Jerry Buttimer (Cork South Central, Fine Gael)
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The sole topic for discussion this afternoon is the ambulance service review by Health Information and Quality Authority, HIQA. I take this opportunity to welcome to the meeting Mr. Phelim Quinn, chief executive of HIQA; Ms Mary Dunnion, acting director of regulation; and Mr. Marty Whelan, head of communications and stakeholder engagement.

At the beginning, on my own behalf and, I am sure, behalf of all in the room, I formally congratulate Mr. Quinn on his appointment as the new chief executive in replacement of Dr. Tracey Cooper and wish him every success, and pledge to him the committee's full co-operation. We all look forward to working and engaging with him over the coming years. We hope that, in his capacity as CEO, he might come back to us at a later date to speak on his vision of and role in HIQA in the future as opposed to doing so as part of a meeting dealing with the issue before us.

The meeting today is to hear evidence from the officials of HIQA on an important review on ambulance response times, which they have carried out and published this morning. With that, I ask Mr. Quinn to make his opening remarks.

Mr. Phelim Quinn:

I thank the Chairman for those good wishes from himself and the committee. I am conscious that we published this long and complex report this morning and I will do my best to-----

Jerry Buttimer (Cork South Central, Fine Gael)
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May I interrupt Mr. Quinn and say that even though I am four years into the job as Chair, the L-plates still apply. I must read about privilege. My apologies.

Witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if witnesses are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses 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 or make charges against any person by name or in such a way as to make him or her identifiable. I remind members of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against any person outside the House or entity by name or in such a way as to make him, her or it identifiable.

Mr. Phelim Quinn:

I will try to cover a fair amount of ground from a long and complex report that we have completed on pre-hospital emergency care. On behalf of the Health Information and Quality Authority, I thank the Joint Oireachtas Committee on Health and Children for giving me the opportunity to discuss the findings of our review of pre-hospital emergency care services I am joined by Ms Mary Dunnion, acting director of regulation, and Mr. Marty Whelan, our head of communications and stakeholder engagement. We welcome the opportunity to appear again before the Oireachtas committee and to engage with members.

Last year we developed a three-year assurance programme, with the aim of providing assurance on the quality and safety of health-care services in line with the requirements of the Health Act 2007, that is, to monitor nationally mandated standards for health and social care services provided by the HSE and other specified providers. The focus of this programme is to find out how services are performing against the standards and to provide feedback aimed primarily at improving services.

As part of our three-year assurance programme, HIQA had planned to undertake a review in the final quarter of 2014 of pre-hospital emergency services against the national standards. However, following a number of reported concerns, the then Minister for Health, Deputy Reilly, asked the authority to bring forward its review. Our work began last March.

The purpose of the review is to provide assurance to the public that the following are in place: clear strategic direction with implementation plans and control measures for the national service; effective governance and leadership arrangements at all levels within the service; clearly defined schemes of delegation; appropriate controls in place through service level agreements with third parties delivering services on behalf of the national service; appropriate quality and risk management arrangements; workforce is well organised, skilled and there is a culture of continuous improvement; and the use of key performance indicators to include response times and clinical outcomes and other quality assurance metrics to assure the public that the ambulance service is both safe and effective.

Over the past ten years there has been a considerable range of progress in respect of the following in the services. There have been clinical competencies developed using pre-hospital emergency care practitioners, increases in the number of paramedics and advanced paramedics, and expansion in treatment options that these health-care professionals provide to patients as the first point of contact, and these represent a very significant advance in patient care. The service providers, the practitioners themselves and the Pre-Hospital Emergency Care Council deserve great credit for all of these advancement. However, many legacy issues associated with the former fragmented nature of multiple providers remain, and the National Ambulance Service has struggled to fully integrate as one entity.

Significant change to ambulance service provision in Ireland will be vital to improve services for patients. Our review identifies challenges in relation to: workforce and leadership, the models of care, fleet and fleet deployment, clinical governance and risk management, the relationship between the National Ambulance Service and Dublin Fire Brigade, and dispatch times and emergency response times.

I will now briefly outline some of the main findings and recommendations of our review. Our review found a number of challenges in the area of workforce and leadership. As a result, we believe that there is a requirement for more effective leadership, clear strategic planning and ongoing constructive co-operation between management and their staff. This is not currently happening. Investment in management support and training, better management performance and a more comprehensive focus on performance management and quality improvement, should deliver better quality services for patients. A lot of change has happened within senior management ranks, mainly through internal movement, and in some instances the frequency and rapidity of these changes in the past few years in management appears to have created issues. These include that some staff in management reported to us that they did not have formal job descriptions that outline the specifics of their roles and their aligned responsibilities. More worryingly, some staff reported to us that while they have accepted new positions within the service, they do not have the appropriate technical knowledge.

Our review concludes that strategic planning for the service will require consideration of plans for wider organisational and health service reform. The draft national ambulance strategy 2014-16 does not fully reflect the impact of wider reform and how pre-hospital emergency care needs to complement new models of care provision, including the potential impact of the emerging hospital group structures and their delivery of unscheduled care.

When looking at models of care, the authority found that the number of calls received per year for ambulances in Ireland continues to increase and in the past year, there has been a reported increase of 10%. Increased call volume translates into an ever increasing number of patients being transported to hospital for treatment and we believe this is unsustainable. This has created delays in patient hand-overs at overcrowded emergency departments, EDs, and creates an inability to rapidly turnaround ambulances from emergency departments and free them up for additional calls.

We believe that the service model needs to be reviewed. At present, an emergency vehicle is dispatched to all calls, without examining the potential for treatment or triage over the telephone.

In addition, following arrival on scene, unless the patient refuses to be transferred to hospital, the vast majority of patients are automatically transferred to hospital emergency departments. This model of care does not consider the potential for the transportation of the patient for treatment to a setting that may be more suitable to meet their needs such as a local injury unit, or indeed the possibility of treatment and discharge on the scene by the ambulance crew itself.

Both the National Ambulance Service and Dublin Fire Brigade must develop and implement an ongoing community education programme that would promote appropriate use of ambulances. Such public education should seek to reduce unnecessary requests for ambulances and should increase public awareness and acceptance of the skills and competencies of paramedics. The strategic direction of emergency ambulance service provision needs to be clearly articulated by the HSE. The flow of emergency medical admissions by ambulance should be monitored by all, but managed by the National Ambulance Service.

The clinical governance agenda is currently underdeveloped across both the National Ambulance Service and Dublin Fire Brigade. The appointment of a full-time medical director in the National Ambulance Service has improved clinical expertise at a leadership level. However, effective clinical governance requires that there should be a collective leadership responsibility. There is currently no clinical audit in the National Ambulance Service. Therefore quality assurance of clinical care being delivered is very limited. That is not acceptable and needs to be addressed.

The National Ambulance Service has only recently started to review adverse clinical incidents. A new policy, which is aligned with best practice, was introduced in 2011. The service has good visibility of severe incidents and thoroughly investigates these to identify potential for learning. The system works less well for more minor incidents and reporting of incidents is not operationally embedded. Ongoing analysis of the collective experience of such events allows for the prioritisation of improvement efforts on the basis of risk, and is a crucial aspect of any successful risk management strategy.

HIQA observed a fundamental disconnect in the internal organisational mechanisms that are used by the service providers for reporting of risks. The current infrastructure for proactively capturing and subsequently managing risk in the National Ambulance Service is overly complicated and it is ineffective in its ability to effectively escalate and rapidly address persistent issues.

It is recommended that the National Ambulance Service should improve its patient advocacy approach, including its responsiveness to the handling of patient complaints. When looking at the relationship between the National Ambulance service and Dublin Fire Brigade we were concerned to note there was no evidence of integrated management of pre-hospital emergency care in Dublin, the most heavily populated region. The current governance arrangements between Dublin Fire Brigade and the National Ambulance Service is disjointed with inadequate quality assurance and accountability controls.

The provision of safe and effective pre-hospital emergency care services by two distinct agencies, with a critical interface, requires a rigorous service level arrangement, which clearly articulates governance responsibilities for both parties. Both service providers must address the operational inefficiencies that our report identifies and must publish an action plan outlining proposed steps to improve individual and collective performance in call handling, dispatch and co-ordination of calls between both services. For necessary performance improvements that are identified in HIQA’s review and which rely on co-operation between both services, a joint action plan between both service providers should be produced and published.

As a matter of urgency, both the National Ambulance Service and Dublin Fire Brigade must put the necessary corporate and clinical governance arrangements in place to provide a fully integrated ambulance service in the greater Dublin area. This should include a binding service level agreement that includes formal quality and performance assurance reporting mechanisms. In addition, the HSE must immediately involve Dublin Fire Brigade in the National Ambulance Service control centre reconfiguration project to ensure a seamless and safe transition of services in Dublin.

One key issue we looked at in this review related to dispatch and emergency response times. HIQA supports the decision to move towards one national ambulance control centre, which will be located over two sites in Ballyshannon and Tallaght. Significant change in many other areas will be vital to improve services for patients. Three different computer-aided dispatch systems were in use at the time of HIQA’s review but the systems were not integrated, which meant that the National Ambulance Service continued to operate as six different services within defined geographical areas, rather than as one national entity. This means that there appears to be limited visibility of ambulance resources outside the geographically defined areas.

There is considerable potential for improvement in ambulance service response times if efforts are directed towards improving the operational efficiency of call handling and dispatch by control centres. In addition, both ambulance service providers should improve response times by looking to match available resources to anticipated demand over the calendar week and through more tactical, dynamic deployment of resources away from station, based on predictive analysis of ambulance need.

Regular monitoring of the service’s ability to meet targets helps to deliver quality assurance, improvement and public accountability. Both the National Ambulance Service and Dublin Fire Brigade must monitor their performance through a consistent, reliable, accurate and balanced system of measuring and reporting against key performance indicators. These should include the seven minute 59 second first response times for all ECHO and DELTA calls, which are currently not reported. We also believe that the specific response times for cardiac arrest, stroke and heart attack and for ambulance turnaround times at hospitals should be introduced and reported upon.

When examining issues concerning the ambulance fleet we noted a lack of ongoing investment increases the probability of an ambulance breakdown impacting on patient care in an emergency situation. The National Ambulance Service replacement policy clearly outlines that once a vehicle has been in use for seven years or has reached mileage in excess of 500,000 km, it should be replaced. Despite this policy, 18% of the current fleet is eight or more years old.

Geographical challenges in rural and sparsely populated areas present difficulties for ambulance services that strive to achieve timely and appropriate responses to ECHO and DELTA calls. To achieve timely and appropriate responses to ECHO calls, which account for 2,500 to 3,000 calls per year relating to the sickest patients that require ambulance services, the National Ambulance Service must as a priority develop and support a comprehensive national programme of community first response schemes in all rural and sparsely populated areas. Efforts should be focused initially on those communities that are most challenged in achieving rapid responses and do not have schemes in place.

Our report contains 12 crucially important recommendations which relate to aspects of service provision in the National Ambulance Service and Dublin Fire Brigade. In addition, further areas that require improvement are also included throughout this report. It is expected that on foot of these recommendations and this report, both service providers should formulate written plans aimed at driving the necessary improvements in the quality and safety of the State’s pre-hospital emergency care services. Eight of the recommendations relate to the provision of emergency ambulance services nationally and must be addressed collectively as well as individually by the National Ambulance Service and Dublin Fire Brigade. Four of the recommendations relate specifically to the National Ambulance Service, and these must be addressed by the National Ambulance Service and the HSE.

The Irish health service is undergoing a period of significant change. As the acute hospital service moves towards a model of hospital groups, ambulance services must be fully included in this strategic planning process and must operate as a clinical service that is embedded in the unscheduled care system. This change should be reflected in the strategic plans of both the HSE and emergency ambulance service providers.

There is scope within current resources for significant improvement for patients in pre-hospital emergency care services. Many of the required changes that this HIQA review outlines can be achieved with strong leadership, effective management, staff buy-in and a detailed and strategic approach. There is scope too for other changes which would make a significant difference to ambulance service performance. I refer, for example, to effective management and staff co-operation, improvements in operational efficiency in the practice of call handling and dispatch, combined with dynamic deployment and matching resources more effectively to anticipated demand.

We believe they will make a difference. Changes in these areas could translate into measurably better response times with current resources. It is important that the HSE, the National Ambulance Service and Dublin Fire Brigade act now to address the findings of this report.

I thank the members of the committee for inviting us here to discuss the report. I look forward to their questions and their views on how HIQA can work with service providers and the committee in the interests of improving the quality and safety of pre-hospital emergency care services.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. Quinn for his presentation.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I join the Chairman in extending congratulations and best wishes to Mr. Quinn in his new role and responsibilities. I ensure him of our co-operation and good wishes always.

I have read the report's executive summary. I would like to know the methodology of the review. Where was the engagement? With whom did HIQA engage? I ask that because I do not get a sense from the report that it considered matters in a geographically dispersed way. I think it might be more particular to the centre, but that may be just my impression. How was it carried out? With whom did HIQA engage? Was it geographically inclusive? I can understand Mr. Quinn saying in his contribution that geographic challenges in rural and sparsely populated areas will always present.

My family have experienced three incidents in the past 12 months. I live in an area within a mile of which there is an ambulance station. There is another one 15 miles away from that and another 30 miles away. In each of the three incidents, one of which resulted in a death as a result of a heart attack, another of which was my heart attack - I am sitting here before Mr. Quinn and the details are all verifiable where it took place in a GP's surgery - and the other, last Saturday week, where I had to kneel before my mother, who had collapsed, and was unable to lift her, in all three incidents and despite the three ambulance stations being close to us that I mentioned, including one in my home town, the ambulance came from more than 45 miles away. I am just one citizen sitting here today. I should be very thankful that I am.

My point is no criticism of HIQA. It is all to do with how it goes about its business. I have gone through the recommendations and I have some comments and questions on those. Mine is just one family. My wife's brother might not have lived in any event if the ambulance had come from any of the other three closer stations than the one from which the ambulance was dispatched. The general practitioner and the support nurse where I had a heart attack last January were incredulous at the time. When they came from Virginia to Monaghan town they could not even find it. It is no reflection on the ambulance crews, who are wonderful people, as I can attest to. My mother is a hospital patient as we speak. Again, only in the past fortnight, I was on my knees because I could not move for a full hour waiting for that ambulance to come.

That experience is replicated for many families throughout the country. We need to get serious about the issue. I do not accept it is about geographic location or anything else. There are no excuses in the wide earthly world for what happened in the incidents to which I can personally attest. This is not second-hand information; I was present at all three.

How was the review carried out? With whom did HIQA engage? I will raise the matter again. In respect of my patience and holding back on making any comment about my experiences, I have just lost it with the third and most recent incident with my mother. It is no longer good enough for me to hold back. I am saying it out and sharing it here today with colleagues as well as with representatives of HIQA.

Will Mr. Quinn explain recommendation No. 2 in the report. There is almost a question as to whether the national ambulance office is to operate as a distinct entity, under the remit of the acute hospitals directorate of the HSE. Does Mr. Quinn still see the national ambulance office as a separate, distinct and continuing entity? What does recommendation No. 2 spell out for the future of the national ambulance office?

On recommendations Nos. 1 and 3, recommendation No. 3 is more prescriptive in terms of the relationship between the HSE and Dublin Fire Brigade. Recommendation No. 4 in the same context uses the words "safe transition of services in Dublin". Is HIQA proposing in the recommendation a cessation of the situation where the greater extent of ambulance cover is provided quite efficiently through the Dublin Fire Brigade service? Representatives of Dublin Fire Brigade have appeared before the committee in the past. It is a big issue.

Recommendation No. 5 refers to reviewing the current practice of 100% delivery to hospital emergency departments. That is worth considering. While not in the three incidents I shared with the witnesses, I can cite other incidents where it might have been more appropriate on the assessment of the individual patient concerned that a more local minor injuries unit in one of the non-acute hospital settings could have been a more appropriate delivery point, rather than adding to the untold distress that is the reality in emergency departments in acute hospitals. I think the review is worthwhile and I ask Mr. Quinn to comment further on it.

Recommendation No. 7 refers to a seven minute and 59 second first response time for patients who are in cardiac or respiratory arrest. The incidents I have cited will have the recorded times for notification and response. They were off the Richter scale. Two of those were cardiac arrests, including mine. I was transported from Cavan initially and then on the St. James's and operated on that evening. Seven minutes and 59 seconds sounds all fine and good. It was achievable if the ambulance had been dispatched from the station closest to each of the three situations I have cited. However, the ambulance passed that station and passed two others also closer than the station from which the ambulance was dispatched. I find that intolerable.

When Monaghan Hospital lost its acute services, we were promised that we would be compensated by a fully staffed state-of-the-art ambulance service to cater for all emergency needs. We have not got within an ass's roar of it. I say that with great vexation.

Jerry Buttimer (Cork South Central, Fine Gael)
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To be fair to Mr. Quinn, it is not in his remit to grant, provide or procure services.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I am aware of that.

Colm Burke (Fine Gael)
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I welcome Mr. Quinn and thank him for his presentation. We wish him every success in his new role.

I am a little frightened by the report which states that many managers outlined that they had changed roles with the service in recent times. It said some of these staff reported that they did not have formal job descriptions which outlined the specifics of their roles and the aligned responsibilities. More worryingly, some staff reported that while they had accepted new positions within the service, they did not have appropriate technical knowledge.

Six months ago, I identified that the HSE had appointed 1,100 staff without job interviews.

Jerry Buttimer (Cork South Central, Fine Gael)
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Can we deal with the ambulance service, rather than going into this?

Colm Burke (Fine Gael)
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I am dealing with the ambulance service because this is now a replica of that issue. We now appear to have people-----

Jerry Buttimer (Cork South Central, Fine Gael)
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To be fair to Mr. Quinn, he is here to answer in regard to the report today as opposed to other HSE matters.

Colm Burke (Fine Gael)
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I accept that.

Jerry Buttimer (Cork South Central, Fine Gael)
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Be fair, he is not responsible for that.

Colm Burke (Fine Gael)
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Is Mr. Quinn saying that from his evidence, people have been slotted into positions who are not qualified to hold them? That is what the report seems to be indicating. If that is the position, I am saying that the people who put them in there should resign or be fired. It is outrageous that we are slotting people into positions who do not have the technical know-how. Someone has to be answerable for this matter. I need clarification on that.

Jerry Buttimer (Cork South Central, Fine Gael)
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Does Senator Burke have a mobile telephone near the microphone?

Colm Burke (Fine Gael)
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It is off.

There is another issue I want to identify. In the last week, it has come to my knowledge that staff who were working with the ambulance service have not been redeployed or retrained in the roles they previously had. Some of them are now sitting in offices without any responsibility of any description. I wonder if, in preparing this report, Mr. Quinn was aware of that. The issue identified in the report is very worrying. It is not a case of another report sitting on a shelf because action needs to be taken on this matter. I thank Mr. Quinn for the report, but this issue needs to be clarified.

Ciara Conway (Waterford, Labour)
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My question is an amalgam of the issues raised by Deputy Ó Caoláin and Senator Colm Burke. I am sorry to refer back to Deputy Ó Caoláin's tragic personal story. The report mentioned that people do not have technical expertise. Is Mr. Quinn saying that people in the ambulance response unit do not have the technical expertise to deploy an ambulance that is closer than the 45-mile distance to which Deputy Ó Caoláin referred? If so, that is outrageous. I know it is not Mr. Quinn's responsibility but that is a worrying finding from the report - that people are in positions but do not have the technical expertise to carry out their functions. Who appointed these people? Did the report look into that?

Mr. Quinn spoke about challenges regarding leadership. I would like to know a little bit more about that aspect. Who are these leaders who are challenged? The way in which they are managing and deploying resources within their service is obviously inadequate. How can somebody be given a job that they do not know how to do? We would not ask an occupational therapist to carry out surgical procedures. If it is the case that people are being appointed to posts for which they are unqualified, that is outrageous. It is a serious finding. If that is the case, I thank Mr. Quinn for unearthing it.

As regards the relationship between the Dublin fire brigade and the ambulance service, it would appear that there is little or no communication and they operate in a disjointed manner. Nearly half the population lives within the greater Dublin area, although there are challenges in rural areas. If that is the case, why is it happening? That potential duplication of services seems ludicrous when we know it is difficult, in some places, to get an ambulance to a crisis within the required time.

The report referred to community engagement concerning ambulance services. Can Mr. Quinn explain that to me because I do not understand it? Is he talking about Order of Malta services, the Civil Defence or other first responders? I would like to know a little more about that and what can be done to improve it.

What jumped out of the report for me was that we have people in positions who reported to HIQA that they do not have the appropriate technical knowledge. That is outrageous. While I thank Mr. Quinn for his report and for attending the committee today, we need to delve more deeply into the issues raised by his report.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will ask Mr. Quinn to respond to the points raised so far because I have other speakers as well.

Mr. Phelim Quinn:

I thank all three committee members for their comments. If we take the issue around our methodology first, I will hand over to Ms Dunnion who lead the review. She will be able to outline the extent to which we engaged in respect of the review. We will then deal with some of the other issues.

Ms Mary Dunnion:

The first part of the review was who made up and was conducting the review. In that context, there were three members from HIQA and three external people were also used on the review. They included the recently retired deputy director of operations for Northern Ireland ambulances, a CEO from a NHS ambulance trust, and a medical director from the UK. They provided the clinical and service expertise to the review team.

Jerry Buttimer (Cork South Central, Fine Gael)
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They had no vested interest in terms of their association with the ambulance service here?

Ms Mary Dunnion:

No. They would all have had the controls in place in that regard.

The review itself was conducted beginning in June 2014. It involved meeting in excess of 200 members of the national ambulance service staff. They ranged from leadership levels down to front-line care providers. Reciprocally, we met 10% of the Dublin fire brigade staff.

Our meetings with staff were conducted through focus groups which were randomly selected. We randomly selected them from their duty rosters. It referenced and brought together staff from all sites all over the country.

Each control centre was visited and a lengthy time was spent in each control centre run by the national ambulance service, and the one control centre run by Townsend Street. In addition, the review team went on ambulance trips and responded to emergency calls across the country with the ambulance service. That was the on-site component of the review.

The methodology associated with that was in line with the terms of reference which we published in April. Mr. Quinn outlined them in his presentation. In tandem with that we had an extensive documentation request which mostly looked at governance, management and workforce issues. We then looked at the data. We used the data in the context of response times which are nationally published. They were 18 minutes and 59 seconds. We also looked at unpublished data, which is the seven minute and 59 second response. We also pulled 24-hour data ourselves on St. Patrick's Day. In the timeframe of our review it was our opinion that would have been a busy 24 hours.

We took those data from all over the country and analysed and reviewed them. We came to our conclusions through that whole process. In that context, we were assured that we covered the geographical terrain. In addition, we looked at other jurisdictions, particularly those that have rural settings. Though we did access English data, we particularly looked at Wales, Scotland and Northern Ireland. We had an expert from Northern Ireland on the review team. We also looked at other jurisdictions. That is an indication of how complete was the methodology we applied.

Jerry Buttimer (Cork South Central, Fine Gael)
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Has there ever been a need to consult service users, such as, for example, the family mentioned by Deputy Ó Caoláin or people who have complained about either response times, an ambulance getting lost or whatever? Is that the normal practice?

Ms Mary Dunnion:

We did not meet people who had used the service, with the exception of those whom we met when we conducted the review, because we did not and have not received unsolicited information from people accessing ambulance services and complaining about them. That would be our general methodology approach because we have those groups ourselves, as it were. While the authority did not receive that information, we have met patients who have accessed the service.

We have found that the National Ambulance Service does not have a formal engagement with people using the service. We recognise that situation as a very significant deficit and we have made a recommendation in this regard. It is a missed opportunity to learn and improve the service. We have identified a recommendation in that. I hope I have covered the methodology element for the Deputy.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I thank Ms Dunnion. The Chair has picked up on the obvious additional area that I would have liked.

Ms Mary Dunnion:

Thank you.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I understand what HIQA had to do.

Mr. Phelim Quinn:

A couple of specific issues have been raised. Two Deputies raised the substantive issue of appointing managers who do not have technical skills. I assure them that our description referred mainly to the senior management staff of the National Ambulance Service whom we interviewed. They reported to us that they had been appointed mainly through internal movement within the service and, at times, without appropriate job descriptions matched to the strategy of the National Ambulance Service. On a couple of occasions they also reported to us that they believed they had been appointed to senior management positions without the relevant technical skills. I do not want it reflected here that specific on the ground the staff or middle managers had reflected they were inappropriately appointed on the basis of the possession of technical skills. It was senior management staff, in the main, who had reported that particular deficit. The deficit is important and key because such staff are charged with strategically leading and operationally managing the service. The range of deficits and challenges that we found are very complex and require technical skills to achieve positive outcomes for the service and for service users.

Recommendation No. 6 highlights our other recommendations to extend the role of paramedic staff and advanced paramedic staff. We believe, at the minute, that there is not a sufficient number of advanced paramedic staff working in the services that would allow them to expand into a wider scope of practice. We have also unearthed, through the course of the review, the fact that a number of paramedical staff have left the service but have not been replaced in an appropriate way. There are issues with workforce planning and development to meet the needs of an emergent service.

Jerry Buttimer (Cork South Central, Fine Gael)
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Are there staff without the appropriate technical knowledge in a leadership position?

Mr. Phelim Quinn:

A number of staff reported that to us, at that level.

Jerry Buttimer (Cork South Central, Fine Gael)
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Surely a leader requires the competency of being able to ask, cajole or bring staff along on a journey of change. The report signifies and highlights how the health service and ambulance service is being transformed. The HSE is not part of Mr. Quinn's remit. How does he think the HSE has allowed this situation to evolve over time?

Ms Mary Dunnion:

We would have expressed concerns about some of the issues and concerns articulated by the Chairman. During the course of the review the HSE began and requested its HR department to undertake a management review of the National Ambulance Service. The purpose of the review was to look at the competencies required to align it to the strategic direction the HSE was planning. The results of the review were not available to us as the review team because they are due to be completed towards the end of the December. Although the work had begun, to our knowledge, unfortunately we did not have the report. That is why in the four recommendations that specifically deal with the National Ambulance Service there is quite an extensive recommendation regarding management training, mentorship, management development and the requirements that are essential in leading the service going forward.

Colm Burke (Fine Gael)
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Was it identified that people had been appointed without interview? It has been mentioned that people were moved rather than interviewed.

Ciara Conway (Waterford, Labour)
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Who made those appointments?

Ms Mary Dunnion:

We do not have the detail of who interviewed or appointed people. We do know there was an internal transfer of posts within the National Ambulance Service.

Ciara Conway (Waterford, Labour)
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People were slotted in.

Sandra McLellan (Cork East, Sinn Fein)
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Yes.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is it not a source of concern and worry that people could be put into positions of autonomy or leadership when they are not up to the job or have not got the requisite skills or competencies?

Ciara Conway (Waterford, Labour)
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Or degrees.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is that not a bad way to start?

Mr. Phelim Quinn:

Yes. It is for that very reason that we made recommendation No. 9. We believe that there is a requirement and urgency to develop the management and leadership of these services in regard to management and leadership skills.

Jerry Buttimer (Cork South Central, Fine Gael)
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As Chair of this committee I find it quite troubling that such a situation has been allowed to happen.

Ciara Conway (Waterford, Labour)
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We should, as a matter of course, ask whoever is responsible for HR in the HSE to come before us immediately because this situation is outrageous.

Jerry Buttimer (Cork South Central, Fine Gael)
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I was going to make a proposal at the end of the meeting but I will say it now in light of the Deputy's suggestion. I propose we invite the National Ambulance Service, the HSE and Dublin Fire Brigade in again at the end of this process. That will be the first part of what we will do. I do not want to pre-empt the discussion but I agree with the Deputy's proposal.

Three other speakers wish to contribute. I suggest Mr. Quinn finishes his response to the first batch of questions and then we will have Deputies Regina Doherty, Senator Crown and Deputy Fitzpatrick.

Mr. Phelim Quinn:

Members raised a number of other issues. One issue raised was the relationship and ongoing communication between the National Ambulance Service and Dublin Fire Brigade. During the course of this review we evidenced that an ongoing difficult or fraught relationship appears to have existed between the two services. The two services appear to operate in specific silos. In some instances that is evidenced even in the relationship within the control centre which is a shared building. We have specifically recommended that their relationship needs to be worked on as a matter of urgency. Recommendations Nos. 1 to 8, inclusive, stipulate a need for a jointly created action plan to force co-operation and joint communication by the two services. That element is key for us.

We have also conducted a major programme on the ambulance control centre's reconfiguration. We have evidenced a lack of co-working with Dublin Fire Brigade for this major project. Recommendation No. 4 is based on the involvement of Dublin Fire Brigade in the national call centre reconfiguration programme which is essential to iron out operational inefficiencies moving forward. As I have heard Ms Dunnion mention on a number of occasions, unless we address some of the operational inefficiencies before the move to the singular call centre model, all we will do is carry them from the old model to the new one. Therefore, we have asked for the involvement of Dublin Fire Brigade in that respect.

We have covered the issues of general workforce development and planning. Deputy Ó Caoláin mentioned our recommendations for Dublin Fire Brigade to move forward. We have definitely not made any specific recommendations to discontinue the service being provided by Dublin Fire Brigade. We believe it provides a very safe and effective service but there are challenges in its system and we commend our recommendations to it to address some of them.

We are also conscious of the fact that there are two further reviews into the ambulance services or the pre-hospital emergency care services taking place in Ireland. One is a capacity review that we believe will be reported upon before the end of this year. The other review specifically deals with Dublin Fire Brigade. It was commissioned by Dublin City Council and we believe it will be published in February 2015.

We were again asked about community engagement and first responder schemes. Some of that may relate to the issues the Deputy has experienced personally. Ms Dunnion will take the committee through the first responder schemes and the relationship with the seven minute 59 seconds target.

Ms Mary Dunnion:

One of the issues the Deputy raised was the model of care. This year there has been a 10% increase in the number of people calling an ambulance and the natural pathway for patients is that once they call, an ambulance is dispatched and they are dealt with and transported to a main emergency department. If they consent to a main emergency department, 99.9% of patients will be transported. That model is not sustainable nor is it in line with what is happening in other jurisdictions. For example, elsewhere some services have managed to reduce by 40% the number of patients transported to a main emergency department. That is not simple to do because it requires investment and planning and embracing the concept and moving with it. We have made a recommendation that a properly trained person should triage people over the telephone to find out exactly what is happening and whether they need to go to a hospital or whether there is another pathway for them. Trained practitioners can go to see the patients and treat them there, discharging them if appropriate. This is based on the development of the competencies of advanced paramedics and paramedics and involving medical staff in taking calls and the management of patients. That opportunity is there and it needs to be worked towards.

I refer to community first responders. When something tragic happens to somebody such as in the cases cited by the Deputy, an ambulance with advanced paramedics needs to be dispatched. Equally, however, somebody who is trained and competent as a first responder is also required. He or she can be a trained lay person, an advanced paramedic in a fast mobile vehicle, a GP, a garda or whomever. The response times in the west and the south are the least good but they are also the areas, particularly, the west, that have the lowest number of community responders. The areas with the biggest problem have had the least local investment in the context of community responders. We have made a recommendation that the NAS immediately begins the training of people as responders and, aligned with that, introduces a communications system at local level engaging with the public to bring them on stream to work towards an effective first response scheme.

In that context, first response in seven minutes 59 seconds is not publicly reported. We looked at the data, which is collected, and it shows that are poor response times to the seven minute 59 seconds target. It is for that reason we have made a recommendation in that regard because we firmly believe as a review team that unless the service providers are collecting data, there is no way they will drive improvement. We have, therefore, made a recommendation specific to that for all Echo and Delta calls, which are the critical calls, and we have said the service providers, NAS and Dublin Fire Brigade, must specifically report heart attack, cardiac arrest and stroke response times. It is to create momentum to drive improvement that we are requesting the implementation of that recommendation.

Regina Doherty (Meath East, Fine Gael)
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Every time HIQA officials appear before the committee, the quality of the information they provide is superb. From an efficiency perspective, I wish we had more statutory agencies that worked along the same lines as it. I wish Mr. Quinn the best of luck in his new role.

Both the NAS and Dublin Fire Brigade have appeared before the committee singing the praises of the services they offer but HIQA's report is blistering about them. According to the report, there is a senior management skills deficit, no technical expertise in certain areas, no clinical audit of the NAS, no strategic directive, no effective governance, insufficient advanced paramedic staff to allow the service to progress and an internal transfer of posts without interview and with skills deficits on the part of those who are moved, which is the killer. This is a blistering report compared to the picture painted for us over the past number of months.

The data are key. HIQA's focus groups were drawn from personnel around the country. Following the committee's previous hearing in this regard, I visited two centres - one run by the fire brigade and one run by the NAS. I was struck by the difference in morale and self-esteem in both establishments. There is a vast and stark difference in the reported numbers by both organisations. On the basis of the focus groups, does Ms Dunnion agree there is a much higher level of esteem among the fire brigade personnel than among the NAS staff? There is also a much greater difference in staff attendance. Can she see reasons for the stark differences between the fire brigade and NAS in the data? I acknowledge HIQA uses a hierarchical structure and treats them both as providing the same service. However, they do not provide the same service and they perform at different levels with vastly different budgets, yet the organisation with the lesser budget is performing at a much greater capacity than the organisation with the larger budget. Are there obvious reasons for that other than the stark issues I referred to?

Arising from my visits, we conducted research in the Houses of the Oireachtas with our own research team into best practice in other countries, which offer what may be termed "all singing, all dancing" emergency services. One of the glaring differences is 42 different organisations around Ireland try to offer emergency services whereas best practice in Seattle and Canada, for example, is to have one emergency service authority. What is Ms Dunnion's opinion on that?

Peter Fitzpatrick (Louth, Fine Gael)
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I congratulate Mr. Quinn on his new role. I love to see improvements in anything. One of the main reasons I am on the committee is health is one of the most important aspects of people's lives. Will the officials elaborate on the new national control centre, which will open in Tallaght in 2015, with a back up centre in Ballyshannon? It will integrate the six regional services. Will this improve the service in the control centres?

My main focus is the national service replacement policy on vehicles. Once a vehicle has been in use for seven years or has reached mileage greater than 500,000 km, it is replaced but the officials stated that despite the policy, 18% of the current fleet is eight years old or more. Louth County Hospital is located in my home town of Dundalk. Over the past 12 to 18 months, there has been a great deal of concern about the ambulance service at the hospital. The paramedics, advanced paramedics and the drivers all do a fantastic job but many vehicles have broken down over the past number of years and the public are concerned. Does the 18% statistic refer only to County Louth or to the entire country?

John Crown (Independent)
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As previous speakers said, the report has highlighted inefficiencies and I am sorry but the officials may have presented these data. How many ambulances do we have per head of population? How many are there in Northern Ireland and Scotland? Does HIQA have the statistics for most countries in western Europe?

Sandra McLellan (Cork East, Sinn Fein)
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I also congratulate Mr. Quinn and wish him well in his new role. I thank HIQA for the report, which was published today and which, I think, everybody here agrees is quite shocking but at least honest.

With regard to the finding in the report that many staff in leadership positions do not have the appropriate technical knowledge, I took a quick look over recommendation 9. While it is only a recommendation will it be implemented and when might that happen? In the meantime, will these staff who do not have the technical knowledge or the leadership skills continue to work in those positions? If they do not have these skills, they should not be in these positions and they are putting lives at risk. What if these staff cannot be trained? Will they be removed from these positions? What would happen to them?

Mr. Phelim Quinn:

There are a number of specific issues that, between the two of us, we will try to address.

On the latter point first, if the committee does not mind me saying, we have made 12 recommendations, eight of which are to be jointly addressed by the National Ambulance Service and the HSE in conjunction with the Dublin Fire Brigade. I appreciate that HIQA's current monitoring function powers are not enforceable but we would say that we have tried to orientate this report towards improvement through the making of these recommendations. We have found significant challenges within these services but we believe that these services need to continue to exist in a safe and effective way.

Jerry Buttimer (Cork South Central, Fine Gael)
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In saying that, within the structure and culture of the HSE, will the recommendations that Mr. Quinn has promulgated be followed up and acted on? I accept he has not got powers of compellability in that regard.

Mr. Phelim Quinn:

I was asked my view on strategy on HIQA in the future. I believe that there is a requirement for a robust performance management mechanism across the health and social care system. At present, it appears to be transferring, from 1 January, into the Department. What we say is that, in conjunction with the Department of Health, the HSE should accept these recommendations and see their implementation over the course of a realistic timeframe. Some of these recommendations can be achieved in a relatively short period of time and others will take longer but we believe that the services and those who procure or commission those services need to performance manage the recommendations and their implementation.

Deputy Regina Doherty asked a number of technical questions and they relate to the focus groups, etc. Ms Dunnion has had closer involvement with the specifics of the review.

Ms Mary Dunnion:

If we take Deputy Regina Doherty's first point - her concern on the lack of clinical audit - that would be well-founded. There is clinical audit in the Dublin Fire Brigade but it requires much more development. The reason the clinical audit is in the Dublin Fire Brigade is that it has had a medical director on a part-time basis for a longer time than the National Ambulance Service. The latter's medical director was appointed only in 2011. Notwithstanding that, there are significant opportunities for a clinical audit to already take place and those opportunities need now to be taken.

There was a reluctance on the behalf of the National Ambulance Service to conduct a clinical audit because it was waiting for an electronic record and was not using the paper record. We would have seen that as a deficit and that the paper record should be used for clinical audit because many places do not have electronic records and are using paper records.

Jerry Buttimer (Cork South Central, Fine Gael)
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For the person watching at home as we debate this who does not understand some of the jargon, can Ms Dunning explain what is meant by the statement in HIQA's report that there is no clinical audit?

Ms Mary Dunnion:

What it means for the public is that although they may experience good care, there is no system in place to assure those who manage the service that there is good care, there is no assurance for those who deliver the care that it is being monitored and that lessons can be learnt where there may not be good care, and there is no way to assure members of the public formally that there is care in respect of their individual experience. Of course, the big loss is that if there is not good care, it cannot be detected and it is not possible to manage, change it and learn from it. That is probably the most important example.

There is a difference between those whom the committee met from the Dublin Fire Brigade and those whom it met from the National Ambulance Service. Dublin Fire Brigade is a uniform service and by its nature it has the constituents of that. It is well organised, there are clear communication pathways and the staff are responsive to any issues, or to recommendations or direction given through their management line. In the National Ambulance Service, there are a lot of legacy issues, which we saw. In the groups that we met - as I stated, we met quite a large number of staff - there was dissatisfaction. It permeated through. Probably the biggest manifestation was the poor communication processes that they perceived to be in place. They would, for example, have cited areas where information was passed down by memo as opposed to somebody talking to them. What we saw is that although staff were complaining, it was in a desire to improve the service. That was tangible through all the groups that we met and is noted in the report. We recognise the need for good communication processes and the dissatisfaction that happens when those are not in place, which is what we witnessed. As a consequence, we have a recommendation related to that within the report. They were two different groups of staff. They are structured differently. One is a fire service and emergency service, and it is in existence a long time and has probably the cohesiveness which arises from that length of time.

On staffing, the review would recognise that there are not enough advanced paramedics. Also, we would have seen that in the attrition rate within the ambulance services, particularly the National Ambulance Service, for paramedics more than advanced paramedics, the replacement factor does not match the attrition. When paramedics are recruited, it takes two years before they are able to function on their own. If one does not have a good replacement practice then there will be shortages. That is why we made the recommendation regarding workforce planning because we would not have seen that such was in place. As Mr. Quinn stated, we have been informed by the HSE that the capacity review which, because it was happening in tandem with our review, looks specifically at resources and what is required in the service moving forward, will be ready for publication at the latter end of December. That review should give a more comprehensive view of what is required but we saw deficits in the numbers that would be required for the service.

Mr. Phelim Quinn:

In respect of the question asked by Senator Crown, the capacity review should also provide us with some specific comparisons with ambulance resources in other jurisdictions.

Mr. Phelim Quinn:

I am not sure-----

Ms Mary Dunnion:

In the context of Ireland, there are 266 ambulances and 57 response vehicles. By comparison, Northern Ireland with a population of 1.7 million, has 60 ambulances and 40 emergency response vehicles. Their emphasis is more on the emergency response vehicle because that is what gets the trained competent paramedic to the person in seven minutes 59 seconds, whereas we have the opposite balance.

Jerry Buttimer (Cork South Central, Fine Gael)
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Would Ms Dunnion have an opinion as to what model we should pursue here?

Ms Mary Dunnion:

It would not have been within the expertise of our group. It is for the capacity review.

Jerry Buttimer (Cork South Central, Fine Gael)
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That is fair enough. In his presentation, Mr. Quinn mentioned the ambulance fleet, 18% of which is eight or more years old. Should we be concerned about the quality or roadworthiness of the fleet and its reliability?

Mr. Phelim Quinn:

Deputy Fitzpatrick asked the same question. We reported on what the National Ambulance Service provided to us by way of information.

The National Ambulance Service provided us with its policy on fleet replacement and gave us the number of vehicles that fall outside its policy.

The Chairman asked whether those ambulances are unsafe. They fall outside the policy is what we would say. We have been assured that they have been subject to other forms of checks at least to provide certification of roadworthiness. However, the propensity for those vehicles to break down increases when they increase in age and mileage. It is a factual thing and is something that would cause us some concern.

Deputy Fitzpatrick asked us about the move to a national control centre and whether it will be effective. The review team's experts believe it would be an effective measure because it would merge national ambulance services into a single entity. Also, it would provide an opportunity to better integrate the National Ambulance Service with the Dublin Fire Brigade but only if the latter was involved in the project which is why we made such a recommendation.

Peter Fitzpatrick (Louth, Fine Gael)
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HIQA carried out an inspection of Louth County Hospital a good few months ago. There is a lot of concern in the area about ambulances breaking down. When can we expect HIQA's report on ambulance services for Louth County Hospital to be published?

Jerry Buttimer (Cork South Central, Fine Gael)
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That is a generic question. Today we are dealing with the national review.

Peter Fitzpatrick (Louth, Fine Gael)
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I am concerned about ambulance services and HIQA has carried out an inspection. Can the delegation follow up on my query and get back to me?

Ms Mary Dunnion:

I do not think we carried out such an inspection. We conducted a hygiene audit of Louth County Hospital so would not have looked at pre-emergency hospital care services. We did witness and experience, in a review, that ambulances broke. That situation was reported by all of the focus groups and would have been witnessed by our reviewers while they went to collect a patient.

Peter Fitzpatrick (Louth, Fine Gael)
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A national ambulance driver told me that HIQA arrived to examine the ambulance and have a look at the area.

Mr. Phelim Quinn:

That was part of this review.

Ms Mary Dunnion:

That was part of this review.

Mr. Phelim Quinn:

Ms Dunnion is right.

Ms Mary Dunnion:

It was not a review of Louth County Hospital and they were doing it from the control centre.

Mr. Phelim Quinn:

That is correct.

Jerry Buttimer (Cork South Central, Fine Gael)
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Deputy Maloney has indicated. He has not spoken yet so I call him next.

Jerry Buttimer (Cork South Central, Fine Gael)
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Their work is very important.

Ciara Conway (Waterford, Labour)
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It has been mentioned that the vehicles fall outside the policy. Does that mean we do not have a national standard for ambulances in terms of roadworthiness, an ability for clinicians to carry out their work, patient safety and equipment checks?

Ms Mary Dunnion:

The fleet would have to adhere to a certification and that is done.

The National Ambulance Service has a vehicle replacement policy based on a seven-year life cycle and whether a vehicle has reached 500,000 km in mileage. Other jurisdictions only use years and not mileage which means the National Ambulance Service applies an additional criteria. All jurisdictions have a time of seven years.

In terms of data, the NAS has recently installed a system that allows it to begin to get a total oversight of its fleet. Up until the beginning of the review it did not have such an option. The new system is to be put on all the vehicles and is being rolled out. I imagine, at the pace it was going, that by the end of the year it will have full oversight. We looked at the data that the NAS gave us and could see that 18% of the vehicles required replacement. We also saw that the timelines for its replacement policy were behind schedule so that is a challenge.

Ciara Conway (Waterford, Labour)
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Is there a HIQA national standard for ambulances?

Ms Mary Dunnion:

There is a certification of vehicle roadworthiness.

Ciara Conway (Waterford, Labour)
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Is there a national standard for ambulance services in general?

Mr. Phelim Quinn:

It is just a national policy.

Ms Mary Dunnion:

It is just a policy.

Ciara Conway (Waterford, Labour)
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If there are no standards then there is no minimum requirement and no measurement.

Jerry Buttimer (Cork South Central, Fine Gael)
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I take the point made by the Deputy. What happens if, for example, HSE south had three ambulances with mileage of over 500,000 km?

Mr. Phelim Quinn:

Let me outline the key issue. In good governance terms, the National Ambulance Service has a policy based on two parameters - the age and mileage of a vehicle. We appreciate the latter parameter is not used in other jurisdictions but it has been set within the policy of the National Ambulance Service. The only thing we could do, in this instance, was to manage the service against its own policy and that is what formed the basis of our conclusions.

Ciara Conway (Waterford, Labour)
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We asked about national standards.

Mr. Phelim Quinn:

I wish to address the specific points made by Deputy Maloney. To be clear, we met a significant number of staff, on the ground, as part of the focus group discussions. I had limited but some experience of that and we saw a very significant range of very dedicated staff that are very committed to doing a good job. We have also seen that the National Ambulance Service has transitioned from what it would have said was a patient transport service to quite a technical and well versed clinical service. We need to see that service move forward in an improved way using a properly managed change management process.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Before the Chairman thanks everybody I suggest he formalises the proposition which I am happy to second.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank HIQA for its report and thank Ms Dunnion, Mr. Quinn and Mr. Whelan for attending. The debate has been very enlightening. We all recognise there has been a significant change in the ambulance service. As Deputy Maloney has said, it is important that we pay tribute to the staff who have changed the modus operandiof the service, from transporting people to now responding, taking care of and looking after people. We should acknowledge the work done by the people who work in the ambulance service, and very often in difficult and trying services. It is right to express our appreciation to them.
In terms of reports, we have today's report and there are two further reports in the pipeline. It is in that context that I propose, and as a result of this meeting, pending the review and subsequent to the review, we should invite the National Ambulance Service, the HSE and Dublin Fire Brigade to attend a meeting at a date to be finalised. The purpose of the meeting would be to continue, as HIQA has done already, monitoring the ambulance service. Is that agreed? Agreed.
Having listened to today's report three issues arose. First, a need for co-operation and integration between the National Ambulance Service and Dublin Fire Brigade. Second, an audit must take place. Third, we should focus on improving measures.
HIQA cannot compel anyone to act on its recommendations but it is important that they are acted upon.

I hope the culture within the Health Service Executive, HSE, will be to accept, as Mr. Quinn noted, the recommendations with a view to improving the service. Does Deputy Regina Doherty wish to ask a question?

Regina Doherty (Meath East, Fine Gael)
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While all members have agreed the joint committee should invite in the HSE, the National Ambulance Service and Dublin Fire Brigade, can I ask when? Some random point in January probably is not-----

Jerry Buttimer (Cork South Central, Fine Gael)
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The capacity review report is not yet available and in fairness, while the joint committee can bring them in before Christmas if possible, I believe we would be speaking in a vacuum without that capacity review. We have received one part of a report in a series of reports that does not give members the whole picture.

Regina Doherty (Meath East, Fine Gael)
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While I see what the Chairman is saying, I am unsure about that. Even were the capacity report to conclude that 50% more staff members were required, that would not address some of the issues discussed today, including some serious issues such as people being in senior management positions without the skills to provide that service. This probably is the key starting point as to why the service being provided is as it is, notwithstanding the wonderful people who, while desperately lacking in morale, are trying to provide those services. Consequently, I am unsure whether waiting until January is sufficient.

My second point concerns the lack of authority of the Health Information and Quality Authority, HIQA, to make sure the recommendations are enforced that was mentioned earlier. That is the job of the joint committee and arising from this meeting, the strongest of letters should be sent to the Minister stating it is not the case that the recommendations should be implemented but that they absolutely must be implemented. Moreover, if they are not - within a period of perhaps three months - somebody should appear before the joint committee to explain why they have not been implemented and if delays have arisen with regard to the implementation, what steps are being taken to make sure they will be implemented. I ask that such a letter be written today.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is that agreed? Agreed. Again, I will bring them in as soon as possible. I have no argument or problem with that.

Ciara Conway (Waterford, Labour)
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The joint committee should bring them in as soon as possible, because it is not about the overall picture. The organisations concerned should be asked to appear to respond to this report, which is fairly damning.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is that agreed? Agreed. I will try to get them in before Christmas. That is fair enough and I have no issue with it.

I again thank the witnesses for their attendance and again welcome formally Mr. Phelim Quinn as the new chief executive.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Before the meeting adjourns, may I make one last comment?

Jerry Buttimer (Cork South Central, Fine Gael)
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In regard to what?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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In respect of everything members have discussed. As Deputy McLellan noted, it is really bad. However, as for my point at the outset, I must state it is my belief that it is worse. It is the patient experience, the experience of people, that is missing from the report by HIQA. That is a huge untold story and I could not have shared what I did only I have lived it myself. That is out there and all too sadly, it is universal.

Jerry Buttimer (Cork South Central, Fine Gael)
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While we can all refer to this anecdotally, in the case of my family we had a first responder who probably saved someone's life by being prompt and so on.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Of course.

Regina Doherty (Meath East, Fine Gael)
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To come back to what Deputy Ó Caoláin is saying, this should not be anecdotal as there is a patient safety authority. There is a patient safety director within the HSE and I would like to know what he thinks of this report and what actions he actually is taking in this regard.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy made a request to bring in the HSE and I will do that.

Regina Doherty (Meath East, Fine Gael)
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We are still waiting. There actually is a person who has statutory responsible for patient experience and patient safety.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy only made the request a minute ago.

Regina Doherty (Meath East, Fine Gael)
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However, they bloody well do not talk to patients.

Ciara Conway (Waterford, Labour)
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The joint committee has asked them to appear before. Why will they not appear?

Regina Doherty (Meath East, Fine Gael)
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The meeting is "to be advised".

Colm Burke (Fine Gael)
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I refer to the issue I have highlighted. While I acknowledge it is a separate issue, it is the crunch issue whereby people are being promoted without interview. This is a huge issue.

Jerry Buttimer (Cork South Central, Fine Gael)
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The joint committee can address that at its meeting with the HSE before Christmas.