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.