Oireachtas Joint and Select Committees
Tuesday, 16 December 2014
Joint Oireachtas Committee on Health and Children
HIQA Review of National Ambulance Service: Health Service Executive
I welcome from the Health Service Executive Ms Laverne McGuinness, deputy director general; Ms Paula Lawler, deputy national director of human resources; and Mr. Ray Mitchell, assistant national director of the parliamentary and regulatory affairs division; and from the National Ambulance Service Mr. Martin Dunne, director, and Dr. Cathal O’Donnell, medical director. The purpose of this session is to consider the report on the HIQA review of the national ambulance service and provide members with an opportunity to engage with the Health Service Executive and the national ambulance service on the findings of the report. We must conclude this part of the meeting by 7 p.m. when the second session will commence.
Witnesses are protected by absolute privilege in respect of evidence they give to the joint committee. However, if they are directed by it to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.
I invite Ms McGuinness to make her opening statement.
Ms Laverne McGuinness:
I thank members for the invitation to attend this meeting to discuss the recently published Health Information and Quality Authority, HIQA, review of pre-hospital emergency care services and the Health Service Executive's initial response to the report's findings and recommendations. I have provided a detailed briefing note on the national ambulance service and its transformation programme. I have also circulated a copy of the executive summary and recommendations of the national capacity review, an independent, external report commissioned by the HSE. I will, therefore, focus on a number of the key areas highlighted in HIQA's report.
The Health Information and Quality Authority's review of pre-hospital emergency care services acknowledges that a lot of progress has been made by the national ambulance service in recent years. The acknowledgement by HIQA of the significant role played by the ambulance service in improving patient outcomes in the areas of stroke and acute coronary care is particularly noteworthy. The report also identifies a range of challenges for the future improvement of services under headings already identified by the HSE as requiring attention. The 12 recommendations made by HIQA are being implemented or will be incorporated into the planned programme to improve ambulance services.
The working and governance arrangements of the national ambulance service and Dublin fire brigade are discussed in the report. Both organisations will work collaboratively in the implementation of the recommendations set out in HIQA's report. In advance of the outcome of the joint review of the Dublin fire brigade, early engagement will take place at corporate and operational levels and between the medical directors of each service on the establishment of a formal link in the area of medical assurance.
To develop a modern and improved ambulance service, the national ambulance service commenced a significant change programme in 2012 which identified the need for changed and improved work practices and investment in infrastructure, information technology and the ambulance fleet. Ten key strategic objectives were identified as necessary to meet the growing needs and demands of the service.
These are: implementing national control centre reconfiguration; undertaking a national ambulance service capacity review; implementing the response times improvement framework; engagement with patients and families; reviewing the provision of emergency ambulance services in Dublin city and county - the Dublin fire brigade review; developing and implementing the electronic patient care record; developing and implementing clinical performance measures; developing and implementing a clinical audit programme; expanding the community first responder scheme; and developing options to move to a BSc model of education for paramedics.
To give effect to this programme of change, significant investment has been made in the ambulance service at a time when other parts of the health service have experienced significant budget reductions. Some €26.2 million has been invested in the national ambulance service in 2013 and 2014 in the development of the national control centre and the related information and communications technology, including computer-aided dispatch. A further €11.5 million was allocated in 2014 - as part of the fleet maintenance programme - for the purchase of 36 new emergency ambulances and two critical care ambulances, as well as 180 new defibrillators and 20 mechanical resuscitation devices. A sum of €5.4 million will be allocated in 2015 for the purpose of putting in place a range of developments, including the opening and staffing of ambulance stations at Lough Lynn, Mulranny and Tuam, the completion of the national control centre, a clinical audit and the elimination of on-call services in the west. In 2015, €7.5 million will also be allocated for the purchase of 47 brand new ambulances.
Ms Laverne McGuinness:
The recent investment programme addresses the most immediate staffing and service infrastructural deficits. There is a recognition that future investments in services should be supported by an appropriate strategy which will ensure services delivered will be in line with best international practice and meet demand in a safe, efficient and effective manner using the most appropriate care models. In this regard, a number of important reviews were commissioned and are under way. They include: a national capacity review, the purpose of which is to independently determine the resource requirements and optimal deployment of the resources to meet the needs of a modern ambulance service and assist in the delivery of the target response times; a joint review of the provision of emergency ambulance services in Dublin city and county in order to determine the optimal model of ambulance provision which ensures patients receive the highest standard of emergency response and where the care provided meets all national safety and quality standards; a review of the national ambulance service's management capacity and governance, which will support the continued delivery of the key priority projects under way as part of the transformation programme; and an independent review of the national ambulance service fleet.
A number of goals were achieved under the 2012-14 reform programme. The migration to a single national control centre, coupled with a new computer system and digital radio, will bring transformational improvements in the delivery of the service. This key project will deliver a single, state-of-the-art national emergency control centre for Ireland across two sites at Tallaght, the main or hub site, and Ballyshannon, the resilience or back-up site. The project involves the centralisation of multiple small control centre sites from 11 sites to two. It also requires a change in the model of working where the role of an emergency medical controller is being replaced with a new model of operation whereby there are separate call taker, dispatcher and supervisor roles. Seven control room centres have migrated to date and there are currently four command and control centres in operation, namely, Townsend Street, Wexford, Tullamore and Ballyshannon. The move from Townsend Street to the new state-of-the-art facility in Tallaght will take place by the end of January 2015. In addition, the entire information system, including call answering and dispatch, is being replaced. A computer-assisted dispatch system will be implemented fully in 2015. The national ambulance service has also introduced a national digital radio communications system. These key projects will significantly enhance the service's ability to dynamically deploy ambulance resources and improve response times.
On ambulance response times, there was an increase of approximately 10% in all emergency calls - close to 1,000 per month - between January and December 2013. In September 2014 the national ambulance service responded to 24,018 emergency and urgent calls, bringing the total number of emergency calls this year to 217,144. This represents a further increase of 3.8% over the same period in 2013. The target set for 2014 in respect of ECHO and DELTA incidents was that 80% of calls should be responded to by a patient-carrying vehicle in 18 minutes and 59 seconds or less. National performance at September 2014 was 78.5% for ECHO calls and 69% for DELTA calls. The corresponding performance figures for 2013 were 65.7% and 63.4%, respectively. Members will note the improvement in the figures for 2014 over those for 2013. This improvement has been supported by a number of factors, including investment in new technology and intermediate care vehicles which now facilitate 75% or approximately 3,000 of all inter-hospital transfers of patients.
Ms Laverne McGuinness:
Notwithstanding this, the HSE acknowledges - in line with HIQA's report - that there is room for greater improvement, particularly in the area of call activation and the enhancement of community first responder schemes. The national ambulance service is working closely with Community First Responder Ireland in expanding the 104 such schemes in operation nationally.
Specifically, in the context of the HIQA target of a 75% response rate to the 7 minutes 59 seconds target for first responders, the independent national capacity review has found that this overall target for 75% of first responders is not achievable on foot of a number of factors. The national ambulance service serves a very rural population, with 40% of incidents arising in rural locations. In England only 12% of incidents are classified as rural in a typical ambulance service. This will have significant implications for the ability of the national ambulance service to perform to the same standards as an English ambulance service. In Ireland the rate of ambulance calls per head of population is 40% of that in England. While this difference cannot be fully explained, there is some evidence to suggest access to GPs in Ireland is easier, particularly out of hours. However, the scope of alternative care models to reduce response times may be less than in other jurisdictions. The capacity review further indicates that, with a very significant further investment, it would be possible for the service to - at best - achieve an eight minutes performance in 64% of cases across Ireland. This compares to a figure of 79% for a typical English service. The level of investment required is in the order of an additional 290 full-time staff, as well as additional vehicles such as emergency ambulances, intermediate care vehicles and rapid response vehicles.
Quality of care outcome measures provide a true indication of service performance. During quarter 3 of 2014 the national ambulance service started to report on the clinical outcome measure relating to return of spontaneous circulation – the internationally recognised indicator. The service is achieving a performance level of 39% in this regard, compared to a best international practice benchmark of 40%. HIQA's report acknowledges the importance of clinical outcome measures and the need to combine them with response times.
Ambulance turnaround times at hospital emergency departments also continue to improve, with 67% of emergency ambulance vehicles and crews released to respond to other calls within 30 minutes or less. This compares to a figure of 63% in September. Some 94% of calls had crews and vehicles clear and available within 60 minutes. The figure in this regard for September was 93%.
The national ambulance service operates its fleet in line with the requirements of CEN 1798/1789, Road Traffic Act, Department of the Environment, vehicle manufacture, etc. The fleet consists of 262 emergency ambulances, of which approximately 150 are required for daily deployment. This leaves 112 vehicles to serve as back-up. During 2014 the national ambulance service completed the fleet programme upgrade of 36 new emergency ambulances and an additional two critical care transport vehicles, as well as the purchase of 180 new defibrillators and 20 mechanical resuscitation devices, at a total cost of €11.5 million. A further 47 emergency ambulances will be procured during 2015 at a cost of €7.5 million. In addition, an extra 25 intermediate care vehicles were purchased in 2013. These transfer approximately 3,000 patients between hospitals each month. Since the end of June 2014, the national ambulance service has engaged a mechanical engineering firm to review the fleet and the maintenance systems in place. A full report in this regard will be available at the end of the month.
HIQA’s report is the subject of careful consideration by the national ambulance service. The report has identified areas of the ambulance services that are working well. These include: the successful implementation of protocols in conjunction with hospitals for stroke and acute coronary syndromes leading to better patient outcomes; the move from 11 to one national control centre over two sites is well under way and will lead to improved performance in call handling; the jointly commissioned review by the HSE and Dublin City Council, due to be completed in quarter one in 2015, will inform the process for enhanced governance and ambulance service delivery arrangements across Dublin city and county; the introduction of intermediate care vehicles; the appointment of a medical director who strategically oversees the delivery of pre-hospital clinical care; and the expansion of the clinical competency of pre-hospital care practitioners with the introduction of advanced paramedics and additional training and upskilling.
While many of the recommendations in the HIQA report are being implemented as part of the planned programme of work, the HSE acknowledges there are areas where additional focus is required, particularly management support, the relationship between the HSE and Dublin fire brigade, DFB, response times, clinical audit and developing new models of care. HIQA’s meeting with this committee on 2 December focused on a number of issues in the area of workforce and leadership. More specifically, page 39 of the report states that a number of staff reported that they did not have a formal job description or the requisite technical skills for the particular posts that they occupied. The director of the national ambulance service, NAS, meets regularly with his senior team and at the most recent meeting on 5 December 2014, the team members took the opportunity to confirm that they have the requisite skills to carry out their roles effectively.
There have been six internal management changes over the past 12 to 18 months and these involved, staff moving from the role of operations resource manager to operations performance manager. All posts were filled following a competitive process with a competency based interview. All posts have a specific job description. Workforce planning and management development and a review of all job descriptions will be progressed during 2015 as part of the implementation of the recommendations from the management review which is due to be finalised in early 2015.
Both the NAS and DFB have statutory powers for the provision of emergency ambulance services in the Dublin city and county areas. While work was completed to develop and put in place a service level arrangement, a legal challenge by the European Court of Justice in 2007 has meant that this is not possible. Since 2012 the HSE has developed and put in place a memorandum of understanding with the DFB. HIQA recommended the development of an improved working relationship between the NAS and DFB. The HSE and Dublin City Council jointly commissioned a review of all aspects of the ambulance service operated by the DFB in the Dublin area. This represented a very significant turning point in developing a more positive relationship between the two organisations and all efforts will continue to be maximised in developing further improvements in the working arrangements.
While work is under way to develop the clinical audit function within the NAS, it is acknowledged that more work and investment is required. Additional funding has, however, been provided for 2015 to advance clinical audit. The NAS recognises that other models of care delivery can be utilised and some of these are in place in other jurisdictions. The NAS commenced a pilot treat and discharge programme in April 2014. Currently, all patients are routinely transported to an acute hospital emergency department in accordance with bypass and other protocols. Public acceptance of alternative models will require a carefully constructed consultation and education programme.
In 2015 the NAS will develop a multi-year strategy which will be informed by the HIQA review and other reviews commissioned by the HSE and will take account of the new hospital group structures. I acknowledge the contribution the ambulance staff make every day in providing often lifesaving care to the public. They constitute a very committed, dedicated and compassionate workforce and deserve our support. The HSE is determined that the investment will continue to deliver the best possible outcomes to the public. This concludes my opening statement and my colleagues and I are happy to answer any questions the committee members may have.
I thank Ms Laverne McGuinness for her presentation and welcome the representatives from the national ambulance service, NAS. In her opening statement, Ms McGuinness referred to a programme of change, stating, “In order to develop a modern and improved ambulance service the NAS commenced a significant change programme in 2012”.
She then went on to outline the ten key strategic objectives of that programme. One of them was to undertake a national ambulance service capacity review and another was to implement the response times improvement framework. When one looks at the situation in relation to each of these - I refer, in particular, to the national capacity review - Ms McGuinness stated that these reviews are already under way. This is the end of 2014. These were signalled as objectives back in 2012. In fact, an indication was that the NAS had commenced a significant change programme back then. It is two years plus since then and it would not give me confidence. What Ms McGuinness said is that the national capacity review is to independently determine the resource requirements. At what point is that review? It seems like an inordinate delay.
Number four of the four updates in relation to these is an independent review of the NAS fleet. We already know from the information provided to this committee that 20% of the fleet is more than eight years old, with more than 500,000 km on the clock, and of a standard that could let people down in circumstances where emergencies present. How long will the independent review of the fleet and the independent review of the resource requirement, in its broader sense, take? These are urgent requirements not only in relation to ambulances and personnel but to how effectively the network of ambulance centres across the country are placed. Ms McGuinness actually indicated three of them in the course of her address. How many ambulance centres are there currently? Are they all in service on a 24-7 basis? Does Ms McGuinness have the figures for each of the HSE areas? If she does not have them to hand, maybe she could provide them. If she has them, I would welcome that, in particular in relation to the north east, where there is a belief and anecdotal evidence that there are serious delays. I have already recounted here personal experience of that, including in this year.
Lightfoot highlighted in its summary of recommendations that the national ambulance service should undertake further investigation into why emergency calls per head are so low in Ireland by comparison to England. It is something to which Ms McGuinness referred also. She said that this difference cannot be fully explained. There is a serious differential here of 40% in terms of the difference in ambulance calls per head of the population. It would suggest to me that Irish people are reluctant to call an ambulance when perhaps that would be what they should do. Is it consequential on previous experience and a lack of confidence? These are important and serious questions and it is not enough to park the differential. It would appear that calls for ambulance support and service in the neighbouring island are significantly greater.
Ms McGuinness talked about the Dublin fire brigade and made the reference to the NAS and the DFB having statutory powers for the provision of emergency ambulance services and that work was completed to develop and put in place a service level arrangement but she did not reflect was what actually said to this committee a short time ago. The notation by HIQA was that the Dublin fire brigade - I mean no disrespect to the representatives of the NAS here today - had a more acutely refined response time and performance. It drew a clear distinction between the NAS and the Dublin fire brigade. Are there lessons for the NAS to learn from the Dublin fire brigade? These are not my words. I am asking the question certainly, but the evidence that is at the backdrop to the question is presented by a body entrusted to carry out these assessments and give of its expert and professional opinion. I am not drawing a distinction between the two. In fact, I have no experience at all of the Dublin fire brigade service and only have an excellent experience of the personnel working in the NAS. However, what I do not have is an excellent experience in terms of call out time.
Ms McGuinness may be aware that I have personal experience. My family never had occasion to call an ambulance but in the past 12 months, we have had three occasions. Two of them were cardiac and the other was a collapsed state of an elderly member of my family. The first cardiac resulted in the death of the victim while the second was myself and I was more fortunate. Each of the three addresses where the events took place are half a mile from an ambulance station in our town. Two other stations are located close to us. The ambulances all came from 45 miles away. I instance it only because I was present at all three events. I say it as no criticism of the personnel who presented in all cases and to whom I take my cap off. However, it has to ring alarm bells.
I do not believe for one moment that in the three incidents, each of the other three stations were completely out of service or already in service, whatever was the case. I am really anxious to know what is the status of the station in Monaghan at Rooskey and the situation at Castleblayney and at Cavan General Hospital. Why was it that on each of those three occasions, ambulances to present in Monaghan town had to come from Virginia in the south east of the neighbouring county of Cavan?
I welcome Ms McGuinness, Mr. Dunne and Dr. O'Donnell. We all welcome the fact this HIQA report has finally been published and we have an opportunity to debate it. In many ways, it makes for sobering reading. This issue has been debated in the Dáil and has been raised by numerous Deputies on many occasions in terms of the concerns they have in regard to response times and resources for the national ambulance service and the need for us to ensure there is confidence among the general public that there will be a timely response in the event of an accident and the ambulance service being called into action.
The report highlights many deficiencies in the national ambulance service. I do not think we can pretend they are not there. If one goes through the report in detail, it quantifies them. In some areas, the review identifies challenges in relation to workforce and leadership, the model of care and fleet and fleet deployment.
I put down numerous parliamentary questions in regard to the age of the fleet and the mileage of same. I think that has been dealt with in the context of the HIQA report. Certainly, there are major concerns about the age of the fleet and the reliability of same and the servicing of it. Incidents have been reported to us and they have been published nationally in regard to some of the fleet just not being up to standard in terms of safety, both for the personnel operating it and the transferring of patients.
As I said, some incidents have been highlighted very publically. I am quite sure there have been others, as identified in the HIQA report.
Deputy Ó Caoláin referred to the national ambulance service and its relationship with the Dublin fire brigade. It defies logic that we have a situation where they do not seem to be talking to each other and that proper structures do not seem to be in place so that they can complement and assist each other in a meaningful way. That has been highlighted in the report. Are there difficulties, in the context of the national ambulance service, the HSE or whoever, in dealing with that?
A delegation from the Dublin fire brigade came before the committee. It seemed to have a fairly efficient system in terms of call out times and responses to emergencies. We do not seem to view the national ambulance service and the Dublin fire brigade as complementing each other and using their resources efficiently and effectively in a compatible way. Perhaps the witnesses could refer to that.
Ambulance services have been debated during Private Members' business in the Dáil on numerous occasions. The report states the national ambulance service serves a very rural population, with 40% of incidents arising in rural locations. In England, for example, 12% of incidents are classified as rural in a typical ambulance service. It goes on to state that this will have significant implications for the ability of the national ambulance service to perform to the same standards as the English ambulance service.
That leads to a number of questions. In terms of response times to echo and delta call outs, we are not meeting the HIQA targets. We do not need a report to identify that problem because it has been highlighted regularly and raised consistently. We are not meeting those times, and we need to ask why we are not meeting the targets in a manner we would consider appropriate.
The resources and personnel of the national ambulance service are being reduced in some areas, in particular in the west and Roscommon, where there seems to be a view among the public, which is supported by HIQA, that there is a deficiency in resources. In rural areas across the country there is major concern that the national ambulance service does not have the necessary capacity. This is no reflection on the personnel who have highlighted on numerous occasions the enormous pressures under which they work. They have to travel large distances to and from emergencies to take patients to hospitals.
Do we now have to accept, as identified in the HIQA report, that we need extra resources? There is no point in pretending otherwise. Mr. Dunne previously stated to the committee that it is one of the finest ambulance services in the world, and I have no doubt it is, in the context of the resources with which it is provided. It is a miracle it is providing its current level of service, and that is a reflection of the professionalism and competence of the people working on the front line. They have to be resourced and assisted, and need extra personnel and vehicles.
Call-out targets are assessed on the basis of a patient-carrying vehicle being the first responder. Are we beginning to massage the figures with regard to call-outs? Very often the first responder is considered the first response. However, as the committee previously discussed, the targets should be based on a vehicle that can transport a patient, rather than on first responders. I ask for some extra clarity on that.
Another key area identified as tying up scarce resources are lines of ambulances outside emergency departments in hospitals throughout the country. Recently, Beaumont Hospital had some 40 patients on trolleys, and had to cancel elective surgeries and send out a message that it did not want people to attend the emergency department. The national ambulance service took patients elsewhere. One of the bizarre things happening is that what are already scarce resources, namely, highly trained personnel, are waiting outside emergency departments. In this day and age there should be some mechanisms to ensure patients can transfer more seamlessly into emergency departments and beyond.
I do not expect the national ambulance service to resolve this issue, but the HSE has an obligation to address what is a glaringly obvious problem, namely the transfer of a patient from an emergency situation to an emergency department, through the acute hospital setting and, eventually, out the other side. The idea that we have had numerous instances of ambulances being tied up for long periods of time is very concerning.
How many minutes do I have?
The HIQA report has a lot to say about the broader issue of governance. What will the response to that be, in terms of the national ambulance service? Will it oversee the process by which the issues highlighted in the HIQA report are addressed? Will the HSE do it or will HIQA have some role in the continuous monitoring of the issue raised in the reports? The national ambulance service has enough to do in terms of trying to deliver a service. Overseeing the recommendations and observations in the HIQA report would put additional pressure on it.
Some ambulance services and emergency departments in hospitals have closed in rural areas. That has a knock-on effect on the pressures being placed on the national ambulance service in delivering emergency care. Do we have joined-up thinking in terms of the primary care setting, which is critically important and means that patients do not have to travel to and present themselves at emergency departments? Do we have a strategic plan for the closure of emergency departments in some rural hospitals, in terms of putting resources in place rather than waiting for the ambulance service to be bolstered? In doing that, we need to make sure we have a proper, fit-for-purpose ambulance service to pick up the pieces from such closures.
I refer, for example, to Roscommon County Hospital where the emergency department was closed. There has been a similar downgrading of services in Mallow, County Cork. The personnel in the national ambulance service have to travel significant distances to transfer patients on a regular basis under an emergency setting, and often under light.
The HIQA report clearly identifies that as an issue, particular in rural areas.
The Chairman will be lenient. I thank Ms Laverne for the presentation. I compliment the ambulance service for the service it provides throughout the country.
Over the past two weeks I have made the time and effort to meet members of the ambulance service who are working on the front line. A few of the issues raised concern me. One is the number of people employed as supervisors. There are days when a number of supervisors are on call and others when no supervisor is on call in some centres.
A second issue is that in every area there are advanced paramedics who have gone through the training process. Some days quite a number of them are on call, whereas on other days no advanced paramedic is on call.
A third issue relates to Cork, Kerry and Limerick. I understand 15 people are working in call centres who have not been redeployed.
Could I get clarification on the total number working in call centres throughout the country who have not yet been redeployed and when is it intended to deal with this matter?
The next issue I wish to raise is in regard to skills and has been found in that respect in the HIQA report. I would like to get clarification from the human resources department with regard to people working in the area of human resources. It would be good to clarify all the training and skills people working in that area have because a skill in this area is a particular skill in itself. This was one of the issues identified in the HIQA report. We have not got full clarification as to where this skills deficiency is arising. It is an issue that has been raised with me.
The next issue I wish to raise is in regard to meeting with senior management. The report indicates there was a meeting on 5 December 2014. Could we get clarification on the senior management involved? Are we talking about grades 7 and 8 or grade 6? One of the complaints I received is that there is a lack of and serious deficiency in communication at national level down to people working at grade 6. One of the matters highlighted to me is that all the issues identified in the HIQA report were ones that had been raised at meetings within the ambulance service during the past two or three years. I am open to correction on this but I understand there is a move whereby the centre will be located in Tallaght. Will the Dublin fire brigade ambulance service also operate from that centre or will it operate from a separate centre? That may have been clarified already but I would like clarification on it.
A major issue that has been raised with me is how staff rotas are devised and who is on call. As one person put it to me, it is like running a Garda station where all the gardaí are on duty but no sergeant, superintendent or inspector is on call. That worries me. This issue has been raised by people who are working in the ambulance service. It is a concern that has been raised by people I met who have first-hand knowledge of it and not by those with second-hand or third-hand knowledge of it.
I wish to raise the matter of the training programme. Major cutbacks have occurred in all the health services during the past number of years. One of the issues raised with me related to training. It is one of the areas that seems to have suffered. Is it proposed to ring-fence a certain budget for training and upskilling people who require such back-up support? Has that been examined for 2015? What numbers are involved? I understand there are 1,600 people in the ambulance service and of them 300 have been upskilled to the scale of an advanced paramedic but that up to 60% of those in the service should be upskilled up to the scale. What programme is in place for doing that and what is the timescale for trying to achieve that target?
I thank the Senator for those questions and I allowed him five minutes to make his contribution. I will get a response from Ms McGuinness. We will prolong the meeting given that a vote was called in the Dáil. Following Ms McGuinness's response, I will call Deputies Regina Doherty, Fitzpatrick, Conway and Naughton.
Ms Laverne McGuinness:
In response to Deputy Ó Caoláin's question regarding the change programme, the change programme we commenced in 2012 related to the having a single national control centre and this is in line with international best practice. That control centre will be based in Tallaght. It is ready and will be opened in 2015 and there will be a resilience site in Ballyshannon. When the centre is open it would be useful if the members of the committee were to visit it. It is a state-of-the-art facility and it will change the model of operation. When the computer system is in place, it will be possible to monitor where every ambulance is in the country and to deploy from the centre the most appropriate and nearest ambulance to where it is required. The centre has all the equipment that a modern service would require. That invitation is extended to the committee to visit the centre when it is opened.
The other ten strategic priorities were identified during the course of 2013 and the Deputy mentioned one in particular relating to the capacity review. Very few companies have the skills set to carry out a capacity review. One had not been carried out in the ambulance service previously. Given our rural geographics, the purpose of the review was to examine where best our ambulance stations should be placed. The stations has been in place for a significant number of years and given the changes in demographics and movement in members of the population, the review was to assess if any changes needed to be made.
We have put in place a number of intermediate care vehicles. In 2012 we had 11 intermediate care vehicles, which are the vehicles used in hospital transfers and now we have 56. We needed to identify how many of those vehicles were needed. We did not have the expertise in our service to address that. We also needed to identify how many additional ambulances would be needed. The response time targets had been set down by HIQA. A preplanned capacity review had not been carried out to determine the number of ambulances that would be needed to meet those targets and the number of paramedics and advanced paramedics that would be needed to provide that level of response. That was why we carried out the capacity review.
That review will be completed by the end of December this year and we will have it before Christmas. I have provided executive summary of it to the committee. The Lightfoot summary is the executive summary of the capacity review. It specifically deals with the 7 minutes and 59 seconds first-response time and signals that the 75% response rate target is not achievable and that to achieve a 64% response time target would require very significant investment in terms of 290 wholetime equivalents, extra ambulances, extra intermediate care vehicles. The executive summary provided by Lightfoot divides the country and indicates that some countries are more rural based than others and that there are minor urban areas. That will result in a variation in response times, even with the investment of most significant of resources. When the capacity review is finalised we expect we will able to identify the blackspots. We have already identified there are significant blackspots in the west, in Mulranny, Tuam and Loughglynn. We are staffing those and they will be opened in 2015 and on a 24 hour, seven days a week basis to address the needs and concerns there but there may be other areas there that also need to be addressed. That was the purpose of the capacity review. That will be published and will be available to the committee.
A number of concerns were raised about the fleet and the Deputy correctly stated it is an ageing fleet. We got extra money in 2014 and put in place 36 new ambulances. Obviously, we would like to have much more money to replace them every year if that was possible but it is not possible within the financial constraints prevailing. We also put in place two critical care vehicles. It is great that in 2015 we have money again for 47 new ambulances. These will be totally new ambulances. This will be mean every ambulance will have be from 2007 or be younger or older whichever way one wants to cause that. Every ambulance will be capable of being remounted and having its engine replaced, which was not possible with the older service. All our ambulances are maintained. There is a full maintenance register and protocol in place and it is very strictly monitored. No ambulance is in operation with over 500,000 miles on the clock. When engines are replaced, it is not possible to turn back the clock or the mileage shown on the odometer. One would not know if there were 500,000, 600,000 miles or only 120,000 miles on the engine. We have introduced a change whereby a sticker is put inside - which is a simple solution - indicating that the engine has been replaced at whatever number of kilometres were on the engine.
The independent review by the firm we commissioned was an extra level of surety to assess what else we need to do with regard to the maintenance of the fleet and to have an independent assessment in terms of our fleet requirement. That will be available also at the end of December. These reviews take time because a great deal of data have to be gone through to analyse what is required.
We have 100 stations. Mr. Dunne will give details in regard to Dublin North East in particular, which is what the Deputy requested.
Ms Laverne McGuinness:
Apologies, the north east. The response to emergency calls is slower in Ireland compared to the UK. The capacity review shows that the rate of call out of our ambulance service is 40% that of the UK.
We are looking through that and Dr. Cathal O'Donnell will speak about it in more detail. It signifies that we have wide access to our GP services, including out-of-hours access. Our GP services are accessible on a 24-hour basis. It is very unlikely that a person would go to a GP and not be seen. The situation in the UK is not the same. At the moment we transport 100% of our patients to hospital and HIQA has said that we need to look at alternative models of care. However, given that only 40% of people are actually ringing the ambulance service in the first instance, we have less of an opportunity to divert patients elsewhere. We are looking at "treat and discharge" and "hear and treat" as part of alternative models of care. We need to do that in collaboration with GPs. Dr. O'Donnell will elaborate on that further.
There is an ongoing working relationship between the Dublin fire brigade and the national ambulance service. In the briefing document I outlined some of the legal constraints regarding service level arrangements which the European Court of Justice ruled on. We could not enter into a formal service level arrangement but we do have a memorandum of understanding in place under which we transfer funding. It is not the optimum working arrangement that two service providers are providing different models of care across Dublin city. The Dublin fire brigade does not use a separate call taker and dispatcher, which is the model we have moved towards.
We are working towards enhancing our working relationship. We have met Dublin fire brigade again and there are ongoing meetings between the Chief Fire Officer and the director of the national ambulance service and at the highest levels of the organisation, the Director General and the City Manager have agreed a joint implementation plan in response to HIQA. However, there are areas that need to be streamlined in the interests of patients and that is why we commissioned the capacity review for Dublin city and county. That review will be publicly available in February 2015. It took a little longer than anticipated because there was a very wide consultation process involving unions, service users and various stakeholders, including HIQA.
Regarding Rooskey and Monaghan, my colleague Mr. Martin Dunne will address the issues raised.
Sorry to interrupt but I wish to inform members that we will finish this segment of the meeting at 7 p.m. I will hand over to members at that point for further questions and then we will end the meeting at 7.30 p.m. or 7.40 p.m. at the latest.
Dr. Cathal O'Donnell:
I thank Deputy Ó Caoláin for his question which relates to an interesting finding from the capacity review. We had expected that there would be a difference but we were slightly surprised at its magnitude. In the UK, and in England in particular, in terms of emergency and unscheduled care over the last ten years, there were issues with out-of-hours access to GPs and they put in place a number of different initiatives to address that problem, including urgent care centres, walk-in centres, minor injury units and NHS Direct, which was a telephone advice service which did not work out very well. That service has now been reinvented as the 111 service. All of that meant confusion for the average member of the public who had a medical problem. People did not know what was the correct pathway for them so they reverted to what they were comfortable with which was either ringing 999 or attending a hospital accident and emergency department. That goes a long way towards explaining the difference. Members of the public in the UK tend to dial 999 more for issues now than they would have done in the past because the correct pathway for them was unclear.
The second issue is that in rural Ireland in particular, people tend to ring their GP even when they should not do so but should call an ambulance, perhaps because they have a good relationship with him or her. GPs are very good at recognising that and will often divert such patients and the GP co-ops would often transfer such calls to us. I think that explains the difference in the context of the 40% finding, which is in stark contrast to the situation in the UK.
Mr. Martin Dunne:
In the north east area comprising Louth, Meath, Cavan and Monaghan, there are ten ambulance stations located in Navan, Dunshaughlin, Ardee, Drogheda, Dundalk, Castleblayney, Monaghan town, Virginia, Cavan town and Trim. With the exception of Trim in County Meath, all of the stations are 24 hour stations, staffed around the clock. The station at Trim works on a 12-hour, five-day week basis. It is what we call an emergency dispatch point and calls are responded to by a rapid response vehicle crewed by an advance paramedic in the area to give immediate help to patients in that area.
One must take into account that under the control room centralisation programme which is ongoing, we have developed call taker and dispatcher roles. We used to have a singular point of contact, known as an emergency medical controller who did both jobs. We have split that job into two specific roles and both are licensed under the Pre-Hospital Emergency Care Council, PHECC, to carry out their role and function within the control centre. When one dials 999 or 112 now, one speaks to a dedicated call taker in any of the national control centres who is trained, licensed and registered under the PHECC. The call is then moved automatically to a dispatcher who is also licensed and trained under the PHECC and he or she deals solely with dispatching vehicles. The operating procedure is that in any case the closest emergency ambulance is dispatched. While these two sections of the control room work in isolation somewhat, they also work together because they have full view of everything that is going on in the area at any given time. They are also supported now by call taker supervisors, dispatch supervisors and the control manager on a 24/7 basis. If there are any issues ongoing, they are immediately escalated to that level within the control centre.
Ms Laverne McGuinness:
Deputy Kelleher asked a number of questions too. I have dealt with his questions on the fleet and the relationship with the Dublin fire brigade and will now deal with his questions on response times. I referred to the capacity review which will address some of the concerns around response times. We are improving our response times for both ECHO and DELTA calls. The times given relate to the patient-carrying vehicle getting to the scene. In other words, the 17 minutes, 59 seconds response time relates to ambulances arriving on scene. That has improved from 63.4% to 69% with regard to DELTA calls and from 65.7% to 78.5% for ECHO calls but we still have some way to go. Some additional improvements can be made in call activation within our resources but additional resources will be required to bring about further improvements.
The issue of delays at emergency departments is very significant and one on which we are focusing. It is not something that can be dealt with solely by the ambulance service itself. We are working with the acute hospital services in order to improve turnaround times at emergency departments. In January 2014 we introduced what we call an "escalation framework" in the emergency departments whereby if ambulances are blocked up for a period of time, that escalates right up through to the highest level in the organisations and telephone calls are made and we say, "This is unacceptable; we are nearing a point where ambulances will have to be locked". That has significantly improved the situation for us although it is still not where we would like it to be. At this point, 94% of ambulances are released in less than an hour and 67% are released within 30 minutes or less. We have a pilot programme in place in Cork University Hospital whereby the minute an ambulance arrives at the back of the emergency department staff in the department see it on their screens and know they must be on their toes and carry out the clinical transfer as quickly as possible. There is more work to be done in this area but it is being done collaboratively between the hospitals and the ambulance service. This must be seen in the context of the fact that our emergency departments have been particularly busy this year. There were an extra 6,000 admissions in the year to October. They are busy indoors in the hospitals and then the ambulance service has also experienced an increase in calls of 1,000 per month. There is congestion at both ends in that regard.
Deputy Kelleher asked who will be monitoring or overseeing the implementation plan. The plan will be developed jointly between Dublin fire brigade and the national ambulance service. It will take account of the various reviews which are coming on stream, namely the capacity review, management review and the review of the Dublin fire brigade service.
It will be overseen nationally by the HSE, Health Service Executive, while the Department of Health will have a significant role in it, as well as HIQA, the Health Information and Quality Authority, requiring regular updates.
Regarding the closure of accident and emergency departments and the ambulance service, significant ambulance resources were put into Roscommon to ensure a safety net. Bypass protocols are in place but that means an ambulance would have to travel a further distance to bring the patient to the appropriate hospital.
Mr. Martin Dunne:
Senator Colm Burke raised questions about the number of supervisors on call, etc. Each ambulance station would have a supervisor on the ground. Some have two to three while others one. They used to be known as general duty supervisors but are now part of an operational crew. Part of their duties are to respond to calls, as well as undertaking supervisory duties. Sitting over that are resource managers who look after a cluster of stations and, depending on rostering, are on duty from eight o’clock to four, nine o’clock to five or seven o’clock to seven. On top of that, there are performance managers who work across the country. That is the way the escalation process works up through from the stations. There may be some days when there is no supervisor on board or on duty but this would be down to annual leave or sick leave. It is the practice to have supervisors rostered for every day.
Mr. Martin Dunne:
I can confirm it later.
Advanced paramedics are highly skilled members of the ambulance staff. It takes two years of training and we are committed to a continuous training programme in this area, no matter the economic environment. Up to 300 advanced paramedics are available and are rostered on duty with a paramedic to ensure a skills-mix on board an ambulance. They are also rostered to be on rapid response vehicles to deliver emergency hospital care while waiting for a transporting vehicle. In 2015, we are scheduled to train a further 40 advanced paramedics which will bring us to a complement of 350. We are working to having 40% of the operational staff complement, not 60%, being advanced paramedics. It is a two-year window so there is a continuous roll-over.
There are three skills models available to the national ambulance service, NAS. First, the emergency medical technicians who are used predominantly-----
Mr. Martin Dunne:
The emergency medical technician staff operate the intermediate care vehicles. Their role is to do intermediate transfers between hospital facilities, nursing homes, etc, which allows the emergency ambulances to perform their core function, namely responding to emergency calls. There are paramedics on board, approximately 1,100, along with advanced paramedics. There are licensed call takers and dispatchers in the control centres across the country.
The control centre in Townsend Street, Dublin, will move to a new state-of-the-art command and control centre in Tallaght by the end of January 2015. Tallaght will then be the main hub for five eighths of the country while Ballyshannon will deal with the remaining three eighths. The reason for the selection of this model is based on international best practice. We found it is better to have a live robust model for resilience all the time. For example, the UK has one control centre for an area. The problem we found with that is that in the event of a breakdown in services, it can take several minutes to get a resilience centre up. Accordingly, we have two centres which will be fully staffed.
The state-of-the-art building has been specifically designed for the job it must do. Much time went in to ensure it does what it is supposed to do. It can operate for four days on its own electricity generation. The building has a command and control centre, the national ambulance training college and NAS administration. It is classed as a level three data centre with the amount of data connectivity it has and the resilience built around it in the case of any breakdown. At any stage, as Ms Laverne McGuinness said, committee members are welcome to see the building.
There is an educational and competency assurance plan for ambulance staff which has been in place for the past three years. It will be updated again in 2015. This will give operational staff members, the emergency medical technicians, paramedics, advanced paramedics and staff supervisors five days of training across the year at a minimum which includes ongoing cardiac revalidation, drug administration, etc., all required to ensure up-to-date competencies. Thirty staff are attending a joint HIQA and Institute of Healthcare Improvement-run course since the start of 2014. Up to 114 staff have completed the legal framework course across the HSE. Fourteen staff and managers are on personal development courses up to third level degree standard including masters degree level. We have put in support mechanisms for managers. A technical company of mechanical engineers is doing an independent review of the fleet and gives us support in the delivery of services as the vehicles are built to and maintained to a European normalisation standard.
The NAS is an associate member of the UK Association of Ambulance Chief Executives, AACE, which covers all ambulance services there. We share information on a regular basis and have technical support from it in operations for control centres.
I apologise for the suspension. We will add ten minutes to the end of this session but I am conscious that another group is to come in. Mr. Martin Dunne was in possession so I invite him to conclude, after which we will hear from the remaining members of the committee.
Mr. Martin Dunne:
The last point Senator Burke made was on a communication flaw regarding the meeting on 5 December. That meeting was a leadership team meeting, a senior management team meeting. I have such meetings with senior managers of the national ambulance service. Afterwards, senior managers go back to their areas of operation and cascade the information down, in whatever way they deem fit, in respect of the reports.
Ms Laverne McGuinness:
On response times, the first responder can be an ambulance. Therefore, whatever is despatched first can be an ambulance so it can get to its destination within 17 minutes and 59 seconds. However, the ones that we report on with regard to this period are all ambulances; they are all patient-carrying vehicles. An ambulance can be either a first responder or one of the responses dispatched as part of meeting the target of 17 minutes and 59 seconds.
On the question of communication in regard to grade 6 staff, their complaint in the southern region is that there is no one in charge. The person in charge, based in Dublin, is not communicating with them. This is why I am asking why there cannot be a meeting between all the grade 6 personnel within the ambulance service? Rather than hearing a report from HIQA, it could be heard directly from them.
I thank all the speakers for their comments and the information given thus far. Some of the questions I was to ask have already been answered so I will hone in on two points, the first of which pertains to Mr. Dunne in particular. One of the most worrying points made to us a couple of weeks ago arising from the HIQA report was on the fact that there were people in senior positions appointed without due process during recruitment. Senior personnel were appointed who did not have the qualifications or experience required, and there were senior personnel who claimed to HIQA that they did not have the skills necessary to carry out their duties in their current roles. Mr. Dunne stated he had a meeting with his senior managers and they all said they were happy out and that there is no need for concern. Is that the box ticked with regard to the concern raised with HIQA? Alternatively, as raised by Senator Burke, are we to delve down and have individual conversations? Are we to consider specifically the people who were appointed but who did not go through the proper recruitment process and those whom HIQA can state do not have the required skill set or qualifications for their positions? Could Mr. Dunne expand on that?
I am curious about why it is proposed to carry out clinical audits only next year although there has been a clinical director in the Ambulance Service apparently for two years. I do not wish to be smart in making this point as I totally agree that focusing on the numbers is probably not the right way to go. They are very stark and, as Ms McGuinness stated, we cannot meet the demand based on the resources we have. However, we need to focus on the outcomes. If we have a clinical director, why are we not already focusing on clinical outcomes? With respect, given that we are only starting to focus on outcomes, what has the director been doing over the months in which he or she has been working in ambulance services? Perhaps there is considerable backroom work to be done. Perhaps the delegates will explain this to us.
With regard to the turnaround times in hospitals, it is nice to see there is an improvement. Perhaps the delegation will tease this out. The improvement about which I have been told is an interim measure involving something called an ICO unit that has been introduced in hospitals. Perhaps the delegation will explain exactly what an ICO is. For how long do patients actually stay in an ICO holding? Are patients still considered to be in the care of the Ambulance Service or are they passed over to hospitals such that they are accounted for in counts of the numbers on trolleys? What kinds of patients are not put into an ICO unit? What statistics are there on the waiting periods, types of patients and turnover in the ICOs?
I thank the delegates for attending. A sum of €7.5 million has been allocated for 2015 for the purchase of 47 new ambulances. With 262 ambulances in the fleet, my question concerns the locations of the 47 new ambulances. What happens to the ambulances that they replace? In 2014, €11.5 million was allocated as part of the fleet maintenance programme for the purchase of 36 new emergency ambulances, two critical care ambulances, 180 new defibrillators and 20 medical resuscitation devices. To what locations where they are allocated? What happened to the 36 replaced ambulances?
I am very concerned about ambulance vehicles that are over eight years old and those that have clocked over 500,000 km. In recent months in my town, Dundalk, there have been a few breakdowns of ambulances on the way to Our Lady of Lourdes Hospital. Of the two 262 emergency ambulances, 150 are deployed daily and 112 are for backup. Where are all the ambulances? In the north east, there are ten ambulance centres. How many ambulances are actually in the north east?
In 2013–14, €26.2 million was invested in the single emergency control centre based in Tallaght, with backup in Ballyshannon, meaning that 11 sites were to be merged into two. Seven control sites have already joined up, leaving just four. The work on the centre in Tallaght is well under way. When will 11 become one?
There has been an increase of 10% in the number of emergency calls. To date in 2014, 217,114 calls have already been made. How can we reassure the public that one single emergency control centre will be able to cover all 26 counties in the State?
I thank the delegates for their reports today. Most of my questions have been asked. I just want to focus on one or two issues. We constantly hear on the ground about the lack of trained personnel and resources. We are sometimes told ambulances are actually parked up because they do not have personnel to operate them. Two weeks ago, I heard two reports about ambulances that had been parked up. In the first case, an ambulance had to travel a greater distance than usual, taking over an hour to get to its destination. In the second case, and ambulance had to go from Kilkenny to Youghal, which is quite a long distance. It took over an hour and a half to get its destination. When it got there, drugs had to be administered but there were no personnel on board to do so. Consequently, another ambulance had to come from Dungarvan. There are many question marks associated with the availability of trained personnel and resources. These are just two cases that happen to have been brought to my attention two weeks ago. Both occurred in the same week.
The other point I wanted to focus on was our meeting here on 2 December. That report categorically stated that some senior and other staff did not have the required skills or technical knowledge to do the job. That was on 2 December and Ms McGuinness states here that she met with her senior team on 5 December, when the team members took the opportunity to confirm that they had the requisite skills to carry out their roles effectively. How many people were actually at that meeting and how many people said that? Three days earlier, the opposite is quite clearly stated. Did Ms McGuinness meet five or ten people? Are there still people out there who are not trained? How is the HSE going to overcome that?
On the capacity review, it states here that the level of investment required is in the order of an additional 290 full-time staff as well as additional vehicles, emergency ambulances, intermediate care vehicles and rapid response vehicles. Is that actually likely to happen? Does the HSE have the funding for this?
Finally, will the national ambulance service come in under budget this year?
These questions may already have been asked, but to go back over what Deputy McLellan raised, we heard quite clearly from HIQA and from the HSE's own members that they themselves felt they did not have the requisite skills. That is what they told the inspectors. There is obviously a variance between what HIQA is telling us and what Ms McGuinness has told us today. She said they all have job descriptions and went through an interview process. This is the complete opposite of what we heard from HIQA. I would like to know how we have come to that.
The HIQA report also discussed how the national ambulance service was in breach of its own policy regarding replacement of vehicles in some instances. Was the issue years versus miles?
It is stated that the HSE is in breach of its own policy. Why have a policy if it is going to be breached? The other question I wanted to ask concerns standards. Are there best practice standards? Is there a national policy on pre-hospital care? Who put these standards in place and who oversees them? The witnesses might tell us more about the pre-hospital care council - who they are and what their function is. Whom do they oversee and do they have a role in ensuring people have the requisite qualifications? We spoke about call-takers and dispatchers being licensed, yet staff members said they felt they did not have those skills in interview with HIQA. Other than HIQA, who is the watchdog for the profession? Who makes sure that standards are being met?
I will be as concise as I can. I think the national ambulance service is doing a phenomenal job considering it has one hand tied behind its back when it comes to resources. There are three times as many ambulances in Northern Ireland as in the Republic, and we are trying to compete on a level playing field, which is impossible. In her initial contribution, Ms McGuinness said response times are improving and this is correct, but the latest available figures for the west show that 45% of life-threatening incidents are responded to within a 19-minute period. Those figures are 12 months old. For the last six months I have been looking for current figures and the only thing I have got in that time is a link to the HSE website. It would be nice if we could have the current figures.
We have three ambulance black spots in the west of Ireland. They were identified by the Western Health Board back in 2001 and at long last today we have a commitment to operate on a 24/7 basis. In the HSE service plan there is €700,000 set aside to operate these three stations. The Minister of State, Deputy Lynch, told us in the Dáil that it would take €1.8 million to provide a 24/7 operation in the three stations. Is the money being made available now to provide that without the removal of resources from the surrounding stations? Why has it taken so long to resource this? We have had the Western Health Board report and an independent review in 2005 of the ambulance services in the west and nothing was done about it. There was a whistleblower's report given to the HSE last year and to the Minister this year listing 216 incidents and near misses in a six-month period in County Roscommon, and yet we have to wait until HIQA publishes a report before anything can happen.
My final question concerns the capacity review. It seems the HSE is throwing in the towel as far as rural Ireland is concerned. The witnesses are comparing the situation here with that in England, which in my view is a whitewash. Looking at Scotland, 74.7% of responses there were within the eight-minute target in 2012-13 and we are saying we cannot achieve that here. In Northern Ireland their target for responses within eight minutes is 72.5% and not less than 65% in any area. Ms McGuinness is saying that at best, with the resources put in, we can only do it 64% of the time. It might be worthwhile looking to see what they are doing in Northern Ireland and in Scotland rather than England.
These delays are lives lost and that is the reality of it. It is also important to point out that the HSE is still not publishing its figures for first responses within eight minutes. We do not even know what is happening on the ground at the moment as we do not have those figures. When are we actually going to start seeing some real response times regarding first responders landing at the scene of the incident and carrying out the type of work we know our ambulance service can do?
What is the attitude of the ambulance service to freedom of information requests? Does it have designated officers? Is it a fact that a recent freedom of information request from me had to go to the appeals officer in the HSE to address the total lack of information I was getting? I very much welcome the fantastic work the ambulance services is doing and the lives it is undoubtedly saving. When there are occasional concerns, I think we are entitled to get answers to those questions and not to be obfuscated or information to be stopped. My request concerned four incidents in County Louth. All I got was the date and a line about a service provider having an issue with another service provider. There is a lack of transparency on the rare occasions when we need to have clarity. Because people do unfortunately pass away - and it is nobody's fault and the ambulance service is certainly doing its extreme best - I still have to deal with complaints and I do not have answers as to what exactly happened. I find the ambulance service is refusing to give me anything and is going out of its way to put a black line through information. If we want transparency and accountability we should have it here and I want it from the ambulance service.
Ms Laverne McGuinness:
Regarding Deputy Doherty's question on positions and senior management - I will get Mr. Dunne to respond in a couple of minutes - what I set out in the opening statement was that all senior management positions have gone through a competitive process. There is a job description in respect of each of them. Over the last 12 to 18 months there were six senior positions which all went through a competitive process with a very specific job description. There were two staff members at a senior level working within the ambulance service who were reassigned to alternative roles which they had the skill sets to carry out. They were reassigned at the same grade and HIQA was quite complimentary of that in the report.
I have asked HIQA to identify the particular posts in order that we can address this issue immediately.
Ms Laverne McGuinness:
That is what I said. I stated it had made specific reference in this regard. It stated "some staff reported that while they had accepted a new position within the Service, they did not have the requisite technical knowledge for the particular post". Consequently, we specifically asked in respect of senior management because approximately six posts were replaced in the past 12 to 18 months, all of which went through a competitive process. There was a specific job description for these posts and Mr. Martin Dunne again met his senior team on an individual basis to ascertain whether any of the team members had particular skill deficits that they thought needed to be addressed. I also asked HIQA whether it could identify this but because of confidentiality issues, it could not do so. Notwithstanding this, we are certainly not leaving it lie at that. As the joint committee is aware, a management capacity review has been commissioned to examine what is the appropriate organisational structure for the management of ambulance services and all job descriptions will also be reviewed in that light. We are certainly not taking this issue lightly and are giving it significant consideration.
As for the issue of clinical audit, while the medical director of the national ambulance service, Dr. Cathal O'Donnell, will speak about it, we are measuring clinical outcomes. We started doing so in the third quarter and it takes some time to put it in place. One key outcome we are measuring is return of spontaneous circulation. We are reporting and achieving a rate of 39% against a best international rate of 40%. There is much more work to be done in the clinical area and clinical audit, but Dr. O'Donnell may wish to speak on the subject.
Dr. Cathal O'Donnell:
I thank Deputy Regina Doherty for bringing up the subject because it is close to my heart. To put it in perspective, we operate a paper-based clinical record. When paramedics interact with a patient, they record the details of that interaction on a piece of paper called a patient care report, PCR. It is a standard form with two copies, one of which goes with the patient in the hospital and becomes part of the ongoing clinical record, while the carbon copy stays with the ambulance service. The form has 640 individual data fields on it and on an average call, 129 are filled in. We handle 700 999 calls every 24 hours spread over 100 locations and if one multiplies it out, we are generating approximately 33 million individual pieces of data each year. Consequently, from a paper-based system perspective, it is not possible to undertake any form of meaningful clinical audit in terms of the human and financial resources it would be necessary to put in place to so do.
Dr. Cathal O'Donnell:
Will the Deputy, please, let me finish? Moreover, were we to do this using a paper-based system, the lag time in having meaningful data would be significant. The solution is an electronic patient care report, which is what all modern ambulance services use and is what we aspire to use. It comprises using a tablet - perhaps similar to the one the Deputy has in front of her - with drop-down menus and data collected. This means that one can pull out the data electronically instantaneously and that patient information can arrive at the hospital even before the patient. For the past two or three years I have been pushing very hard to get this through the Estimates process, but, unfortunately, it has not yet happened. This year, for the first time, we received some revenue money towards it and we are exploring how we might implement it. Because I recognised a year ago that this would not happen any time soon, starting in the new year we will put in place an interim solution, whereby we will scan the paper-based records and use what is called optical character recognition technology to pull information from them. It is not as good as an electronic patient care report, but-----
Dr. Cathal O'Donnell:
Yes. Ms Laverne McGuinness has mentioned the single clinical outcome indicator that we have implemented in recent months; it is called return of spontaneous circulation. If someone has a cardiac arrest in which his or her heart stops and if we, as a service, that is, the paramedics, can restart his or her heart beating by the time we get to the emergency department, we are measuring this against the total number of cardiac arrests attended to and will report it. Separately last year, in conjunction with the Pre-Hospital Emergency Care Council, we commissioned an academic piece of work to identify a set of clinical outcome indicators that would be suitable for pre-hospital care in this country. That process is now complete and we have a menu or suite of more than 100 clinical outcome indicators that have been identified through an academic process as being suitable for use by us or any other ambulance service in Ireland. When we receive a methodology - either the scanning solution or, I hope in the longer term, the electronic patient care report, ECPR - we will have both the technology and meaningful clinical outcome indicators.
To conclude by referring to response times, ultimately, a response time is a very crude measure of the performance of an ambulance service. All it measures is how fast one will get there. I am a doctor and much more interested in how the patient is when we get there and doing what we must do. I suggest clinical outcome indicators are a much better measure.
Ms Laverne McGuinness:
As for Deputy Regina Doherty's question on emergency department turnaround times, we are improving, but there still is a road to go. The figures I have provided are for the vehicles to be ready again to take another call, that is, there is no holding of patients. The figures I provided in respect of 94% being available within one hour mean that the ambulances are then available to pick up another patient or take another call. They are actually cleared at that point in time in that the trolleys and everything else are back within the ambulances within that time and not in any holding or clearing bay, as referenced by the Deputy.
In response to Deputy Peter Fitzpatrick on the control centres and the movement towards them, the Tallaght control centre will be opened on 31 January 2015. By February Tullamore and Wexford will be the only two centres that will not be on the single system because it is one control centre over two sites. The centres in Ballyshannon and Tallaght will be in place and only the Wexford and Tullamore centres will remain to make the transition to Tallaght, a transition which will be completed in 2015.
As stated, 47 new ambulances will come into service in 2015 and replace fully the older vehicles which will then be decommissioned. As for the aforementioned 36 new ambulances, there is a decommissioning programme and while Mr. Dunne will go through the technicalities, there is chassis and cab replacement, as well as engine replacement. There is a system for technical replacement involving recycling in this regard.
Deputy Sandra McLellan raised specific points with regard to Kilkenny and Youghal to which Mr. Dunne might respond, as well as to the question asked by Deputy Peter Fitzpatrick on what happens to the vehicles.
Mr. Martin Dunne:
As Ms Laverne McGuinness noted, this year we will be getting 47 new vehicles. They will replace the older vehicles in their entirety which will be removed from service and decommissioned. We receive a certificate of decommission for each vehicle we decommission. That is the way we operate and we will be decommissioning 47 vehicles, which will leave us with the oldest vehicles available probably being from 2007 upwards, which will keep us compliant with our own policies and procedures.
On the command and control centre, as Ms McGuinness has indicated, the centres on two sites will be running the service throughout the country and when we move across, one site will be live in Ballyshannon and the other in Tallaght.
In addition, in the past year we have replaced 35 chassis and cab units. As I have stated, the vehicles are constructed under a CEN regulation, a European regulation for the construction of vehicles; they must be built to a certain specification. All of our vehicles are built to that specification and certified as such. They are built in such a way that they have a roll-on, roll-off structure, in that the pod on the back is designed and developed in such a way that it will last approximately 15 years. Last year we replaced the chassis and cab in some of them by taking out completely the old chassis and cab and rolling in a new chassis and cab underneath. The units are then matched in order that any remedial work that must be done on the pod or the patient compartment is done automatically and developed at that stage. For example, it may need to be resprayed or the interior may require refurbishment. They are bolted up and are again recertified as being fit for purpose. Next year the handiest way to put it is that it will be a case of one in and one out, in that the 47 new vehicles will replace those older vehicles not fit for demount and remount. We will be leaving them to one side and dispose of them appropriately.
In respect of the ten centres in the north east, how many ambulances does the service have in the region? Second, where did the 36 new emergency ambulances procured in 2014 actually go? Similarly, where will the 47 new ambulances in 2015 go?
Mr. Martin Dunne:
To be honest, I cannot give the Deputy an answer off the top of my head as to how many vehicles there are in the north east. I can state all new vehicles are prioritised, whereby the oldest ones are replaced across the country on a fair and equitable basis.
That will also be the case in respect of the 47 vehicles that will enter the fleet. All of the older vehicles nationwide will be decommissioned, with the result that the oldest vehicles will date from 2007. Replacement will proceed in an equitable manner across the country based on the information available from the fleet management systems and in conjunction with performance managers on the ground.
Mr. Martin Dunne:
As I stated, I cannot comment directly on specific incidents because I do not have the relevant information. The standard operating procedure is to dispatch the closest emergency vehicle. This would have occurred in the case highlighted by the Deputy. In some cases, two vehicles will be dispatched, depending on the skills set identified when triage is undertaken in the command and control centre. All of the paramedics are registered and trained to clinical practice guidelines, CPGs, to allow them to administer certain levels of medication. The advanced paramedics are licensed to administer a higher level of medication. If a call indicates a patient requires an advanced level of care, an advanced paramedic will also be dispatched, resulting in two vehicles being dispatched to a scene in some cases.
In the case to which I referred the ambulance crew who arrived at the scene realised another vehicle needed to be dispatched. They had to wait for the second vehicle to arrive because they were not qualified to administer the medication required. I understand it took in excess of 90 minutes for the second vehicle to arrive from Kilkenny, which is a long distance from Youghal.
Mr. Martin Dunne:
As I indicated, ambulance service staff operate at three levels, namely, emergency medical technician, paramedic and advanced paramedic. They operate to a certain level under the Pre-Hospital Emergency Care Council which is responsible for the governance of the level at which medication can be administered.
Ms Laverne McGuinness:
Deputy Sandra McLellan also referred to the capacity review and the staff it had identified as additional resources. This matter will be considered when the capacity review becomes available in full and we know what are the requirements for future services. The review which will be completed at the end of December will take a wider view of what resources are required and where they will be needed. We will consider its findings when they become available.
Some of Deputy Ciara Conway's questions on the fleet and care standards have been answered. HIQA and the Pre-Hospital Emergency Care Council set standards. Dr. O'Donnell may wish to speak about standards of care.
Dr. Cathal O'Donnell:
Deputy Ciara Conway was concerned about the role of the Pre-Hospital Emergency Care Council, a statutory body that is independent of the Health Service Executive. Broadly, the council is analogous to the Nursing and Midwifery Board of Ireland and the Irish Medical Council. It sets standards for the pre-hospital care sector and has three main areas of activity. It sets clinical practice guidelines which are the algorithms to which all of our staff and the staff of other ambulance services operate. For example, if an ambulance crew was called to a person with asthma, it would operate to the clinical practice guideline or CPG for asthma. The same applies in the case of patients with chest pain, head injuries and so forth. The clinical practice guideline outlines the standard of care, drug treatment and level of clinical care required to administer the drug in question.
A second function of the council is to administer the professional register for all staff working in this area. In the same way that I must maintain registration with the Irish Medical Council, paramedics, advanced paramedics and emergency medical technicians must maintain registration with the Pre-Hospital Emergency Care Council.
The third and most significant function of the council is to set standards for the educational institutions which train advanced paramedics, paramedics, emergency medical technicians and others such as cardiac first responders who complete a one-day training course that is primarily aimed at laypersons.
While the council performs several other roles, its main activity is to regulate the sector in which we work through the three streams of activity I have outlined.
Ms Laverne McGuinness:
Deputy Denis Naughten asked a couple of questions. The purpose of the ambulance service is to try to respond to as many calls as possible in the quickest time possible. Front-line ambulance service staff pride themselves on doing this. They are extremely committed and dedicated employees who work very hard and come to the rescue of patients when they are at their most vulnerable.
The reason the information on eight minute response times has not been published is that we do not have the information infrastructure to do so in a safe manner. Notwithstanding this, we are trying to do so.
The purpose of the capacity review was not for us to throw our hands in the air because this cannot be done but to identify how we can provide services, particularly in areas of the west where there have been gaps and black spots, as quickly as possible. The international capacity review was established for this reason. It did not only compare the Irish ambulance service with its counterpart in England but also with the services in Scotland, Wales, Australia and New Zealand. It carried out a large amount of comparative research, which is the reason it is taking longer to complete than we expected or would have liked.
Ms Laverne McGuinness:
That information will become available when we have the full capacity review. The information available to the joint committee is the executive summary, which is what I also have. The committee will be able to view the full report when it becomes available. I wanted to provide the information available to us at this time.
We met representatives of the Health Information and Quality Authority on the day before the report was published. As members will be aware, in 2010 HIQA set a target of achieving the eight minute response time in 75% of cases. This is no longer a requirement. Based on the information available, we must set a response time - a stretched target of what is achievable - for categories of minor urban and rural areas and towns and put in place a stretched trajectory for continuing to improve over a specific period. It is now recognised that the 75% target may not be achievable in particular rural areas.
Another objective of the capacity review was to identify what resources might be needed to make the target more achievable. The HSE recognises that the service is not as good as it should be in respect of community first responders, of which only 105 are in place. We met representatives of Community First Responders Ireland with a view to widening the scope of first responders. The capacity review will inform us on where best we should target community first responder schemes. This information will become available at the end of December, at which point we will put in place an implementation plan.
The HSE intends to publish the information on the target of seven minutes and 59 seconds. However, we need to be able to separate the statistics from rural and urban areas and set a target that is deliverable and achievable because it will not be possible to achieve a 75% target with current resources.
Ms Laverne McGuinness:
The Deputy asked whether the HSE had responded to this issue only when HIQA had reported. That is not the case. Our estimates process starts well in advance. We had highlighted staffing issues at Loughglynn, Mulranny and Tuam ambulance stations as among our most significant priorities. Loughglynn featured in our 2014 capital plan. This station will be ready by the end of the year and funding is available. I understand job offers were made as late as today and that we will offer staff places at the earliest opportunity to address current deficits. This was part of a planned arrangement. We sought funding to address gaps and it has become available.
Ms Laverne McGuinness:
The executive summary of the report only became available on 14 November. When we have the full report, we will seek to identify where stations should be located and black spots addressed. As I stated, population patterns have changed since the current ambulance stations were established. Population movement has taken place in various communities and pockets. We will seek to identify where are the best locations for the dynamic deployment that will best serve the population.
Mr. Martin Dunne:
The west was prioritised this year to ensure we would be able to staff appropriate stations. We also looked at the on-call system still in place in some parts of the west. We have prioritised the on-call service and ambulance stations in Tuam and Mulranny. We also intend to redeploy staff from existing cohorts in the stations that surround Loughglynn to allow us to provide appropriate 24-hour cover in the area.
Mr. Martin Dunne:
It would not be the intention of the ambulance service to frustrate anyone in respect of freedom of information requests. I am not 100% sure to which request the Deputy is referring. However, I must inform him that we are obliged to uphold confidentiality not only in respect of the people to whom he may be referring directly but also in the context of ambulance staff and some of those who are stationed in control centres. Some of the black lines to which the Deputy refers are instances where we are obliged to redact certain information.
With respect, I received no information at all. That is my point. The national ambulance service cannot just institute a blanket ban. I did not provide anybody's name and nor did I provide any personal information. I was just seeking to discover what the hell happened and to what the complaints related. That is all I want to know but I cannot obtain the relevant information.
I merely wish to ask one of my questions again. Perhaps I did not frame it in the appropriate way in order to obtain the right answer. Will Ms McGuinness indicate what are ICO vehicles and where they are based? How is the data relating to them being analysed? What kind of patients are being transported in them? How long are the average journey times for patients being transported in these vehicles? What kind of patients are not transported by means of these vehicles? Where do patients sit within the vehicles and are they still considered to be the responsibility of the national ambulance service?
Ms Laverne McGuinness:
I failed to answer the Deputy's question because I did not understand what she meant by referring to "ICO" vehicles. I think she is referring to ICVs or intermediate care vehicles. These are the vehicles we have put in place in order to free up ambulances. Intermediate care vehicles, rather than emergency ambulances, are used to transfer patients between hospitals. They are used for transportation purposes and to deal with calls that are not as urgent as delta, echo or other emergency calls. Every month, 3,000 people are transferred between hospitals by intermediate care vehicles. There are 56 of these vehicles at present and 25 of these were bought new in 2012. They have made a significant impact in the context of the improvement in response times.
Ms Laverne McGuinness:
They are very effective. Some 76% of all inter-hospital transfers are now carried out using intermediate care vehicles. HIQA and the capacity review both acknowledged their success. What we need to discover is the actual number of these vehicles we actually require. Those currently in use are at maximum capacity. They are not available 24 hours a day and, potentially, this is a matter which should be considered. The capacity review may identify the fact that we need to provide the service on a 24-hour basis in order to free up more ambulances.
HIQA's report states - Ms McGuinness states the HSE has already acted on this - that certain people indicated that they do not possess the appropriate skills in respect of the duties they currently perform and that they have not been given job descriptions. Ms McGuinness provided an undertaking to review the position in this regard. There appears to be a stand-off between the HSE and HIQA. How were the people who were interviewed by HIQA selected? Did the authority interview everybody or were certain individuals put forward for interview? What process was used? What Ms McGuinness is stating now is different to what the representatives from HIQA indicated last week. Deputy McLellan asked the same question. How many people were interviewed? Something does not add up in respect of this matter.
Ms Laverne McGuinness:
There is no stand-off between HIQA and the HSE. We welcome the report compiled by HIQA, particularly as we are determined to consider anything that will lead to improvements in the ambulance service. What we have said is that in respect of the posts that have been put in place in the past 12 to 18 months, all the staff involved underwent a competitive process and that appropriate job descriptions have been provided. HIQA has met over 200 staff throughout the service. The recommendation it made - which will be acted upon - is that all job descriptions need to be reviewed. Over time, roles are expanded, etc., and, as part of the management review, which will be completed in February 2015, we will be reviewing the various job descriptions. We asked HIQA if it could provide specific information in order that we might get to the nub of the problem straightaway but, for reasons of confidentiality - and as the Deputy will, no doubt, appreciate - it was unable to do so. However, the director of the national ambulance service has met the senior management team in order to discover whether the problem is at that level. That is not the case.
Ms Laverne McGuinness:
There is a competitive process which prospective staff and existing staff seeking promotion are obliged to undergo. This process is facilitated by our national recruitment service, which is operates under licence from the Public Appointments Service. There is a job description in respect of that particular role but, over time, roles may change. So it is something that will be considered. We cannot address it today because if 200 people have been interviewed by HIQA, they self-selected from a full list of staff.
Ms Laverne McGuinness:
I have already written to HIQA and it wrote back to advise that it cannot - in the interests of confidentiality - provide the relevant information to us. We need to do something more comprehensive. The report has been available for just over a week. Speaking to 200 staff will take a significant period.
How many staff did the HSE interview? Was it five, ten, 20 or 100? I have not received an answer in this regard. In light of Ms McGuinness's presentation, it would appear that everything is fine. However, if the HSE only interviews only five or six people, it is obvious that everything is not fine. Will Ms McGuinness indicate whether the national ambulance service will operate within budget during the coming year?
Ms Laverne McGuinness:
It is stated on page 39 of the HIQA report that "some staff reported that while they had accepted a new position within the service, they did not have the requisite technical knowledge for the particular post". What we have said is that when staff are seeking appointment to posts, job descriptions are provided and interviews are held by our national recruitment service, which operates under licence from the Public Appointments Service. People are assessed against a level of competencies and at interview they are either deemed suitable or unsuitable to perform the particular role involved. Anybody undergoing that competitive process is offered a position. People stating after the fact that they do not possess the requisite skills is a matter we will be obliged to probe because that would not have appeared to have been the case during the interview process. Use of the word "technical" is interesting. All our medical and paramedical staff are fully trained, so it must, therefore, be in the management field or the administrative category. As Mr. Dunne outlined, there is also a full training programme. Over 114 people are currently involved in a performance training programme and there are more involved in a master's programme. A range of developments is in train. We are aware that we need to develop our managers fully. In view of the fact that a restricted funding environment has obtained across the health service in recent years, this is not something in which we have invested heavily. It is, however, part of our workforce plan for 2015 and we will be acting upon it.
On the budget, the national ambulance service will come to a nearly break-even position by the end of the year. It has operated very well within its overall budget of €138.5 million. It will have €145 million for 2015 and it will achieve a relatively break-even position by the end of December next.
In view of that financial allocation, are the relevant targets achievable and reasonable? Ms McGuinness referred to the response times suggested by HIQA as being unachievable in Ireland and listed the reasons for this. Are the financial model and the level of resources allocated sufficient? I accept that the HSE would like to obtain more money. However, we must deal with matters as they stand. In view of the fact that there have been major changes and a great deal of commentary regarding the performance of and structures relating to the national ambulance service, are the response times to which I refer achievable?
Ms Laverne McGuinness:
We set out in the national service plan, the first port of call, the level of additional funding to improve the service and response times which will take account of the immediate concerns. It does not take account of the extra 290 staff for the seven minute and 59 seconds response time but will certainly deliver the staff for Mulranny and Tuam, complete the control programme, start the clinical audit and examine the overall elimination of the on-call service in the west. It will not only improve the service but make available more ambulances for deployment across the west. We looked for more money and we are grateful to have received the additional €5.4 million.
Will the delegation liaise with Deputies O’Dowd and Fitzpatrick on their queries too?
I thank the delegation for attending this meeting and apologise for the interruptions during it. I pay tribute to the men and women who work in the national ambulance service and thank them for the work they do. It is important when we hear criticisms of the service that we also remember the staff save lives and provide a sterling service.
I propose a brief suspension to allow members of staff who have been here since the beginning of the meeting to get a quick cup of tea. Is that agreed? Agreed.