Oireachtas Joint and Select Committees
Wednesday, 22 February 2023
Joint Oireachtas Committee on Health
Ambulance Services, Recruitment and Retention of Personnel, and Response Times: Discussion
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Apologies have been received from Senator Frances Black. Before we get to the main item on today's agenda, the minutes of the committee meetings of 14 and 15 February 2023 have been circulated to members for consideration. Are they agreed? Agreed.
The purpose of today's meeting is for the joint committee to meet the National Ambulance Service and Dublin Fire Brigade to consider issues relating to the ambulance service, with a particular focus on recruitment and retention of personnel and response times. To commence the committee's consideration of the matter, I am pleased to welcome, from the National Ambulance Service, Mr. Robert Morton, director, Professor Cathal O'Donnell, clinical director, and Mr. William Merriman, general manager of HR operations. I am also pleased to welcome, from Dublin Fire Brigade, Mr. Dennis Keeley, chief fire officer, Mr. Richard Sheehan, senior executive communications officer, and Mr. Martin O'Reilly, district officer.
All those present in the committee room are asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid-19. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that the comply with any such direction.
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, her or it identifiable. I also remind members of the constitutional requirement that members must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit members to participate where they are not adhering to the constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any members participating via Microsoft Teams, prior to making their contribution to the meeting, to confirm that they are on the grounds of the Leinster House complex.
To commence the meeting, I invite Mr. Robert Morton to make his opening remarks on behalf of the National Ambulance Service. The witnesses are all very welcome.
Mr. Robert Morton:
Good morning. I thank the committee for the invitation to attend today's meeting to discuss the National Ambulance Service.
I am joined by colleagues today. I will not repeat their names as the Chair has done the introductions. The National Ambulance Service, NAS, operates from over 100 locations around the country. At the end of January, we had 2,125 staff. With regard to accountability, we operate under the HSE’s performance accountability framework, which sets out the means by which we are held to account. This operates predominantly through the HSE service plan. Clinical governance is provided by a full-time clinical director, Professor O'Donnell, who is supported in that role by a number of other senior clinicians around the National Ambulance Service.
We submitted a briefing note in advance of this meeting that focuses on the areas of recruitment and retention and performance, which I believe were of interest to committee members. The NAS, through the HSE's national recruitment service, continued to actively recruit new staff throughout 2022. We launched a rolling advertising campaign for qualified paramedics, student paramedics and intermediate care operatives in March 2022. The campaign for student paramedics in particular was highly successful and the NAS College was oversubscribed for the September 2022 intake of student paramedics, which saw 90 students start at our three campuses, which are in Tallaght, Ballinasloe and Tullamore. The second round of the student paramedic campaign for 2022 closed for applications on 5 September 2022 and 85 new student paramedics began training with the NAS on those three campuses on 19 December 2022.
We had 209 new staff start across the National Ambulance Service in 2022 with the majority, 181, starting in patient and client care, that is, as emergency medical technicians, intermediate care operatives and ambulance officers. This area also covers paramedics and advanced paramedics. This compares favourably with an average of ten leavers per month. This figure includes retirements, resignations and people securing promotional opportunities in the wider HSE.
The student paramedic recruitment campaign for 2023 has commenced. It kicked off on 16 January 2023. Remaining panellists from the previous campaigns are being offered opportunities to join the next intake, in September, which we hope will see 128 student paramedic places offered on the BSc programme, although that is subject to the establishment of a fourth educational site in County Cork, which is a work in progress. Estimates planning for 2024 has begun and is already well under way. This includes plans for a fifth educational site, in either Wexford or Sligo, to expand our educational capacity further.
To support staff retention, the NAS has developed a people plan for the three-year period from 2022 to 2025. The overarching purpose of this plan is to enhance employee experience, optimise the working environment and meet the expectations of health policy in Ireland. Working in partnership with our workforce, we have introduced changes to our deployment model that reflect the reality of the current capacity deficit while seeking to address some of the key issues our staff have raised, which include travel times, late finishes and access to rest breaks. Staff feedback on this work to date has been positive. A key issue for many staff is the location of their assignment. Therefore, in 2022, we introduced a policy of assigning staff to a location within 45 km of their home address, which has been very well received and has contributed significantly to our attractiveness when recruiting.
National aggregate response time targets for calls are set out in the HSE’s service plan each year. Calls may be described as purple, the new categorisation, or echo, as it used to be known. These labels refer to life-threatening cardiac or respiratory arrest. Calls may also be categorised as red or delta, referring to life-threatening illness or injury other than cardiac arrest. These calls account for approximately 48% of all 999 calls received. Lower acuity 999 calls, the other 52%, can be further triaged through our clinical hub by clinicians, that is, doctors and nurses, to establish if sending an emergency ambulance is appropriate compared to other options such as self-care or visiting a pharmacy, a GP or a GP out-of-hours service. In 2022, the HSE's national service plan set national aggregate key performance indicator targets for emergency calls. It was targeted that 80% of purple or echo calls would be responded to within 18 minutes and 59 seconds and that 50% or red or delta calls would be responded to in 18 minutes and 59 seconds. Response time targets are national aggregate targets and are therefore reported on nationally. With regard to the NAS's performance against those targets in 2022, 71% of purple or echo calls were met within the target time, as against the targeted 80%, and 43% of red or delta calls were met within the target time, as against the 50% target. As members would imagine, there was considerable variation across the year. Further details on performance in respect of echo and delta calls over the previous three years have been supplied in the briefing note.
The HSE recognises that both the HSE and Dublin City Council have statutory powers to provide ambulance services in Dublin. The Department of Health and the Department of Housing, Local Government and Heritage have established a task and finish group on behalf of both Ministers to look at any outstanding issues or areas of concern. This group had its first meeting yesterday. Despite the challenges of recent years, the continued investment by Government and the HSE in the National Ambulance Service is contributing to progress on the shift to reorient healthcare away from a hospital-centric model, as envisaged under Sláintecare. In November 2022, the HSE board approved a new ten-year NAS strategy that provides a roadmap for the continued development and enhancement of the National Ambulance Service in Ireland. The strategy has been submitted to the Department of Health and is currently being considered with a view to informing a memo for Cabinet. That concludes my opening statement.
Mr. Dennis Keeley:
I thank the Chair and committee for today’s invitation and I welcome the opportunity to attend and discuss the issues facing the ambulance services. I am the chief fire officer with Dublin Fire Brigade and ambulance service. I am accompanied by my colleagues: Mr. Martin O’Reilly, district officer, and Mr. Richard Sheehan, senior executive communications officer. Dublin Fire Brigade provides the function of the fire authority for the four Dublin local authorities, namely, Dublin City Council, Dún Laoghaire-Rathdown County Council, South Dublin County Council and Fingal County Council. The brigade operates a 24-7 fire, rescue and emergency ambulance service from 12 full-time and two retained part-time stations. We also operate the east regional communications centre, an administrative headquarters, a fire prevention and enforcement section, a brigade training centre and a logistics workshop.
Dublin Fire Brigade, DFB, provides emergency cover to Dublin city and county, a region with a population of more than 1.43 million, which represents 28.5% of the population, and covering an area of 922 sq. km. In 2022, Dublin Fire Brigade processed in excess of 180,000 emergency fire and ambulance 999 or 112 calls. DFB responded to just over 81,000 medical incidents with in excess of 100,000 appliance movements mobilised to support ambulance incidents. Dublin Fire Brigade is particularly proactive with respect to safety and has achieved international accreditation, memoranda of understanding or both for all aspects of its service delivery, including ISO 9001 and ISO 45001 and recognition as an International Academies of Emergency Dispatchers, IAED, centre of excellence. The service is guided by the range of policies and procedures issued by the national directorate for fire and emergency management, which sets the national policy for fire authorities, the Pre-Hospital Emergency Care Council and the Health Information and Quality Authority. The objective of Dublin Fire Brigade is to respond and deal with fire and medical emergencies as statutorily obliged.
DFB has provided an ambulance service to the citizens of Dublin since 1892. All full-time firefighters are trained paramedics and rotate continually between firefighting and emergency medical services, EMS, duties. The east regional control centre, ERCC, receives and process 999 or 112 medical emergency calls for Dublin city and county. ProQA, the advanced medical priority dispatch system is used to code and assign a response priority to the emergency calls. The ERCC is accredited as a centre of excellence under the International Academies of Emergency Medical Dispatch. Dublin Fire Brigade normally operates a fleet of 12 emergency ambulances, each staffed by two paramedics available to respond 24 hours a day, 365 days per year. Since the early stages of the Covid-19 pandemic, an additional two emergency ambulances have been in operation, bringing our fleet up to 14 emergency ambulances. In addition, there are 21 front-line fire appliances crewed with up to 120 paramedics available to respond and support the emergency ambulance fleet as part of our fire-based EMS response. Our EMS training institution is accredited by the Pre-Hospital Emergency Care Council, PHECC, and supported by the Royal College of Surgeons in Ireland. Some 83 of our personnel provide advanced paramedic interventions.
In 2022 the following activity was recorded: 81,984 emergency medical incidents were managed, 52,165 patients were treated and transported to hospital, 4,387 critical medical incidents were managed, 453 cardiac arrests were managed, 148 ST-elevation myocardial infarction, STEMI, patients were transported to a primary percutaneous coronary intervention, PPCI, facility within 90 minutes of having an electrocardiogram, ECG and 483 positive stroke patients were transported to a facility that performs stroke thrombolysis.
Demand for ambulance services continues to grow. Computer-aided dispatch, CAD, activity is a measure of ambulance incidents created on the emergency response co-ordination centre, ERCC, CAD system. The annual figure for ambulance incidents created in 2017 was 114,543. In 2022, the number of ambulance incidents created was 148,974. This represents an increase of 30.06% in the annual number of incidents created since 2017.
Incident duration is measured from the time an ambulance is mobilised to an incident until the time it becomes available for the next incident. Duration time is calculated in minutes. Dublin Fire Brigade, DFB, has witnessed an increasing trend in incident duration times. In 2017, the average incident duration was 51 minutes. In 2022, the average incident duration was 64 minutes. Factors that influence that number are the offload turnaround time at hospitals and the fact that patient care is now more complex, with protracted interventions. Regarding offload turnaround time at hospitals, in 2022, the average offload or hospital turnaround time in Dublin hospitals was 39 minutes, with 16% of incidents having a turnaround time in excess of 60 minutes. It should be noted that in 2020, the comparable average turnaround time was 29 minutes, with 6% of ambulances experiencing offload delays in excess of 60 minutes.
Concerning patient care, clinical practice guidelines issued by the Pre-Hospital Emergency Care Council, PHECC, have led to an increased time on scene for paramedics involved in patient care. On queuing of incidents, when a resource is not available, an incident is placed in a queue until a resource becomes available to respond. Queuing of incidents is now systemic, with over 80% of incidents placed in a queue during peak hours, which now stretch from 0900 hours. to 2400 hours. Due to a surge in demand in November and December 2022, the highest number of incidents placed on a queue was recorded. The rise in queuing times for delta incidents is particularly worrying as they are deemed to be clinical status 1, or life-threatening conditions.
HIQA response standards set in 2012 identify the key performance indicators for emergency medical service, EMS, response at three clinical levels. A key area of concern is the ability to achieve the target for delta calls, with a requirement to reach 80% of all delta calls within 19 minutes. In January 2020, DFB had 12 emergency ambulances and 45% of all incidents that month were delta calls. DFB reached 58% of these incidents within the target timeframe. In the same month, 7% of incidents had a hospital turnaround time greater than one hour. In January 2023, DFB had 14 emergency ambulances. The overall number of incidents managed was similar to the same month in 2020 and 46% of all incidents that month were delta calls. DFB reached 40% of these incidents within the timeframe. In the same month, 17% of incidents had a hospital turnaround time greater than one hour.
On the ability to achieve the target for echo calls, which have a requirement to reach 75% of all echo calls within eight minutes, in January 2020, DFB had 12 emergency ambulances. 2% of all incidents that month were echo calls. DFB reached 59% of these incidents within the timeframe. In the same month, 7% of incidents had a hospital turnaround time greater that one hour. In January 2023, DFB had 14 emergency ambulances and the overall number of incidents managed was similar to the same month in 2020, with 2% of all incidents that month being echo calls. DFB reached 52% of these incidents within the timeframe. In the same month, 17% of incidents had a hospital turnaround time greater that one hour. These statistics point to a direct correlation between extended hospital turnaround times and the availability of ambulances to meet demand.
Agreed interagency activity measurement between DFB and the National Ambulance Service, NAS, has been in place since January 2017 and has been successful in identifying the high levels of activity as both organisations co-operate to maximise combined available resources. High levels of contact are a daily occurrence and, as per agreed protocols, DFB requests assistance from NAS as required. In 2022, DFB requested resources from NAS on more than 63,000 occasions. NAS indicated it could not provide a resource for 76% of these requests. These figures suggest the combined resources of NAS and DFB cannot meet current ambulance demand in Dublin city and county. In support of the Sláintecare implementation strategy, DFB actively engaged with NAS on a pilot basis to utilise fully alternative pathways through the National Emergency Operations Centre, NEOC, clinical hub. This provides an avenue for lower acuity calls to be transferred, triaged and treated via the clinical hub.
DFB has a quality and patient safety, QPS, committee chaired by the assistant chief for DFB emergency ambulance services. The fire brigade’s medical director and the managers of each section of the fire brigade also attend. The QPS agenda includes updates on capacity and demand, complaints and compliments, adverse clinical events, clinical audit, fleet and logistics, recruitment and training. This is the conduit to ensuring effective governance within our service. DFB and NAS have a joint operational working group which oversees day-to-day co-ordination and co-operation between both services. The managers of both control centres and the operational chiefs are represented at this forum. A collaborative approach to the issues that face both organisations in relation to capacity, demand offload delays at hospitals and alternative pathways are discussed and plans are developed to enhance overall service provision. DFB is actively engaging with NAS to utilise fully alternative pathways through the NEOC clinical hub. DFB and NAS have a medical director group which meets regularly to discuss clinical issues common to both organisations, for example, a common approach to the introduction of clinical guidelines, learning from adverse clinical events and clinical directives.
Response rates to our recruitment campaigns are very positive and to date attracting applicants to fill vacancies in the service has not presented a challenge. Attrition rates among our operational staff are low. In the past five years, less than 1% of operational staff chose to leave the service to pursue other careers. To date, the people who join our team remain with the team. DFB currently has a recruitment campaign in process and arrangements are in place in May 2023 for a class of recruits to commence training. In 2022, 108 personnel completed initial training and commenced operational duties. Ongoing training, career development and lifelong learning are important in DFB to ensure staff have the right skill sets to meet organisational objectives. Dublin Fire Brigade and Dublin City Council provide a very supportive educational scheme of assistance, giving our personnel access to and financial support for third level courses and development programmes.
Regarding the fleet, recent positive investment has dramatically reduced the age profile of our front-line fleet. Continuous review of the fleet profile and engagement with National Ambulance Service have seen good results in this area. Equipment management of ongoing replacement, maintenance and certification of EMS equipment is a continuous and detailed process. The costs associated with equipment purchase and maintenance are increasing. Supply chain issues are also impacting delivery times for some equipment and consumables. DFB recently tendered and awarded a contract for the provision of a new asset management system to improve the management of operational assets. The implementation of an electronic patient care reporting system could improve data gathering, management reports and monitoring of patient outcomes. Digital TETRA radios were installed in our fleet in 2021 to improve communications between our crews and the ERCC. The CAD system in Townsend Street is due to undergo a technical refresh to include new hardware, furniture, telephony system and TETRA radio functionality.
The Covid-19 pandemic is one of the biggest public health crises faced globally and its implications for our emergency ambulance services, which are already under pressure, have been quite significant. The professionalism of our paramedic staff has been especially commendable during the pandemic. DFB senior management worked very closely with our staff to ensure sufficient personal protective equipment, PPE, information, clinical guidance, risk assessments, procedures and training were maintained to allow continuity of services while affording the highest level of safety to our paramedics. Revised protocols and procedures introduced during the pandemic have contributed to increased incident duration times, further affecting performance levels. Examples include donning time for PPE, post-incident decontamination and increased hospital delays.
The current operating environment for our ambulance service remains challenging and can best be summarised as follows. Demand for ambulances is continually identified as being far in excess of DFB's capacity to meet HIQA performance standards. Demand is rising, thus exacerbating the situation. Treatment methodology is more complex. Incident duration times are getting longer. Offload hospital delays have increased. Incident queuing times are getting longer and delta cases are identified as being severely compromised by lack of resources. Ambulance unit hour utilisation rates in DFB are very high. Complaints, predominantly about ambulance response times, from the public are rising.
Despite the challenges outlined above, the management team in DFB is fully committed to the provision of high-quality pre-hospital emergency care and fully engaging with stakeholders to seek agreement on the development on a joint service model to enhance service delivery going forward. Discussions are ongoing to establish the foundations for the development of a revised model. We hope this could realise our vision for the service, which is to make Dublin a safer place to live, work and enjoy, by being a modern, community-focused, influential fire, emergency ambulance and rescue service.
Bernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source
I thank the witnesses for appearing this morning and for their respective reports.
I compliment them on the work they do and the degree to which they respond to emergencies in the best way and fastest possible time. I have a couple of questions for Mr. Keeley. What issues need to be most urgently addressed to deal with the trends as they appear at present post Covid and to deal with the situation in the future with a substantially increased population and increased demand?
Mr. Dennis Keeley:
I can break down the more urgent needs into a number of particular issues. Resources are obviously a significant factor. Dublin Fire Brigade is operating with 14 ambulances. Our colleagues in the National Ambulance Service, NAS, reach out for support. They also seem to have a deficit of resources to support the requirement. Working in conjunction with our colleagues in NAS, we need to utilise alternative pathways and maximise capacity to treat patients in their homes or alternative locations rather than taking them to accident and emergency departments. That area needs to be expanded and Dublin Fire Brigade is working with NAS on that pilot at the moment. This issue is predominantly around resources and it is the biggest issue.
Bernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source
To what extent has the Dublin Fire Brigade identified the precise resources needed and relayed this to the responsible authorities in terms of quantity and quality?
Mr. Dennis Keeley:
Several reports have indicated the level of additional resources needed. Considering the complexities of the answer and the question, the work is being tackled by the task and finish group my colleague mentioned, which involves both Ministers appointing a group to discuss an alternative model in the future for the ambulance service in Dublin. The complexity of that answer revolves around a working group to hammer out a solution that would see the resources of both agencies working smarter and more efficiently to resolve the issues around resource and capacity.
Bernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source
For the committee to understand fully the precise nature of the requirements that are needed on an ongoing basis, starting from now, will Mr. Keeley tell us whether they need 40 or 50 more ambulances, how many extra staff they need and where they are needed? To what extent is the rota being changed so as not to have the same people on the front line and thereby creating variety?
Mr. Dennis Keeley:
From my perspective, we operate a rotational system in terms of the rota. Our paramedics and firefighters rotate so that we do not have a situation where the same people are continually providing ambulance service. That works for us in terms of burnout and how we try to look after staff.
As for the exact number, the task and finish group has been given six months to finish its work, from which a model on a way forward will indicate how the joint services will deliver services for the greater Dublin area and what that will look like in terms of capacity and the number of ambulances that will be required in the Dublin Fire Brigade and the National Ambulance Service. I wish I could give the Deputy a figure but it is a very complex situation that does not allow for a specific number of ambulances that will solve this problem. It is about how we work and the way we work. It is about maximising the efficiency of both services and how we deliver that, in addition to creating those alternative pathways that will reduce the number of patients arriving in accident and emergency departments.
Bernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source
I understand that, but the reason I asked the question was so that it would be possible for us to identify what exactly is required to provide the optimum service at all times. The term "lack of resources" covers everything now. I am not suggesting Mr. Keeley is using that expression. We need to identify precisely what the needs are and how we propose to deal with them. I am aware of the working groups that have been set up. Have there been any particular incidents that occurred in the past 12 months whereby it was obvious there were deficiencies in the system that needed to be addressed?
Mr. Dennis Keeley:
I would be dishonest if I said that did not happen daily. We do not have sufficient resources to deal with the cases. When we are queueing incidents, we are not hitting the standards that are required, and therefore those incidents concern me. We have queues the length of which are in excess of the time we would want. That is happening frequently.
Bernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Is it of such a frequency that would alarm Mr. Keeley, given his knowledge of requirements of the system?
Bernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source
What issues have come to Mr. Morton's attention that would alert him as to the urgency of the need for particular improvements at particular times? What are his conclusions? For instance, has he identified staff for rota changes? Staff retention has also been mentioned as an issue in some areas. Will he say precisely what is happening with the retention of staff?
Mr. Robert Morton:
As regards trends, we are seeing a big shift in how people access unscheduled care generally. We are seeing far more people access episodic illness and injury care through 999 and 112 and self-presenting at accident and emergency departments rather than the traditional model of attending their GP followed by an onward referral. There has certainly been a change in health-seeking behaviour and we are seeing this across all aspects of healthcare. Our response to that is about diversifying the model of care we provide, and that is very much with Sláintecare in mind.
Much of our energy is focused on alternative care pathways, as Mr. Keeley mentioned. We are developing new services that focus on particular groups. For example, we are developing a clinical hub that is staffed by doctors and nurses, and we will introduce paramedics into that model this year. It is a secondary clinical triage where a clinician has a conversation with a patient to determine whether there is a more appropriate mechanism or referral option for that patient other than sending a traditional ambulance. We have developed a frailty response model, which has been rolled out in a number of locations and will be further rolled out in 2023. That focuses on older people over 65 years of age and particularly those over 75 years of age. It is about supporting those people to stay at home and connecting them with other services in the community, such as community intervention teams, home support services and frailty services in hospitals, where we are deploying occupational therapists, physiotherapists and advanced paramedics. We are also mobilising community paramedics who work very closely with general practitioners. Much of what we are trying to do is to bring care closer to patients, in their locality or their home. That is how we are responding to the trend.
We are very clear on what we need in terms of capacity. I came into this post at the end of May 2021. I commissioned a capacity review in July 2021 that identified an immediate requirement, which is on the record of the House in a meeting of the Committee of Public Accounts in December 2021. We need 1,080 staff pretty much straight away. It is just not possible to get 1,080 staff but that is what we need. It would provide 90 ambulances throughout the country. Over a period of ten years, we have identified a workplace requirement of 4,385 staff who would be required to deliver all services, not just ambulance services, over a ten-year period.
We have a very clear workforce plan, which is very challenging to deliver in the current context. On retention, one of the key issues we hear from our staff when they do exit interviews is about the nature of the job. Shift work is the number one issue that people find most difficult to cope with. It has the greatest impact on their work-life balance. What we have tried to do, in partnership with our trade union colleagues, is focus on those issues that staff tell us create the greatest impact. That is about trying to prevent late finishes, trying to make sure they have access to breaks and trying to make sure they are not travelling great distances. That is one of the dysfunctionalities that occur when there is a capacity deficit. You get an inbred issue of dysfunctionality which happens by virtue of the fact that there are not enough resources to respond. Those are the sorts of local issues we are focusing on, pretty much guided and informed by our staff.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I welcome the witnesses. I tabled some parliamentary questions in advance of this session so I have a breakdown of response times by region and so on, which I will reference. Mr. Keeley said a few moments ago that the Dublin Fire Brigade's ambulance services are not hitting the standards that are required. That is quite a stark statement. I do not blame him or his staff, who are obviously doing their best. Would he accept that not meeting the standards is unacceptable in the first instance?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I want to get to the response times. In terms of the Delta calls, which were referenced, the figures for last year are quite stark. Mr. Keeley might be able to explain why this is the case. In December 2022, the percentage of status 1 Delta incidents responded to within the 19 minutes was 19%. Going back to 2019 it was 33%. Only 19% of those Delta incidents were responded to within the standards that have set by HIQA. Why is the figure so poor for that month last year?
Mr. Dennis Keeley:
That was a particularly bad month. In fact, it was a record month in terms of the number of calls and activity we received. We put it down to a combination of the various illnesses that were circulating in the community at the time, including Covid. We have seen an improvement in the figures since December. That was a very unusual month. Unfortunately, often those unusual months and outliers can be repeated later on. We have generally seen peaks over recent years in January and February. The peak for this winter period seemed to appear in December, which resulted in the reduction in our performance.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I am going to get to the other figures in a second. Was there a report, the Brady-Flaherty report, done on the Dublin Fire Brigade and the wider ambulance service a number of years ago? Maybe Mr. Morton can answer that question.
Mr. Robert Morton:
There was a report done. It was commissioned jointly by the HSE and Dublin City Council and followed on from a piece of work done by HIQA. It was conducted by two experts in the field, one from a fire background and the other from an ambulance background.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
When was that done? What year?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Did that report make recommendations?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Was it published?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Why was it not published?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Would it not be in the public interest to publish it, given that it made recommendations? I have received a copy of the report myself but it has not been published so I do not want to go into the details of what was in it. We should be seeking for that report to be published in the first instance because it raised a number of fundamental questions. We cannot be doing reports and then not publishing them. We cannot do our job as a committee if we do not have access to all of the reports.
I also received a copy of the workforce plan, or at least an executive summary of it. That was sent to me as well but I am not sure if that has been published. I just want to read a paragraph from it, which is troubling for me. The witnesses mentioned some of it as well. It sets out the capacity demand and the increase in capacity that needs to be put into the system over the next number of years. It says we need 3,018 whole-time equivalents and a total increase of 2,160 whole-time equivalents but then there were also 858 retirements and turnovers. It refers to the 1,080 that were mentioned and additional numbers in the national service plan. They are quite big figures. It is a massive increase in capacity that is needed. I am not sure if there is a plan there to reach it by the dates that have been set.
I just want to read something from the conclusion of that document. It says that the National Ambulance Service emergency capacity review 2022 assessed the level of 19-minute performance that could be achieved if activity were to increase at the projected rate to 2027 and response cycle times were to stay at current levels. It concluded that if it continued with current response times, the National Ambulance Service would have insufficient resources to respond to the projected demand and as a result the 19-minute performance would be considerably less than 40%. That is quite a stark statement.
I will give out some of the response times I got in response to my parliamentary questions just to add some further context. These are for Echo and Delta incidents, which are both life-threatening. These figures are broken down by month and by year. In 2019, for the east region the average response time for Delta and Echo calls was 15 minutes. In 2022, it was 22 minutes. In the midlands, the average response time in 2019 was 19 minutes and that went to 29 minutes in 2022. In the mid-west, it was 16 minutes in 2019 and 25 minutes in 2022. The worst region of all was the south east. The response time was 21 minutes in 2019, which is bad enough, and it is now 33 minutes. In the southern region it was 18 minutes and is now 31 minutes. There are quite stark and big increases in response times. Would Mr. Morton not agree?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Why are the National Ambulance Service and the Dublin Fire Brigade not making more noise about this? I know they have published a capacity review but these response times are not good at all. They are unacceptable, to be quite frank. People depend on the ambulance service when there is an emergency. For people living in the south east, which I do, the average response time for life-threatening calls is 33 minutes when it was 21 minutes. That is an increase of 12 minutes on average for a response time. That is an average; we know some people wait longer. It is beyond unacceptable. What level of engagement is there with the Department and the HSE from the witnesses' perspective? They should be shouting from the rooftops that these figures are going in the wrong direction and will continue to go in the wrong direction unless the capacity is put in.
Mr. Robert Morton:
That is a very fair summation. What the Deputy is reflecting is a growing gap. Mr. Keeley touched on this. There is a growing gap between demand and capacity. Demand is growing at a pace that is far outstripping any growth in capacity. Take the last 12 months for example. In 2022, emergency call volumes increased by 15% and actual conveyances and responses increased by almost 8% in that one year. Our workforce has only grown by 9.9% since 2019. The growth in workforce simply cannot keep pace with the growth in demand. What have we done about that? To answer the Deputy's question-----
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
It states in the 2022 capacity review, as Mr. Morton said, that recruitment efforts are currently being surpassed by service demand.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
We are not even standing still. It is worse than that. Capacity is being overtaken by service demand. The level of additional capacity needed has been outlined, that is, a figure of over 4,000. That would be more than double the existing workforce, would it not?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Over what time period would that be?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Is there any chance of that target being met?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Is that being done?
Mr. Robert Morton:
It is. This year our plan is to invest in a new facility in Cork and next year in Wexford or Sligo. The following year we will invest again in Wexford or Sligo - whichever comes last, as it were. Ultimately, we need to get to a doubling of our education capacity. We need to establish a driver training school. When we look at our limitations, they are around our ability to recruit.
In 2022, we have invested in an internal recruitment team. In 2023, we are investing in additional education capacity and starting to develop a driver training school. We are finding that all of these enablers are very limited but we are starting from a low base. It is not just a question of demand exceeding capacity but also of where we started. We had several years of austerity and a lack of growth in capacity while demand was growing in the background.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I need to come back in once more. I have to put it to Mr. Morton again that the response times are completely unacceptable. The percentage increase in the targets which are not being met is also really concerning. I received a submission from a qualified paramedic, titled the failure of the recruitment campaign, NRS02294. I want to read one paragraph from it and for Mr. Morton to respond to it because if recruitment is so important, we have to get it right. It states that at a time when the National Ambulance Service is experiencing a staffing shortfall of such magnitude that it has been rightly described as a crisis, the recruitment of qualified paramedics could dramatically reduce the staffing shortfall in a way that is safe, cost-efficient and readily available. It continues to state that unfortunately, the campaign for Pre-Hospital Emergency Care Council, PHECC, qualified paramedics currently being run by the HSE recruitment service on behalf of the National Ambulance Service can be described only as an embarrassment to the National Ambulance Service, an insult to qualified paramedics who applied for the position and, overall, a complete failure. It states that only 9% of eligible candidates were offered a position in the past seven years, after an average time of waiting for deployment of 300 days on a panel of successful applicants. It states the recruitment campaign has failed to achieve its objectives.
I assume this was sent to every member of the committee. Will Mr. Morton respond quickly to that?
Mr. Robert Morton:
The obvious response is that we would not accept it. Our experience of qualified recruitment has been mixed and disappointing. Generally, we get about 40 applicants a year. Those applicants are often repeat applicants, so when one looks at the cumulative numbers, they look much bigger than they actually are, but when one actually counts the heads, the number is low. This year, we have made ten offers to qualified paramedics. Only six have accepted the offers. We have found that even since 2014, we have had a number of clinical incidents. We had a mixed experience of people who joined the National Ambulance Service with qualifications obtained outside the State because to be a registered paramedic, one has to be accepted by the competent authority in Ireland, which is the Pre-Hospital Emergency Care Council, but one's qualifications and experience can be very varied depending on the jurisdiction one comes from, whether EU or non-EU. We have had a mixed experience so we have decided to abandon the idea of qualified recruitment. Frankly, it has not worked for us.
We have been working with one of our educational partners, the University of Limerick, UL, to look at a completely different model, which we will introduce this year. We hope to see a different approach whereby we will recruit postgraduate interns and take people in as interns whether they are qualified or not. We will put them through an internship ourselves.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
The submission was sent to me and I assume it was sent to others. Did Mr. Morton receive a copy of this?
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
Good morning. I thank the witnesses for their presentations. Listening to them all and reading the documentation we have before us, one cannot help but get a strong sense that there are major problems with governance of the ambulance service. It involves the two organisations here this morning, the HSE, the Department of Health and the Department of Housing, Local Government and Heritage. One wonders where the buck stops. I am particularly interested in finding out more about the reason for issues of governance in the Dublin area and how exactly things work between the NAS and Dublin Fire Brigade. Who decides how the service will operate? I do not know where that decision-making happens.
The people who pay the price for this are people living in the Dublin area who depend on the State to ensure a proper, responsive, timely ambulance service. We are not getting that at the moment. The figures point out that clearly. The Irish Timesreported just last year that barely a quarter of ambulances were being turned around on time at hospital emergency departments. There is a logjam somewhere and we need to know exactly where that is. It was reported that 56% of delta calls involving life-threatening emergencies were not responded to within the target time. The majority of delta calls were not responded to. That puts people living in the Dublin area at serious risk. At this stage, given the number of agencies involved, that is simply not good enough for people living in the Dublin area.
The Brady-Flaherty report was completed in 2016 and we have not seen it yet. What undercurrents are going on here? There are clearly undercurrents which prevent people in the Dublin area from getting the kind of ambulance service they need. We need to get to the bottom of that. Why was that report not published?
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
Whose report is that?
Mr. Robert Morton:
I understand it is jointly owned by the HSE and Dublin City Council. It was jointly commissioned so I believe it is a jointly-owned report, but that is as much as I know about it.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
On that point, is the committee right to go to Dublin City Council and the HSE?
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
It is really not good enough that the head of the ambulance service is essentially shrugging his shoulders.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
When it comes to this report, I do not think that is fair.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
I am on the clock. Paul Cullen of The Irish Timeswent to a lot of trouble to get his hands on this report. He had to go through the entire freedom of information process and appeals. It was finally released to him. If a report is released under freedom of information, it should be publicly available to anybody who requests it. I would expect the witnesses would supply us with that report in the next two weeks. We know, thanks to Paul Cullen, that patients in Dublin are at potential risk from sub-optimal ambulance provision in the capital from two overlapping State agencies, according to the report, which was commissioned and published in 2016. There are two overlapping agencies providing services and nobody seems to be in charge. The article states, "Significant extra resources are required, deployed in a very different way, if response times are to be optimised". It also states, "The governance and financing of ambulance services in Dublin has been “problematic” over the last 20 years ... with the DFB claiming it is insufficiently funded for the service it provides." It states, "Both organisations require “considerable improvement” and there are concerns about clinical governance in both."
Those quotes that I have read out are absolutely damning of both organisations with regard to governance or lack of governance. Why are we still talking about this? The problems have been going on for 20 years and it is time they were addressed. We know this new task and finish body has been established to look at an alternative model. I want to ask both organisations what that alternative model should be, in their view.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
If Mr. Morton does not mind, I would like him to answer the question I posed.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
What is Mr. Morton's view, from the National Ambulance Service, of what that alternative model should be?
Mr. Robert Morton:
The alternative model is what we are doing at the moment, which is about trying to respond differently to 999 calls. Patients and staff tell us that many people who dial 999 do not need and do not want a traditional ambulance. They want a different model of healthcare. Broadly speaking, that is happening outside Dublin and probably needs to happen everywhere, including Dublin.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
What needs to happen to make that occur? Where does the decision-making need to be?
Mr. Robert Morton:
First, we must agree what the ambulance service delivery model will be in Dublin and the two Ministers have put in place a process to reach a conclusion on that. There are thorny and difficult issues, as the Deputy can imagine, when there are two organisations running with their own separate governance models and that is basically what we have. One is obviously a health service and the other is a local authority service.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
It is not good enough to say to the people of Dublin that there are thorny issues involved. There have been thorny issues involved for the last 20 years. When are they going to be sorted out?
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
What is Mr. Keeley's view or the view of Dublin Fire Brigade on what that alternative model should be?
Mr. Dennis Keeley:
I am very aligned with the comments that Mr. Morton has made in relation to the provision of services. A revised model which, where possible, keeps people in their home or takes them to alternative locations where they can be treated more efficiently and quickly, without the necessity of arriving at an overburdened accident and emergency department has to form part of any future service. Dublin Fire Brigade is working with colleagues in the NAS on pilot programmes in the city in that regard. We are very much committed to continuing that evolution of ambulance services right across the city and county. The future and answer for the task and finish group must happen very quickly. Most, if not all of what the Deputy has said, cannot be ignored. These are very serious issues. I recognise the significance of the statistics that the committee has been bombarded with this morning. It is a very serious situation.
The comments the Deputy makes suggest that there are two disparate organisations working independently of one another but I can assure her that is not the case. A lot of work goes on in terms of assurance around clinical governance, management-----
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
Okay, but if the two organisations are of the one mind about the new model, who needs to be making decisions to introduce that new model and to make it possible? At what level does that decision-making have to take place?
Mr. Robert Morton:
The task and finish group includes representatives from both Departments, as well as representatives from Dublin City Council, the HSE, the NAS and Dublin Fire Brigade. Overall, it is being managed and chaired by the two Departments but ultimately, the decisions have to include the most serious and senior levels of Government.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
Thanks for that. I have one further question about what is happening in relation to students in the University of Limerick, UL, and why they cannot get clinical placements in the NAS. Those who are studying there and who need to get clinical placements have to go abroad. That seems incredible. Why is that the situation?
Mr. Robert Morton:
I completely agree with the Deputy. I was aghast at that when I started in 2021 but then I looked deeper into the issues.
As the Deputy knows, those going to university apply through the CAO system but that does not mean to say that they are work-ready or employable. Obviously, when someone comes to the NAS for an internship, he or she must be employable. In other words, public sector employment standards apply, including the need for Garda clearance, employer references, occupational fitness tests and so on. What we found was that many, if not all, of the students who applied for an internship were not passing the competency requirements to actually do the job. We have worked very closely with our colleagues in UL and provided them with a lot of constructive feedback and they have re-engineered the programme on the basis of that feedback. We worked very closely with them in the latter part of 2021 and last year, we started to see graduates from UL joining the NAS for internships. We expect to see a lot more of that this year. We are working towards a target of September this year to get almost all of the graduates from UL to come into the NAS on a graduate internship basis. It is something that we recognised as a problem and we have been working very closely with UL to resolve because it is part of our future workforce strategy. We will never be able to train enough people. We have to be able to recruit apprentices but we also have to be able to attract people through the university sector as well.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
I do not have time to go into that further but I would say that as well as the various agencies I have referred to already, there is another agency that is important, namely, the Pre-Hospital Emergency Care Council, PHECC. At some stage, I would like to know who on earth that council is and what is its role because that is not by any means clear, which does seem to be problematic.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I welcome our guests and will start by thanking them all for their very hard work, particularly during Covid. I know that during these sessions there is often a lot of robust questioning, which is our job, but I wanted to start by saying that the work that Dublin Fire Brigade and the NAS do is incredibly appreciated by people like me. Our guests are at the coalface in terms of dealing with not enough resources or supports and trying to make it work. I wanted to put that on the record first.
I will start with the interagency task force. I want to focus in my ten and a half minutes on the phone services that we use. Will the task force be looking at that?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
The first experience for a lot of people calling an ambulance will be actually ringing the ambulance and that is what I want to talk about.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Okay. Most of us will know this already but for clarity, that area is bordered by Monkstown on one side and Balbriggan on the other.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Who is the provider for that phone service?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Who is the phone service provider for the NAS?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
British Telecom will direct a call to the Dublin Fire Brigade or the NAS. Is that correct?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
That is automatic, based on the area code.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I want to return to something in the Dublin Fire Brigade's opening statement. Mr. Keeley said that the fire brigade requested resources from the NAS on 63,000 occasions and in 76% of these cases, the NAS was unable to provide a service. I want to unpick that because it is obviously a very high number. When the call comes in to Dublin Fire Brigade from somebody who is in the middle of Dublin who has phoned for an ambulance but the fire brigade does not have resources available out of its 14 ambulances, the fire brigade then rings the NAS. Does that happen automatically or does somebody literally pick up the phone?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
There is someone in Dublin Fire Brigade who is tasked with ringing NAS.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Even if it is continuous dialogue, there is a human being involved. It is not an automatic system.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
So there is no Eircode postcode-type system. I imagine that when British Telecom is sending a notification of a call to either the Dublin Fire Brigade or the NAS, it generates an Eircode postcode and a case number but when the two organisations are talking to each other, somebody picks up the phone and speaks to the other party.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Are calls ever bundled?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Okay. I ask Mr. Keeley to explain what bundling calls means.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Okay and are there guidelines for bundled calls in terms of response or turnaround times?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I presume the calls are being bundled by priority category.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
They are not being bundled by location, for example.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Obviously we are working on timelines here so would the priority standards-----
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
When a person calls the NAS, does the service have a standard for saying something is a DELTA call, and if the service cannot answer, will the caller get off the phone at a particular stage? Does the service have a timeline?
Mr. Dennis Keeley:
The service has standards for the severity of the call, as the Deputy indicated. If there is nothing available in the NAS or no ambulance in the DFB, depending on the severity, our call-taker can decide to send a fire appliance or a fire engine as a follow-up to that. Other than that, the case goes on a queue.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
It goes on a queue for the DFB.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I am aware this is hard to follow but it is useful to understand what this looks like on a day-to-day basis. Let us say I am the person in Mr. Keeley's organisation and I ring the NAS. The person I speaks to apologises and says the service does not have anything right now. Does that close out that call for the NAS, and it goes back into the DFB's queue?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
What happens if the NAS has resources in ten minutes' time? Does the call ever get resent?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I am trying to understand how quickly the data are being generated and then closed off. I turn to the NAS. As far as the service is concerned, once the DFB gets off the phone, that is a closed-out call and the fire brigade must then recontact the NAS.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Will Mr. Morton comment on the efficacy of that as a mode of communication? It contrasts with what I had imagined, namely, a fairly automated phone service. This is very human-based, if Mr. Morton does not mind my saying so.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I did not suspect anything other than that.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Will the task and finish group be looking at whether that phone system should be one phone system? Is that on the table?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
What are the respective attitudes to a move towards such centralisation?
Mr. Dennis Keeley:
There is general agreement one system is the way forward. Both services should sit on one system so there is electronic transparency, we will say, to simplify it to reduce that inherent risk Mr. Morton mentioned. The general sense and the agreement across all parties is it should be a single system and that should in fact be the NAS's system.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Does Mr. Morton agree?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Is it fair to say the figures Mr. Keeley provided of 63,000 calls to the NAS with resources not being available 76% of the time are impacted by that interaction between two different phone services?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
That the NAS was not able to provide backup resources in the vast majority of the 63,000 calls is a very stark piece of information. Does Mr. Keeley think the fact it is human beings talking to each other across two different systems has impacted that information? Does he think the 76% figure would be lower if we had one system and one service?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I completely take that point.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Do two services ever go to the same call?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
It is a really straightforward question.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Has it happened in the past 12 months, for example?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Does it happen every month?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Do we have data on that?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
That is a very good point. Two different people might ring for an ambulance, give the same Eircode postcode, and it might end up in two different systems. How occasional is occasionally?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Mr. Sheehan thinks it is one or two per year.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
About ten to 20 times per year two services go to the same call.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I ask someone to explain where the Coast Guard fits into that phone system.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Mr. Morton can anticipate the question I am going to ask. Does that mean the Coast Guard picks up a phone and rings the NAS if it needs the service?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
It is not automated.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
No data are automatically generated by a call.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Okay. I will finish on how that phone system interacts with the community first responders. Is that a human being picking up a phone call or is it automated?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Is it an app?
Mr. Robert Morton:
From a NAS perspective, a text message is received. Some will have TETRA radios, but the majority will get a text message. They are geofenced, effectively, on our CAD system. The community first responders, CFRs, are geofenced into a particular geographical area. What the CAD system does is to hunt for every single resource in that area and alert every available resource in that area. If a CFR has declared themselves available, they will get a message saying there is an incident at that location and asking can they mobilise.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
That is automated.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Is it automated for the DFB?
Mr. Dennis Keeley:
That is not the case with us at the moment. Our CAD system is an older system. We have been working on the technical aspects of it, which I can now say we have resolved. We are now just putting the policies and procedures around some of the aspects of mobilising, such as how to cancel or if there is a safety issue. I expect the automated system will be up and running by the second quarter of this year.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
The first responders are therefore dealing with a different system between the NAS and the DFB.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I have one last tiny question. How many of the first responder calls logged by the system do not end in the provision of an ambulance?
Mr. Robert Morton:
Over Covid it was probably about half. I should not say Covid; I mean the winter period. That is because we introduced a new process with our community first responders to do welfare calls on patients. During the really pressurised period of December and January, we were mobilising. We did a trial with our CFR scheme in Tramore. The responders trialled the idea of responding to falls. About 97% of patients who have a fall have no injury. We found the trial to be very successful. CFRs went out and effectively provided comfort, care and empathy to patients while they were waiting for an ambulance. In those cases, many of the patients did not go to hospital subsequently or maybe declined the ambulance. Generally speaking, outside that period, most CFR calls also result in a conveyance to hospital.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
What does Mr. Morton mean by "most".
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Is it 90%?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I thank the Chair.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
I thank everybody for their statements. When an ambulance is not available at a particular time, the DFB will send out a fire tender. How many times does that happen per year?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
That is per year.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
What is that as a proportion of all calls?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Why would it be the case that an ambulance is not available, requiring the DFB to intervene?
Mr. Dennis Keeley:
As the Deputy will be aware from the report, we have a finite number of ambulances and resources. When they are tied up, whether it is on a case or at a hospital, and we have a life-threatening case and no resources in-house, we contact the NAS. If it has no ambulance available, we dispatch an appliance with paramedics and equipment on board that can treat that patient, pending the arrival of an ambulance.
It is not instead of the ambulance but just pending the availability of one. Depending on the nature of the case, we may prioritise it for the dispatch of an ambulance over another case.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Does it in any way compromise the medical event that is occurring if there is not an ambulance with the fire tender?
Mr. Dennis Keeley:
I would contend that in the absence of sending the fire tender, the patient will be compromised because there will be no paramedic or medical assistance en route. If a clinical diagnosis is made and the patient has been transferred to hospital but there is no ambulance, every delay is likely to have an adverse outcome. Having said that, a large number of paramedics will nonetheless arrive and each fire tender has lifesaving equipment on board. I would have to take each case on its own merit. The ideal circumstance is that an ambulance would arrive-----
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Before the fire tender.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Mr. Keeley is saying such cases could happen 3,000 times a year.
Mr. Dennis Keeley:
Yes. That figure includes the response of a fire tender in support of an ambulance that might be en route. If information that is gleaned indicates that the inclusion of additional responders would assist in the treatment of that patient, for a variety of reasons, we will dispatch a fire tender with the ambulance.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Paul Cullen wrote an article in The Irish Times a number of weeks ago relating to HIQA reports in 2014 or 2017 that indicated there remained discrepancies involving the duplication of services in Dublin. Have the issues raised in those two reports been addressed?
Mr. Dennis Keeley:
The previous question related to the arrival of dual appliances, if I can use that term. That issue has dramatically improved thanks to the procedures that are in place relating to the joint service in both centres. While it cannot be totally eradicated, and I would not claim it has been, that part of that discussion has dramatically improved.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
My final question relates to something that was not covered in Mr. Keeley's opening statement. A number of weeks ago, the committee heard testimony from healthcare workers regarding physical and verbal assaults in the workplace, which was shocking. Have members of the fire service been subjected to that degree of intimidation and violence in the workplace in recent years?
Mr. Dennis Keeley:
Certainly, and I refer to physical as well as verbal assault. Firefighters have been subject to serious physical assaults requiring long-term treatment, while verbal assaults, which are much more common, are still a recurring issue, probably weekly. We have a number of processes and procedures for our staff's welfare and to help them deal with that, and we use the auspices of our social media to try to educate the public on the role of the emergency services. That goes through both our social media and our school visits to try to get across the problem of intimidation or assaults on emergency workers.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Has the issue increased in recent years or has it always been the case that workers on the front line are subjected to this kind of assault?
Mr. Dennis Keeley:
I do not see any evidence to suggest it has worsened in recent years. It has always been the nature of the work. Unfortunately, there is a strong correlation between that kind of behaviour and alcohol use. There are certain times of the evening and night when it can be expected and our staff are very wary of that. We generally work in close collaboration with An Garda Síochána, and our control centres can sometimes give a heads-up to our crews before they respond regarding what is happening at the scene and can advise them to be extra careful or to request the assistance of An Garda Síochána to attend with them.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
Like other members, I pay tribute to all our firefighters and ambulance drivers and crews for the fantastic work they do on the front line for us all. I might begin with the NAS and the percentage of echo and delta calls that was mentioned as having been responded to within an appropriate timeframe. Mr. Morton stated the service had met the key performance indicator to a degree of 71% for echo calls. Will he give some facts and figures on the remaining 29%? That is more than one quarter of calls that were not responded to within an appropriate or acceptable period. What is the breakdown of that 29%? How bad is the issue?
Mr. Robert Morton:
The 80% target is designed to reflect the reality of rurality whereby there are some places that simply cannot be got to. Aggregate targets, by their nature, mean some patients will experience an incredibly quick response of five or six minutes, whereas other patients will have a delayed response. A total of 71% of patients were responded to within 90 minutes of an echo call in 2022. As for the balance of those patients, the average response time nationally was probably 24 or 25 minutes, but within that there would have been significant delays for some patients. In the month of March 2021, for example, which was the peak of the Covid period in early 2021, some patients waited several hours for an ambulance.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
The balance of probability would suggest that as a result of those delays, people who lost their lives would not have done so if the response had been quicker. Would that be fair to say?
Mr. Robert Morton:
That is conceivably possible. Solid work has been done by our colleagues in the UK and they have found there is a correlation between harm and a delayed response. They carried out solid, evidence-based work on that and found a link between the two. How long a delay it takes to cause harm is difficult to know, but Professor O'Donnell might wish to comment on that.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
Based on that work that was done in the UK, can Mr. Morton estimate how many fatalities have resulted from delayed ambulance responses?
Professor Cathal O'Donnell:
It is a good question. It is intuitive that if somebody needs an ambulance, the more quickly it gets to him or her, the better it will be for everyone. Within the breadth of 999 calls we get every day in both our organisations, there is a wide spectrum of acuity. If I trip and fall coming out of this meeting and sprain my ankle, or if I have a heart attack, clearly there is a difference between the two cases. As for quantifying the harm, it boils down to how long the delay is and what is wrong with the patient. That is why we stratify our response and why we triage calls. The Senator mentioned echo calls, which are the highest level of acuity we have-----
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
In Professor O'Donnell's professional opinion, have there been fatalities in this country in recent times as a result of delayed ambulance responses?
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
Professor O'Donnell will concede that permanent harm has been done to people as a result of delays in ambulance response times.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
How many people suffered permanent harm in 2021 and 2022?
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
I understand that.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
The entire heath system has a capacity issue; there is no doubt about that.
With regard to attacks and to follow on from the points raised by Deputy Gino Kenny, how many ambulance staff are on sick leave as a result of physical attacks? Has the NAS done exit interviews to identify the number of people who have left the ambulance service due to their experience of being attacked physically or verbally? It is more about physical attacks, although a verbal attack can be just as bad, to be frank. How many people in the NAS are currently on sick leave as a result of being attacked?
Mr. Robert Morton:
In the past five years, there have been, on average, 22 incidents per month that could be described as being in the category of assault. We are seeing a modest decline in the number of physical assaults but an increase in what one might describe as aggression, such as verbal assaults. There is far more aggression towards our staff. That is the feedback we are getting. As regards the impact on staff, we have injury at work grant systems. At any one time, there are approximately six people in receipt of injury at work grants. Those are average figures but there is a correlation between the two. We see far fewer people experiencing a longer-term impact from the assault than the total number of assaults, if that makes sense.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
With regard to sick leave among ambulance crews, what are the percentages in terms of sick leave? How many crew members are currently out sick?
Mr. Robert Morton:
It varies from month to month but the average trend is sitting at approximately 7%. Internationally, the trend pre Covid was 6%. Most ambulance services experienced approximately 6% pre Covid. That is a higher percentage than in most aspects of healthcare, but most aspects of healthcare take place in a far more controlled environment than the one in which our staff work. Our staff work in a dynamic environment, one that is often aggressive and, as Mr. Keeley mentioned, fuelled by alcohol or drugs. We would expect sick leave to be modestly higher in the context of an ambulance service. It is currently running at approximately 7.5%.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
Was the NAS consulted on the new UHL protocols for Ennis hospital before they were introduced? What is the view of the NAS on the protocols in terms of their success and implementation?
Mr. Robert Morton:
I might ask Professor O'Donnell to comment on that. We are consulted on all those changes. Ultimately, they are integrated healthcare models of care, so they have to be discussed with all involved, including the NAS, community services and so on. Our general view is that the protocols are quite successful. Professor O'Donnell might have more insight in that regard.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
Did the NAS advocate for those protocols, given the pressure on the emergency department at UHL? Did the NAS request that these protocols be introduced?
Mr. Robert Morton:
We would agree with any change. We did not advocate for them specifically in isolation but we have regular conversations with all the clinical care programmes. The relevant clinical care programme in the context of the situation to which the Senator is referring is the national acute medicine programme. These clinical care programmes continuously review the models of care that are being delivered by the HSE. We regularly engage. Professor O'Donnell and I have meetings with some of the various programmes every six weeks or so and we regularly explore opportunities for innovation. We have regular dialogue. I will ask Professor O'Donnell to address the specifics of the pathways to which the Senator is referring.
Professor Cathal O'Donnell:
We were integrally involved with them. It started with a pilot at Mallow General Hospital in north Cork. We designed that pilot in conjunction with colleagues in Mallow and we were centrally involved in then introducing those protocols in the mid-west. We would support them going into other parts of the country where there are medical assessment units. It is good for patients, hospitals and the NAS.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
I thank Professor O'Donnell. How many unpublished reports compiled by the NAS have there been in recent years?
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
What is the most recent report published by the NAS in terms of a review of its operations?
Seán Kyne (Fine Gael)
Link to this: Individually | In context | Oireachtas source
I welcome the teams from the NAS and Dublin Fire Brigade. I wish to put on record my thanks to the NAS, the HSE and the Government for the new ambulance bases in Tuam and Mallaranny in the west of Ireland and the extra ambulance team in Galway city. There was a commitment initially to a new deployment base in Connemara but that has been extended now to a commitment to a full-time ambulance base in the region, and I welcome that.
There has been reference to response times and population centres and so on, but what areas are the witnesses now considering in the context of geographical black spots?
Mr. Robert Morton:
I will ask my colleague, Mr. Merriman, to provide specifics. In general terms, we conducted a demand and capacity analysis. We commissioned it in July 2021 and it reported in May 2022. It highlighted a number of key areas of deficit. To the best of my recollection, the area of greatest deficit was County Sligo and the area east of Enniscrone was the most difficult in which to mount an effective response. There are a number of other areas across the country that feature on our radar every seven days. We do a formal review every seven days. Mr. Merriman leads a process every Monday morning to look at the seven-day forecast going forward. I ask him to speak about the areas he believes provide the most challenge to us every week.
Mr. William Merriman:
There are a number of areas throughout the country that cause significant issues in terms of reaching our key performance indicators, KPIs, mainly due to geographical location. These mainly centre on the west side of the country. There are areas on the south-east coast and so on that we are currently considering as well. An example is the likes of Recess, in Connemara, to which the Senator referred. We have put in additional staffing within that area. The replacement of the existing health centre there is ongoing and we hope to be in that facility by the third quarter of 2023. Areas such as that have low demand and, in reality, there is a question in respect of the need for an ambulance to be there on a continuous basis.
I refer to the need to keep people's skills up and everything else. It does not reach that threshold. We will always have areas in respect of which we will find it challenging to meet the KPIs. In the context of the likes of deployment points, we are doing a significant piece of work in conjunction with our partners in HSE estates. Where new primary care centres and so on are being developed, we seek to put in a deployment point within that from which we can deploy a resource at times of day that our computer-aided dispatch, CAD, system predicts there may be activity within that area. That will allow us to deploy ambulances, albeit only for two or three hours a day, possibly, but it will assist us to get to the area more quickly than if the ambulance had to come from Galway city or County Mayo or somewhere like that. There are areas similar to that throughout the country and they are an ongoing development that we hope to improve throughout 2023.
Seán Kyne (Fine Gael)
Link to this: Individually | In context | Oireachtas source
As regards response time, how much of the delay is due to turnaround times at emergency departments? Obviously, Limerick is under pressure and Galway, too, has experienced pressure. Are those the two areas experiencing the greatest difficulties in terms of turnaround times?
Mr. Robert Morton:
The two areas of greatest difficulty in that regard have been the south west and the Saolta footprint. Throughout winter, we have seen extraordinary efforts and great improvements in the area of turnaround times.
To put that into numbers for the Senator, throughout 2022 we saw a gradual process of reducing the average turnaround time across the country, which had been approximately an hour and six minutes. As we came into January, that was down to approximately 50 minutes. Pretty much every week over four weeks, the average across the country sat at around 50 minutes. Cork University Hospital, CUH, in particular made massive improvements. In fact, it is a shining example of what can be done. It really made huge improvements. How we effected that collectively and collaboratively was through a lot of effort from within the hospital but we also deployed what we call hospital ambulance liaison persons. Basically, these are members of the NAS who go in, work as part of the team in the hospital and try to lubricate the physical and clinical handover of the patient to get the ambulance back out as quickly as possible. That has worked quite well and has been very well received. We have very strong feedback on that from our colleagues in the Saolta University Health Care Group in particular, who have found it to be very effective. Generally speaking, there is now an incredible awareness within the hospital system of the impact of turnaround times on our ability to respond. We really get a lot of constructive engagement from hospital colleagues in that area.
Seán Kyne (Fine Gael)
Link to this: Individually | In context | Oireachtas source
I thank Mr. Morton. Going back to the concerns about recruitment issues, Deputy Cullinane mentioned the recruitment campaign and the information we received. The report we have received under freedom of information, which is based on figures obtained over the seven years up to 1 November, show that there were 538 applications for posts of qualified paramedics. Some 405 of those applicants were invited to sit an exam, but just 75 of them, or less than 18%, passed the multiple choice exam and just 56 completed all the remaining recruitment stages and got to a panel that led to a job offer. Effectively, out of the 405 applicants, only 37, or 9%, have been offered a post in the NAS. Mr. Morton quite rightly said that some of them may be repeat individuals. We all want the best people for jobs. Does the NAS have very high standards or are our applicants not up to scratch? Why is it a multiple choice exam? If I ask what the capital of Canada is, people either know it is Ottawa or they do not. Why are applicants not just asked a question? I am not familiar with the questions and what they might be asked but why not just ask the question rather than giving multiple options? The feedback in the report from applicants is that the multiple choice questions are worded confusingly; have arguably more than one correct answer; do not provide enough clinical information to answer what is being asked; or ask questions that are outside the knowledge scope required by the PHECC. The report also states that passing the test requires considerable luck. Can the witnesses comment on those figures and on the reason for the multiple choice component?
Mr. Robert Morton:
I will speak about the number of registered paramedics in Ireland. Our colleagues in the PHECC, the regulator which registers paramedics, would probably say that there are approximately 2,500 paramedics registered in Ireland at the moment. It is probable that approximately 1,400 of them work in the NAS and between 800 and 900 of them work in the DFB. When those numbers are extrapolated, the number of actual registrants who do not work for the NAS or the DFB is probably very small. Many of them do not live and work in the jurisdiction. Of those who do, some of them work in other areas. For example, there are many registered paramedics who work in the HSE but do not necessarily work in the NAS as they have secured other positions. The numbers overall are small in the context of what we want to achieve.
I can add my own direct experience to the conversation about people who have secured registration in Ireland. I am a registered paramedic in Australia and the UK. I have not done the same training programme as a paramedic in the UK or Australia; I have done Irish paramedic training. To spin it around, if somebody who comes from the Marshall Islands, for example, secures registration in Ireland, we need to ensure they are familiar with our practice, they have worked as an autonomous practitioner and they are safe to be individually privileged by the clinical director. Ultimately, this is about patient care and safety. We have to assure ourselves that these paramedics are safe to practise. That has been the basis of the competency-based assessment. That assessment is based on the clinical practice guidelines which are available to anybody to scrutinise. They are on the PHECC website, so we expect applicants to be familiar with them. Our experience has been really mixed. We have come around to the view that the best way forward is not to throw the baby out with the bathwater. What the Senator is highlighting is exactly that. It is a pass-or-fail assessment. The applicant either passes the test or does not. We have come around to the view that the best way forward is to take the applicants in, subject to all the other employment checks, and effectively finish off their training in the Irish context. We fully accept that the model, as it stands, is not delivering what we need. It is not going to make the necessary contribution we need to our workforce plan, which is why we are going to change it. We have already decided to change it in 2023.
Seán Kyne (Fine Gael)
Link to this: Individually | In context | Oireachtas source
Has it been decided that the multiple choice element will be changed?
Mr. Robert Morton:
We are abandoning the entire recruitment process. We are working on the basis of a postgraduate internship model, which effectively means that from approximately the middle of the year onwards, we will be running a new campaign. We will be trying to run it in concert with our colleagues in UL to coincide with its graduation process in order to capture its graduates as well as those from other jurisdictions who are seeking to move back to, or move to, Ireland.
Seán Kyne (Fine Gael)
Link to this: Individually | In context | Oireachtas source
That is welcome. From what I was reading, there was a concern that the NAS was ignoring UL and concentrating on its own campaigns. The integration of the university's standards is welcome. UL has stated that since 2016, when its programme was established, many of its graduates have had to go to the UK and not one UK ambulance trust has required its students to undertake the type of exams required by the NAS before their internship. Mr. Morton stated that he is qualified in the UK based on the Irish education system and standards. The UK was able to accept the students from UL but the NAS was not.
Mr. Robert Morton:
An important point of clarification is that when students from UL go to the UK, they do not practice as paramedics. That is the difference. They are going to the UK to get experience but they are not getting experience as paramedics; they are actually practising as what is known in the UK as an associate ambulance practitioner, which is equivalent to our emergency medical technician in Ireland. That is a flaw in the process, which is why we have been working very closely with our colleagues in UL to get to a point where we are asking why we cannot do an internship model here and give the students practical experience as a paramedic intern rather than as what is referred to as an associate ambulance practitioner in the UK.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
I thank the witnesses. I thank all the people with whom they work for their dedication, commitment to their jobs and delivery of service.
I wish to go back to what was said about CUH and turnaround times. Can Mr. Morton explain what it has done differently that has helped? It might be helpful from the point of view of other emergency departments. Will Mr. Morton outline what it has done differently?
Mr. Robert Morton:
I will mention some high-level pieces. I will ask Professor O’Donnell to comment because he has been intimately involved in the entire process. From our perspective, the first thing has been to look at the escalation protocols. Mr. Merriman's team has worked with the chief operations officers of all the hospital groups in order to look at how we escalate the issue when ambulances are delayed. That is about trying to bring more timely and more localised escalation and has been well received. We have also looked at the model of cohorting, which means that when there are two or three ambulance crews at the hospital, one ambulance crew will look after two patients to release another ambulance to get it available to await 999 calls. The hospital ambulance liaison person has been a big feature in supporting and driving that relationship as well. I ask Professor O'Donnell to comment on that.
Professor Cathal O'Donnell:
It has been a very successful piece of work. It is a very successful collaboration with our colleagues in CUH. Various measures have been put in place by both our organisations. We are still working through them and tweaking and fine-tuning them. I spent most of the day there on Monday working through them again. Regarding some of the specific things Mr. Morton mentioned earlier, the ambulance service personnel we are putting at the back doors of hospitals around the country, who are called hospital ambulance liaison personnel, are individuals at supervisory grade who work very closely with an identified equivalent nurse manager to spot the issues and the often small things that can slow things down.
We are getting much better at sharing data and together identifying where are the choke points. We are working through that and getting our different data systems to talk to each other better. That has been very successful.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Can this be implemented in hospitals across the country?
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
What timescale will that be rolled out in? Is it the next six or 12 months?
Professor Cathal O'Donnell:
The former, I would hope. Part of the meeting we had with them on Monday was on identifying what worked and what did not. This is a problem we have been trying to deal with over many years and the single biggest thing that helps at hospital level is sustained senior management focus. We have had that in spades in CUH in recent months and it has been a pleasure working with them on it.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
I will raise another issue in relation to the Cork-Kerry region. It was stated that the Cork-Kerry alternative pre-hospital pathway, APP, car attended 2,810 calls in 2022. What is that about? This is obviously not an ambulance but there are personnel attending when a call comes in. What service is provided?
Mr. Robert Morton:
I will ask Professor O'Donnell to comment in a minute but, at a summary level, it is an EMT and a doctor dispatched to clinically appropriate 999 calls with a view to providing the patient with an alternative pathway. We have started a trial in Cork and are working to expand it into Kerry. I ask Professor O’Donnell to talk about the bones of it.
Professor Cathal O'Donnell:
We are fortunate that my medical colleagues in CUH as a group are very interested in pre-hospital care. We have done many things with them over the years and this is one example of a positive collaboration. As Mr. Morton said, it is an EMT from the National Ambulance Service. We provide a response car and there is a doctor from CUH, usually at senior trainee level. That vehicle is targeted at low acuity calls. These are people who have dialled 999 and have - we think based on the 999 call information - something that does not necessarily require hospital treatment. We send a doctor to the scene to do an assessment and to say either the person does not need to go to hospital or to say to the person what he or she needs and to put those things in place for them on a planned or outpatient basis or by liaising with the person's general practitioner. It has been hugely successful.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Is it within a certain radius of CUH? There are areas of west Cork which take two hours to get to. Do they go out that far or is it co-ordinated in Cork city and the immediate surrounding area?
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Does Professor O'Donnell believe the service could be developed further?
Professor Cathal O'Donnell:
Absolutely. The rate-limiting step is the doctors. We have an issue, as I am sure the Deputy is well aware, around medical staffing in the system and in emergency departments. CUH, because it is a big model 4 with a big emergency department and a huge cohort of non-consultant hospital doctor, NCHD, staff, has the capacity to release someone. Smaller hospitals do not have that. That is an issue we had in Kerry. It has been rolled out in Kerry and has been successful but not as successful because of staffing challenges in the emergency department in University Hospital Kerry. The short answer to the question is “Yes”, but with the proviso that putting the physician into it can be problematic because hospitals want to keep doctors in the hospital seeing patients.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Going back to the overall numbers, we got a briefing note on winter capacity and performance. I am confused about the overall figures for emergency calls. The figure given for December and January 2023, which is a two-month time period, was 115,603 calls for urgent care. That is 1,865 calls per day. Is that the average? Are we talking about well over 1 million calls per year? We also got a figure for Dublin, which was 148,000 calls. Can we get a figure for all calls over 12 months?
Mr. Robert Morton:
There are three numbers: the calls coming in, the responses that go out and the patients that are conveyed. Calls coming in increased by about 15% year on year. If memory serves me right, it was about 339,000 in 2021 and it shot up to 379,000 in 2022. The Deputy referred to the winter period. There was a daily average of 1,835 over the three months of that period but we had days which exceeded 2,000 calls. That is double the average, which is about 1,000 per day.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Does that figure of 379,000 include calls to the Dublin service as well?
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Okay, and then Dublin was 148,000.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Dublin Fire Brigade was 148,000.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
It is over 500,000 calls in real terms.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
That is nearly 10,000 calls per week.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
What proportion of the 379,000 calls required an ambulance to be dispatched? I am not sure we are getting the full figure for the demand for the service.
Mr. Robert Morton:
Probably the most interesting question anybody could ask is about understanding the clinical acuity of workload. Our call categorisation systems at the moment are focused on identifying or hunting for the sickest patients. They are referred to as purple or red, or echo or delta, calls. Those calls attract the targets. Our experience is those are not the sickest patients. The sickest patients are often over 75 years of age, have chronic comorbidities, multiple complex conditions and do not fall into the highest acuity categories. Those patients end up being transported to hospital and are twice as likely to be admitted to hospital as a person under 65 years. We are having a conversation with the designers of the medical triage system on the need to look at this again in terms of the impact age has on clinical acuity. To articulate that, where it is a 35-year-old man with chest pain versus a 75-year-old person with shortness of breath, the probability is the 35-year-old man will be categorised as a potential heart attack or a delta call and get a fast response while the 75-year-old who is short of breath but whose other indicators seem normal will get a slower response in clinical acuity terms, though that patient may be much sicker. Clinical redesign work needs to be done in the background by the people who designed the system.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
On clinical redesign and elderly patients discharged from hospital who come back in within a time period, have we done an analysis of that timeframe? I have seen figures, though not recent ones, indicating quite a large number are back in hospital or calling services within six weeks of discharge. Has having the appropriate level of support once they are discharged from hospital been looked at? It is not necessarily Mr. Morton's area but I am sure the ambulance service comes across this, where they know from talking to a patient that he or she was only in hospital six weeks earlier.
Mr. Robert Morton:
In the sector it is known as the recontact rate. We do not measure that. Some international services do and say between 4% and 6% of patients brought in by ambulance and subsequently discharged then recontact the emergency number, whether 999, 111 or whatever the case may be. The small insight we have into that question is through our pathfinder teams. These teams consist of an advanced paramedic and an occupational therapist or physiotherapist. They focus on the over-65, but predominantly over-75, age group.
They focus on patients who are frail and older and have complex needs. The first aspect we are finding with those patients is the emergency response and the second aspect is the follow-up. We are finding that each patient requires an average of three follow-up calls to ensure he or she does not end up back in hospital. That is giving us a good insight into how effective the model can be, if one invests in good follow-up. That does not answer the question specifically, but with regard to our experience-----
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Does Mr. Morton believe we could be doing more?
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
I have come across a number of cases. In one instance, a person was in hospital for 12 weeks in total, before being discharged. However, no nurse called to the person and the person ended up back in hospital approximately four weeks later.
Mr. Robert Morton:
It is important to say it is not just about what the NAS does; it is also about how we work with other services. There are considerable developments in our enhanced community care programme that our colleagues in community services are developing, with regard to the integrated care programme for older people or the integrated programme for chronic disease management. There are natural synergies that flow across the health system. We are developing community paramedics. In west Cork, our long-term ambition is to have community paramedics operating in the west Cork area. They would interact with local GPs, but they would also connect patients with older people services and chronic disease teams, locally, as part of community help networks. That is where somebody accesses care through 999 but, in fact, what we do is we connect with them, deal with the immediate exacerbation of their condition and then plug them in to all of the other local services. That is the future of healthcare in Ireland. It is not about taking everybody to hospital. It is about only taking the patients to hospital who require large, acute hospital care, whereas our historical model is about taking everybody to hospital, whether they need to go or not. That is the big change we are embarking on.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Mr. Burke identified the progress CUH has made. There are other areas where we can make progress. In the Dublin scenario, does Mr. Morton see progress being made on that issue? In fairness, all of the staff in the HSE, the NAS and the Dublin city fire brigade are extremely dedicated and committed. However, we can get a more efficient service in the next six to 12 months and not have any duplication in the process.
Mr. Robert Morton:
That is possible. It is the work of the task-and-finish group. Some of what I have mentioned is already work in progress. Mr. Keeley has touched on the lower acuity calls we work on with our colleagues in Dublin fire brigade. Our clinical hub will look at a number of those calls already. We have a pathfinder team in north Dublin and in Tallaght. Many of the calls they respond to may have originated as 999 calls into Dublin fire brigade. Much of that collaborative work is already there and up and running. However, the question is about scaleability. I will translate it into numbers. At the beginning of 2022, we were managing 1.89% of all 999 calls through an alternative referral pathway. In January 2023, it was 4.4%. There has been a threefold progress. At one stage, we reached almost 5%. We know that the opportunity is there. It is just a question of a multi-year programme of investment to get to a point where we can offer the types of services that Sláintecare envisions and effectively provide those services, whether it is in Dublin, Carndonagh or anywhere else.
Cathal Crowe (Clare, Fianna Fail)
Link to this: Individually | In context | Oireachtas source
I welcome our witnesses and thank them for being here this morning. I was following much of the earlier discussion in my office. I ask that they forgive me if I ask any repetitive questions. I am trying not to. I think all my questions are new. I will ask about the requirement one has with regard to vehicle licensing. What level of driver licence does one need, to work for NAS?
Mr. Robert Morton:
Driver licences were a considerable barrier to recruitment in early 2021. We recruited people at the beginning of 2022. We only got six applicants for 96 places. We identified driver licences as a major barrier. We changed the eligibility criteria and introduced a phased system whereby one had to have a car licence to apply, a provisional licence to start and secure the appropriate driving licence within six months. That has massively addressed a major issue for us, but it has also left is with a new problem, whereby we now have people who are novice drivers and still require driver training within NAS. We only have two instructors. We have to establish a driver training school internally. We do an emergency service driver training programme which is a three-week bachelor of technology accredited programme. It is a UK-based standard, but there is an Irish standard called the emergency service driving standard, which is accredited by the Road Safety Authority, RSA. Our goal this year is to recruit ahead of driver training this year, with a few to securing accreditation from the RSA and getting to a place where we can deliver driver training internally. It is a tremendous bottleneck in recruitment.
Cathal Crowe (Clare, Fianna Fail)
Link to this: Individually | In context | Oireachtas source
Does NAS have a metric on how many people may have lost out on entry to the course in Cork or University of Limerick, UL, on the basis of not having the right licence at the time?
Cathal Crowe (Clare, Fianna Fail)
Link to this: Individually | In context | Oireachtas source
One of the reasons I ask is that I am on the Oireachtas Joint Committee on Transport and Communications. We were in this very room last week, talking about driver licences. I was able to give an example from my emails, of a youngster in west Clare facing a 29-week wait to get tested. He missed out on becoming a paramedic, because of that. We were told last week, in this very room, that there is now a way to triage and get people to the top of the list, if they are destined for professions such as paramedic ambulance cover. We ask NAS to engage with that, if it is not already, because the RSA and testing sites have a facility in recent weeks to triage and leap-frog young drivers who might be destined for paramedic work to the top of the list.
I see NAS has plans for September to have 128 new entrants to the course in Cork, which is fantastic. What about the course that operates in UL? Of course, it operates independently, but the pathway from the University of Limerick into NAS is not defined. I note that part of students' training requires them to go overseas. I think they go to Manchester for a six-month period or thereabouts. NAS has more expertise, but from what I can ascertain from speaking with many undergraduates, is that when they are in Manchester, the NHS is snapping people up and keeping them afterwards. We are putting hundreds of people through our third level system, the best and brightest of paramedics, and ensuring they take up contracts with the NHS. Should there be a better linkage between UL, akin to Cork, in order that we not only train them up to the highest of standards, but we retain them?
Mr. Robert Morton:
I could not agree more. Both myself and Professor O'Donnell have had the conversation, on many occasions, on why we have traditionally sat back and watched graduates go to the UK. We have been working very closely with the head of school in UL since 2021. We have looked at a complete redesign of the entire process. We got in our first five graduates from UL. Approximately 32 people go in to the programme every year. We got our first five graduates from UL in 2022 and we are working towards a new recruitment process in 2023, which will coincide with the graduation process in UL. We expect to be in a position to take almost all of their graduates in 2023 and thereafter, going forward. The Deputy is right, but I think we have arrived at a solution.
Cathal Crowe (Clare, Fianna Fail)
Link to this: Individually | In context | Oireachtas source
That is good to hear. Will the practical placement of the reconfigured course involve placement in Ireland?
Mr. Robert Morton:
It will. The placements we will offer in Ireland will be paramedic internships. We mentioned earlier earlier on, when the Deputy may not have been in the room, that when they go the north-west ambulance service NHS trust in Manchester in Cumbria, they do not do paramedic internships. They practice as associate ambulance practitioners, which is a step below a paramedic. What we hope to offer is probably more akin to the college course they are undertaking.
Cathal Crowe (Clare, Fianna Fail)
Link to this: Individually | In context | Oireachtas source
That is a sensible approach. I commend NAS on it. That is where everyone wants it to get to. One of those UL graduates has recently been in contact with my office. The person is fully graduated and has three or four years' practical experience with the NHS ambulance service. The person is mad to get back here to Ireland and is finding it impossible to get in to NAS. I will read about six lines of what the person has explained as being the problem.
When candidates apply for a position with the NAS, they have to undertake a multiple-choice exam, which this person has referenced. They say that they have been dedicating every spare minute they have to studying for these exams but that, each time, they have been presented with questions that are completely out of the blue. They say it is like the questions are set up for a group of people who have been told very specific things and, once they remember them, they can answer the questions but, if you try to apply medical logic or take a scientific approach to the question, there are multiple correct answers. They actually believe that having more knowledge is a disadvantage in this exam and do not understand why the NAS cannot just take on a group of paramedics, just as it recently recruited emergency medical technicians, EMTs, and have them do a short induction programme. They say that these paramedics would be on the road within a matter of weeks and note that this is the way it is done in the UK, where it works fine. They say they do not get why the management of the National Ambulance Service is against it.
Will Mr. Morton respond to those comments? This is not an undergraduate student but a graduate with four years' experience who is unable to get through the multiple-choice examination. I have no idea what questions are on that paper but it is a barrier and there should be some way to induct such people into the Irish system. They have all of the medical and paramedic knowledge. Surely there is a better way to get them in so they can crew ambulances and go out to emergency situations.
Mr. Robert Morton:
People have actually passed the assessment. The Deputy mentioned repeated attempts. This person has attempted the exam on several occasions but has not passed it. There might be an individual story involved in that. The process being described, which we recognise, results in either a pass or fail. In other words, it is a cliff-edge approach, which rarely works today. We have already decided to abandon that process and move towards an induction model. There is a reason we have always done it differently for EMTs and continue to do so. There are 3,500 registered EMTs in Ireland but they rarely have any clinical experience. We have traditionally always recruited EMTs and put them through an induction process to make sure they gradually adapt to the work environment, which is obviously very challenging. We have always expected qualified paramedics to be able to hit the ground running, which is why there has been a cliff-edge assessment. People are either good enough or they are not. The reason for this traditionally - and I stress the word "traditionally" - has been that the regulation of paramedics in Ireland is contained within relatively weak legislation. Each paramedic must be individually privileged to practice. This privilege has to be issued individually to each and every paramedic. In our case, it is issued by Professor O'Donnell. Unlike other autonomous practitioners, who stand on their own two feet, we have to assure Professor O'Donnell that every paramedic is competent because he is effectively carrying the can. That is why we have had the competency assessment. We have now decided to abandon that approach and move to an induction process to align with what we are doing with the University of Limerick, UL. All of those individuals will be captured and hoovered up by that approach. We will try to bring in everybody we possibly can. However, it is also important to recognise that paramedic registration is only one aspect of public sector recruitment.
Cathal Crowe (Clare, Fianna Fail)
Link to this: Individually | In context | Oireachtas source
That is good to hear. A new protocol took effect in the mid-west in early January whereby many patients who would have attended University Hospital Limerick are now being transferred to the medical assessment unit in Ennis. I believe there are plans afoot to implement something similar in Nenagh. How is that working operationally for ambulance crews? It is working from a public point of view but the hospitals are telling us they are losing out on surgical days, so there are pluses and minuses involved already. I would love to hear whether it is overstretching ambulance crews. Is it pulling them further from their bases?
I have another question, which may be most appropriate for Mr. Keeley, from the Dublin Fire Brigade. Is there a role for the retained fire service in providing some form of ambulance cover in rural counties like Clare and up along the west where many places are far-removed from an ambulance base?
Mr. Robert Morton:
The medical assessment unit, MAU, pathway is good for the patients who benefit from it, for the patients who are seeking to access 999 services generally and for our staff. It basically means that patients are getting care closer to home, getting care that is probably more appropriate and getting access more quickly. That is good for patients. For our staff, it means journey times, or job cycle times, are shorter. The probability of being trapped at a hospital many miles away and not getting off duty on time is lessened, which is good for staff. It also keeps the ambulances local for longer. If the ambulance is going to Ennis, Nenagh, Roscommon or Mallow, as the case may be, it can be turned around more quickly, which is good for patients seeking to access 999 services. It is good all around. I may ask Professor O'Donnell to touch on the clinical aspects in a moment.
On the second part of the Deputy's question, the national directorate of fire and emergency management in the Department of Housing, Local Government and Heritage has done some very good work on the retention of retained firefighters. One of the recommendations, recommendation 6, suggests that retained firefighters in Ireland should be considered for deployment in other response roles, including things like responding on behalf of the National Ambulance Service. That aligns with current Government policy as seen in the task force report on sudden cardiac death from 2007. Recommendation 5.19 said that other uniformed responders should respond to emergency calls to try to reduce mortality from out-of-hospital cardiac arrest. We believe that retained fire services could play a very strong role in supporting the National Ambulance Service. We believe it could make a great difference with regard to out-of-hospital cardiac arrest. Fire services, including our colleagues in Dublin Fire Brigade, participate in the steering group on the national out-of-hospital cardiac arrest strategy. One of the focuses of the group's work is considering how fire services can become more involved in that area. We see a stronger aspect to that. I will ask Professor O'Donnell to touch on the MAU pathway piece.
Professor Cathal O'Donnell:
The pathway has been very successful and very safe. We have had no adverse incidents. To take the example of Clare, the Deputy's constituency, the pathway is really good for Clare patients who fit the criteria. That is the key point. There are very specific clinical criteria. The safety net is a telephone call between the treating paramedic and the receiving doctor where they discuss the merits or otherwise of the case. For patients, it means they go into a hospital that is closer to home and they go into a bed in a medical assessment unit rather than a trolley in an overcrowded emergency department. A significant proportion are turned around the same day and discharged with a treatment plan in place. It is also good for the wider community. To take west Clare as an example, there are two ambulance stations, in Kilrush and Ennistymon. In November, if you dialled 999 in Kilrush, our crew would have gone out and brought you to Limerick, which is an hour and a half's drive away, and the crew may then have been held up for two or three hours waiting to get you handed over. Under the new regime, if you meet the clinical criteria, you will have half the drive and the ambulance's turnaround time will be quicker. That ambulance resource is then preserved for people in west Clare because it is back at the base.
I will mention a caveat because it is important to manage expectations. When we started this, we knew that the numbers were always going to be modest and we have seen that to be true. We are talking about two patients a day. It may be three on a good day or it may be one. It is not going to solve all of the problems with the hospitals and with the National Ambulance Service but, where it can be applied, it works for everyone, including our staff, as Mr. Morton has said, because they are back at the base more quickly and have a better chance of getting off on time and getting their meal breaks. It has been a win-win all around.
Cathal Crowe (Clare, Fianna Fail)
Link to this: Individually | In context | Oireachtas source
I am finished my questions. I thank the witnesses for their answers. They are making good headway. I have my fingers crossed that we will see more recruits. I thank the witnesses for everything they are doing and ask them to pass on my best wishes to all of the services' front-line staff for everything they are doing.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I would like to be associated with those remarks. Both services save people's lives every day. As part of that, many of their staff must see horrific scenes that they must bring home with them at night. I am aware of an incident in my constituency. The responders, who included ambulance service staff, are still dealing with what they saw that day. We are conscious of the risks the services' staff took and of the commitment they showed during the Covid pandemic, although not exclusively at that time. We are also conscious of the challenges they face. Verbal abuse and attacks on staff were touched on this morning. All of that is unacceptable.
I may sum up some of the things we are hearing this morning. A lot of the issues regarding numbers and so on can be very technical and people tend to switch off when they hear such big numbers.
We heard that it is taking much longer for ambulances to arrive. There is a general acceptance in this regard, and that is what we are picking up. The matter has been raised at previous meetings. I remember raising the issue - this is unprecedented as far as I am concerned - of 11 ambulances parked outside Tallaght University Hospital at one stage in November. The following week, there were six ambulances outside the Mater Hospital. Again, that was unprecedented. There were also issues in the context of turnaround times. We are being told it is taking longer for ambulances to arrive. There are not enough ambulances and not enough staff. There are not enough people in training, even though that training was oversubscribed. There is probably not enough space in the existing training centres. We are hearing that demand is growing. The witnesses gave us the figures in that regard, which I will go into again. It is worrying that Dublin Fire Brigade has had to request support from the National Ambulance Service on 63 occasions. This just goes to show the challenges the organisations involved are facing.
Recruitment is oversubscribed. We got the figures on the numbers of people who are leaving the service. There was a net gain this year with regard to the people coming into the service. The challenge is that we need approximately 5,000 people in the next eight years. We really need 600 or more people to come into the system every year. The system is not capable of taking that number. We heard that a new centre has opened in Cork, and there is a possible fifth centre. The system is crumbling despite all the efforts of the staff. I should have mentioned that fact that staff are being asked to work longer in many cases and that is also having an impact. We accept the huge commitment they have shown. We see something really special in the figures from Dublin Fire Brigade in the context of loyalty and staff not leaving. There is something special there. Dublin Fire Brigade should try to hold on to that as it expands.
How do we square the circle regarding the figures? How do we jump from relatively small figures? They are not going by tradition but the demand is there. How do we expand this service over those years? I hear what the witnesses are saying that the Cork situation is ongoing and a work in progress. When do we expect to see that? The witnesses might also touch on the ministerial task force trying to deal with this stuff. It had its first meeting yesterday, which was useful. How often will it meet? Will that deal with the problem of the elephant in the room and all the other issues we are discussing?
I know there are many conclusions. However, I want to put a question to both groups. How do we deal with these big challenges? How are we going to up those numbers? We heard the back and forth in respect of those issues. The other matter no one has touched on is that in order to go into these services, people need to be fit, strong and of sound mind. There are probably other criteria. People need to have the wherewithal to deal with stressful situations and so on. That all comes with the training. I could take a course tomorrow but it does not necessarily mean it would suit me.
The other issue our guests might touch on is whether the age profile is going down in both services. I hope it is. I have two questions for them. How do we square the circle with regard to the challenges they mentioned? What can we, as a committee, do?
Mr. Robert Morton:
I will start and then hand over to Mr. Keeley. Workforce planning is a massive challenge to say the least. Like directions in County Kerry, we would not want to be starting from here. It is where we are starting from, however. Ultimately, we must find a way to work up from where we are.
One of the things we are convinced about is that we need to double our capacity, but even doubling our own educational capacity will eventually reach, if you like, a rate-limiting factor, which is clinical internships within the wider health system. Ultimately, paramedic interns and students require clinical placements. Eventually, people are competing for a fixed volume of clinical placements. I refer to nursing students, health and social care professional students and so on. We need to grow our own capacity. We also need to look at apprenticeships. We have spoken to Solas about that. The support of the committee, for example, with the whole idea of apprenticeships is welcome. We also need to work with more universities. At the moment, we have a formal relationship with University College Cork and we have a growing relationship with the University of Limerick. However, there are other universities we would like to work with in due course to create more opportunities for people to do a bachelor of science in paramedic studies. That creates more avenues for us.
Then there is the international domain and the number of Irish people who are living abroad and who, perhaps, have a desire to come home. How do we make it interesting? How do we incentivise them in doing that? One of the ways of thinking about it, which is clearly beyond the scope of the HSE, is recognition and how we value our workforce. We had a very solid piece of work done in conjunction with our trade union partners that took the form of a review of roles and responsibilities. It basically recommends a change to the professionalisation and workforce model in the National Ambulance Service. It has recommended changes, for example, to remuneration arrangements. That is clearly beyond our scope. The HSE as an employer does not set terms and conditions. Certainly, the HSE supports a very detailed business case, which has been designed in collaboration with the trade unions. That business case is with the Department of Health. I presume it will eventually find its way to the Department of Public Expenditure, National Development Plan Delivery and Reform. It will also probably be taken into consideration in future national pay talks. Obviously, there is a mechanism by which to look at the reward and remuneration of and the recognition arrangements for paramedics, generally speaking, working in the National Ambulance Service. That is obviously beyond our scope, however. That is an important factor in terms of supporting retention but also attracting new people and encouraging and supporting people to move back from abroad.
In terms of the task and finish piece, the Chairman is right; it is really difficult. It has been going on for many years. There have been several attempts to unpick the issues involved but it would certainly be the case, and Mr. Keeley will probably share this view, that the Ministers appear to be focused on achieving an outcome with which they will both be happy. They have tasked us and others in both Departments with achieving that outcome. That is really what we are working towards. The schedule of meetings are likely to be every month. That is what it is shaping up to be. The next meeting has already been scheduled from yesterday. There seems to be a lot of energy behind it at the moment. I will hand over to Mr. Keeley-----
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Mr. Morton might comment on the age profile.
Mr. Dennis Keeley:
Dublin Fire Brigade's focus is on Dublin city and county. Our scale is somewhat different from colleagues in the National Ambulance Service in the context of that focus. We operate 14 ambulances. What the future looks like in terms of the capacity and expansion of our service will very much fall from the task and finish group. Will we be in a situation where we will need additional ambulances as a result of the findings and solutions that, as Mr. Morton said, will hopefully evolve over the coming weeks and months?
We have been very fortunate - and the Chairman touched on this - in terms of staff retention. We advertised relatively recently. Thousands of people applied. We will build a model of recruitment based on our needs for the coming two to three years. We will have a panel of approximately 200 based on our requirement to fill positions in our fire and ambulance services. We anticipate small enough numbers of staff retiring. We have the capacity to expand our numbers based on our current recruitment campaign.
We agree with Mr. Morton that the commitment to the task and finish group seems to be at a moment of high commitment at a political level. We certainly want to get a solution through this process and make an input into it. That solution is a Dublin-based one. Dublin Fire Brigade will play a big part in it. We and all parties to the process see Dublin Fire Brigade contributing in the long term to the provision of ambulance services for Dublin city and county. The model will evolve from that and if it is an expanded service, Dublin Fire Brigade is well placed to fulfil it.
Funding for the service is at the core of the issue. Part of the task and finish group's role will be to resolve the issue of funding and get to a position where Dublin Fire Brigade can provide the service required by citizens, in agreement with the HSE on what capacity might look like. We are also aligned with the future of the ambulance service nationally, which we hope will involve fewer people going to accident and emergency departments and, where possible, people being appropriately cared for in their homes or in other centres. Dublin Fire Brigade is committed to supporting the NAS and working with it to achieve that outcome.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
What is the average age of the members of the Dublin Fire Brigade?
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
That is the case right across the services.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I will start with the different types of response calls. Clinical status 1, the life-threatening cases, are the ones we need to respond to as quickly as possible. They are echo and delta calls. We then have Charlie and bravo calls, which are clinical status 2, serious but not life-threatening, and alpha and omega calls, which are clinical status 3, non-serious or life-threatening. Are any calls in those categories happening because of a lack of alternative care pathways? For example, we have a serious problem with overcrowding in hospitals. Part of it is due to capacity problems in hospitals and part of it is because the wrong people are going to the wrong place such as people going to emergency departments who should be cared for elsewhere. One good example is not being able to access a GP out of hours. Is that part of what is driving increased demand on the National Ambulance Service, especially I imagine as regards alpha and omega calls and possibly Charlie and bravo calls? Do the witnesses have any data on whether the lack of GP or other out-of-hours services is putting additional pressure on the National Ambulance Service?
Mr. Robert Morton:
There are two interesting issues around that. For example, if we take the three-month winter period when our call volume pretty much doubled and look at the concentration of the period over the festive season, on some days we had more than 2,000 calls. We saw a dramatic increase in lower acuity calls during the day. One could associate that with the availability of other health services. A reasonable correlation can probably be drawn between the availability of GPs and people accessing ambulance services. The second matter is probably indicative of a trend. When we look at our sources of demand - an AS1 call is basically a 999 call - 999 calls are growing exponentially. In our ten-year review from 2017 to 2027, we are projecting a 107% growth rate across 999 call volumes. However, call volumes that come from GPs are in decline. We have seen a 6% reduction in the number of calls we receive from GPs. The numbers suggest that more people are accessing healthcare through 999 calls than would have traditionally ended up with us via a GP.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
There is some evidence to suggest that. We hear a lot about the offload turnaround time in hospitals, which have unfortunately increased, as Mr. Keeley noted in his opening statement, through no fault of paramedics. We hear about ambulances parked outside hospitals from which patients cannot be disembarked because no bed or capacity is available. Is that a growing problem? During the months Mr. Morton mentioned, that would have put pressure on all services, including the NAS. Is that issue of people waiting longer for access to a bed, waiting hours if not days on trolleys, or the lack of bed capacity have an impact on the ability of the NAS to do its job? If ambulances are waiting longer outside hospitals, what impact does it have on the NAS's ability to deliver a service or how big a problem is it? Perhaps Mr. Keeley could answer that question as he referenced it in his opening statement.
Mr. Dennis Keeley:
In the Dublin area, the average time is 36 minutes now, which is an improvement. It is a problem. When ambulances are sitting at accident and emergency departments with patients, they are obviously not available to respond. Much work has been done. Mr. Morton mentioned earlier - the Deputy may not have been here - that staff have been allocated whose specific task is to liaise with hospitals at the back door, as Mr. Morton put it, to try to improve the turnaround times. That work has been successful. Dublin Fire Brigade has an avenue to make contact when our queuing times are escalating.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Mr. Keeley is saying it is a problem but a contingency plan is now in place. More is being done to alleviate that problem.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I will come back to the Brady-Flaherty report. It has been mentioned by a number of witnesses, including Mr. Morton. This committee requested that it be furnished with the report. Before they leave, will the witnesses confirm whether there is any impediment to them giving this committee the report? Do they have to get permission from Dublin City Council or the Minister or can they make the decision to give it to us?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Exactly, and most of it was serialised in a newspaper anyway. I ask for that to be done. Were the recommendations of the report fully implemented?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
When we get a copy of the report, we could be back asking the witnesses to identify the recommendations that have not been implemented and asking for the reason or rationale. Am I correct that Mr. Damien McCallion commissioned that report? He is now in a senior position in the HSE?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I think it was.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I will come back to two critical issues, response time and delivery of services in Dublin. There are particular problems with response times in the south east. I met Mr. Morton and some of his colleagues and senior management in the past about that region. Before I ask about that, I will return to the issue of delivery of services and governance in Dublin. We talked about an alternative model. A working group is in place and Ministers are working on the issue. Mr. Morton mentioned that there are thorny issues which have probably impeded a quicker decision being made on this. I put it to him that those thorny issues are that we have two organisations that potentially have different views. Can we assume there is a difference of opinion between the NAS and Dublin Fire Brigade as regards what might be the best model for Dublin or are they and their representative organisations on the same page? This has been going on for a long time. I have met senior staff in the Dublin Fire Brigade service who I imagine meet all politicians and who say there are differences of opinion. Is part of the problem that the two organisations have different views?
When I look at the delta response times for Dublin for 2022 and compare them with other parts of the State - it was not only for December, there were particular circumstances in December - the figures show that 19% of delta calls were responded to within the 19-minute target. I will compare that with other regions. The national figure is 30%.
It was 33% in north Leinster, 28% in the south, 36% in the west and only 19% in Dublin. In November, it was 27% in Dublin but 48% in north Leinster, 38% in the south and 45% in the west. I could go through each month but I will not. My point is that those delta response times in Dublin are way behind other areas. Will Mr. Morton outline why he believes that is the case? When he mentioned "thorny issues" that impeded a decision being made, is that because there are different views within the two organisations?
Mr. Robert Morton:
Regarding the first question, the straight answer is that it is a capacity issue in Dublin. Dublin just does not have enough ambulances. It is not just about ambulances; it is a multiplicity and diversity of responses. The simple fact is it just does not have enough. I could compare Dublin to similar cities, for example, Adelaide, where I worked for quite a period. It has a similar population and a similar geographical spread, etc. There are more than double the emergency resources in Adelaide than in Dublin, even though there is the same population and the same-----
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
How did we get to a point where we allowed a situation to arise in which there is an average of 30% statewide for delta calls but only 19% in Dublin?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Mr. Morton said it was due to capacity and not enough ambulances. How does Mr. Morton think it got to that point?
Mr. Robert Morton:
The key issue around capacity generally is that demand rises faster in a large urban area like Dublin. On the east coast, for example, demand for ambulance services traditionally, pre-Covid-19, was rising at 4% per year, whereas it was 3% per year on the west coast. Fundamentally, this is the fallout from a lack of investment over many years.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
That does not correlate with the other information I have. I wish to come back to Mr. Morton and get a response to the different opinions on the alternative model for Dublin before the session ends. On the issue of response times, in the south east, the average response time for both delta and echo calls was 21 minutes in 2019. In 2020, it went up to 22 minutes. In 2021, it was 28 minutes and, in 2022, it was 33 minutes. I assume that the 33 minutes refer to when an ambulance arrives at somebody's door from the point of a call. Is that what that means?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
It is quite a shocking figure, for someone who lives in the south east. It is more shocking when considering that it includes cardiac services. In County Waterford, my constituency, there is no 24-7 service for primary percutaneous coronary intervention, PPCI, as Mr. Morton will be apparent. People in counties Tipperary and Waterford and other parts of the south east have to travel by ambulance to Dublin or Cork if they have a life-threatening cardiac issue, yet the average response time for emergency calls is now 33 minutes.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
This is a yearly figure, so they can fluctuate. I am being fair by looking at year-on-year comparisons.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I would like Mr. Morton to answer the question about the alternative model for Dublin. Everything I have heard today from both key witnesses is that there are capacity issues, more ambulances, ambulance paramedics and capacity are needed and response times are going in the wrong direction, which we can see from the figures. I do not see the urgency in the response. I do not have time to go into the workforce plan, but Mr. Morton mentioned a ten-year plan. The workforce plan I have is from 2022 to 2026. That states 3,018 whole-time equivalent positions are needed. I do not see any chance of those figures being met. I would like Mr. Morton to answer the question because there is a lot of concern about the Dublin service. The figures will be different in big urban areas, but only 19% of delta calls responded to within the HIQA timeframe is a shocking figure. It is out of sync with other areas. Mr. Morton said there are particular problems with capacity but there are also clear issues with the governance model and work is being done. Are the "thorny issues" because there are different views within the NAS and the DFB on what the best model is?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I am not asking that question. I am asking whether, in Mr. Morton's view, there is a difference of opinion in what the two organisations see as the best model. I understand it is a difficult question to answer because Mr. Morton may have a view of what the best model, which may differ from that of Mr. Keeley's organisation. That is partly why we are in the position we are in.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
There needs to be a level of honesty about the problem is. Will Mr. Morton define what he meant by "thorny issues"?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
If Mr. Morton and Mr. Keeley, for example, were given the authority to come up with an alternative model, does Mr. Morton think they would be on the same page and they could do it?
Mr. Robert Morton:
We would certainly start on the same page. How you get there is the challenge and whether or not you can bring all the other stakeholders with you. The challenge is to bring every other stakeholder with you in this scenario. That is what the task and finish group is seeking to achieve. It is about recognising that there are not just two organisations; there are parent organisations, Dublin City Council, the HSE, parent Departments, Ministers and trade union partners.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I accept that. At the end of the day, it has to be about what is right for patients.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Will Mr. Keeley respond?
Mr. Dennis Keeley:
It is a difficult question to answer. The task and finish group has identified critical aspects or critical thorny issues, to narrow it down, that must be addressed during the process. If those particular issues can be addressed, there will be a single model that both services can provide for Dublin. That will be patient-focused and will deal with safety issues around patient care. There are not that many thorny issues. They range from financing and funding of the services to the system two the services will sit on, how that will work and what it will look like.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Does it include a greater role for the NAS in Dublin?
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
This is one of the issues identified.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I was not trying to catch anybody out. We all want the best outcome for the people of Dublin, whatever that is. We need to get that resolution as quickly as possible. I commend all the DFB's staff for the excellent work that is being done.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
A comment was made about people not contacting their GP or going through that route and, instead, calling the emergency services and that there is an increase in that. The acting CEO of the HSE was before the committee and he said there is a belief among some sections of the population that if someone rings 999 and he or she is picked up by an ambulance, he or she will get into the hospital system more quickly. He said that is not the case. Will Mr. Morton comment on that?
Mr. Robert Morton:
That is true. Ultimately, when someone arrives at the emergency department, he or she will be categorised into one of four categories whether he or she comes by ambulance or not. That is done by a triage nurse, generally, more or less in every hospital. They use a system not dissimilar to what we use. It is called something different but it pretty much arrives at the same thing. What they are looking for is that the sickest patient will be brought in. That sickest patient may not necessarily be the patient who was brought in by ambulance. It could be somebody who got out of a car, stumbled into the emergency department and collapsed on the floor. Going by ambulance does not get someone up the queue. That is the simple fact of it.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
We have had people in here to discuss the winter plan. Additional moneys were made available for the winter plan, including €7 million for the pathfinder projects, which our guests have talked about this morning. I think we all accept that the allocation is a welcome development and the more we can spread that across the State the better. Has the initiative had an impact on hospital turnovers? We have been told this morning that there has been an improvement and, if so, it is important that we acknowledge any improvement. This morning, many of our questions has been very negative. However, our guests have mentioned that there have been improvements in the fleet, equipment and ICT. If there are positive developments then it is important we acknowledge them. Does Mr. Morton believe the funding for the winter plan has made a significant impact?
Mr. Robert Morton:
Yes, it has. In the winter of 2021-2022, for example, we received €5.9 million and that was recurrent money. Normally, winter money would not always be recurrent but this was recurrent money. We were able to deploy the money to mobilise nine pathfinder teams and, at this stage, four or five of those teams are already up and running. The remainder are due to be up and running by the end of March. They are located in Beaumont, Tallaght, Waterford, Limerick and Cork. They will be in Kilkenny, Letterkenny, Galway and another place. They will be up and running. This year, we will extend the pathfinder model to both Navan and Tullamore. The money is having a real impact. It is really impacting on patients, particularly older frail patients. It is having a much greater impact for our colleagues who work in the acute hospitals system because those are the patients who have a 57% chance of being admitted once they arrive at an emergency department, ED, unit. Also, their average length of stay tends to be twice the average length of stay of somebody under-75 years. That sort of investment gives a lot of impact to the wider health system and creates bed capacity for patients trying to access care. This winter, for example, we got €6.8 million non-recurrent money, which has been incredibly useful. We have used that money for hospital ambulance liaison people and increased our intermediate care capacity to support patient flow between hospitals. Again, the funding has been incredibly helpful because it has enabled hospitals to manage some of the surges they have had to deliver and kept hospital beds moving as best they possibly can by trying to keep patients moving out to nursing homes, residential care facilities or model 2 hospitals, for example. The investment has gone in but it stops on 31 March so that is this year's money but the pathfinder project will continue.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
We have dealt with this funding issue before, whereby funding, which was allocated and put towards the winter plan, has not been spent. I welcome the fact that this money has been spent.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
We have reached the end. I thank the representatives the National Ambulance Service and Dublin Fire Brigade for their assistance on this very important matter. I echo all the earlier calls by members of this committee to ask the organisations to convey our appreciation to their members for their work and commitment. As Mr. Kelley has said, a service is provided 365 days year and we appreciate it all. I hope we have dealt with some of the issues concerning the challenges that face the service. I think they are huge challenges. Again, as a committee, we hope to be able to support the demands the organisations have outlined here. We have had a useful meeting.
Mr. Robert Morton:
We extend an invitation to the committee. We have done so before and some members have availed of our invitation. I suggest that the committee visits us at our National Emergency Operations Centre, NEOC, in Tallaght. There is a standing invitation for any committee members who want to visit.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Now there is no excuse for me not to go. I adjourn this meeting until our meeting in private session next Tuesday.