National Ambulance Service: Motion [Private Members]

I move:

That Dáil Éireann:

notes that:

— the National Ambulance Service (NAS) and emergency services are at crisis point, with health care professionals expecting a very challenging winter with insufficient ambulance capacity;

— response time standards state that life-threatening callouts should be responded to within 19 minutes in 81.5 per cent of cases;

— State-wide response times for life-threatening callouts (Clinical Status 1 – ECHO: Patients who are in cardiac or respiratory arrest) within this timeframe have decreased from 80 per cent in December 2017 to 76 per cent in December 2019, in particular outside of Dublin; and

— State-wide response times for potentially life-threatening callouts (Clinical Status 1 –DELTA: Patients with life-threatening conditions other than cardiac or respiratory arrest) within this timeframe have fallen from 54 per cent in December 2017 to 49 percent in December 2019, and that rates in the summers of 2020 and 2021 were down on previous years;

further notes that:

— the annual spend on private ambulance services has risen from €2.1 million in 2011 to €10.1 million in 2019;

— in 2019, the three top spenders on private ambulance services were Letterkenny University Hospital (€1.6 million), Mayo University Hospital (€1 million), and Cavan General Hospital (€682,973);

— ambulances are too often travelling in excess of 150 kilometres to reach a destination,with instances in excess of 200 kilometres, and there are extreme geographical disparities in ambulance coverage;

— ambulances are often left idling outside of hospitals due to a lack of bed capacity and an inability to transfer patients, particularly Covid-19 patients, as accident and emergency services are not operating in an efficient and effective manner, resulting in cancellations of scheduled care and contributing further to the waiting list crisis;

— an unacceptably high proportion of shifts, possibly as many as half or more, already run overtime, with 12-hour shifts often lasting 15 hours or more, leading NAS staff to have low morale with widespread burn out and occupation-related mental health difficulties;and

— the attractiveness of a career in the NAS is damaged by the terms and conditions of work under the current system, which is a reputational issue also affecting medical scientists and other underappreciated professions in the health service; and

calls on the Government to:

— urgently complete and fund the recommendations of the capacity review on the adequacy of the NAS, to identify additional budgetary needs to phase out the use of private services, reduce reliance on overtime, fill vacancies, and expand staffing and the ambulance fleet to meet need;

— urgently review the adequacy of the spatial distribution and coverage of the ambulance fleet, ambulance stations and rapid deployment points, to ensure an equitable distribution of services across regions and to reach response time standard targets;

— avoid call centres directing long-distance callouts to teams which are nearing the end of their shift and ensure adequate coverage to support this;

— advance legislation relating to specialist paramedic grades and rapidly advance funded expansions to primary and community services, in particular those relating to community paramedicine and chronic disease management, to provide alternatives to hospitalisation and reduce the strain on emergency services;

— establish a clinical framework to provide for ‘hear and treat’ and ‘see and treat’ alternative care pathways, to further reduce hospitalisations;

— provide more appropriate hospital beds to avoid patients being left in ambulances and admit them to hospital in a timely manner;

— expand mental health supports for the NAS workforce, including access to counselling and psychiatric services where appropriate; and

— ensure redeployment opportunities within the health service, particularly to non-emergency community roles, for frontline paramedics who are fit to work but cannot return to frontline emergency roles for health reasons.

I will be sharing time with some of my colleagues. I have tabled this motion because, as is the case in many areas of healthcare at the moment, we have a lot of burnout and fatigue in the National Ambulance Service. I have met many ambulance paramedics and members of the National Ambulance Service in recent weeks and months. I am sure the Minister is aware of many of the pressures the National Ambulance Service is under. We often hear the words "burnout", "low morale" and "fatigue" in relation to our front-line healthcare services. It is no different in the National Ambulance Service.

I met yesterday with the SIPTU representatives and many ambulance paramedics on a Zoom call. I again heard at first hand the consequences of what is happening as a result of the lack of capacity in our National Ambulance Service. There are no breaks for many of those who are on long shifts. Ambulance paramedics often work for 12 hours. They cannot get a break, even a lunch break, and many of them talk about a desktop lunch because they simply cannot get time to eat properly. That has a consequence for them. Even after the long hours they work, if there are 15 or 20 minutes left at the end of their shift, they can be given a call-out to somewhere 100, 200 or 300 miles away from their destination, adding lengthy hours to an already long shift. There are many more consequences for the ambulance paramedics. There is real fatigue and burn-out in that community.

There are also consequences for patients. We hear more and more anecdotal evidence from patients and families that people are waiting too long for an ambulance to arrive. I put that directly to ambulance paramedics I met, including those from SIPTU last night, and they say that is precisely what is happening. They say they cannot stand over a service where the response times are not what they should be. One ambulance paramedic remarked to me that he came onto his shift last week, starting at 7.30 p.m. His first call was to respond to a call that came in from a patient at 11.38 a.m. He had to respond to that call, arriving six or seven hours later, and had to deal with that challenge, through no fault of his own. An awful lot of moral injury applies here with regard to the impact that has on front-line staff. Ambulance paramedics have to do their best. They want to make sure they take whatever call comes in. A child could be sick. An older person may have fallen. Yet, at the same time, those ambulance staff know they need a break or are coming towards the end of their shift. They have to deal with all of that, day in and day out. I am hearing more about that kind of moral injury, not just from members of the National Ambulance Service but right across our healthcare system. It all comes back to a lack of capacity.

I can pre-empt some of what is in the Minister's response. A number of working groups have been established by the National Ambulance Service to look at some of these issues around breaks, late call-outs at the end of shifts and many of those sorts of areas. However, they have not been actioned. We need to see even those small steps implemented as quickly as possible. I also know a capacity review is being conducted. When I talk to ambulance paramedics, they relay to me that the nearest comparable country is Scotland, where there is a staff complement of 5,000 while we, in this State, have a staff complement of just over 2,000. We are far behind. Our fleet needs to be greater than it is, as does the number of paramedics. We need more emergency medical technicians and more staff generally in our ambulance services. The consequence of that not happening is that ambulances will not arrive on time. More burnout and fatigue will be the result.

I have also been told by managers in some hospitals throughout the State that ambulances can be parked up for hours on end because the hospitals do not have the beds to transfer or decamp patients from the ambulances into the hospital. It can happen for hours on end. Those hospital managers told me they have had ambulances, sometimes a fleet of ambulances, parked up for hours outside their hospitals because they do not have the beds for those patients. In those scenarios, the ambulances are acting almost as hospital trolleys. How mad is that? How frustrating is it for ambulance paramedics and people who use the service?

This motion is a sincere attempt to say to the Minister that we need action. I hope the Minister will support this motion and I think he should be able to. We are calling for the completion of the national capacity review and for its publication when it is complete. We are also calling for the proper resourcing of the service. Let us put in place a strategy for the National Ambulance Service that properly resources it, increases the fleet and personnel and ensures we can provide a fair service. We must ensure ambulance paramedics are fairly treated. Let us address the issues of burnout, low morale and fatigue and put in place a plan in which ambulance staff can have confidence. I know there are new personnel at the head of the National Ambulance Service and I wish them well and want them to succeed. I ask the Minister to support the motion and, more than that, I ask that he actions the requests in the motion.

Last week, Deputy Cullinane and I met with representatives of the National Ambulance Service to discuss the crisis at University Hospital Kerry. While we were there, problems with the ambulance service came up time and again because they are intrinsically linked. Nearly every day, my office is contacted by people who cannot get healthcare due to the ongoing crisis. Worryingly, a common concern is the inability to get an ambulance service. People are referred to the emergency department by their GPs or they have an emergency but must wait hours for an ambulance. It is commonplace to hear of ambulances being sent from Limerick and Cork to take Kerry people to University Hospital Kerry, and vice versa.

Before coming to the Chamber, I spoke to Ms Rita Sheehy, who worked in medical practice for almost 20 years. She said that things went from bad to worse six years ago when the call centres were centralised. She told me one ambulance from her area went to Rosscarbery last weekend while another went to Union Hall. The Kenmare ambulance ended up in Waterford. I am not sure, given the crisis in healthcare in Kerry, that there is an understanding we have three peninsulas in our spread-out county, with the resources for only 150,000 people. We do not even have that. We have a population during the summer months of close to 500,000 people and the services are clearly not there.

Young children and elderly people end up being driven to hospital by family members, which creates risk and places parents and family members in a bind. Should they wait for paramedics to come or risk driving their loved one to hospital before it is too late? People must face these choices due to the lack of ambulances in Kerry. I previously asked the Minister to base ambulances in Killorglin and Abbeyfeale. Both areas are adjacent to communities grossly underserved in normal times and feel completely abandoned during this crisis. I again invite the Minister to come to Kerry, go to the hospital, meet people and meet with the ambulance service.

I am hearing more stories of ambulances waiting for hours to transfer patients into hospital. It is common to hear of five-hour waits and sometimes eight-hour waits. Staff shortages and a lack of beds mean highly vulnerable patients and paramedics are waiting too long to be seen. It is not good enough. The Minister needs to take action. I urge him to do something before it is too late and someone loses his or her life.

For some time now, our ambulance services have been under considerable strain. It is not unusual to receive complaints from people who have had to wait for long periods for an ambulance, even after calling the emergency numbers. People have to wait up to an hour or more for an ambulance to arrive. In some cases, on arriving at the hospital, an ambulance has to wait outside with the patient due to overcrowding in the emergency department. There are three hospitals in use for Dublin North-West, the constituency I represent. Those are Beaumont Hospital, the Mater hospital and Connolly Hospital. Each is under considerable pressure because of the wider issues our health system faces due to a lack of resources. Those hospitals are only a ten- or 20-minute drive away from most people in the Dublin North-West constituency. However, if you are ringing 999 for an ambulance, it is because you have a medical emergency and need help urgently. For whatever reason, you cannot make that journey without the help of an ambulance.

The National Ambulance Service has pointed out that due to the lack of a single call and dispatch model, the dispatch process in Dublin is not as seamless as in other areas and it is not possible to integrate all calls in one database to ensure improved planning and performance monitoring. That needs to be considered.

We are being told that ambulance units are being sent for hundreds of kilometres to respond to calls in Dublin to fill in all the gaps. This takes resources from the areas where they are supposed to be based. It makes no sense. Our motion calls for many measures that need to be considered, but ultimately the point is that we need an urgent review and an improvement of ambulance and accident and emergency resources for patients on arrival. We need ambulance services to be properly funded and to have more staff, equipment and vehicles. Patients must not be let wait for a long time in an emergency. Lives are at risk. The ambulance workers are at the front line. They are under so much stress and strain, especially since Covid. They are exhausted and burnt out and they need help.

We are all aware of the enormous pressures on our health service. Covid laid bare the enormous deficits. We are reaching crisis point again in respect of hospital capacity, including ICU capacity. The National Ambulance Service, like many parts of the health service, is in crisis. Staff are reporting that morale is at an all-time low. Staff are completely burnt out. Paramedics often have to travel over 200 km to a call-out due to disparities in ambulance coverage in different parts of the country. Staff have reported having to work for over 15 hours per day, often as a result of having to travel hundreds of kilometres towards the ends of their shifts. It is little wonder that healthcare workers are not being enticed to stay here or come here to work.

The healthcare system is dysfunctional and affecting the health and lives of those who work in it. This is bad news for patients. I have heard from many in my constituency who are upset over the times for which their loved ones have been left waiting for an ambulance. Last year a gravely ill 95-year-old woman was left waiting for three and a half hours. During the summer an ambulance was called for a GAA player who appeared to be seriously injured on a playing field. He was a five-minute drive from Our Lady of Lourdes Hospital but it was decided that he should not be moved given his injuries. He waited an hour and 40 minutes for an ambulance. It turned out that the ambulance came from Tallaght as there was none available locally.

The National Ambulance Service is missing its response targets for call-outs in life-threatening circumstances. We are aware that there are elderly and vulnerable people waiting hours for ambulances. We need to support those working in the National Ambulance Service. The best way we can do so is by increasing capacity in the service so staff will not be so overworked and overstretched and so we will not be overly reliant on private ambulances. We need to identify where additional funding is required, phase out private services, fill vacancies, increase the number of staff and expand the ambulance fleet to meet demand. We need to do all these for the sake of patients across the State and for paramedics and healthcare workers, who have given so much to us in the past year and a half, but also long before that.

I thank my colleague Deputy David Cullinane for tabling this motion. We need action and need it now. The red tape in recruitment, which was spoken about, needs to be removed. We need more beds in our hospital system and to increase hospital capacity to prevent patients from having to wait in ambulances and on trolleys. We need to expand our ambulance fleet to ensure all communities, both rural and urban, are properly served. It is just not acceptable that the complement of the National Ambulance Service, 2,500, is but half that of Scotland, 5,000.

There are many in this room who have had to call an ambulance at some stage or who, unfortunately, had to travel in one as a patient. For the vast majority, calling an ambulance is the last resort when someone is really ill. An ambulance is called in extreme circumstances and with great reluctance. When an ambulance is called, people expect an appropriate response time. However, this is increasingly not the case in both urban and rural communities. I have heard of people having to wait for an ambulance for an hour or more.

My family had to come face to face with the reality of the pressure the ambulance staff are under just this day last week. My mother, who is in her eighties, was very sick last week with an infection and an ambulance was called at 1 p.m. Despite numerous calls throughout the day, an ambulance did not turn up until 5.30 p.m. We live in East Wall, and my mother was brought to the Mater hospital, which is just up the road. Does the Minister believe that is acceptable in a modern health service? I certainly do not believe so.

Last night I was shocked to see on the RTÉ programme that the first recorded case of a patient having to wait overnight on a trolley was in 1998. There are 409 people on trolleys as we stand here today. That the first recorded case was in 1998 is shocking. It is not acceptable and there are solutions. It is time we got on with listening to the workers, management and Deputies in this Chamber and implemented the solutions that exist. Not doing so with a sense of extreme urgency is to continue to put people's lives at risk.

It is obvious that we need an urgent review of ambulance resources and the configuration to ensure the emergency service is adequately resourced and run efficiently and effectively. I acknowledge the trojan work of the dedicated paramedics and other emergency staff. I have seen at first hand their absolute dedication. They deserve much better than what they are being presented with. We are talking about protecting and saving lives and retaining, supporting and protecting ambulance workers – workers who are burnt out from long, exhausting shifts. How can the Minister stand over an emergency service that is constructed and resourced in a way that means seriously ill patients must wait up to two and a half hours for an ambulance? The bottom line is that we need to stop the criss-crossing of ambulances, whereby they are travelling hundreds of kilometres, by expanding our ambulance fleet and ensuring rural communities are served properly.

Yesterday I joined the nurses outside Mayo University Hospital when they were protesting over conditions and safety. Their main concern was the safety of patients and staff. That should concern the Minister, and it should certainly concern us all. I hear accounts of routine delays in offloading patients at emergency departments due to a lack of capacity. The nurses have raised the issue of the severe lack of nursing staff to take over the care of patients from the ambulance personnel. This is the problem arising. Right now in Mayo, the nurse–patient ratio can be as high as 1: 15, instead of 1:7, due to the shortage of staff there. The problem is that ambulances are lined up outside the hospital. Two weeks ago I spoke to the family of an 85-year-old woman, a cancer patient, who had to wait outside Mayo University Hospital for over six hours without morphine on her referral by Westdoc.

It should be much easier for UK-trained paramedics to transfer their registrations so they can work in Ireland. They tell me it is easier for them to go to Australia than to come back to their own country. We need to address the crisis in the National Ambulance Service and, indeed, the wider health service.

On the roll-out of the booster vaccine, particularly to those for whom it is now being rolled out, will the National Ambulance Service be doing what it did on the last occasion? What is the timeline for that? When will housebound people in their eighties and nineties get the booster vaccine? Will it be through the National Ambulance Service?

I thank Deputy Cullinane for tabling the motion. It is a good motion and we will not be opposing it.

I acknowledge the extraordinary work that is being done by the women and men in the National Ambulance Service. Before Covid arrived, they were doing an extraordinary job. They did not have the resources they needed. The investment was not going in; that is the truth. A very good and credible strategy was launched in 2016 that did not get the resources that it needed. That was the situation before Covid arrived. Since it arrived, those working in the National Ambulance Service have been under extraordinary pressure. They have been among the most impressive people I have met as I have met health workers and others all over the country who have been involved in the fight against Covid.

All present remember the pop-up testing and tracing tents that were deployed. That was the National Ambulance Service. As Deputy Conway-Walsh stated, we remember the housebound and the urgency to get to them; a lot of that was the National Ambulance Service. We remember the urgency of getting vaccines out to various parts of the country; that was the National Ambulance Service. It has done an extraordinary job. While it was supporting the Covid efforts in testing and tracing, getting to the housebound and in vaccines more broadly, its staff were continuing to do their day job in respect of emergency response. They have done and continue to do an absolutely extraordinary job and I think every Deputy in this House will acknowledge and thank them for their amazing work through Covid.

I welcome the opportunity to address the motion with colleagues. The National Ambulance Service is a statutory pre-hospital emergency care provider. It operates as part of an integrated health system in which care begins immediately at the time of an emergency call and continues through appropriate treatment, transportation and handover of the patient to the clinical team at the appropriate emergency department or alternative facility.

It is fair to say the National Ambulance Service has undergone a significant amount of change and reform in recent years. It has changed from a service that traditionally transported patients to hospital for treatment to a service that is clinically led. That is an incredibly important and fundamental change. For example, it is now treating patients over the telephone, at the scene, at the patient's own home much of the time and on the way to a medical facility.

Right now, we are investing more than €200 million in the National Ambulance Service. The budget for next year will be in excess of €200 million. This means that NAS annual funding will have increased by approximately €30 million since 2019, which really is important because I agree with the Deputies who are calling for investment. Importantly, in the budgets for this year and next year we have matched that with action. Deputies have rightly stated that we need to see action and the money. I am delighted to be able to share with them that since 2019, the last year of the previous Government, funding has increased by 18%, which is very important. Since the 2016 plan entitled Vision 2020 was published, the NAS has increased staff numbers by 16% and there is far more change on the way. Building clinical capacity in the state-of-the-art national emergency operations centre, NEOC, in Tallaght has facilitated the introduction of alternative care pathways such as “see and treat” and “hear and treat”, which are really important and allow the NAS to assess and treat many patients at the lowest appropriate level of acuity, resulting in better outcomes for the patient and more effective use of healthcare resources.

I and the Government are committed to supporting the NAS as we continue with its development and transformation. Significant achievements have been made. Those working in the service deserve great credit for that. In addition to the funding for the budgets for this year and next year, I am very happy to share with colleagues - some of them will already be aware of this - that the National Ambulance Service has been allocated €5.7 million in targeted funding under the winter plan. This is important targeted funding in response to rising demand for access and it focuses on the “see and treat” measures, which will reduce the number of patients who have to be brought to an emergency department.

As set out in the national service plan for this year, there are specific targets in place that the NAS must meet in responding to life-threatening calls. The service works to achieve these targets by prioritising the allocation of resources to higher acuity calls and patients. I am aware that, as Deputies have noted, the wait times for lower acuity, non-life-threatening calls have presented a particular challenge recently as the NAS has been experiencing unusually high demand. While this is in line with the current experience of many parts of the hospital system, I know it is a concern for all present and certainly for all those working in the NAS. I have been advised that several particular factors are currently impacting on its ability to meet response times. These include a significant increase in demand for ambulance services. In fact, since February of this year, the NAS has seen an increase of 20% in emergency calls. That is a very steep increase. In addition, as all present will be aware, emergency departments have been extremely busy, which has negatively impact on turnaround times, that is, the time required to release an ambulance from an emergency department following patient transport. We are also dealing with a depletion of resources due to increased levels of sick leave, such as due to staff being a Covid-19 close contact, for example, which is impacting on the availability of front-line staff. There is also the ongoing need for enhanced infection prevention and control measures. I am fully committed to supporting the National Ambulance Service in responding to all these challenges, as it is doing. The unprecedented level of funding allocated in the past two budgets is evidence of that. The funding will help the service to address capacity shortfalls and build on the staffing levels increases and continue with that, which is important.

Successive reports on emergency ambulance capacity have highlighted that there is a shortage of qualified paramedics in Ireland, regardless of funding allocated. What are we doing about this? We are training more paramedics. There are more than 200 student paramedics at different stages of the paramedic degree programme right now. Of course, colleagues will be aware and, I am sure, fully supportive of the amazing advanced paramedic role. We are seeking to have more of those as well. They are doing an incredible job. It has been a really positive innovation in the ambulance service.

The stated target of the HSE is that 80% of ambulances will be released and available for tasking within 30 minutes of arrival at an emergency department. I am aware this target is not being met and that the pressures in emergency departments are a significant contributing factor to the release of the ambulances. The HSE has commissioned a review into this issue with a view to identifying what can be done in the short term to assist with it. I am advised that the initial findings of this review are currently being assessed by the HSE. I look forward to sharing and discussing those findings with colleagues.

I note for the information of the House the progression of delivery of acute bed capacity projects that is happening across the country in line with the requirements set out in the 2018 capacity report. This is relevant to the debate on the National Ambulance Service because to achieve the desired turnaround time, one of the many things we need in the acute hospitals is a significant increase in beds. The progress in this regard includes an increase in permanent acute bed capacity of 795 beds compared with the number available on 1 Jan 2020, with a target of 938 to year end. We also have €52 million in funding provided for critical care this year to allow for an additional 66 beds and to be followed by an additional €10.5 million for next year, with the stated aim of bringing the number of critical care beds from 255 at the start of Covid to 340 by early 2023. That will be an increase of one third, or 33%, in ICU capacity, which is significant. As we have discussed previously in the House, we are not stopping there; we are driving on with a very significant increase. In fact, the target we have set and on which we have Government agreement is in excess of the number identified in the previous capacity report.

The past few months have been challenging for the National Ambulance Service, as all present will be aware. Our clear focus now must be on continuing to support the capacity building and reform to ensure the service offers the right care at the right time and in the right place. We are acutely aware that the past two years have been incredibly challenging for the healthcare services. The experience of the National Ambulance Service and the women and men who work in it has been no different in that regard. While continuing to provide front-line services, it has done an enormous job in the Covid response, including carrying out more than 2 million Covid-19 tests. I thank the Deputies for tabling the motion. The Government will not oppose it. It contains very good ideas and I look forward to continued discussion.

There was an error in respect of the speaking time in the previous Sinn Féín slot. There were two and a half minutes remaining, which should have been allocated to Deputy Martin Kenny. I ask that 12 and a half minutes be allocated to this slot to make up that difference, if the Leas-Cheann Comhairle is agreeable. It is the same amount of time overall. Is that fair enough?

Every Deputy will want to share with the Minister their experiences in their own constituency. My home county of Donegal has had major problems with ambulance services in recent years. There are a number of families who have lost loved ones due to the length of time it took the ambulance to arrive. There is no doubt about that. They have very courageously told their stories and campaigned for a better ambulance service. I am sorry to report, having spoken to people who work in the service over the past few days, that there is not enough personnel in place around the county. There are not enough ambulance bases, ambulances and personnel to cover the county. On top of that, the number of people waiting on trolleys over the past number of weeks in the major acute hospital, Letterkenny University Hospital, has been at the top. In that regard, currently, Letterkenny University Hospital is second only to University Hospital Limerick, which has a terrible problem with overcrowding and people waiting on trolleys in the emergency department. There is a backlog at the emergency department in Letterkenny and ambulances are backed up. From speaking to families, I know that there have been many instances of great distress being caused to the patients and the paramedics operating those ambulances. Their business is saving lives. They have done that and have got the patient to the hospital, only to face a backlog. The working conditions are utterly unacceptable. Their business is saving lives; that is what they signed up to do.

To be clear, my point is that there is not an adequate ambulance service in County Donegal. I do not think there is a recognition of the unique geography of the county. The paramedics who work in the service are under unbelievable pressure. That must be dealt with and Letterkenny University Hospital must be helped to tackle the crisis in beds, nurses and doctors. The two crises in the ambulance service and the acute hospital in Letterkenny lead to impossible working conditions for the front-line emergency workers who are working there. They are being failed and it is not acceptable. I appeal to the Minister to examine the issue with his colleagues and to make it clear to the National Ambulance Service and the Saolta Hospital Group.

People in Ireland are tired of the dire state of the public services that they rely on. Since the days of austerity, funding has been whittled away, and in many areas we are left with hollowed-out services. Nowhere can this be seen more than in our health service. We are told of all the extra money that the Government is throwing at it, when really, we are standing still when it comes to services.

Waiting lists continue to climb, overcrowding continues to worsen and the National Ambulance Service and emergency services are at crisis point. We spend millions of euro each year on private ambulances rather than on improving the working conditions and strength of our ambulance service. Our motion calls for that life-threatening call-outs to be responded to within 19 minutes. The importance of the golden hour response time seems to have been dangerously stretched when we hear stories of ambulances having to travel further and further to attend to patients. We are increasingly hearing stories of desperate families waiting long periods for emergency responders. Ambulances left idling outside hospitals due to overcrowding is wrong on many levels and leads to unacceptably long shifts. NAS staff are suffering from low morale, as we have heard, and burnout is widespread in the service.

We cannot blame Covid for these problems, as these and other challenges meant that we were at breaking point before the pandemic. The Government must urgently review the adequacy of NAS resources. It is vital that we identify exactly what is needed to phase out the use of private services, reduce reliance on overtime, fill vacancies and expand staffing and the ambulance fleet. As part of this, what is needed is to provide adequate healthcare in this State. We also must provide more appropriate hospital beds to avoid patients being left in the back of ambulances and ensure that they are admitted to hospital and treated. We cannot neglect public services in this country any longer. We need a Government that works for the people and for workers and their families.

I wish to commend my colleague, Deputy Cullinane, on introducing the motion. Nowhere is it more evident how vital the National Ambulance Service is than in a rural community and constituency like my own. Nowhere are funding cuts, staff shortages, burnout and inadequate facilities more evident more keenly felt than in rural communities. I know from the calls that I have received on this issue that the service is not fit for purpose in counties Carlow and Kilkenny. It is totally and utterly unfair to those who work in the sector. A recent incident reported in Carlow emerged where a Thurles ambulance crew from County Tipperary were sent to Tullow, County Carlow, only to be diverted to New Ross, County Wexford, then on to Kilkenny before being sent back to Carlow town. This is a regular occurrence. It is absolute craziness.

Carlow's ambulance crew has been screaming out for a new depot, as the current facilities on the ground at St. Dympna's Hospital are completely unacceptable. The Minister should visit the site, if he has not already, to see how inadequate they are. A new ambulance base is needed. I ask that that be prioritised.

The shortage of paramedics in counties Carlow and Kilkenny was evident recently in the case of a constituent who had to wait on the side of the street for an ambulance for two hours. This was not the fault of the people working in the sector, who are overstretched and burnt out. On top of the burnout and the crazy situation facing staff, they are also working 18-hour shifts and face long drives home. Many have to opt to stay in a local hotel, if possible, due to the tiredness. Paramedics seem to be diverted all over the place. Life and death decisions are being made by overstretched and under-resourced paramedics, which is unacceptable. I reiterate how unfair this is to those working in the sector.

If resources in an area are already responding to calls, the job is then given to the next available ambulance, which could be hours away from where the caller is. In counties Carlow and Kilkenny, that could mean an ambulance being dispatched from anywhere in the country.

In January 2020, SIPTU called for immediate and effective action to be taken by the Minister for Health and HSE to relieve the pressure being experienced by ambulance professionals throughout the country. It was ignored, and the unacceptable situation of paramedics treating patients in the loading bays of hospitals instead of hospital beds has continued. I cannot impress on the Minister enough that our services and personnel must be resourced so that they can perform their duties to the best of their ability. I commend all those who work in that sector. I do not know how they do it. Their morale must be so low at times.

A number of years ago, I met ambulance staff in County Sligo and they told me the arrangement in place was what they called "dynamic deployment". One would think it was NATO on manoeuvres in the south Indian Ocean. However, it was code for fewer ambulances covering a wider area. It meant that ambulances from Sligo were spending a lot of their time going up to Letterkenny, perhaps over to Castlebar, away into the midlands or up to County Monaghan. Therefore, when people were looking for an ambulance locally, it was not there. There was an incident two months ago in which a lady was hit by a car by Carrick-on-Shannon, where there is an ambulance depot. She lay on the side of the road for almost an hour an a half before an ambulance was able to come. That is the experience of many people. When there is an emergency and a crisis, we are told to dial 999 and act fast. We are told that in cases of stroke, for example, time is critical and we must react quickly to get the person to hospital and treated. Yet, our ambulance service which is there to do that, is simply failing. It has failed for a long time. This is not news to any of us in the Chamber. We have known about it for some time.

The Minister mentioned that more resources were being put in and more money was being provided. However, the experience of people is that they are not seeing those resources. That is the reality of it. When I speak to the staff, it is the same situation. There are fewer staff trying to do more work. There must be a re-examination of this dynamic deployment model, how it has worked and how it has failed. If the Government is to continue with that model, where ambulances will be dispatched over vast areas of the country, there needs to be an examination of how much more resources need to be put in to provide for that. It simply has not worked and there needs to be recognition of that. Any new design of a system which can work in future will clearly require more staff and more vehicles. Everyone that we speak to tells us that.

I wish to commend Deputy Cullinane on bringing forward the motion because every Deputy, Senator and councillor in the country, regardless of political affiliation, has been inundated with messages from ordinary citizens out there. When there is a crisis in their lives they expect to be able to get an ambulance and get to hospital. It is bad enough that when they go to hospital, they face waiting times and other issues. In their moment of crisis, the State is letting them down. It is paramount that we deliver for the ordinary people and ensure there is a proper ambulance service in place.

I will begin by acknowledging the work that paramedics do throughout the State day in, day out. They are the first on the scene to horrific incidents and they tend to people at the most frightening times of their lives. They do all of this under immense and growing pressure. I also acknowledge the National Ambulance Service and the management team there. Last year, I spoke to them about an ambulance blackspot in west Roscommon in my constituency. It had been identified by HIQA in 2014 as a blackspot. At that time, there was just a day service Monday to Friday that closed at 6 p.m. and a night service on Saturdays and Sundays with no day service. There was only one permanent crew in place during that time and the four people were run ragged. I do not know how they did it. For me they very much sum up the incredible commitment of our paramedics throughout the State.

I brought this issue to the attention of the National Ambulance Service. It conducted a report and found that between January 2019 and October 2020 a staggering total of 4,259 calls were received for the Loughglinn region of which more than 93% were emergency calls. On the back of this report, the NAS agreed to make the Loughglinn service 24-7. I am grateful that the NAS not only listened but acted and did so very speedily. Now is the time the Government has to act. While that was a positive and a good news story at long last for west Roscommon, we have an issue in that there is a total lack of resources nationally. This is stretching ambulances and paramedics on duty to the absolute limit.

Every day, several texts go to paramedics offering overtime in various areas to cover shifts. In many cases they physically cannot be done. I know of several texts that went out this week for counties Roscommon, Mayo and Galway. As has been said, paramedics are also working dangerously long hours. I know of a shift last week from 10 a.m. to 10 p.m. and the crew did not get back to base until 3 a.m. the next morning. There are issues, which need to be dealt with. They have been highlighted. As has been said, this is not Sinn Féin saying this; this is paramedics on the ground. We need to act.

I welcome the Sinn Féin motion. We are supporting it. I want to speak on two specific scenarios as they relate to my county of Cork. They certainly reflect the experiences of the Sinn Féin Deputies as they related stories from their constituencies. An email I received from a person stated that on the previous Saturday an elderly man aged 85 crashed into two parked cars on the side of the Ballyhooly road coming out of Glanworth. I am being deliberately parochial because it needs to be highlighted. The email stated:

The man called the ambulance immediately. The man was informed the ambulance would be 20 mins. I offered 1st aid at the scene. The man appeared ok but had pain in chest and down his left arm. The fire brigade attended the scene quickly ... The man was kept in the car waiting for the ambulance. The fire brigade crew kept him as comfortable as possible with blankets and a tarpaulin. The emergency services told the man that his ambulance had been diverted to a heart attack and his ambulance was cancelled. An advanced paramedic did arrive about 1.5 hrs after the accident had happened. Around the same time a local doctor ... saw the lights and came to help. The gardai were on the scene throughout. Eventually 2.5 hrs after the accident, as the night was cold and wet, the man had to be taken from the car and brought to a neighbour's house for his health and safety. At this point there was 5 fire engines, 3 garda vehicles and an advanced paramedic on the scene. They were able to clear the rd and open it again. It was 3 hrs 20 mins before an ambulance eventually came and it was 4 hrs after the accident before the man left in the ambulance for hospital.

This is quite a typical case. I mentioned the location because I want to put on record that it is a rural area in Cork but no more than a 20-minute drive from Cork city and the nearest tertiary hospital and no more than half an hour from the nearest secondary care facility. This is happening and it needs to be acknowledged. I grant that the Minister has acknowledged the problem. I absolutely accept that he has said more financial resources are being deployed to deal with the issue and that he is in the process of recruiting 200 additional paramedics who are going through the system.

There is a legitimate expectation on the part of every citizen to expect that emergency services operate on the basis of the pre-hospital emergency care guidelines and that there is a time limit by which each call will be triaged. It is very clear to me that if there has been a change in the protocols when people ring the emergency phone line calling for an ambulance, that change has not been communicated to our citizens. If there has been a shift in what people's legitimate expectations are in respect of an ambulance coming to a scene and if there have been some changes in these protocols then they certainly have not been communicated to the public. This needs to be addressed.

Notwithstanding all of this, the simple thing that occurred in the incident I detailed was that there should not have been any ambiguity in any protocol for pre-hospital guidelines involving an 85-year-old man in a road traffic accident. There should not be any ambiguity about the need to ensure that an ambulance arrives on time and within the pre-hospital guidelines. This is why I am articulating the case.

I also received the following email from a paramedic:

I'm a paramedic in the National Ambulance Service and I've recently learned of a Bantry/Fermoy ambulance crew who crashed returning to base ... apparently a result of exhaustion.

The crew in question had clocked up 600 km+ in one shift. Thankfully neither the crew or another road user was seriously injured ...

The crew escaped with little or no injuries however the next time the crew, the potential patient they carry and other road users may not be so lucky.

This is a result of NEOC (national emergency operational control) and national ambulance service managements refusing to treat paramedic/emts with the dignity they're entitled to and deserve

This runs to the heart of the issue. It really does need to be sorted.

We welcome the motion. I am delighted to see it this evening. In this country at present, not only are people not guaranteed access to a GP or access to an out-of-hours GP service, they cannot even be sure whether they will get an ambulance if they need it. Something is going seriously wrong. The place is going to hell in a hand cart fairly lively. I know we are in the middle of a pandemic. We all understand this. The testimonies the Minister has heard this evening are crucial. We need to see the ship being turned around quickly to ensure people have confidence that the system will deliver for them and that at a very minimum an 85-year-old man could have the legitimate expectation for all of his years that if he was involved in a road traffic accident, the case would be prioritised.

The issue raised by Deputy Cullinane on the length of time that ambulances spend in emergency departments needs to be tackled. It is not good enough for the Minister to say HSE has commissioned a review into the issue with a view to identifying which remedial measures might assist in the efficient release of ambulance resources from emergency departments. We have known for ages that this has been going on. I could not put a timeline on it. The dogs on the street know that ambulances have been backed up at emergency departments since Adam was a boy.

The day for coming into the House-----

I am unsure as to what the Deputy's internal arrangement for sharing time is but the Deputy is probably over-----

----with that kind of language is gone. We need a response. I apologise to my colleague, Deputy Nash, for going on.

I thank the Leas-Cheann Comhairle very much. The points and all of the issues made by Deputy Sherlock, as we know, predate the pandemic. I join with colleagues in commending the work of the ambulance service before the pandemic and the sterling work that they have done throughout the pandemic, particularly in the visits that they have made to the house-bound, together with the sensitive way in which they go about their business. This gratitude must be put on the record of the House. I thank them for their activity in that regard in my area of Louth and Meath.

The Minister will probably agree that front-line health workers of every description should be entitled to the very best working conditions. As far as emergency medical technicians, EMTs, in Drogheda are concerned, that is not the case. Drogheda is Ireland's largest town and serves one of the most densely populated areas in the country. EMTs in my home town work in intolerable conditions. Their base is at the old Cottage Hospital in Drogheda and it is not fit for purpose and never was. They occupy a space in a building that was meant to be temporary that has now taken on a state of permanence.

I will give the Minister one example of the inadequacy of the facilities. A few weeks ago the washing machine and dryers were out of action and there was no running water available to wash the interior of ambulances, that is, during a pandemic. There was no running water available or no facilities to wash uniforms. I do not want to get started also on the showering facilities. I raised this with the HSE before. Replies to me say that Drogheda is a priority for capital investment for a new base. In February and March I sent the HSE a list of prospective sites. I have tried to follow that up to weeks ago with the HSE but there has been radio silence since and over the past few months.

I believe the Minister will agree that hard-working EMTs are entitled to better than this. We need a new base in Drogheda. This needs to be expedited. We need a timeline and I would appreciate an update, if not from the Minister this evening then from the HSE and very shortly, please.

Glaoim ar an Teachta Cairns ó na Social Democrats.

We are all aware of the instances in recent months of unacceptable waiting times for ambulances and paramedics being directed, sometimes hundreds of kilometres, to respond to an emergency. This is obviously deeply distressing for families and communities who should be assured of access to emergency services. These fears are even more acute in rural areas where waiting times can be much more significant. The delays in the ambulance service are a cause of worry in themselves, but coupled with the erosion of health services in areas like Cork South-West, communities are deeply troubled by the implications.

Bantry General Hospital is still awaiting the necessary investments to guarantee its future, while the closure of some services due to staffing in the summer demonstrated its precarity. Furthermore, the rationalisation of SouthDoc has resulted in reduced hours in Castletownbere and the closure of the Kinsale service. Combined, all of these issues greatly impact the rights of people in the area to access appropriate medical care.

The focus on ambulance services is incredibly important. This is always part of a multifaceted and interlocking system. We need greater support for all of these features together.

In discussing this motion, it is important to note that we have very dedicated and professional paramedics and ambulance service staff who are doing everything they can to respond to calls. Anyone who has interacted with them understands the commitment and skill they display in dealing with emergency and difficult situations. Emergency services are an essential public service. There should be no doubt or worry that ambulances, in this case, or the fire brigade or An Garda, will respond immediately to emergency situations. This has to be a bare minimum. This has to be a service the State guarantees. Unfortunately, this is not the case.

Instances highlighted in this House and in the media in recent times reveal considerable waiting times, with several cases in Cork. The response times for both life-threatening and potentially life-threatening call-outs have decreased in recent years. Reports from within the NAS, however, show over-stretched staff and inadequate resources where paramedics and other staff have their 12-hour shifts overrun, putting themselves and others at risk. This is simply unacceptable.

After a recent ambulance crash, the Southern Star reported that members of the ambulance crew have begun to speak out. They say that "enforced overtime", which sees their 12-hour shift extended to 14, 16 and sometimes 18 hours, presents a real danger to them, patient outcomes and the long-term effectiveness of the service.

There are four ambulances in west Cork but they often travel massive distances to attend life-threatening calls in Cork city and Kerry on a daily basis, sometimes resulting in one or no ambulances being in west Cork. People have been in touch with me and it was amazing to hear other Deputies saying that it is a very common occurrence for people to be waiting more than three hours for an ambulance. Can you imagine if that happened to you? I cannot believe how common it is and I thought it was an outlier down where I am from.

Paramedics are reported having to apologise to patients for the length of time it takes them to get there, something that was described by one paramedic as embarrassing. Worse than that, it is dangerous. They have said that this has to be highlighted because people are going to die due to delays. We must have sufficient numbers of ambulances based around the country and have staff who work reasonable hours to be able to respond safely and effectively to emergencies. We must also have a service that reaches all communities in a timely manner.

The NAS has identified issues leading to delays in responding to calls in different areas of the country, including increased arrival-to-hand-over delays at emergency departments and infection prevention measures. Congested emergency departments can leave ambulances waiting at the hospital and tie up paramedics who should be out answering calls. It illustrates the complexity of the circumstances and the interconnection with other shortcomings in the health service.

As we face into the winter season of increased numbers presenting in hospitals, especially through emergency departments, will this situation only get worse? Any efforts to address the delays in ambulance responses have to consider all of the factors involved.

The NAS capacity review from 2015 highlighted the need for increased investment in vehicles and technology, the redeployment of ambulance stations around the country to service communities better and the hiring of additional staff. In cases where seconds can make all the difference, it is essential that the necessary investment is made in the service. For example, the improved locating of ambulance stations would decrease drive times and lead to an improvement in response times.

Ambulance crews also believe the switch to operating the service from a regional to national basis is not as effective as it might appear on paper and this needs to be considered.

The motion rightly calls for the urgent implementation of the review’s recommendations. In addition, the capacity review calls for different clinical options as alternatives to converging all patients into already overcrowded emergency departments.

In England, the development of alternative care pathways has allowed ambulance services to treat up to 50% of patients by means other than transportation to accident and emergency departments. However, this requires the creation of link-in services and availability of out-of-hours GP facilities, social services and emergency dental services. More specialist paramedic grades and the development of community first responder schemes can also play a role here in not only reducing the strain on ambulances and acute hospitals but in providing emergency interventions and care at the point of need.

The role of air ambulances in providing rapid emergency care, especially for island and coastal areas, needs to be acknowledged this evening also. The air ambulance is underutilised and underfunded.

Finally, ambulances are not just about emergencies, they are often key assets in transferring patients or people with additional needs for care in acute settings or even appointments. We need the capacity in the system to ensure these services are available to people.

I have recently been dealing with a case where an older person in west Cork has regular appointments in Cork city but is not guaranteed to make them due to the unavailability of vehicles. This is now a constant source of worry for the family who are struggling to make alternative arrangements and is simply unacceptable.

We need a properly resourced ambulance service that guarantees the numbers of vehicles and supported staff to ensure the best possible response times. It is the least the families, communities and the workers themselves deserve.

It is also necessary to provide other services that assist and improve the function of ambulances from fully resourced emergency departments and rural hospitals to out-of-hours GP cover and empowered paramedics. All of these features are connected and necessitate proper investment and co-ordination and this cannot happen fast enough.

I thank Sinn Féin for bringing forward this motion and I encourage all Deputies to support it. I know that the Minister said that he would not be blocking this motion but the question is when he will bring the measures requested in.

I move amendment No. 1:

To insert the following after “but cannot return to frontline emergency roles for health reasons”:

“and

— direct the Health Service Executive to recognise the National Ambulance Service Representative Association, who are members of the Psychiatric Nurses Association, as

a trade union with full collective bargaining rights for its members employed in the NAS.”

I thank the Sinn Féin Party and congratulate it on a very good motion. It is good to hear that the Government will not be objecting to or opposing it like it normally does, just for sake of it, and I hope the motion will make a difference.

There is one further matter I wish to mention. The Minister was not in the Chamber this morning when I mentioned it. On top of all of the details about the crisis in our service and how that could be improved by having a more efficient flow-through to beds and ambulance services, etc., there is the question of home care packages.

Many beds could be freed up from our hospital services and ambulances would not be waiting outside if those beds could be freed up if there was not the total chaos in the provision of home care packages. I understand, from talking to local health teams in Ballyfermot and beyond, that many workers are leaving the companies that provide these packages because their pay and conditions are so poor. They are not paid for travel time or expenses for using their own cars or if they have to take taxis and buses. They are constantly under pressure by the companies that employ them. A lot of these inefficiencies etc. can come down to workers' rights and how they are treated, in particular if we cannot recruit and retain staff. This situation could be addressed by dealing with this group of workers in the home care industry in a proper and decent way.

That brings me directly to what I want to say about our amendment. We want to add to the motion "to direct the ... [HSE] to recognise the National Ambulance Service Representative Association... [known as NASRA, affiliated to] the Psychiatric Nurses Association, as a trade union with full collective bargaining rights for its members employed in the ... [National Ambulance Service]". The Minister may recall when he was in opposition that on at least seven days this group of more than 500 workers in NASRA systematically organised. They were often outside the gates of the Dáil, sometimes hundreds of them at a time. They banged on our doors to ask this Minister and previous Ministers to tell the HSE to recognise this group of workers with almost half of the National Ambulance Service in its membership. The previous Ministers refused to do so and I am now appealing to the Minister not to do likewise.

My brother is gone now, but he was an ambulance driver. For many years workers in the ambulance service were extremely frustrated at the low levels of representation and services they got from their unions. They have a right to move on and establish themselves in other unions. A union they are connected with, namely, the Psychiatric Nurses Association, PNA, has 50 years of experience in organising within the health service. That is important.

When it comes to trying to advance legislation on how to bring on community paramedicine and chronic disease management to provide alternatives, we will have to talk to workers. We cannot leave them out of the loop. I understand there are trials in place, but there is a cohort of workers nobody is talking to . That is why this matters in a very concrete way. It matters in terms of fulfilling the objective of having a workforce that buys into, agrees with and is enthusiastic about major changes to be made in their lives. That is why the amendment to the Sinn Féin motion is so important.

I mentioned that my brother worked in the service. One of the first things he had to do when called out when he was very junior, and at a time when the training was not nearly as good as it is now, was to attend a car crash where a man had been decapitated. He suffered very badly psychologically for a very long time with the memory of that. He got no counselling, support or backup. I do not think he even got sick leave at the time. The section of the motion that refers to expanding mental health supports for the workforce, including access to counselling and psychiatric services where they are appropriate, is absolutely essential. After all, these workers are dealing every day with complex cases and life and death. Without them, we would all suffer greatly. Due to the fact they are suffering, the service is suffering.

There is a domino effect from the time an ambulance tries to get to someone, to the time it gets to the hospital, meets the trolley crisis and bed blocking happens, a term which I hate but which explains the situation best, and then to not having home care services. There are a whole load of complex problems. The Government must talk to workers and this is a crucial cohort of workers that has to be recognised.

There have been several ambulance crashes in Cork in recent months. Deputy Sherlock gave one example of an ambulance that had been on a 600 km journey. The standard of driving in the service is high, so we must ask what factors are at play. Could it be the case that fatigue might have been a factor in the other cases? It is not at all unusual for there to be overruns in the schedule for an ambulance team. Overruns of up to five hours are not unknown. Often, an overrun can be linked to intercounty run and sometimes to an interprovincial run. Not only are these overruns contributing to fatigue, the situation is compounded by the fact that ambulance teams are often being forced to work through lunch and dinner breaks.

I will pause while the brothers have consultations over here. Sorry, folks; I am trying to speak. The ignorance of it. It is astounding.

The point I am making is that the situation is compounded by the fact that ambulance teams are often being forced to work through lunch and dinner breaks. While the working time Act provides for rest breaks to be ignored in the event of an emergency, there can be no real argument that this clause is being seriously abused by the National Ambulance Service management. What is being asked of ambulance personnel may not stand outside of the law, but it certainly stands at complete odds with anything that might reasonably be expected of a worker.

Will the Minister commit to publishing the results of the investigations into these crashes when the reports are complete? If fatigue is a factor, and I strongly suspect it is, there must be no cover-ups. This is a major issue in the ambulance service. The most consistent voice within the National Ambulance Service raising the issue of fatigue over the past ten years has been NASRA, whose members are part of the PNA. These are issues that would have had to have been addressed by now had NASRA and the PNA been at the table. Yet, the Minister, this Government and the previous Government, which the Minister supported, have denied them that place at the table in a clear example of modern-day 21st century union busting.

With more than 500 members, NASRA is, without doubt, one of the two largest trade unions in the National Ambulance Service. Why does the Government continue to deny it a place at the table? When will it change this union busting policy?

I support the motion. I raised this matter with the Taoiseach last week. I requested an urgent independent review of the ambulance service. Since I highlighted the issue, I have been contacted by paramedics, patients and medical professionals from every corner of the country. Story after story has been relayed to me, some through anger and others through tears, but all of them through frustration and desperation.

This service is in crisis and I am not sure that the Minister, the HSE or those who are responsible for delivering the service are fully aware of the extent of the problem. This service is failing those who strive every hour of every day to provide emergency care. This service is failing men, women and children throughout the country. This service is failing full stop.

I could quote stories of the anguish and suffering being experienced by patients, and it would be a long list. We have all heard them. Every public representative here has heard the stories emanating from paramedics, ambulance crews and the public who have been affected by this problem. Most of these stories we hear are heart-rending. Each one is a catalogue of human suffering. The realities of our flawed National Ambulance Service cannot be allowed to become a vote-catching opportunity for any elected representative, including me.

We have a duty to demand that this be put right. This is our duty, in the first instance as human beings and in the second as elected representatives.

We cannot fail on this issue. It is too important, and failure is not an option. We must start to improve what is a substandard service, which is being experienced every day by people everywhere. We must tackle this national crisis by engaging with and listening to the front-line staff. We must ensure those who are doing the job have the means, structures, conditions, support and co-operation to do it safely and effectively.

The words "health and safety" have become so much a part of everyday life that one wonders if they are now simply taken for granted. It is ironic that health and safety regulations in the case of paramedics, who are recognised globally as being among the most highly skilled medical professionals, are constantly ignored or sidelined. If an individual has a licence to drive a heavy goods vehicle, he or she is obliged to obey the Road Safety Authority rules. These rules require a maximum of four and a half hours driving which must be followed by a 45-minute break. The driver's working day must be no longer than nine or ten hours, with weekly and fortnightly limits to be observed. Weekend breaks are also enforced.

A paramedic is expected to work 15-hour or 16-hour shifts, without rest periods and with no enforced weekly breaks. Meal breaks can be requested but cannot be guaranteed. Eating food in an ambulance in the current Covid environment is not exactly a healthy practice, yet this is the only option for paramedics as they travel the motorways. As they travel the motorways they pass numerous big glowing road signs that state, "Tiredness kills". A good work-life balance is long recognised as essential for healthy living. Some 57% of all paramedics' shifts do not finish on time. Nobody can predict which ones will be part of the 43% that might get home on time. This puts massive stress on families and on the well-being of the paramedics who are trying to do their best to be all things to all people.

When I raised the current ambulance service debacle with the Taoiseach last week, he referred in his response to pre-hospital emergency care. This is the primary function of paramedics, who are licensed to practise by the Pre-Hospital Emergency Care Council, PHECC. Countless lives have been saved because of their interventions. We owe them a huge debt of gratitude. Their job should be complete when they arrive with a patient at the emergency department. The hospital staff should take over responsibility at that stage. However, the reality is very different. In recent years, the ambulance has become an extension of the emergency department. Crews are caring for patients in ambulances for up to five and six hours because the receiving hospital staff have no place for the patients. This is not pre-hospital care.

Three things must happen immediately, and they are just three of many actions that are battling for priority. Front-line paramedics must be taken off Covid testing. The ambulance service is already grossly understaffed. Highly skilled paramedics should not be diverted to Covid testing. The deployment of the new interns due out of training schools must be monitored carefully. My request is that interns be placed as close as is practical to their homes or localities. Interns are on very poor wages. They get no travel or accommodation allowance. I know several interns based in Tipperary who are travelling daily because it is cheaper for them to travel to west Cork. They could leave Tipperary at 10 p.m. or 11 p.m. and report back for duty again the morning after at 8 a.m. It is simply unfair and unjust to treat young people like that, and it is happening regularly.

I also agree that paramedics must have NASRA recognised as their union of choice. This group was formed by paramedics to be their independent voice. It was initially recognised, but the HSE withdrew the recognition. Will the Minister enlighten us as to why this recognition was granted and then withdrawn? Paramedics and ambulance crew feel very strongly that their views are not represented adequately, and they believe there is a conflict in the fact the union that is currently representing them is also representing the management of the HSE. This should be recognised and reflected in the decision of the Minister.

The lid has been blown off the pathetic state of the ambulance service. That lid can never be allowed to close again until the voices of those who work in and depend on the National Ambulance Service are both heard and heeded. The problems in the ambulance service are compounded and exacerbated by a general malaise in the healthcare system. The Minister mentioned the lack of acute beds. There is an urgent need for a significant increase in bed capacity. For example, last week the Taoiseach received a very warm welcome on his visit to open a new 40-bed unit in South Tipperary General Hospital. His visit was well received by the management and staff and, indeed, patients across Tipperary. I do not see the Deputy tonight and I wish him well, but the only note of hostility was from Deputy Mattie McGrath, who did not want to see the Taoiseach in the hospital or in the constituency. The Taoiseach in his tour of that hospital saw a 39-bed unit on which €2 million has already been spent. An additional €5 million would make 39 additional beds available. I ask that this gets priority.

To reply to Deputy Lowry, he must realise that Deputy Mattie McGrath is ill at present. He has reason to be critical of the Taoiseach and certain hospital closures in Tipperary previously. The Deputy must have forgotten that.

I start by thanking every worker in the ambulance service, in west Cork and throughout the country, who has had to work under immense pressure in a failed ambulance service. The service is untouchable as the HSE and this Government are covering up what I call a shambolic situation that, unfortunately, is costing lives day after day, and nothing is being done. I and my colleagues have tirelessly raised the crisis we see nationally. I can see at first hand the disaster this Government has allowed to happen, which has led to many incidents in west Cork. I even raised these incidents with the Taoiseach. To be honest, Shep the dog would have done something about what I raised. The Taoiseach promised to look into it but, of course, it was west Cork so nothing happened. There are a small number of ambulances in west Cork. I hear that the Castletownbere ambulance is in Kerry all the time. The Clonakilty ambulance is now dubbed the Cork city ambulance as it is always in the city. The other two are based in Bantry but are in Cork city most of the time, outside Cork University Hospital with patients. That leaves no cover for west Cork if there is an emergency call.

I will outline a small diary of incidents which would prompt a massive inquiry if they occurred in any other sector. I asked the HSE and the Taoiseach and I now ask the Minister to hold this inquiry. To date, nothing has happened. On 1 August, a man was struck in Castletownbere. There was no ambulance in Cork county so he lay on the ground for two hours and 45 minutes. Second, in late August, there was a car accident in Schull with three people injured. Fire and Garda personnel laid the three injured on the roadside and rang for an ambulance.

There was no ambulance in west Cork. They waited two hours and 30 minutes before an ambulance came from another county. There were three persons seriously injured in Skibbereen with no ambulance available in Cork county. That person died waiting.

A person on Long Island just off Schull had a suspected stroke. The family rang for an ambulance but there was no ambulance in west Cork and the family waited for one hour and 30 minutes. A few weeks ago - this made the front page of the Southern Star - I got a call from a grandparent telling me that his grandchild fell seriously ill at a school north of Bantry. The parents rushed to the school to be told they could not get an ambulance. The ambulance service advised them to drive the child to Cork University Hospital. After some frantic driving by the child's father with the mother minding the child in the back of the car, they stopped in Coppeen as they thought their child had passed away. This is scandalous and needs to be looked into.

I thank Sinn Féin for bringing this very important motion before the House. We have all had experiences of hearing from constituents of the crisis in the ambulance service. Before going into that, I thank most sincerely the people who operate the service in County Kerry with whom I have considerable dealings. The personnel in the ambulances are excellent, kind, diligent, hard-working and put in very long hours. I meet them regularly when they are finishing shifts, starting shifts and in between shifts. They are very frustrated, to say the least, at how the system is being managed.

Considering the size of County Kerry, it is totally crazy how often the Iveragh Peninsula in south Kerry, for instance, might be left with no ambulance whatsoever. There are times when Killarney, the tourism capital of the western world, is left with no ambulance service because the ambulance goes to Cork. When the button is released and an ambulance has discharged its patients, it could be sent up to Tipperary. These types of situations are happening over and over again. It is beyond belief that it is being allowed to continue.

I was one of the most vocal critics in this country of the centralising of the ambulance service when it was taken away from the system that we had in the past. I did so at the time because I knew taking away the local knowledge and the local system would be detrimental and unfortunately, I was proven right. It was brought here to a disused fire station where they put in two different types of computers that could not talk to each other for a long time and the left hand did not know what the right hand was doing. Ambulances were going east and west, and the people in ambulance control did not know what was happening. It was a completely shambolic system.

I agree with the motion. I again thank Sinn Féin for tabling it. Each of us is demanding that the ambulance service be put right in the interest of the safety of the patients it deals with.

How many front-line response ambulances do we have in the country? How many supervisory officers do we have in ambulance cars who have not been rostered in the community? How many calls per week or per month do the supervisory officers make or attend? I am calling for a full review of the service, like a Garda division. There needs to be a front-line medical section and a clerical section. As training of an advanced paramedic is quite specialised, why does the National Ambulance Service expect paramedics to perform clerical duties and run budgets? I understand that paramedics are being used in test centres. How can this happen when we have a shortage in the ambulance service? Ambulance staff and paramedics save lives. Surely we should have fewer ambulance cars and more ambulances.

I think a service agreement for a call to be turned around in 90 seconds is important. However, why is this not applicable to a journey response - a time to get to the patient? This also needs to be monitored. It is unbelievable to hear that an ambulance from Cork is servicing Kerry and an ambulance from Limerick is servicing Tipperary, Cork and Kerry. Talking about a 90-second response time for an ambulance is brilliant but it takes an hour and 45 minutes to get to the patient. That is crazy.

I have seen ambulance paramedics told to go to an accident an hour and a half away. An hour into the journey, they are turned around to go back to their station again because another ambulance can get there sooner. There should be an ambulance service for each individual county and cover for areas that need it. The 90 seconds to get an ambulance out is absolute nuts. We need to ensure we have the correct number of ambulances. We need to get rid of the ambulance cars and put in more ambulances.

I too thank Sinn Féin for bringing forward this very important motion. It is one of the most hurtful things that is happening in our county at present. We do not have an adequate service. I compliment the drivers, paramedics and all the staff who do an excellent job. It is the management of the ambulance service that is wrong without a shadow of a doubt. Ambulance workers are burnt out from long exhausting shifts. Ambulance staff work very hard to perform an invaluable service in caring for our communities.

Far too often, patients are left waiting for far too long when they need urgent medical help. This not only causes considerable distress to patients but can worsen the medical outcomes. We must stand up for our ambulance service workers and ensure they get the support they need to do their jobs properly. We need to expand our ambulance fleet to ensure rural communities are properly served and not left behind as they are at the present time. We need to increase hospital capacity to avoid patients being left waiting in ambulances.

Up until 2012, we had a very good ambulance service before the reconfiguration of the National Ambulance Service. What it actually meant was a reduction of the ambulance service. Ambulances are being deployed from south Kerry deep into the heart of west Cork. Recently an ambulance crew started off at 8 o'clock in the morning and took a patient to Cork University Hospital. When they pressed the button coming out of there, they were sent to Dungarvan to take a patient to University Hospital Waterford. When they came out of Waterford, they were told to go back to Dungarvan for a second patient and took that patient back to Waterford again. Then they thought they were coming back to Kerry but they were told to go to Clonmel. That is the God's honest gospel truth. That happened. Our county of Kerry was left a whole 12-hour shift without that ambulance, which is not good enough.

We are on the back burner because more ambulances go to Cork and not so many Cork ambulances go to Kerry. Therefore, we are left without a service. A farmer had four fingers cut off. After a long wait, his wife had to wrap up his hand, bundle him into a car and take him herself. The last drive that Ambrose O'Sullivan got to the hospital, instead of being in an ambulance was in his wheelchair in the back of a Transit van. That is not good enough. We had a better service years ago than we have now. The Government needs to wake up and do something about it.

This motion could be addressed to many if not all areas of the health service: insufficient capacity; lack of funding; staff shortages; enormous pressures and mental strain on staff; and a constant ongoing crisis affecting both those who need the service and those who work in it. Despite increased funding and a commitment to employ more staff, there is difficulty in recruiting new staff and holding on to trained staff. One of the answers to that relates to poor conditions of employment, including low pay, poor management and low morale among staff.

The figures relating to the National Ambulance Service in the 2018 national staff survey by the HSE are quite shocking. Only 5% of staff felt that senior management acted on staff concerns; only 5% felt that communication was effective; only 6% had confidence in decisions made by senior management; and shockingly seven out of ten had experienced bullying and harassment.

These figures indicate a completely dysfunctional workplace environment - at best, a management that does not listen or engage with staff and at worst, a culture of bullying and harassment. That is within a publicly funded State service employer.

The HSE could make a start in changing this by recognising the right of ambulance workers to be fully represented by a union of their choice, in this case NASRA. I fully support the amendment to the motion in this regard. There are 500 workers represented by NASRA and they feel totally sidelined in giving their experience within the service. I wish the Minister, Deputy Stephen Donnelly, was here, as he sent a tweet on 16 July 2019 stating:

So @PNA_IRL feel they’ve been left with no option but to order the strike back on this Friday. How do we solve this? We need meaningful engagement from both sides, we need to use the industrial relations apparatus of the State and above all we must show RESPECT to workers.

That was the Minister, then part of the Opposition, calling for support and respect for the workers. I wonder if he has started the process of using the industrial relations apparatus of the State to try to resolve this matter. I would have asked him if he had been here tonight.

Alongside poor management is the ongoing problem of a lack of adequate funding and capacity in the service. Workers in the service have been raising these matters for years. In 2014, following an "RTÉ Investigates" programme and a Private Members' motion by Fianna Fáil on the matter, the disparity in the sources of funding in comparison with the North of Ireland and Scotland was highlighted by representatives of the PNA and NASRA at an Oireachtas committee meeting. Northern Ireland, with a population of 1.7 million people, had 1,200 staff and an annual budget of €78 million. With a population of 5.3 million, Scotland had 5,400 staff and a budget of €258 million. Here, with the population then at 4.6 million, we had staff of 1,600 and a budget of €137 million. We had approximately a third of the resources of Northern Ireland and Scotland.

I fully support the motion and commend Sinn Féin on bringing it forward. I thank the Minister of State for indicating the Government will not oppose it but I want its provisions implemented. The annual spend of private ambulance services has risen from €2.1 million in 2011 to €10.1 million in 2019. What are we doing and why are we paying private ambulances when we could expand our services? This should be dealt with in Sláintecare.

Covid-19 has highlighted not only the importance of our ambulance services but the severe stress we put them under due to the complete failure of this Government to provide the necessary funding and investment that these services need. I was in this House in 2014 when we called on the Government to address the lack of staff and resources being reported by ambulance services. I stand here again more than seven years later and very little has changed. The incompetence of this Government, as well as previous Fine Gael and Fianna Fáil Governments, is absolutely staggering. How can we expect to trust these parties can deliver on anything when our ambulance service, which was on the brink in 2014, remains on the brink now?

It is said the service cannot be fixed overnight but I fail to see how it cannot be fixed over seven years. To fix the ambulance service in Donegal would take the provision of three extra ambulances in the county. We need one for the Killybegs base, one in Inishowen and one more for the county generally. Surely it is not beyond the service to provide that.

My office has had reports of staff suffering burnout and exhaustion due to extremely long shifts. Only last month we had reports of a Donegal ambulance being tasked to Tipperary and another tasked to Belmullet. A Donegal patient, meanwhile, was brought to Letterkenny hospital in a Garda car because no ambulance was available. This prompts serious questions about the dispatching of our ambulances. Ambulance crews backed up at hospitals waiting to discharge patients are a typical example of the dysfunction of our health services.

At a recent meeting we heard from the manager of Letterkenny University Hospital and he made a big display, indicating to members that 80% of ambulances at the hospital were freed within two hours every time. This is the precise point as he did not mention that 20% of ambulances are there for longer than two hours. That is what leads to the problem around the county.

More recently there have been fears about the future of our Lifford ambulance base and I cannot stress enough that Donegal cannot afford to lose any more ambulance bases. There has been some good news as well with the roll-out of community paramedics, although that provision now seems to be stalled. These paramedics can divert patients from hospital and have them treated at home, which will save pressure from being exerted on hospitals. Of course, in typical HSE style, the roll-out has stopped, probably to be penny wise and pound foolish.

It is completely unacceptable that the people who are doing the most in this country are being given the least but, unfortunately, that will be the legacy of the Government. I hope its members hang their heads as a result.

I do not mean to be ageist but everybody in this Chamber probably remembers when we had ambulance drivers and they were able to take two people in an ambulance at a time. Everything has changed and we no longer have ambulance drivers but paramedics and advanced paramedics. They are highly trained health professionals and many people in the State owe them their lives.

Equally, we determined, in line with best practice, that ambulances could only take one person at a time rather than two. When that decision was made, nobody ever thought to double the number of ambulances. The number of ambulances stayed the same but the number of people who could be transported in those ambulances was halved. We have infinitely better trained and arguably better resourced paramedics but we are still restricted by the fact we have the same number of ambulances to cater for a larger population than before, when people could take two in an ambulance. I am not suggesting we go back to the days of taking two people in an ambulance but we must bear in mind that people are often waiting longer for an ambulance.

I will speak to the training of ambulance personnel, including paramedics and advanced paramedics. As I said, once these were drivers but now we have highly trained health professionals, which is very good. How are these people entering the ambulance service? Along with running an ambulance service, the NAS has its own sort of training scheme. My understanding is that this is quite unusual in comparison with European standards, as most European states now take paramedics through universities. Of course, we now have university training for paramedics at the University of Limerick. How many graduates of the University of Limerick paramedic course entered the NAS directly or even managed to get work experience there?

My understanding is that few have managed to do this, and the number may be one in recent years. The vast majority of graduates from that course in Limerick end up in the United Kingdom working for its ambulance services. Of course, they are of huge benefit to the people of the United Kingdom but we are training them in our university system. For the most part they are of our nationality, although, as with all our medical personnel, they are not all of our nationality. Will the Minister of State consider this? We need to get more people working in the ambulance service and consider how our resources are spent. If a university is producing graduates, we must ensure those graduates can access work in Ireland and we are not producing graduates to export in an area where we so badly need them working here.

I am not asking the Minister of State to respond tonight. Like many others, I have raised the matter before. I thank Sinn Féin for the opportunity it has afforded for us to raise the matter again.

It appears from what Members are saying that there are people involved in the dispatching of ambulances around the country who do not have an even basic understanding of the geography of the country.

That seems to be the case, given what has been said about an ambulance going from Donegal to Tipperary. I thank Sinn Féin for bringing forward this motion this evening. I am glad to say we are not opposing it. No differently from anybody else in the Chamber, I have listened to the debate on the motion in its entirety. I have a record of answering debates on ambulance services in Connemara, and I am glad to say that ambulance service has been put in place. I am also glad to hear Deputy Kerrane's experience in Roscommon.

I have worked on this over the summer and I have met representatives of the NAS, etc. There are certain fundamental pieces to be put in place. Although we have many ambulances, we must consider a dedicated retrieval ambulance team.

It would be like a mobile intensive care unit. Deputy Danny Healy-Rae spoke about the poor man who lost his fingers. It is needed for the likes of that. Such teams need to be put in place sporadically around the country.

We also need to look at the implementation of a trauma strategy to reduce the need for people to access services through the acute services and the accident and emergency units.

Deputy McNamara raised the ambulance apprenticeship programme. I checked it before coming into the Chamber this evening. It was launched on 11 November and the closing date is 28 November. That is the apprenticeship model. The Deputy spoke about what is going on in our universities. The Deputy said that it is in Limerick, but my understanding was that it is in Cork. I thought a masters programme was taking place in University College Cork. Of the 16 who have been trained, six are on a panel. I cannot answer the question about how many were recruited into the service, but I know there are six on a panel. One would wonder why we have them on a panel and are not using their expertise.

The budget, perhaps.

I will come to that next. A number of elements need to be there. There is a different hierarchy within the EMTs, the paramedics, the advanced medical practitioners, and a broader advance of other groups like the community first responders, CFRs. We have 275 CFRs. They were stood down during the Covid period, but 125 of them are working again. I hope that will come to bear when there is an Echo or a Delta response, because they are closest to the person and give the support at the start while he or she is waiting on an ambulance. There is no excuse for a person having to wait four or five hours. I have heard the stories.

Deputy Lowry made a valuable contribution when he said that 57% of all ambulance workers do not finish on time. He asked about the deployment of front-line paramedics for Covid testing. It is something I will bring back to and discuss with the Minister, Deputy Stephen Donnelly. Deputy Lowry suggested that interns and apprenticeships should be left closer to home because they are not paid an inordinate sum of money. There are numerous reasons, for example with regard to housing, we should leave them closer to home. We do not want to burn them out or turn them off. We would like to give them a reasonable experience in order that they might stay on board. We need them in the profession. We do not want to lose them at their point of entry after working.

I cannot comment on the matter raised by Deputy Joan Collins with regard to the unions because I do not have enough knowledge on it. I will bring it up with the Minister, Deputy Stephen Donnelly. Two or three Members raised that point before Deputy Collins did so.

Deputy Cairns talked about the triple lock. I do not have enough information to answer that question, but I know I have addressed it.

I asked for a clear breakdown on budget 2020. In budget 2022, €8.3 million was allocated to the NAS for the continued implementation of the strategic initiatives aligned with the NAS plan. The training and recruitment of additional paramedics to support baseline capacity needs 49 whole-time equivalents. The strength and clinical capacity in the National Emergency Operations Centre needs eight whole-time equivalents. Addressing tactical and operational management deficits needs 42 whole-time equivalents. Enhanced governance arrangements within the NAS need 29 whole-time equivalents. From what I can see, there is an action plan in relation to recruitment across a number of levels to address it. It does not speak to the point that Deputy Pringle raised about ambulances. That is what we need, and Deputy McNamara also said it. We need ambulances. That was the difference in Connemara. We got the ambulance and the people came around it. It takes the guts of 11 people to man an ambulance so that it can run 24-7. One can work out from that how many ambulances would need to be recruited into those areas. This is absolutely essential. I have heard the horrific stories from front-line workers who have found being out on the ground extremely difficult and very challenging. I have heard about how exhausted they are and the burnout they have felt. What is wrong in the NAS did not just happen over Covid. It was wrong before Covid ever arrived and it has to be acknowledged. I acknowledge that the Minister has sought funding. It is provided for within the budget. There is a plan for the spending within the budget. My experience and engagement with the NAS within my ministerial role has been very positive. They engaged, they found the funding and the staff and they had the will to implement it.

Queries have to be made about the suggestion that temporary amendments could be made to the current deployment model. What are the proposed amendments being considered? When will a final decision be made on whether they will be introduced? Deputy Pringle spoke about the deployment of an ambulance from Donegal to Tipperary. The current deployment model is aligned to best international practice and was put in place following HIQA recommendations regarding safety concerns with former health board level control centres. In the context of current service pressure and capacity issues, the NAS and trade unions have a working group in place that is jointly looking at what work practice changes are possible. This will improve staff experiences without affecting or compromising patient safety. While a timeline for the conclusion of these discussions is not yet available, the NAS has emphasised that there is no intention to move away from the HIQA-recommended model and return to a geographical limited model, which would reintroduce inherent patient safety risks that were eliminated when the local control centres were closed. They should, and I hope they will, look at the piece of equipment - the ambulance or car itself - and at the rapid response between the various areas, and whether that could help in formulating any support that could work. When they did this piece of work in the past, they looked at the UK model and found that the rural capacity response rate there was 12%, whereas our rate was 40%. The geographical spread and the diversification within our need for more local or regional ambulance depots is essential, as is the quality of those depots.

It is sad to hear that when ambulances are left outside hospitals, paramedics are failing to have access to toilet facilities or to eat. It is wrong that they are left having their lunch in the ambulance, which is their place of work all day. I ask the hospital groups to take that on board following tonight's debate. It is wrong that the families and friends of patients are going to the local service station to buy ambulance personnel a cup of coffee or a bun. That is not how we should treat any front-line worker. Most importantly, it is not how we should treat people who are under an inordinate amount of pressure, and are in fact under severe pressure. That is my one ask of the hospital groups. It does not require money. It does not require legislation. It requires a willingness to acknowledge the role played by our paramedics and front-line NAS personnel in delivering patient care.

Deputy Cronin is sharing time with Deputies Paul Donnelly and Cullinane.

I hear and appreciate what the Minister of State has said. Sinn Féin appreciates that she is not contesting the motion. We have to remember that our ambulance service is a critical service that everybody wants but hopes they will not need. I will never forget meeting a fireman who was on duty the night of the Stardust fire. He recalled that it was a very quiet night before all hell broke loose. He said to me that the emergency services are like an insurance policy; we hope for the best when we are at our worst. These services should never be run to their limits.

We all feel fear in our hearts when we are in traffic and hear an ambulance siren. We see cars doing all kinds of manoeuvres to get out of the way. Instinctively, we know it is a matter of life or death. We hope that if we need one, it will come on time, but it will not if it is a Thursday in Maynooth, Celbridge, Leixlip, Kilcock or anywhere in the northern hinterlands of my constituency from Donadea to Johnstownbridge. There is no ambulance service operating from the Maynooth base from 7 a.m. to 7 p.m. due to the austerity cuts from 2012. A person can have a heart attack or a stroke, or sever an artery, on any day except a Thursday between 7 a.m. and 7 p.m. With no ambulance available from the Maynooth base, he or she will be relying on an overstretched service from Naas or Tallaght. Time is of the essence and that time can be lost.

Jenny Moore contacted me last night to recall how she waited for an ambulance for almost an hour and a half outside Celbridge after a head-on collision, fearing the worst for her son in the car beside her.

I have also been contacted by a paramedic regarding two cardiac arrests in Leixlip, both on a Thursday morning last month. In both cases, the response was delayed. Imagine the pressure this puts on our wonderful paramedics, who give 100% to their work, the job and the people they come to help. The Taoiseach and the Minister of State mentioned community first responders last week. I have been involved with Maynooth Community First Responders since I held a public meeting at which I and several others established the group. It is a volunteer group, however. It offers a superb service but should complement the State service. No citizen should have to rely on volunteers for their health. No volunteer should have to carry that burden of responsibility either.

I will finish on this point. Our society has changed. People are less likely to intervene if they see some misdemeanour in the streets. However, if we saw a vandal interfering with the wheels of an ambulance, we certainly would intervene. In its neglect of our ambulance services, the State is that vandal on the street, abusing our paramedic crews and taking the wheels off our ambulances. The treatment of the ambulance services and the citizens who depend on them is really a disgrace. I will leave it at that.

I have listened to the Minister's response and that of the Minister of State. I welcome that the Government is not opposing this motion. It is obvious to anyone who chooses to look that this service, like so many of our health services, really comes down to a postcode lottery. This is another service that is virtually on its knees. The Minister of State spoke about the valued and valuable community first responders who respond to incidents coded Delta but that is not their role. The State should never rely on volunteers to be the first responders in every situation. Even those of us who have no medical training, including me, understand that time is of the essence when it comes to an emergency situation. This is absolutely not the fault of the paramedics and the professional and dedicated staff of the National Ambulance Service. Responsibility and blame for this lies squarely with the successive governments that have allowed this situation to develop. I say that because this has been going on for a number of years. We all know of cases where people have been left waiting for an ambulance while in pain and distress and that is not good enough but we also know of people who have lost their lives while waiting for an ambulance and that is absolutely not good enough.

The staff of the ambulance service in Longford-Westmeath are absolutely burnt out. They truly are. They are doing exhausting shifts and morale is on the floor. One paramedic told me this week that they spent three hours in a queue with a suspected Covid patient. They also told me they had driven like the clappers for 90 miles to get to an incident only to discover that a child had been unconscious for more than 40 minutes after being knocked down. That is absolutely not good enough.

I have some questions for the Minister of State. How many people have applied for, been offered and accepted positions? What is the capacity of the National Ambulance Service training centres? Managers and staff are doing everything in their power but are operating in impossible conditions because there simply are not enough of them. We need to increase the numbers and to ensure that the system becomes robust so that, when we speak about community first responders again, they will be supplementing a service that is fit for purpose.

It is a sad reflection on our health service that many people cannot access a GP. As the Minister knows, in some parts of Dublin and in some rural areas, people cannot register with a GP because of a shortage. We are now seeing waiting lists and waiting times for GPs. In the past, people could contact their GP and get an appointment that day or within two or three days. That is now being pushed out to a week or longer. Out-of-hours GP services are inaccessible or not available to far too many patients. That is putting great pressure on our emergency departments because people are going to them when they do not have access to out-of-hours GP services. Dentists are leaving the dental treatment service scheme for medical card patients at a rate of knots. I know many medical card patients who cannot get access to dental treatment. Far too many patients cannot get access to a hospital bed. They are on trolleys. As was said earlier, the first case of a patient on a trolley was in 1998. There are now hundreds of patients on trolleys every day, as if it is normal that they cannot get access to a bed. We have ambulances parked up outside hospitals. Their patients cannot be transferred into the hospital because beds are not available.

We also have ambulance paramedics and front-line staff who are stressed out and burnt out. One of them described it to me as hell. We do not appreciate the kind of calls they have to attend. They have to deal with children who are sick and children who are dying. They have to cut people out of cars. They tend to people who are reaching the end of their lives after an emergency or an accident that happened on the side of the road. They are the people who go out to respond to those calls. They get up every single day to their job and keep us safe. When they tell us the system is not fit for purpose and that it is unsafe - and they have been saying that to me right across the board from middle management to ambulance paramedics and emergency medical technicians, EMTs - we have a responsibility to listen. They often do not get downtime after attending to a greatly distressing call or accident. Moral injury kicks in. They just need time to recover. A child or older person may have just died. The ambulance personnel may have just been at the scene of a horrific car accident and then, within five or ten minutes, they have to respond to a call somewhere else because of the pressures on the system. That is unacceptable.

Ambulance paramedics have to eat their lunch on the dashboard of the ambulance because they cannot take the time to eat. They are doing 12-hour shifts. They may get a call to respond to an accident 100 miles or 200 miles away ten or 15 minutes before the end of their shift and they cannot say "No" because of who they are and how they have been trained. As has been said, they are advanced paramedics. They are highly trained and highly specialised and they love what they do. They want to treat patients and will never refuse a call but we cannot put so great a moral responsibility on them all of the time that they cannot take breaks or eat properly and that they must sometimes work long shifts for 14 or 15 days without leave because of a lack of capacity in the system.

With respect for the Minister of State and the Minister for Health, who was here for most of the debate, I welcome the fact that additional funding has been put into the National Ambulance Service. Every single cent of additional funding is valued. I certainly value that additional spend. However, I ask the Ministers not to agree not to oppose the motion only to then not implement its recommendations. I do not want to be here again in six months, a year or two years still talking about the same problems. I understand that we cannot solve all of the problems overnight. We need a strategy that is properly funded and that sets out how and when we are going to increase the fleet and the number of personnel. The Minister spoke about training.

I will make one very quick point, if I may. The Minister said in his speech that the national service plan for 2021 set specific targets for response times for life-threatening calls and also for calls with lower acuity. However, he did not say anywhere in his speech whether those targets are being met. The truth is that they are not. That means that patients and those who work in the National Ambulance Service are being failed.

Amendment agreed to.
Motion, as amended, agreed to.