Speeches

Speech by Minister James Reilly TD Private Members’ Business 15 April 2014 – Ambulance Services

At the outset I would like to thank the Deputies for raising this issue and providing me with the opportunity to reaffirm to the House, this Government’s commitment to the development of our ambulance service.

In recent years we have made a very significant investment in the ambulance fleet, in new technology and in our workforce.  Indeed, in 2014 an additional €3.6m and 43 staff have been provided to the National Ambulance Service in the HSE Service Plan.

In recent years we have made a very significant investment in the ambulance fleet, in new technology and in our workforce.  Indeed, in 2014 an additional €3.6m and 43 staff have been provided to the National Ambulance Service in the HSE Service Plan.

A major reform programme is now underway to reconfigure pre-hospital care services in Ireland.  This reform programme will ensure a clinically driven, nationally co-ordinated system, supported by improved technology.  Our aim is to provide a service that is safe, high quality, timely and patient centred.

Response Times

But first, let me address the issue of response times.  There have been a number of media reports recently regarding delayed responses, and I want to take the opportunity to confirm that responding to emergency calls within target is a key objective of the NAS.

It is acknowledged however that response times around the country vary, based on a number of factors including:

–        geographic and demographic challenges (e.g. the west of Ireland)

–        road networks

–        use of emergency ambulances for inter-hospital transfers

–        hospital hand-over times.

HIQA has set emergency response time targets and these have been implemented by NAS on a phased basis since 2011, in tandem with planned service improvements.  In the case of calls classified as ECHO, which are life threatening cardiac or respiratory calls, the 2013 target, set by the HSE, was that 70% of such calls should have a patient carrying vehicle on scene within 19 minutes.  In the case of DELTA calls, which are calls for life threatening conditions other than cardiac or respiratory, the target was 68%.

Notwithstanding the fact that the volume of emergency calls increased last year, national responses for ECHO calls were less than one percent below the target of 70%, with some regions performing as high as 79%.  For DELTA calls, national performance was just under four percent less than the target of 68%.

I would also point out that while the NAS did not reach its targets in 2013, it responded to more calls within the target time than in 2012.  If the volume of calls had remained constant, there would have been a significant improvement in response times.

In order to drive improvements in response times, the bar has been raised this year and a new target has been set in the National Service Plan, for 80% of all life threatening calls to be responded to in less than 19 minutes this year.  It is worth noting that when this Government took office, there were no response time targets at all.

I should however caution that while response times are helpful for performance measurement, they give a very narrow view of service performance, and should not be used in isolation.  Accordingly, when we are assessing performance we should also have regard to patient outcome indicators.  I am pleased that the first outcome key performance indicator, which is for the return of spontaneous circulation in the Emergency Department for heart attacks under certain defined circumstances, is being introduced by the NAS this year.

The NAS is proactively seeking to improve response times and has put in place a Performance Improvement Action Plan.  The plan has 57 action points including;

  • Ø improving call-taking allocation and dispatch and crew mobilisation times;
  • Ø appropriate targeting of emergency and intermediate care vehicles;
  • Ø improving Emergency Department turnaround times.

National Control Centre Reconfiguration

A key measure of the reform programme is the National Control Centre Reconfiguration Project.  The NAS has operated in eight ambulance regions, with no inter-connection of radio and computer systems.  This has delayed improvements in emergency response times, particularly at regional boundaries where the nearest ambulance may be in the neighbouring region.

A reconfiguration project is underway to establish a single national ambulance control centre on two sites, with significant investment in new voice, data and mapping technologies.  This is in line with best international practice and will allow the NAS to deploy emergency resources more effectively and efficiently, regionally and nationally, rather than within small geographic areas.  The National control centre will be located in Tallaght and Ballyshannon, with the project expected to be completed next year.

In 2013, under the Control Centre Migration Plan, Cork, Tralee and Navan Control Centre functions moved to the NAS Control Centre at Townsend Street.  Townsend Street has operated a computer aided dispatch (CAD) platform since November 2013.

National Digital Radio (TETRA) is now online in the former East region (Dublin, Kildare & Wicklow), Cork and Kerry and the former North East (Louth, Meath, Cavan & Monaghan).  It will roll out to other areas during 2014, starting with the former West area.

 On-Call Rostering

In co-operation with staff, the NAS is successfully moving from on-call rostering, where staff are off-site waiting to be summoned, to on-duty rostering, where paramedic crews are in their stations or vehicles during shifts.  This leads to faster deployment as the crew is in position to respond immediately to calls, rather than the average on-call deployment of over 20 minutes.

Intermediate Care Service

A key performance issue has been the use of emergency ambulances for routine inter-hospital patient transfers.  The NAS is developing dedicated non-emergency patient transport, through the Intermediate Care Service, for routine transfers.  This frees up emergency resources for emergency tasks, improving response times and performance.

The ICS, with over 73 IC staff and 36 vehicles, now operate in Cork, Galway, Sligo, Letterkenny, South Dublin, Mayo, Limerick, Louth, Monaghan Cavan, Kerry, Waterford, Sligo and Roscommon.  Further staff will be assigned in 2014.

Turnaround Times in Emergency Departments

As I indicated, improving turnaround times in Emergency Departments is addressed in the Performance Improvement Action Plan.  Ambulance turnaround times at hospitals are now monitored on a continuous basis via the command and control centres.  When an issue regarding turnaround time arises, the NAS operates an escalation policy.  This escalation policy involves contact via the command and control centre to the hospital ED, and the dispatch of an Ambulance Resource Manager to the ED to assist in the mitigation of the delay.  I should also mention that the NAS is currently developing a national ED turnaround framework, to ensure consistent and rapid intervention to any delay in ambulance turnaround times.

Emergency Aeromedical Support Service

Earlier I noted that one of the factors affecting response times is geographic and demographic challenges, particularly in isolated rural areas, such as in the west of Ireland.  One of the ways in which we have met this challenge is through the establishment of the Emergency Aeromedical Support Service.  This is a pilot project between the NAS and the Air Corps, which provides dedicated aeromedical support in the west and other areas, specifically where land transit times would not be clinically appropriate.

The EAS completed 368 missions in 2013, one third involving STEMI-type heart attack patients, who need time-critical transfers to primary PCI units for treatment.

A review of the pilot project found a clinical need for the service and that it should be established on a permanent basis.  An inter-service group is examining how best to do this.  Agreement has been reached with my colleague, the Minister for Defence, to extend aeromedical support by the Air Corps until June 2014, pending decisions on how best to establish a permanent service.

Neo-natal Retrieval Service

Another vital service provided by the NAS is the neo-natal retrieval care service, which was expanded in December 2013 to a 24 hours, 7 day a week service.  This service transports critically ill infants, with their clinical care teams, to high acuity care.  It has now completed over 100 transfers.

Reviews of the Ambulance Service

The ambulance service is under scrutiny in a way that has never happened before.  Three reviews are taking place at present with a view to further improve our ambulance service.

Firstly, HIQA is conducting a review of governance arrangements in pre-hospital emergency services, to ensure timely assessment, diagnosis, management and transport of acutely ill patients to appropriate healthcare facilities.  This review includes an assessment framework designed against the National Standards for Safer Better Healthcare.

The objective of the review is to seek assurance that the NAS has in place;

  • Ø a clear strategic direction, with implementation plans and control measures for the national service;
  • Ø robust governance and leadership arrangements at all levels within the service;
  • Ø clearly defined schemes of delegation;
  • Ø appropriate controls in place through service level agreements with third parties delivering services on behalf of the national service;
  • Ø appropriate quality and risk management arrangements;
  • Ø a well-organised, skilled workforce, with a culture of continuous improvement;
  • Ø the use of care pathways, clinical outcomes and other performance indicators that demonstrate that the ambulance service is both safe and effective.

It is anticipated that the review will lead to a range of recommendations aimed at ensuring the NAS is enabled to develop and benchmark its services, using modern outcome indicator data used by similar ambulance services internationally.

At my request, HIQA brought forward this planned review of NAS and I am pleased that the review has now commenced.  I understand that the review will be completed by the end of the year.

Secondly, the NAS has commissioned an independent national capacity review to determine the level and use of resourcing required for a safe and effective service.  The capacity review is a tool used by many emergency medical services around the world, in order to identify the volume and location of resources required to achieve optimal effectiveness and efficiencies, improve performance, and deliver a better service to the patient.

The capacity review will be undertaken by the UK Association of Ambulance Chief Executives.  The Association has wide international experience in operational and strategic reviews of this kind.  The review has begun and it is expected to be completed in quarter 3 this year.

Finally, in the context of the development of the national control system, the Dublin City Manager and the HSE’s Chief Operating Officer commissioned a joint review of Dublin Fire Brigade’s ambulance service.  The review will consider all aspects of Dublin Fire Brigade’s ambulance operations, including the capacity and capability of ambulance services. The review will inform consideration of the best model for provision of emergency medical services in the greater Dublin area.

There has been much speculation about this review and I am aware of the concerns raised by some about the future of the service.  I want to assure those concerned that I fully appreciate the long and proud tradition of service provided by Dublin Fire Brigade to residents of Dublin.  This review is not in any way a negative reflection on that service; rather it is a means to establish the best way forward in light of the move to a single dispatch system.

The three reviews are being conducted in parallel in a concerted effort to examine our pre-hospital emergency care services throughout the country, with a view to identifying the best way to enable them to meet the challenges of the future.  I look forward to the recommendations of all three reviews, which will be considered in an holistic and coherent manner.  I am confident that the recommendations will guide us in the provision of a modern, forward looking service, capable of delivering the best possible outcomes for the public.

Conclusion

Clearly, much has been achieved in reconfiguring and remodelling our ambulance service.  In this regard I am very happy to acknowledge the very significant contribution made by ambulance personnel throughout the country whose commitment and dedication is second to none.

While we are making progress, I accept that we have more to do.  I am determined to make further progress so that all of our citizens have access to the efficient, modern ambulance service that they deserve – regardless of where they live in the country.

To this end, I want to assure the House that the NAS will continue to modernise and reconfigure its services to ensure that emergency pre-hospital care is delivered in an appropriate and timely manner.

ENDS