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.