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Ambulances and their response times have become almost as politically toxic as hospital waiting lists. During the General Election earlier this year, the issue was frequently raised on the doorsteps by voters. This was especially true in rural Ireland.
“At present, just one-in-four ambulances reach a life-threatening emergency within the target time of 19 minutes in rural parts of the west of Ireland,” Minister for Communications Denis Naughten, a TD for the constituency of Roscommon-Galway, said recently in a statement. “These response times are by far the worst in the country and clearly show that urgent investment is now needed in both ambulances and staff in the west of Ireland.”
Despite commitments by the newly-formed Government to improve the ambulance service, its efforts face significant environmental as well as logistical challenges.
The sheer scale of the problem regarding response times was starkly revealed in a recent report.
The long-awaited Lightfoot capacity review of the HSE’s National Ambulance Service (NAS) found that the rural nature of the population of Ireland means that the NAS cannot possibly achieve HIQA’s prescribed call-out targets.
“There is a very significant gap between the levels of performance that the NAS is currently achieving and the existing standards of 80 per cent at the national level for eight minute performance and 95 per cent for 19 minute performance,” the report states. “We do not believe that it is realistic to expect NAS to achieve these standards (because of the highly rural nature of the areas that it services).
“The best it could achieve, fully resourced and performing at best international standards, is 60.6 per cent. NAS is currently performing at 27 per cent in eight minutes and 67 per cent in 19 minutes, which is below the standards observed in other services and suggests scope for improvement. Particularly in major urban areas, there is scope to improve performance.”
But it is not all bad news. The review identifies “an encouraging improvement trend” in response times due to the introduction of additional intermediate care vehicles (ICVs), which have reduced the workload on the emergency ambulances.
“Our analysis of the performance ‘tail’ for Echo and Delta calls shows that the NAS are getting to 99 per cent of their high-acuity patients in less than one hour. Given the rural nature of the patch, this is a commendable performance and good by international standards. We believe there is scope for NAS to improve overall operational performance by implementing a more systematic approach to day-to-day performance management and strategic planning.”
However, to achieve this, investment would be required in specialised technology designed to help management and front-line staff understand operational data, the report stated.
“In addition, we believe the NAS would further benefit from adopting a structured approach to engaging staff in continuous performance improvement. This could take the form of a series of skill-transfer initiatives, where staff can be trained in continuous performance improvement techniques.”
The current fleet
Currently, the NAS has 264 emergency ambulances in service, with a total fleet of 496 resources. This newspaper has learned, however, that more than 10 per cent of the service’s total fleet has 400,000 kilometres* or more on their odometers. Significant investment is undoubtedly urgently needed.
According to information request to this newspaper by the NAS following a Freedom of Information request, there are 145 vehicles aged eight years or more in the NAS. There are 79 vehicles with between 200,000 and 300,000 kilometres on their odometers, a further 52 vehicles have 300,000-400,000 kilometres, with an additional 53 registering 400,000 kilometres or more on the clock. Of these, 16 are in the HSE West ambulance fleet, as a recent regional health forum meeting heard.
“As part of the HSE NAS Fleet Procurement and Replacement Programme, all front line, patient-carrying emergency vehicles that are more than seven years old will be replaced by the end of July 2016,” stated a response by Mr Padraig O’Riordan, Area Operations Manager, West National Ambulance Service.
“By the end of 2016, the oldest vehicles in the West area will be 2011 — 16 from a fleet of 96. The age profile of the remaining vehicles is 131 upwards. The expectation is that there will be continued investment in a replacement programme going forward to maintain the age profile of the vehicles.”
Speaking at the meeting, Galway City Councillor Pádraig Conneely expressed outrage at the use of “clapped-out” vehicles to transport patients. “Is this good enough, that these vehicles are driving on the mountainous and bad roads that we have in Donegal, and Leitrim and Connemara in particular? No wonder we’re reading about them breaking down on the side of the road.”
However, there is to be significant investment in the NAS this year.
“Under the National Ambulance Service Fleet replacement policy for 2016, over €18 million will be invested under the HSE Capital Programme. Nationally, a total of 50 new vehicles and 35 remount vehicles will be introduced,” the HSE told the Medical Independent (MI).
The Executive was asked for an update on this replacement programme but no comment was received before going to print.
Despite the HSE’s assurances, Mayo GP and former Dáil deputy Dr Jerry Cowley described the information obtained by MI as “unacceptable”.
“We have heard instances of doors falling off ambulances, of them breaking down. This has to change because somebody’s life is in danger or they need urgent definitive care, which they cannot get in a rural area,” he said. “People in rural areas are most dependent on the ambulance service, as the distances are so great to the hospitals.”
Co Mayo GP Dr Jerry Cowley
While he acknowledged that there has been some improvement in terms of ambulances serving rural communities, he said NAS vehicles must meet minimum standards.
“If the vehicles being supplied are below what they should be, it is a recipe for trouble. Anyone who is fighting for their lives needs to be assured that the ambulances serving them are fit for purpose. And vehicles with that sort of mileage, everyone knows well that they’re not going to last. I’m sure not too many ministerial or State cars have that sort of mileage on them. A person’s health, that’s what’s more important.
“The ambulance service needs modern vehicles. No matter what cutbacks there are, we have to ensure that our ambulances are at an acceptable standard. If they have mileage like that, the chance of them breaking down is much higher. It’s an unacceptable ratio.”
The great advances in front-line services have made ambulances into “mobile ICUs”, he said, but the age and mileage of the vehicles constitutes a “weak link in the chain that could cost people their lives”.
Programme for Government 2016
Developing the NAS was identified as a priority in the Programme for Government. As well as improvements to the fleet, the document also makes reference to possible changes to the bypass protocol, which could have major implications to smaller hospitals and emergency department overcrowding.
“We will develop protocols to enable ambulances to take patients to the most appropriate place rather than the nearest emergency department. This shall include treatment and discharge at the scene, minor injury units, MAUs [medical assessment units] and specialist centres (eg, trauma and orthopaedics),” promised the Programme for Government.
“We will continue to deliver safer pre-hospital care. As part of this, three reviews of Ambulance Services (HIQA Governance Review, National Ambulance Service Capacity Review, and a Dublin Emergency Services review) are currently being completed, with the HIQA report already being implemented. We will consider the recommendations when published and there will be an increase in ambulances, EMTs and paramedics every year to improve response times.”
However, this may be easier said than done.
As with other sections of the health service, industrial unrest is fast becoming a feature of the NAS after years of budget cuts and increased workloads.
Last week, NAS staff voted overwhelmingly in favour of industrial action over a dispute on their terms of employment. SIPTU said the grievances centre around the failure of the Executive “to honour a number of agreements arrived at following negotiations at the Workplace Relations Commission regarding staffing levels, the filling of permanent vacancies, payment of correct pay rates and retention of emergency call-takers”.
Despite these challenges, Minister for Health Simon Harris told the Dáil recently that progress is being made.
“On foot of the Lightfoot review, the external capacity review of the ambulance service, 60 actions were identified. Of those actions, 28 per cent are deemed complete, 45 per cent are ongoing and 27 per cent have yet to start. With regard to the HIQA action plan, there were 54 actions, 35 per cent of which are complete, 52 per cent of which are ongoing and 13 per cent of which have yet to start.”
Of the actions already completed, these include the establishment of a NAS and Dublin Fire Brigade operations group to address operational efficiencies, and the appointment of a permanent National Control Operations Manager. It also recommended an improved model for rural and remote locations with an extensive rollout of community first responder schemes, co-locations of paramedics with primary care professionals and continued use of the aeromedical services.
Other actions yet to be started are the development of clinical support capacity, ie, a cohort of clinical support supervisors. “The document is very detailed in respect of the timeline for commencement and delivery. It is the document with the roadmap for a national ambulance service,” the Minister said.