Denis Naughten (Roscommon-Galway, Independent) | Oireachtas source

I move:

That Dáil Éireann:

acknowledges that: — pre-hospital emergency care services in Ireland are changing with the growing and ageing population, and a holistic approach is needed to address the issues that hospitals, ambulance services, community, voluntary services and health care workers are facing;

— Ireland is one of the few countries in the world to boast a National Ambulance Service (NAS) with a single national regulator, the Pre-Hospital Emergency Care Council (PHECC);

— pre-hospital emergency care in regional and rural Ireland is provided by the NAS;

— the NAS works with Dublin Fire Brigade, Air Corps, Irish Coast Guard, Irish Community Rapid Response and Northern Ireland Ambulance Service;

— the NAS provides high-quality, safe and person-centred emergency and urgent care services and is the statutory pre-hospital emergency and intermediate care provider for the State;

— the NAS employs approximately 2,000 staff, including advanced paramedics, paramedic supervisors, paramedics, community paramedics, emergency call takers, emergency dispatchers, aeromedical dispatchers, critical care nurses, clinical hub nurses, doctors and intermediate care operatives;

— at local community level, the NAS is also supported by volunteer-run community first responder schemes;

— community first responders are an integral part of dealing with an emergency in the community in that they have the potential to provide vital lifesaving Cardiopulmonary Resuscitation (CPR) and defibrillator treatment to patients while an ambulance is enroute;

— capacity demand on all pre-hospital emergency care is growing, and the NAS takes more than 300,000 emergency calls annually, with growing demand for service, as the NAS received 1,865 calls a day in December and January, an increase of 19 per cent on the same period a year ago;

— response times are getting longer, and the Health Service Executive (HSE) revealed that the NAS is not meeting the response target times for emergencies, with ambulance response times having increased on average by 10 minutes across some regions since 2019;

— incident duration times and incident queuing times are getting longer;

— life-threatening illness or injury cases are severely compromised by a lack of resources;

— for most patients a quick medical response determines their survival chances; for example, for every minute that elapses after a cardiac arrest, a person's chances of survival decrease by 7-10 per cent, and for every minute that stroke treatment is delayed, a person loses two million brain cells, highlighting the need for faster emergency medical response times especially in the most serious of cases;

— every year in Ireland thousands die from cardiac arrest, approximately 70 per cent of which happen in the home;

— currently there is just a 5 per cent survival rate from cardiac arrest in the community;

— off-load hospital delays have increased, which is compounded by the fact that there are currently less than two acute hospital beds per one thousand people in Ireland, which is below the Organisation for Economic Co-operation and Development average, and for every 82 people forced to wait more than six to eight hours for admittance to a hospital there is one death above the expected mortality rate;

— choking or suffocation is a significant unintentional cause of death in children; and

— the Irish Medical Journal reported in 2020, that there were 4,385 hospital admissions related to anaphylaxis between 2005 and 2016, with the highest rates of anaphylaxis-related admissions occurring in young adults and children; recognises that: — an increase in population numbers and life expectancy will result in significant additional future public health demands, in addition to those currently experienced by health and ambulance services;

— the recently published Royal College of Surgeons in Ireland "Surgery for Ireland" report proposes a new networked approach for emergency surgical care which would place significant additional demand on our ambulance service;

— in 2018, there was a Government decision on the reconfiguration of trauma services following the publication of the report entitled "A Trauma System for Ireland: Report of the Trauma Steering Group", that the plan should not proceed in advance of improvements to air ambulance services and enhanced additional ground ambulance resources;

— while the Telemedicine Rapid Access for Stroke and Neurological Assessment programme has been successful in providing timely care to patients, thus reducing their risk of disability, it remains to be rolled out to all acute emergency departments (EDs);

— the failure to establish a national first responder register by the NAS precludes many of the community first responder scheme volunteers from responding to a local medical emergency, such as cardiac arrest, choking, chest pain or breathing difficulties;

— there is a need to shift more medical care from acute hospitals to community care settings;

— NAS recruitment efforts are currently being overwhelmed by service demand and retention challenges, and in order to meet current and future demands there is a need to:

— recruit an additional thousand NAS staff and resources, including a greater number of paramedics and additional ambulances; and

— double the NAS workforce over the next ten years;

— paramedics are increasingly accepted as healthcare practitioners who can make significant contributions towards improving the health and well-being of populations beyond traditional emergency response and transportation roles, but this needs to be regularised;

— this enhanced scope of practice for paramedics should include the delivery of community paramedics, noting that there are currently just 11 within the NAS, and there is a need to develop specialisms in areas such as aeromedical, retrieval, critical care and mental health paramedics and expanding the scope of practice of frontline emergency paramedics to provide care in line with the Sláintecare principles;

— the paramedic profession has developed significantly in terms of clinical practice over the last 25 years, yet it is not recognised as a profession under the Health and Social Care Professionals Act 2005, nor by the largest employer of paramedics within the State, the HSE;

— this failure of recognition limits career progression, negatively impacts retention, restricts alternative pathways of care and in the case of HSE employees, limits access to health and social care professions (HSCP) education opportunities within the HSE, and as a result the retention of employees within the field of paramedicine generally, and within the NAS specifically, is an area which needs to be addressed;

— PHECC was established under Statutory Instrument No. 109/2000, and in the absence of primary legislation underpinning its role, PHECC cannot:

— protect the Emergency Medical Technician (EMT) or Paramedic title;

— regulate those who do not sign up to its voluntary codes of practice;

— standardise scope of practice across employers as each organisation's medical director must "privilege" the scope of practice for employees/members under the PHECC's "Triple Lock" mechanism addressing credentialing, licencing, and privileging;

— institute fitness to practice processes similar to other regulated professions, such as teaching, nursing, medicine or other HSCP;

— there is an urgent need for a strategic focus on the field of paramedicine, similar to the process undertaken by the Commission on Nursing in the late 1990's, thereby establishing pathways for enhancing patient care through relevant professional governance, appropriate education, and expanded practice, all leading to improving retention of personnel; and

— there is no ready supply of paramedics in Ireland, nor indeed in the international setting, therefore the NAS for the most part must educate its workforce in its own college, and currently the NAS delivers a BSc (Honours) Paramedic Programme and an MSc Specialist Paramedic Programme in affiliation with the School of Medicine in University College Cork; and calls on the Government to: — address the ongoing workforce issues across the entire healthcare system;

— improve the working environment and support for all existing emergency medical care staff;

— establish a commission on paramedicine as a matter of urgency to examine issues, such as:

— primary legislation to recognise and regulate the profession appropriately;

— to ensure that all paramedics have access to an appropriate initial and on-going education;

— institute an expanded scope of practice and specialisms;

— address retention and career progression; and

— tackle the on-going workforce issues within the paramedicine field;

— support the NAS in its efforts to build staffing levels to meet the increasing demand for services, including rolling workforce planning surveys, matching of demand against dynamic deployment models, and the filling of long-term roster vacancies in a timely manner;

— enhance the availability of alternative care pathways available to paramedics, ensuring that care is provided in the appropriate setting including close to or in the home, thereby reducing EDs attendances and associated demand pressure;

— enhance community paramedic numbers to assist in the care of patients with chronic disease in the community setting, thereby reducing ED attendances;

— support the recruitment of additional student paramedics across NAS programmes, and immediately increase by at least 60 students per year the number of student paramedics trained within the NAS College;

— further increase paramedical educational capacity by supporting the establishment of additional campuses throughout the country;

— develop career progression pathways for EMT staff currently operating as intermediate care operators who wish to progress to a paramedic role;

— review and improve the current ED triage system to support a rapid handover of patients from an ambulance to hospital EDs, to ensure emergency ambulances are freed up as soon as possible to become available for 112/999 calls;

— expand the NAS by-pass protocol on the use of model 2 hospitals and their medical assessment and injury units, to treat medically appropriate patients;

— identify through the Advanced Medical Priority Dispatch System what emergency calls could and should have been more effectively dealt with in the community or alternative health care settings;

— undertake an information technology (IT) system review of the NAS to examine current and potential use of IT in the delivery of care, including access to telemedicine support, enhanced pre-hospital diagnostics, on-going practitioner education and enhanced reporting and audit capacity;

— support the development of a public app that allows the 94 per cent of the population with a smart phone to automatically alert ambulance and community first responders to an emergency, and to provide them with advice on performing CPR in the interim;

— install and maintain defibrillators outside all public buildings through a revision of the building regulations;

— provide public funding for defibrillators, to include funding to maintain and monitor the pads and battery replacement;

— ensure the critical care ambulance retrieval service for children operates on a 24/7 basis;

— revise current legislation to facilitate the rollout of additional emergency community medical interventions, such as the provision of epinephrine autoinjectors, inhalers and aspirin in locked defibrillator cabinets, similar or in tandem with public access defibrillators;

— require and fund the provision of epinephrine autoinjectors for emergency use in school and childcare facilities;

— ensure that all staff in school and childcare facilities are trained in the use of the specific epinephrine autoinjector provided to their facility;

— ensure that all staff in childcare services who have completed foundation training undertake and complete a paediatric First Aid Response course funded by TUSLA and the Department of Children, Equality, Disability, Integration and Youth; and

— establish a stand-by pre-hospital emergency response team to deploy internationally in the immediate aftermath of natural disasters like earthquakes, tsunamis, and wildfires.

As Ireland's population grows and ages, pre-hospital emergency care is facing increasing pressure to adapt and the staff within the service are more than willing to meet the challenge. The National Ambulance Service, NAS, has come a long way from the days when it was just a transport service, transporting patients to hospital. The role of the paramedic has changed from being an ambulance attendant to a specialised healthcare worker involved in the delivery of advanced, out-of-hospital emergency clinical care; which is vital to the proper functioning of our health service. However, paramedicine is not considered a profession by the biggest employer of paramedics; the Health Service Executive, HSE.In many countries, the paramedic is increasingly seen as a healthcare professional but, in Ireland, the full potential of the role has yet to be realised. Paramedics are classified as emergency medical technicians, EMTs - healthcare workers on the same paygrades as cleaners and domestic staff. They are not aligned to medical pay scales and remain among the lowest-paid clinical disciplines in the country. Currently, the titles "paramedic", "emergency medical technician" and "advanced paramedic" are not protected. This means that anyone can call themselves a paramedic, even if they do not have the qualifications or experience to provide safe and effective healthcare. This lack of professional recognition makes it difficult to retain staff or recruit new ones. Paramedics themselves have said that they could do much more but their role needs to be clearly defined and legislated for.

One of the areas where they could provide more care is in the delivery of community paramedicine. For this to happen, the community paramedic needs to be recognised as a distinct clinical role, with more autonomy, and the ability to prescribe medication as is the case in other countries, such as the UK. Recognition of paramedicine as a profession, with degree level training and protection of the title, would give our healthcare system a trusted extra set of hands to relieve the pressure faced by our emergency departments every day. Giving more scope for paramedics would mean that more people could be dealt with in their communities and in their homes, providing alternatives, in appropriate clinical circumstances, to overcrowded GP surgeries and emergency departments.

Paramedics, especially community paramedics, could be the link between communities and services such as social workers, community healthcare nurses, pharmacists and GPs. They could even revitalise the home visit role that was once performed by GPs. In Europe, North America and Australia, community paramedicine programmes, working, for example, with older or more vulnerable members of the community, have resulted in up to a 50% decrease in patients being transported to emergency departments.

To make this happen, we want a commitment from Government to establish a commission on paramedicine to transform the role, just as has happened in nursing. The nursing profession is now properly recognised as an equal clinical partner within the health service, rather than as it was historically seen, as an attendant to the doctor. As a matter of urgency, the commission on paramedicine needs to examine issues such as the recognition and regulation of paramedicine as a profession with appropriate primary legislation, an expanded scope of practice and specialisms for paramedicine needs to be clearly set out, and appropriate initial and ongoing education for all paramedics. We must move from voluntary to third level education within the profession in order that it is aligned with the current and future needs of our healthcare services.

Finally, the commission on paramedicine must address the recruitment, retention and career progression issues. More staff are needed due to the increasing demands but that will not happen as long as paramedicine is not seen as an attractive career option. In conjunction with this, pay scales for current staff need to be aligned with the medical profession to reflect and reward the increased responsibilities of the role.

Paramedics could play a vital role in the community. They are trained and experienced but they need support. The role needs to be recognised, regularised and protected. It needs consistency of training and an alignment of pay in accordance with responsibilities. A commission on the future of paramedicine in lreland could make that happen.

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