ambulance crew was actually at a call in Rooskey. The ambulance that answered the call came from Boyle. The Ballina-based crew was in Roscommon and an ambulance from Boyle had to come. On the same evening, another call from Ballina was answered by an ambulance crew from Clifden. I asked how many times ambulance crews had come from outside the county to answer calls in Mayo and how many times ambulance crews based in the county had left it. I was told that information is not available. The HSE has stated the national ambulance service does not currently record some of the information the Deputy has sought. I presumed that to be it. How can we make a judgment about whether the HSE’s services meet the needs of the people we work for? How can we know that the service meets all the objectives if we cannot get what I would consider basic management information systems information?

I do not know how many ambulances are based in County Louth. Perhaps Deputy Nash can tell us. In Erris in County Mayo, which is the size of County Louth, there is one ambulance on call tonight. There is one ambulance on call on Tuesdays, Wednesdays and Thursdays and one ambulance on duty on Mondays, Fridays, Saturdays and Sundays. What is the difference between “on call” and “on duty”? Does the delegation believe it is acceptable that a county the size of Mayo has three ambulances available tonight in case of emergency?

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I welcome the HSE staff. I pay tribute to ambulance personnel throughout the country. They work above and beyond the call of duty, not only daily but also hourly trying to provide a very important service to the public. What we all want, including the staff, is the best patient outcomes for those who avail of the service.

It is clear from the various presentations this afternoon, from our experiences in constituencies and at local level that there is a resource issue. There is a lack of resources available to the service. As I stated previously, a capacity review study is absolutely necessary to ensure a proper service of sufficient quality will be available to the public. There is no doubt that the resources available to the ambulance service do not compare favourably with those available in other jurisdictions. We have received figures in this regard from both the NASRA and SIPTU representatives.

This committee should recommend immediately a capacity review study for the ambulance service. It is urgent. Currently, a review is being undertaken by the HSE nationwide, including in the south east, particularly south Tipperary. The review is effectively putting the cart before the horse. The review is in circumstances in which we simply do not know the required resources. The HSE’s senior management should note that there is absolute opposition to the reductions in the ambulance service being proposed at the base in Cashel, where an ambulance is to be lost and transferred to Carlow.

I compliment the Tipperary ambulance action group, who have come together at very short notice. It comprises members of the public who are quite clearly opposed to the loss of the service because they know the loss of the service to Cashel will mean response times will be even longer than at present. They believe we will certainly not see the response times recommended by HIQA. There will be a less than adequate ambulance service for south Tipperary. I include Clonmel because the review proposal involves the loss of an ambulance in the a.m. period for Clonmel. What is happening currently in south Tipperary is that the ambulances there are being used to cover calls in Kilkenny, New Ross, Carlow and Waterford, including Dungarvan. Obviously, the resources are not sufficient. The effect is that senior management are effectively proposing to downgrade the service significantly at Cashel and Clonmel.

I would have believed the Haddington Road agreement would have provided for the retention of existing roster patterns. Any change proposed, at either Cashel or Clonmel, is in breach of that agreement. What we all want is the best patient outcomes.

However, the proposals on the table for south Tipperary and particularly for the Cashel ambulance base, would not be in the best interests of patient outcomes. They will be strongly opposed by the people of south Tipperary.

Jerry Buttimer (Cork South Central, Fine Gael)
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I now have four members of the committee and two non-committee members offering, so I will take them all together. I will start with Deputies Fitzpatrick and Dowds, and Senators Colm Burke and Crown in that order.

Peter Fitzpatrick (Louth, Fine Gael)
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I thank the HSE representatives for coming here today. With an 8% increase in the population, the closure of accident and emergency units and the distances between hospitals are creating difficulties. In addition, the response time set down by HIQA for Echo and Delta calls is seven minutes and 59 seconds for cases classified as serious or life-threatening, and the task is to achieve that response time at an 85% rate. In 2013, the national ambulance service received an extra allocation of €8 million, as well as an additional allocation this year of €3.6 million, but is that enough? We are talking about people's lives and the ambulance service is so important in this regard. Is the ambulance service getting enough in the budget to counteract current problems?

I have been asked to pose some questions on behalf of my local health committee in Drogheda. How are ambulances and crews allocated divisionally? How long does it take a 999 call, once received, to get a patient in Drogheda to hospital by ambulance? How does this compare with the rest of the country? How many calls for the Drogheda area are handled by Drogheda or by units from other ambulance stations in the region?

Ambulances are being used to transfer patients to regional hospitals, including some in Dublin, for procedures. What impact is this having on the availability of ambulances in the Drogheda area for emergency call outs?

Robert Dowds (Dublin Mid West, Labour)
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I would like the HSE to comment on the national ambulance strategy and what outcomes it is likely to achieve for the service. I also wish to ask about the extent of ambulance hold-ups at hospitals. In the Dublin area, for example, some hospitals are more problematic than others but why is that the case? Which are the worst hospitals and which are the best? Why are ambulances being held up in some hospitals to the extent that they are? What efforts are being made to ensure that ambulances and their crews are not wasting their time for hours on end in Dublin and elsewhere in the country?

Colm Burke (Fine Gael)
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I apologise for having missed quite a lot of today's meeting because I was in the Seanad. I want to welcome the witnesses and thank them for their presentation. I have one question concerning the 10% increase in emergency calls between January and December 2013. Has any reason been identified as to why there was such a substantial increase? Could we have a further similar increase this year? If so, it would be worrying. What are the witnesses' views on those points?

I also wish to raise the turnaround time for ambulances going to hospitals. Is it possible to have additional trolleys for ambulances? In that case, when someone is taken to a hospital, a replacement trolley could be given immediately to the ambulance crew, thus enabling them to do another call without delay. Does the ambulance crew have to wait to retrieve a trolley that is used to deliver a patient? Perhaps the witnesses can clarify that procedure. There is obviously quite a delay in transferring the patient from the ambulance trolley to the hospital setting.

I wish to thank all ambulance service staff for their contribution and the wonderful work they undertake. They are really dedicated and committed to the service they are providing.

John Crown (Independent)
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I also wish to welcome our guests. As somebody who has been a consumer of the ambulance service on the medical side for a long time, I would like to ask the witnesses to address two specific operational questions, one of which is Dublin specific. The situation is common in Dublin whereby the emergency ambulance will be called to somebody who has got an existing relationship with a hospital for a specialist problem. My own perspective in this is that it is often for oncology or cancer, but it could just as easily be for cardiology or diabetes. It seems to me that there is not any discretionary authority resting with the ambulance crew to bring a person to the hospital where their records are and the specialists who know them.

I can understand how organisational questions can determine where someone must be brought, but there is a downstream consequence to that as well. The quality of care a person receives will obviously be better if they go to the place where their relationship exists. Very often, however, in the course of that admission they will be transferred back to the original hospital in the cold light of day when a decision is made that it makes sense to go to that institution for their care. It is one area of policy that could be examined. Without having a free-for-all where everybody goes to a particular institution because it may be popular, could people produce their outpatient cards to show where they have previously attended for treatment?

My second question concerns part of a bigger problem that I worry about a lot, which is the treatment of head injuries. In Dublin and most of the rest of the country, head trauma is concentrated in a very small number of units. Effectively, for most of the country it is in Beaumont Hospital and also in Cork. Really great people work in Beaumont Hospital under difficult circumstances. Without going into my usual song about the shortage of specialists, we have an absurdly small number of neuro-surgeons. As a result, I have come to the opinion - I am sorry if this will make me unpopular, but I have to say it - that we have put together a number of band-aid solutions to try to work the best kind of emergency head injury care we can into the small number of resources we have made available for it. This causes problems because for the kind of head injury for which a surgical remedy is appropriate, necessary and potentially successful, the last thing one wants is delay.

With the best will in the world and no matter how people try to work it, an instant problem is built into a system whereby people are not discretionarily brought to an institution that does not have on-site neuro-surgery for something which is clearly a serious head injury. We need some kind of triage system for emergencies - such as burns, head injuries or penetrating chest injuries - so that they will go to the place which is most suitable to deal with them. We do not have one hospital in Dublin city that could deal with all these problems, including a very complicated trauma involving penetrating heart injury, a head injury plus a burn. That kind of thing can happen. The reason we do not have such a hospital is that we have disbursed our resources across a somewhat unusual number of hospital sites.

As part of that process, there needs to be some better system of getting people with head injuries to the place where they can be looked after. It troubles me a lot because over the years I have personally seen such problems.

Sandra McLellan (Cork East, Sinn Fein)
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I welcome the witnesses and thank them for their presentations. I have one or two questions. We know from pervious HIQA statistics that the national ambulance service has not been able to achieve its targets. In fact, the HSE asked for those targets to be reduced. Why is that the case, if the targets have been set down by HIQA and based primarily on international best practice?

Much has been said about resources not being available to members and the need to ensure that proper resources are put in place.

The national ambulance service representative association, NASRA, has said publicly that the national ambulance service is running on empty as regards staffing and resources. The association said it does not have the personnel or vehicles on the ground to adequately meet the response-time targets being demanded by HIQA. Do the witnesses agree or disagree with that, and can they comment on it?

Jerry Buttimer (Cork South Central, Fine Gael)
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We have some non-committee members in attendance. They are Deputies Denis Naughten, Gerald Nash and Charlie McConalogue.

Denis Naughten (Roscommon-South Leitrim, Independent)
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I wish to correct something I said earlier. The figures I gave on response times related to Echo response times. I want to correct the record in relation to that.

Ambulance staff do a tremendous job in very difficult circumstances and with limited resources. I disagree with Mr. Dunne, who has stated publicly that there are sufficient resources within the system. It is clear from the evidence we have heard today that that is not the case. It is not just me who is saying that. If one looks at the Delta figures, which are the largest cohort of emergency call-outs the National Ambulance Service dealt with last year, one sees that in none of the four ambulance regions in any single month of last year did the service hit the HIQA target of 85% regarding response times for ambulances arriving at the scene of an incident in under 19 minutes. Nowhere in the State was that achieved, yet we are told we have adequate resources in the system.

I have a number of questions. First, why are the first-responder targets note being published? It is also 85% as set down by HIQA whereby first responders are to be at the scene of an incident which is life-threatening in under eight minutes. Will they be published in full? Second, what is the current status of the emergency aero-medical service? It is still at pilot stage. Why is that and when will it be provided on a permanent, 24-hour, seven-day per week basis?

I wish to ask Ms McGuinness a question. In a letter to me dated 16 December 2013, she stated that there are three ambulance black spots in the country, which happen to be in the west in Mulranny in Mayo, Tuam in Galway and Loughglynn in County Roscommon. Why are no additional resources allocated in 2014 to meet needs in those locations? My final question relates to the fact that the HSE and the ambulance service seem to be defending their performance in 2013 on the basis of increased demand, which I am sure existed. However, accident and emergency presentations are down nationally by 3%. If one looks at the figures for the west, north west, Louth, Meath and Limerick, one sees that demand is down significantly in those regions. However, we are still failing to meet basic standards. In the west, one out of two patient transport vehicles is still not arriving within 19 minutes.

Gerald Nash (Louth, Labour)
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I want to refer first to the capacity review. SIPTU expressed very well, as did committee members, that this was an absolute necessity. I was horrified that there has been no capacity review in recent years in the ambulance service. I stand to be corrected if I am wrong. No capacity review informed the HIQA targets which were set some time ago. It is a peculiar way to operate a service. There is a clear demand for a capacity review. I note that it was not referenced in Ms McGuinness's opening statement, but the notion of a capacity review was highlighted in her briefing document to the committee. I welcome that and would like her to record that a capacity review will be undertaken. I would also like her to inform the committee as to the terms of reference of such a review. I would further like her to indicate to the committee which stakeholders she suggests will be involved in the review. It is a necessity that SIPTU and UNITE trade unions are involved. They are key stakeholders in the ambulance service. Patient advocacy organisations should also be included. The HSE should also call for submissions from the public to reflect some of the concerns that are clear in my own community and constituency in relation to the operation of the ambulance service.

I note from the HSE submission that there are 43 additional staff whole-time equivalents to be engaged this year. I also note that the HSE is at an advanced stage in the planning of the Ballyshannon and Tallaght control centres, which is positive. Can Ms McGuinness enlighten the committee as to where those staff will be deployed? Will they be deployed in the control centres or will there be increased personnel numbers on the ground as paramedics and emergency medical technicians to meet the demand which clearly exists? There is a target of 80% in relation to One Echo and One Delta calls. I would like Ms McGuinness to consider with the committee whether that is achievable or not in the context of available resources. I noted at the end of Ms McGuinness's submission the reference to the development of a three-year national strategy. It is important that the capacity review is undertaken in advance of the development of the three-year strategy. It would make sense.

It is mentioned from time to time that if a member of the ambulance service is absent due to illness or other reason, he or she is not replaced. I cannot remember if it was mentioned specifically at today's meeting. The result is that the number of vehicles available in any given area is reduced. Clearly, that has an effect on the service. I understand that it is now policy not to call someone in to replace an individual who is absent. Is that because of resource issues? Absenteeism in the service has been discussed to a certain extent. There may very well be reasons that there is a higher level of absenteeism in the service than in clerical grades. It is a high pressure job, which we all appreciate. Are there regional variations that affect the ability of the service to deliver the level of service required due to absenteeism? If there are high levels of absenteeism, what engagement is there with personnel and the unions representing them to try to address those issues which are clearly affecting individuals and the capacity of the service to operate.

Charlie McConalogue (Donegal North East, Fianna Fail)
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I join the other members in acknowledging the fantastic work of the ambulance service under difficult circumstances. I thank the witnesses for attending today to discuss the issue.

I wish to raise an incident on 30 December 2013 which occurred outside Carndonagh in Donegal where Maura Porter was the subject of a road traffic accident and had to wait almost 50 minutes for an ambulance to be dispatched. While there was an ambulance station in Carndonagh, the nearest ambulance was in Letterkenny. It was an hour and half before she arrived at Altnagelvin Hospital. The family requested an independent investigation. I requested, as did other Deputies, that HIQA look into it. The National Ambulance Service conducted a standard investigation after that incident. What happens to those investigations and can we have the review by the service published? Is it standard procedure in a situation such as that, where a family go through a nightmare scenario and a distressing situation, that the National Ambulance Service would revert to them to explain what happened to lead to such an unacceptable delay?

In response to a parliamentary question I tabled, it was indicated that the call was triaged correctly and the nearest available resource dispatched. Obviously, the problem was that the nearest available resource was so far away. It was also indicated in the reply to my question that the National Ambulance Service had now established an escalation process with Letterkenny General Hospital to ensure that ambulance control at Ballyshannon is informed at the earliest opportunity of any capacity activity or challenge which may affect service delivery. I ask our guests from the National Ambulance Service what exactly that means. Can they outline what happens where an ambulance is called away from its station to a hospital? What is put in place subsequently to ensure that another ambulance takes over immediately?

We cannot have a situation in which, if someone else requires an ambulance after that one has been called out, they are subject to pot luck and have to depend on an ambulance 40 miles away.

Ms Laverne McGuinness:

Deputy Ó Caoláin asked about the first responder and response times, as well as those for patient-carrying vehicles. First responder response time is seven minutes and 59 seconds. The target for ECHO and DELTA calls for patient-carrying vehicles is 18 minutes and 59 seconds. A first responder would be a member of the community who is trained to go to the scene.

The target set for turnaround times at accident and emergency departments is 20 minutes and goes to 30 minutes. This is monitored, and I accept that in some cases there are significant backlogs. A revision of the protocol has been carried out by Dr. Cathal O'Donnell and Mr. Martin Dunne, and this will be put in place nationally. It will have red, amber and green levels, which will correspond to 30 minutes, 40 minutes or an hour, respectively. Sometimes it can be elevated to a certain level because there might be problems in the accident and emergency department itself. Another member inquired if this would be assisted if there were another patient trolley there. However, we have to hand the patient to the clinician, so it is a little more than just having the trolley released.

As for the reason for the increase of 1,000 call-outs per month, there has been an increase in the population, with demographic changes. There is no medical evidence as to why this is the case. Dr. O’Donnell might comment on it.

Dr. Cathal O'Donnell:

It is an international phenomenon that demands on ambulance services increase year on year. The increase we noticed this year of 10% was higher than we would have expected. It is still not clear why that it is. My sense is that because of difficulties that patients perceive in being seen at an accident and emergency department, they are more prepared to dial 999 to request an emergency ambulance in the belief that they will be seen faster. That is just an opinion, however.

Ms Laverne McGuinness:

The single national control centre is not in place nationally at this time. That is why it is important to put that investment into place. We do have a single control centre in place at Townsend Street in Dublin. However, this operates for Cork, Kerry, the greater Dublin area, Navan and Tralee. The area Deputy Calleary referred to would not have that visibility on a national scale. We will have the single centre in place which will be over two sites in Tallaght and Ballyshannon.

It is important to remember that the only response times that are targeted as set down by HIQA and measured apply to ECHO and DELTA calls.

Mr. Martin Dunne:

On the incident in Mayo raised by the Deputy, the command and control centre which takes the call operates a system called advance medical priority dispatch. This allows the call to be triaged to certain different levels, which allows the centre to send the proper clinician in the proper timeframe to that patient. We are trying to develop international best practice command and control centres with the patient at the focus.

Part of this response time is that the treatment starts on the phone. An ECHO call is a cardiac arrest while DELTA is a life-threatening non-cardiac incident. Patients in one of these categories can be treated immediately when they phone in. The operators are trained to tell the caller how to do resuscitation, administer certain levels of medication, including aspirin if available, and operate a defibrillator, even if they might not be trained to use it.

Response times for ECHO and DELTA calls are being measured. Other calls beneath are not. The main response time we are looking at is the transport in the ambulance, namely 18 minutes and 59 seconds. At all times, we will dispatch the closest available resource to the patient. In some cases, that could be a community first responder, a vehicle from the national ambulance service, an off-duty ambulance service member of staff, if one is available, or a transporting vehicle. In some cases, unfortunately, the vehicle that is closest is not as close as it could be. The triage will ensure the closest available vehicle to the clinical presentation of that patient is what is sent.

Dara Calleary (Mayo, Fianna Fail)
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What is the difference between on-duty and on-call paramedics?

Mr. Martin Dunne:

On-duty is a 24-7-365 service in which one works a 12-hour shift. On-call refers to someone who goes home, say, at six in the evening and remains on second-call; if he or she is required, he or she is called in to respond. We have been reviewing that across the country. This actually elongates the response times as the person has to come from his or her home first. We could also be putting our staff in a dangerous situation because they have to get from their homes to the ambulance stations. We have actually stopped using this system except in some areas in the west.

Ms Laverne McGuinness:

We do not use sat-nav. It is not an issue with the level of investment because it would be quite small. Instead, we use the GeoDirectory system. It is managed by the control centre, which can direct the ambulance to the scene and locate it at any particular point.

Jerry Buttimer (Cork South Central, Fine Gael)
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I have an e-mail from someone stating that in a recent call-out to an accident in Cork, two ambulances were dispatched but one was sent in the wrong direction. How reliable is the system used?

Mr. Martin Dunne:

Sat-nav is a commercial, not an industrial, tool. It also requires people to input data to generate a map and route. From our experience, some sat-navs do not take into account road changes, network changes, etc.

Jerry Buttimer (Cork South Central, Fine Gael)
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That is true.

Mr. Martin Dunne:

We have invested very heavily in a complete command and control system, driven by GeoDirectory, the mapping system for the whole country. It is set down over a gazetteer and breaks it down into very tight areas. A command and control centre is split into two halves. When one calls it, one will speak to a call-taker on one side whose sole role and function is to take the ambulance call, not to dispatch. As he or she gets the address, the call-taker gets a menu that automatically generates a map to the location. That allows him or her to dispatch the closest ambulance on that system from the dispatcher, who is in another part of the centre. It is mapped and tracked as it goes along. In some cases it is fair to say there may have been errors, but we have found it to be a most robust system. We are continually updating that system with GeoDirectory to ensure the maps are robust and up-to-date for the whole of the country.

Jerry Buttimer (Cork South Central, Fine Gael)
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Can I just read to Mr. Dunne something I received? It states that the computer system that supposedly selects the nearest resource determines this by line of sight across a map. Apparently, in a recent call, the computer calculated that an ambulance at St. Mary's Orthopaedic Hospital, based at Barrack Street, was nearer to a particular incident than an equally qualified ambulance crew at the Kinsale Road base. It determined the distance as almost 1.5 km closer whereas it is almost 3.75 km further, with many more traffic lights and speed bumps. I know Mr. Dunne cannot comment on specific cases.

Mr. Martin Dunne:

I would not know the ins and outs of the entire case. It is not that I do not want to comment. In an overall context, when one is looking at the complete resource complement across the country, we have found that the safest and most reliable way to direct a vehicle to an area is from the back room. The system tracks that vehicle because it poles every 50 yards, so it can tell it to stop or that it has missed a turn and should turn around. That, along with everything else, has been developed. We are in continuous contact with GeoDirectory to make sure we are getting it as right as we can. In fairness, it is giving us a commitment that it is updating that automatically for us as we are moving on.

Ms Laverne McGuinness:

Deputies Healy and Nash and many other members raised the issue of resourcing of the ambulance service and questioned whether there are enough resources. As I set out in my opening statement, the budget for the ambulance service for 2014 is €137.7 million, which is a significant increase. There was significant investment in 2013, which is the first year that level of investment was made. More than €26 million was provided for the new national single control centre and the 25 new intermediate care vehicles. They only started arriving in June so we really only got the benefit of them towards the end of the year. In fact, we got 36 vehicles last year but funding for 25 arrived as part of the service plan. Preliminary data shows that they are having quite a significant impact, and we will be able to publish that data in due course. Inter-hospital transfers, which do not require emergency ambulance services, are able to take those patients who still need to be transported on stretchers by a vehicle. That means that the ambulances are freed up, thereby enabling us to respond more efficiently and more quickly to other incidents. We got another €3.6 million this year for the control room.

In response to Deputy Nash, I mentioned the capacity review in the opening statement. It said that as part of our national strategy we will carrying out a capacity review. There may be a different interpretation as to what the capacity review is. The capacity review is quite technical in terms of what is required. A lot of expertise is required in terms of benchmarking internationally. We are already progressing in that direction. Perhaps Mr. Dunne might elaborate on what that involves, rather than a wide stakeholder consultation in that regard?

Mr. Martin Dunne:

The Deputy is correct that this will be the first time the national ambulance review has commenced a capacity review. It is probably based on international best practice, and that is the information that has been given to us. We are going through a process at the moment to make sure we can initiate an appropriate capacity review. What the capacity review will be looking at is historical data over the three to four years gone by. It will be looking at the types of patient we have been transporting, the areas where they are being transported from and where they are going. It will match that with the complement of staff and the types of vehicle we have available to us. We will be asked to future-proof it, which will hopefully go three to four years ahead of us. Again, that would be the norm across some of the bigger ambulance services across the world. It is the way they plan ahead, because one can build manpower capacity into it as resource vehicle capacity. That will be telling us where we have our resources at the moment. It will be very robust and strong in terms of telling us whether we have the right amount in the right places at the right time based on actual data. Hopefully, in the next 12 months, we will be able to sit here and discuss that with real live facts sitting in front of us and will be able to answer some of the questions that have been posed.

Ms Laverne McGuinness:

Deputy Fitzpatrick asked whether there was enough funding. There were specific questions relating to Drogheda, so Mr. Dunne might address them. If we cannot address all of them immediately, we will come back to the Deputy with regard to specificity. It is certainly our intention to improve ambulance call-out response times on a national basis, not just in Drogheda. Mr. Dunne might talk about the number of ambulance vehicles and paramedic personnel.

Mr. Martin Dunne:

I will group the answers and try to answer them as best I can. The national ambulance service has launched a complete reconfiguration of the way it is doing its job. It dovetails into every statement that has been made here in respect of availability and capacity. What people must understand is that last year, for the first time ever, we got intermediate care vehicles, so they are an addition to the fleet. They are not removing fleet. Why did we put intermediate care vehicles in? Again, this relates to some of the questions that were raised about inter-facility transfers - in other words, bringing people from Drogheda to Dublin or from the Cottage Hospital across to Our Lady of Lourdes Hospital. That is replicated around the country. For many years - I am a paramedic myself - it was done by the front-line ambulance, the yellow or white one. It is widely recognised that the capacity is not available to do that now. The training levels paramedics and advanced paramedics have are geared towards front-line accident and emergency and pre-hospital care. What we have done is to invest in intermediate care vehicles, which allows emergency ambulances to be freed up to a certain degree so that they can be targeted directly at emergency calls. That is growing because, as Ms McGuinness said, it only started last year.

We have also put in what we call rapid response vehicles, which have been mentioned. Again, if one looks at our counterparts around the world - any of the major ambulance services - one can see that they have supplied response vehicles to get to the patient. As I said earlier on, our only goal in life is to get the proper clinician to the patient as quickly as possible. Even in the areas we are talking about, we are starting to advance the service in respect of having intermediate care vehicles beginning to operate, and we are starting to see results coming from it. It is slow but it is in its infancy and we will develop it. We see response vehicles staffed by paramedics or advanced paramedics. It could be cars or four-by-fours. These vehicles can start to administer care immediately to the patient on the scene while waiting for a transport vehicle to arrive. That takes some of the time used in treating the patient by the transport vehicle out of the equation and they are able to load and transport in a quicker fashion. That is way we are going, and it is ongoing in the Drogheda area. There are two ambulances in Drogheda, supported by a response car in Ardee and intermediate care working out of Ardee. On the other side of that, there are vehicles in Dundalk and Monaghan and there is a full station in Navan to complement that area. We carry out dynamic deployment. Vehicles are always moving. Most of the time, the one place one will not get an ambulance call is in the ambulance station. What we try to do is to get the vehicles out to the areas they need to cover as quickly as possible. That is starting to evolve and develop, slowly but surely.

Ms Laverne McGuinness:

Senator Crown asked about the discretion of an ambulance crew to bring a patient to a particular hospital where they know they should go for their outpatient appointment. He also asked about head injuries and burns. Perhaps Dr. O'Donnell could answer those questions.

Dr. Cathal O'Donnell:

Senator Crown is correct in what he says, particularly around Dublin. Dublin is divided up into very specific catchment areas from an ambulance service perspective, so if we get a 999 call within the catchment area of a particular hospital, we will always bring the patient to that hospital. The reason is that it is the nearest hospital. If someone dials 999, the assumption is that this is an emergency and thus there is a time element to it, so we will bring the patient to the nearest hospital. I understand that this can sometimes cause frustrations, for example, in the Senator's own practice. An oncology patient living in the St. James's Hospital catchment area will be brought to that hospital instead of St. Vincent's Hospital. If the patient's general practitioner has attended the patient and contacts us, we will then follow the direction of the GP and bring the patient to the hospital the GP deems best. A patient might have an active cancer problem but the reason for his or her 999 call may or may not be related to that. Sometimes the nuances of that are quite subtle and it might be asking a lot of paramedics to try to make those distinctions in some cases, but I accept the point. I know it does cause some frustration.

The Senator's second question related to head injuries and bringing patients directly to a neuro-surgical centre. There are two adult neuro-surgical centres in Ireland - Beaumont Hospital and Cork University Hospital - and a single national paediatric neuro-surgical centre at the Children's University Hospital Temple Street. Many, if not most, of those patients have other injuries.

Isolated head trauma can happen, but it is less common than multiple injury. If someone has, for example, a splenic or liver injury or internal bleeding, that issue needs to be addressed prior to dealing with the head injury in many cases. If one is working at the side of the road in the middle of the night and the rain, it can be difficult to make these distinctions. Our ability to transfer patients from the initial hospital to which they are brought to a neurosurgical centre has been enhanced in the past 18 months by our significantly increased use of helicopters. We have been able to bring patients from the west to Beaumont Hospital and from all over Munster directly to Cork because helicopters have allowed us to cut transport times significantly compared to land-based vehicles.

Ms Laverne McGuinness:

Deputy Sandra McLellan raised a number of questions regarding HIQA and its targets. The targets set by the HSE for 2013 were 70% and 68.9% in regard to annual calls. In 2014 we have increased the target to 80%. We delivered almost in full on the 2013 target, with a rate of 69.5%. On whether the targets were realistic and achievable, we set out a trajectory over a number of months for each region for their achievement in order that we would be able to reach them by the end of the year. The targets are set out on a region by region and quarterly basis. A performance improvement plan has also been put in place for each of the regions and specific areas are being targeted in order to monitor the improvement process for call taking and despatch and crew mobilisation times. On the question of crews being on call or on duty, the 20 minute delay in getting somebody is taken into account. The targets also include emergency and intermediate care vehicles. All of these factors are part of a responsive process improvement plan aimed at delivering on our target of 80% by the end of the year in each of the areas and regions. Our objective is to respond to as many patients as we can.

Deputy Denis Naughten referred to the first responder targets and asked why we did not publish the data. The first responder target is seven minutes and 59 seconds. Until we get the new computer system up and running as part of the new control centre, our system will not be sophisticated enough to capture all of the relevant information. Community responders include people like the Deputy and me operating from our homes. We do not have the technology to capture all of that information on a geographical basis. However, it is in our plan for implementation and when we have accurate data, we will certainly publish them. We have collected data in this regard, but they are not accurate because they are only representative of those who report that they responded.

Denis Naughten (Roscommon-South Leitrim, Independent)
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A first responder is not solely a community responder. For example, the first responder in an area without a community responder is an ambulance or a rapid response vehicle. Are all of the community first responders co-ordinated across the country? Can we call them across the country?

Mr. Martin Dunne:

Community first responders are part of our team this stage, with the aim of caring for the patient as quickly as we can. The answer to the Deputy's question is "No" because of technology issues. An appropriate interface is required between the command and control centre and the community responders. As they are community volunteers, they have to develop rotas among themselves. We need to have some way of communicating safely with them, both from a dispatch point of view and for their own safety. We are working closely with them around the country to ensure we have a strong and trusting relationship. The Irish Heart Foundation is also working with us to develop schemes. However, the technology is not sufficiently robust to guarantee the co-ordination to which the Deputy referred.

On the issue of black spot areas, we are trying to allocate dedicated resources in these areas from our current complement of staff. In certain areas we operate what we call dynamic deployment, whereby crews from other areas are sent to provide cover. These crews operate from emergency dispatch points and if they are the closest resource, they respond to calls in the same manner as any other vehicle, regardless of whether they are based in the area in question. We are working with local staff and managers to develop a more robust, continuous and safe system in each area.

Jerry Buttimer (Cork South Central, Fine Gael)
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What does that mean in practice for the communities affected in a black spot? Robust systems are great, but what is delivered on the ground in tangible terms?

Mr. Martin Dunne:

We are trying to ensure we can deploy appropriate staff in these areas at times we can identify from call volumes as giving rise to the greatest needs.

Jerry Buttimer (Cork South Central, Fine Gael)
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How does the service determine the number of vehicles or personnel required to be on duty to provide a safe level of cover?

Dara Calleary (Mayo, Fianna Fail)
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Mr. Dunne has indicated that he wants to move some existing crews to Mulranny. Two ambulances are based in Castlebar and one in Ballina, while one is on call in Belmullet. Is Mr. Dunne saying one of these crews will be moved to Mulranny?

Mr. Martin Dunne:

We consider the issue in the context of services in the wider area rather than individual parts and dispatch on that basis. We take account of all the resources available to us in an area.

Dara Calleary (Mayo, Fianna Fail)
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It is a big area.

Mr. Martin Dunne:

I agree that it is a big area, but we consider the resources available to us in an area and task them in a way that ensures we get to patients in an appropriate timeframe. We are working closely with staff to achieve that aim.

Denis Naughten (Roscommon-South Leitrim, Independent)
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There are insufficient resources available. That is the problem.

Ms Laverne McGuinness:

Deputy Denis Naughten also asked whether the aeromedical emergency service would be removed. Discussions in this regard are ongoing between the Department of Health and the Air Corps.

Mr. Martin Dunne:

It has been accepted that it is a requirement and the Minister has signed off on it. We have set up a working group to ensure we optimise resources to make best use of the service. The pilot scheme has been extended a number of times to allow us to reach that goal in a safe manner. The resource has not been removed and will not be removed until we put in something stable.

Denis Naughten (Roscommon-South Leitrim, Independent)
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What is the timeline for putting in something stable?

Ms Laverne McGuinness:

The Deputy noted that the numbers of presentations to emergency departments were down and asked why our response times were not changing. I have mentioned that we are dealing with 1,000 extra calls and our response times have improved slightly through the use of performance improvement measures. On whether the number of medical presentations has decreased, the fact that GP contacts have increased indicates more people are availing of GP out-of-hours services.

Denis Naughten (Roscommon-South Leitrim, Independent)
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Does Dr. O'Donnell think the closure of nine accident and emergency departments may have been a contributory factor, given that people have to travel longer distances to accident and emergency departments?

Jerry Buttimer (Cork South Central, Fine Gael)
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That is not in order.

Dr. Cathal O'Donnell:

That may be a factor. It may also be related to perceptions about delays in emergency departments. There is a false perception that if a patient is brought to an emergency department as opposed to presenting directly, he or she will be seen quicker. That is not the case; patients are treated on the basis of clinical need. I honestly do not know why we have experienced an increase of 10%. We expect the figure to rise by 2% to 3% year on year. The increase this year is excessive and I suspect it can be attributed to a number of factors.

Jerry Buttimer (Cork South Central, Fine Gael)
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Are the figures increasing internationally or are they peculiar to Ireland?

Dr. Cathal O'Donnell:

The configuration is particular to Ireland.

Jerry Buttimer (Cork South Central, Fine Gael)
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Deputy Naughten is wrong and I would prefer if he would not play politics.

Denis Naughten (Roscommon-South Leitrim, Independent)
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I am just giving the facts.

Jerry Buttimer (Cork South Central, Fine Gael)
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I would prefer if Deputy Naughten would not play politics.

Dr. Cathal O'Donnell:

From an ambulance service perspective, internationally year on year one would see approximately a 2% to 3% increase in call volume every year. That would be the norm. Last year in Ireland it was greater. We are still trying to understand precisely the reasons for that.

Colm Burke (Fine Gael)
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Could Dr. O'Donnell clarify the issue of hand-over of patients? Can we do something about expediting the hand-over of patients from the ambulance service to hospital staff? Has that been examined? Have units been identified where there are far higher delays in the taking over of patients from the ambulance staff, varying from one accident and emergency department to another?

Jerry Buttimer (Cork South Central, Fine Gael)
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In its presentation SIPTU spoke of it being between four and 16 hours.

Robert Dowds (Dublin Mid West, Labour)
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I asked a question specifically on delays in hospitals. From my dealings with one or two ambulance drivers I know they are frustrated about being delayed at hospitals.

Sandra McLellan (Cork East, Sinn Fein)
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Deputy Ó Caoláin asked a question which was not answered on the step ceiling. Could the witnesses answer that?

Dara Calleary (Mayo, Fianna Fail)
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What about the paramedic and emergency medical technician, EMT?

Jerry Buttimer (Cork South Central, Fine Gael)
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We have been here since 3.30 p.m. so I want to give people a chance.

Ms Laverne McGuinness:

On the turnaround times at the accident and emergency departments, we have information on a hospital basis on the number of ambulances released after a period of 20 minutes or 30 minutes. A revised and enhanced protocol has been put in place regarding escalation of any ambulance where there are inordinate delays. We have no reference here to any 16-hour delays.

Sandra McLellan (Cork East, Sinn Fein)
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It came up in an earlier discussion.

Gerald Nash (Louth, Labour)
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It was an historic issue related to the Dublin Fire Service.

Ms Laverne McGuinness:

It would be historic. They are done on percentages and trajectories. The new protocol is being finalised by Dr. Cathal O'Donnell. We will be moving to put that in place so we can see which hospitals are red, amber and green, what action needs to be taken at hospital and ambulance level and what needs to happen as a result of that. That is under way.

Deputy Nash had a question on paramedics and the emergency medical technical staff. I was going to deal with the ceiling at the same time. The question was whether the 43 staff are going to be paramedic staff or in the control room. Those 43 are for the control room but 20 new staff are coming into place and are undergoing a training programme in April.

Gerald Nash (Louth, Labour)
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Is that in addition to the 43 in the control centre?

Ms Laverne McGuinness:

Yes.

Jerry Buttimer (Cork South Central, Fine Gael)
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So that is 63 in total.

Ms Laverne McGuinness:

We have a carry-over programme that was ongoing from 2013.

Dara Calleary (Mayo, Fianna Fail)
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My specific question was whether people who are qualified as paramedics are being paid as EMTs, a grade lower than the job they are doing.

Mr. Martin Dunne:

No, we have three layers of clinician in the national ambulance service: advanced paramedic, paramedic and EMT. One is licensed at a particular level by the pre-hospital emergency care council that was alluded to, that is one's scope of practice area and one is paid at that level.

Ms Laverne McGuinness:

One is paid at the level at which one is employed. One could have trained as an advanced paramedic but one might not be employed as one so one would not be paid as one.

Sandra McLellan (Cork East, Sinn Fein)
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So staff are not redeployed.

Ms Laverne McGuinness:

They are not redeployed.

Sandra McLellan (Cork East, Sinn Fein)
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They are new.

Mr. Martin Dunne:

We have 20 new staff who are starting training in the National Ambulance Service college in April and we have 43 staff coming in who will also be trained, so it is a total.

Ms Laverne McGuinness:

Deputy McConalogue had a question on the incident in Donegal and our incident review policy. We have different responses depending on the particular incident and the level of seriousness right up to escalation to serious incident, which is at a national level. A review is being carried out outside of HSE western region and is being chaired by Dr. Cathal O'Donnell. That review will be concluded in April.

Charlie McConalogue (Donegal North East, Fianna Fail)
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Is that the HIQA review?

Ms Laverne McGuinness:

No, it is a review of the Carndonagh incident the Deputy raised and the lady who, sadly, passed away there. A very specific and comprehensive review is being carried out regarding that incident.

Charlie McConalogue (Donegal North East, Fianna Fail)
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Will that review be published and made available to the family once it is completed?

Ms Laverne McGuinness:

That is a consideration. We publish most of our reviews. The family will be consulted on that.

Jerry Buttimer (Cork South Central, Fine Gael)
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In general when a person has an incident and requires an investigation to take place, does the HSE engage with and meet the family before the publication of the report?

Ms Laverne McGuinness:

Yes, in the most recent event in Midleton, the very sad case of the little boy, we met the family. A patient family liaison person is appointed by our service. In this instance it is a different case but the family will be met.

Jerry Buttimer (Cork South Central, Fine Gael)
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Would the HSE do so as a matter of course? It is a sensitive issue.

Charlie McConalogue (Donegal North East, Fianna Fail)
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The family wished and requested an independent investigation. Dr. O'Donnell is doing that investigation but there is also real concern among the family and the community as to what happened. In such a situation it is crucial that we ascertain what led to that delay, that it be published, that the community be aware of what happened and that it be clear what steps have been taken to address it so that confidence is there that it will not happen again. We want to ensure at least that no other family experiences the same traumatic situation this family did. I also asked about the situation in Inishowen. When one ambulance is on duty after 5 p.m. and overnight and it is called away to a hospital, what happens regarding a replacement ambulance?

Mr. Martin Dunne:

In such a situation dynamic deployment happens. The command and control centres try to use the resources available to them in the best possible way. We continue to try to use the resources we have to the best of our ability at all times. Only a finite amount of resources are available to us and we must operate within legislation to ensure everything is covered in the right way. The control centres take charge of the resources and deploy them to the areas they feel benefit the patient the most.

Charlie McConalogue (Donegal North East, Fianna Fail)
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I mentioned the escalation process and it was referred to in the reply to a parliamentary question I asked about the particular case I mentioned regarding Mrs. Maura Porter. What escalation process is in place and can the witnesses elaborate on how that might assist in preventing such situations recurring?

Dr. Cathal O'Donnell:

The review of the incident to which Deputy McConalogue mentioned is still ongoing and we have not yet met all the staff involved so I do not want to comment in detail on it. The incident review team spent two days in Donegal two weeks ago as part of that and we issued an interim recommendation to the hospital and the National Ambulance Service jointly to develop a shared escalation protocol and work on that is ongoing. Escalation protocols exist and need to be refined in light of what happened, and that work is ongoing.

Jerry Buttimer (Cork South Central, Fine Gael)
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When my father had an accident, the first responder, hospital and ambulance crew were absolutely fantastic and on behalf of everybody I thank the witnesses for being here today, and their staff. Whatever about the issues we may fight about, the staff are dedicated and committed and they should be acknowledged for that. At the follow-up meeting on Thursday we will probably come back to this and review the outcomes from today. I thank Mr. Dunne, Ms McGuinness and Dr. O'Donnell for being here.