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.