Dáil Éireann debate -
Tuesday, 28 Feb 2023

Vol. 1034 No. 3

National Ambulance Service: Motion [Private Members]

Deputy David Cullinane

I move:

That Dáil Éireann:

commends the tireless work of frontline paramedics and operational staff in dealing with increased demand without proportional resource increases;

notes that:

— 80 per cent of life-threatening incidents should be responded to by an ambulance within 19 minutes, as per the Health Service Executive's (HSE) own standards;

— average ambulance response times have lengthened by 50 per cent since 2019, by an average of 9 minutes, going from 18 to nearly 27 minutes, and up to 33 minutes on average in the South-East;

— State-wide response times for life-threatening callouts (Clinical Status 1 – ECHO: Patients who are in cardiac or respiratory arrest) within the 19-minute timeframe have decreased from 80 per cent in December 2017, to 76 per cent in December 2019, to 65 per cent in December 2022, and as low as 59 per cent in the West in December 2022; and

— State-wide response times for life-threatening callouts (Clinical Status 1 – DELTA: other life-threatening incidents) within the 19-minute timeframe have decreased from 54 per cent in December 2017, to 49 per cent in December 2019, to 30 per cent in December 2022, and as low as 19 per cent in Dublin in December 2022; and

further notes that:

— the National Ambulance Service (NAS) currently has cira 2,000 paramedics, and their workforce plan lays out a need for more than 1,300 more paramedics by the end of 2024, and a need to double the staffing composition to more than 4,000 by 2026;

— the NAS needs more than 3,000 paramedics in only four years to meet these targets and account for retirements and staff turnover;

— the NAS has warned that if these targets are not met, performance will continue to decline and the NAS will have insufficient resources to respond to the projected demand, and as a result, 19-minute performance would be considerably less than 40 per cent;

— only 209 new staff started with the NAS in 2022, of which 181 were patient and clinical care staff;

— since 2019, the National Ambulance Service College has commenced training for just 472 new recruits to the three-year Paramedic Studies programme, less than 160 a year;

— the NAS has said that "recruitment efforts are being surpassed by service demand", and Dublin Fire Brigade (DFB) have said "demand for ambulances is continually identified as being far in excess of DFB capacity"; and

— according to paramedics, as many as half or more shifts run into overtime, with 12-hour shifts often lasting 15 hours or more, leading to low morale and widespread burnout and occupation-related mental health difficulties among paramedics, which is damaging the attractiveness of the career and recruitment and retention in the NAS;

furthermore, notes that:

— in 2022, the average off-loads or hospital turnaround time in Dublin hospitals was 39 minutes, with 16 per cent of incidents having a turnaround time in excess of 60 minutes, according to DFB;

— in 2020, the comparable average turnaround time was 29 minutes with 6 per cent of ambulances experiencing off-load delays in excess of 60 minutes; and

— neither the HSE nor the NAS collate or report this data, as confirmed in a reply to parliamentary question 515 answered on 24th January, 2023;

condemns:

— the fact that the Government has not implemented the proposals agreed by Dáil Éireann on foot of a Sinn Féin motion on the NAS on 16th November, 2021, which the Government did not oppose;

— the failure of the Government and Minister for Health, Stephen Donnelly TD, to support our frontline paramedics to manage demand for emergency services and improve performance; and

— Minister for Health, Stephen Donnelly TD, and his Fianna Fáil and Fine Gael colleagues in Government, especially the Minister for Finance, Michael McGrath TD, and the Minister for Public Expenditure, National Development Plan Delivery and Reform, Paschal Donohoe TD, who chose not to provide the necessary fiscal resources in Budget 2023, which in turn is leading to burnout of frontline paramedics and has increased risk for patients due to increased response times; and

calls on the Government to:

— urgently publish a multi-annual capacity and workforce plan to meet the needs of the NAS and DFB to 2026 and 2030;

— 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, reduce reliance on overtime and long shifts, and reach response time targets;

— provide more hospital beds to improve ambulance turnaround times and admit patients to hospital in a timely manner;

— rapidly advance specialist paramedic grades and expansions to primary and community services, in particular those relating to improved use of technology in hospital admission avoidance, community paramedicine, chronic disease management, and integrated care programmes for older people, to improve hospital avoidance and reduce the strain on emergency services; and

— expand mental health supports for the NAS and DFB workforce, including access to counselling and psychiatric services where appropriate, and address outstanding recruitment and retention issues which are a barrier to increasing employment.

In proposing this motion, I start by commending the tireless work of ambulance paramedics and those on the front line, many of whom I have spoken to over the last number of weeks in preparation for this Private Members' motion. We had a healthy discussion at the Joint Committee on Health with the National Ambulance Service and Dublin Fire Brigade last week. Some 80% of life-threatening incidents should be responded to by an ambulance within 19 minutes, per the Minister's, HSE's and HIQA's standards. The reality is that the average ambulance response times for life-threatening call-outs have lengthened by 50% since 2009, by an average of nine minutes, going from nearly 18 minutes to 27 minutes, and up to 33 minutes on average in the south east.

State-wide response rates within the 19-minute timeframe for the echo life-threatening call-outs, which, as we know, are for patients who are in cardiac or respiratory arrest, have decreased from 80% in December 2017 to 76% in December 2019, 65% in December 2022, and as low as 59% in the west of Ireland in December 2022. The State-wide response rates on time for the delta life-threatening calls, which are all remaining life-threatening calls, have dropped from 54% in December 2017 to 49% in December 2019 and 30% in December 2022 and, horrifically, as low as 19% in Dublin in December 2022. Dublin Fire Brigade was clear that the reason for this is a lack of capacity on one hand and, on the other, more lengthy wait and turnaround times at hospitals, with ambulances parked outside hospitals, waiting to disembark patients but being unable to because there are not enough beds.

The National Ambulance Service has about 2,000 staff. I have spoken to the Minister previously on this because we tabled a motion on this last year and recommended that the Minister and Government do certain things, which they simply have not done. As we know, we need to increase significantly the capacity in the National Ambulance Service. The workforce plan that the National Ambulance Service has put in place states that it needs to recruit 1,300 more paramedics by the end of 2024 and that we have to double the capacity, which means an additional 4,000 staff by 2026. That is a very significant increase that has to be met. The training places are simply not keeping pace at all. The National Ambulance Service stated, "recruitment efforts are being surpassed by service demand". We are not even standing still, never mind increasing the capacity, which we need to do. This is a critical area which the Minister is falling short on. We know that we need to double capacity over the next five years. It has been clearly set out in the capacity review. I do not see any of those targets realistically being met. When it comes to life-threatening call-outs across the State, average wait times are going up.

I mentioned the wait time for life-threatening calls in the south east. The average time last year was 33 minutes for the entire year, from when somebody makes a call to when an ambulance arrives. This includes those who are in serious cardiac arrest. The Minister will also know that the south east is the only region that does not have 24-7 emergency primary percutaneous coronary intervention, PPCI, yet it has the highest wait times for life-threatening calls for the National Ambulance Service. That is absolutely unacceptable and needs to be dealt with as part of increasing capacity in the service generally. The National Ambulance Service told us that the average off-load or hospital turnaround time in Dublin last year was 39 minutes, with 16% of incidents having a turnaround time in excess of 60 minutes, and that this was a substantial increase on previous years. When one looks at all the metrics and data, we are seeing people waiting longer and that capacity simply is not being put in.

The Minister needs to publish a multi-annual capacity and workforce plan. That needs to be matched with increased training places and a sense that we are actually going to achieve that plan, because the current plan, in my view, will not be achieved. One has to look at spatial and regional distribution and at the west, north west and south east, where wait times are particularly high. We know we need more beds in hospitals. It will certainly help if we can have more beds so that ambulances do not have to be parked outside hospitals for as long as they are. We need to advance rapidly specialist paramedic grades and to expand primary and community services. Finally, we also need to ensure that there are proper supports for those who are in the service, because the ambulance paramedics I speak to are overworked and doing much overtime. As the Minister knows, it is a stressful job, with difficult situations and difficult call-outs which they have to respond to. They deserve our support too. The Minister has to do much more on this issue.

Deputy Martin Kenny

I commend Deputy Cullinane for tabling this motion. I commend the staff in our National Ambulance Service for the significant, tireless work they do across the length and breadth of the country. In the north west, this has been an issue for decades.

In isolated rural areas the wait times for ambulances have gone through the roof. We see what the averages are but averages can sometimes disguise particularly long individual cases. People have waited an hour or an hour and a half for an ambulance in some instances.

Dynamic deployment is at the core of this. It has been a disaster for people. When we hear of dynamic deployment we think of NATO manoeuvres in the South Pacific but that is not what it means. It means that an ambulance based in Carrick-on-Shannon will be called to south Roscommon to attend a call, from where it will then be called to Galway to attend a call and then on to Mayo to attend another call. Ambulances travel from place to place around the country. It is happening everywhere and local services have been depleted. We see this in areas up and down the country, yet the Government seems to be blind to it and continues with this process that puts pressure on services and has ambulances travelling up and down the country to attend calls far outside of their areas. The service is simply not adequate. There are not enough ambulances, there is no plan in place to provide enough staff for the ambulances that are available and there are not enough ambulance stations. Many of them are very rural and isolated and they cannot get to them in time.

The motion calls for a multi-annual capacity and workforce plan to be put in place immediately. That needs to happen with urgency. This issue has an impact on people. I have been contacted by many people over the years who waited for long periods. I remember a woman who had an accident in Carrick-on-Shannon. A car hit her on the road and she waited for an hour and a half before an ambulance came, yet there is supposed to be an ambulance station in the town. This causes people stress and inconvenience. It destroys their confidence that we will have a health service that can deliver for people.

At Sligo University Hospital and every other hospital in the country queues of ambulances build up outside as patients wait to be admitted because the emergency department is clogged up. The Minister needs to take this seriously and treat it with urgency.

Deputy Denise Mitchell

Emergency health services in Dublin are at breaking point. Front-line paramedics and operational staff have kept the ambulance services running with their tireless work but they have not been properly supported by this Government. The National Ambulance Service is not able to do its job to the level we need because it does not have the capacity. People now wait more than 20 minutes for an ambulance in Dublin and the east coast. The average response time is now 22 minutes but I know of cases in my constituency where people waited for an hour. Delays in hospitals also cause ambulances to be delayed outside hospitals in Dublin for anything from 40 minutes to one hour. The Government and the Minister have failed to support our front-line paramedics to keep up with the demand for emergency services.

The situation is now scandalous. All the figures show that our health services are going in the wrong direction. The crisis is clear to see in our hospitals as well. The average wait time in the emergency department at Beaumont Hospital in December was 17 hours. Elderly people aged over 75 years were forced to wait for more than 17.5 hours, on average, more than 2.5 hours longer than in 2019, with people spending time on trolleys, chairs, in corridors and in corners. The Government must get its act together and implement Sinn Féin's plan to fix our emergency service and better support our paramedics, nurses and doctors. The Minister for Health should urgently publish a multi-annual capacity workforce plan to meet the needs of patients and improve the ability of the National Ambulance Service, the ambulance service in Dublin and our hospitals.

Deputy Claire Kerrane

I welcome this motion and the debate on this important issue. This is a very important issue, particularly in rural areas where people tend to live more remotely and further away from hospitals. Like every other Deputy, I am contacted by constituents every now and again who are frustrated and annoyed because they have contacted an ambulance and have waited and waited for it to arrive. This causes great distress. People call ambulances when they are in need.

Sometimes people are not aware of the way in which ambulances are deployed. An ambulance base may be located only down the road but that is not to say the ambulance is there. In my area, the ambulance could be in Galway, Sligo, Mayo or somewhere else well outside the county. This is particularly problematic where the local base only has a single crew. This is one reason the motion's call for an urgent review of the coverage of the ambulance fleet is so important. This review is key, especially in areas where there is just one crew in place. In my home county of Roscommon, for example, the ambulance bases in Loughglinn in the west of the county and Boyle in the north of the country both have single crews. This puts very significant pressure on the teams in both bases. The areas of Boyle and Carrick-on-Shannon are under particular pressure and when they are under pressure Boyle and Loughglinn are under increasing pressure. Yet, it appears that, rather than providing additional supports, nothing is happening.

There is a serious staffing crisis in the midlands and that is having a knock-on effect, especially in County Roscommon. This issue has been raised with me many times. For this reason, the call for a workforce plan set out in the motion is also very important.

Response times for life-threatening incidents in the west have worsened. They are now 26 minutes on average and, as my colleague noted, one often hears of people waiting for much longer. I spoke to a paramedic earlier today. His 12-hour shift last night was to finish at 7 p.m. He and his crew finished five hours later, at midnight. This happens all the time right across the board. There is great reliance on overtime and shifts running over is practically the norm now. Paramedics can only sustain that for so long and they should not have to. They are facing burnout. This is a serious concern which needs to be dealt with. The motion should be implemented urgently.

Deputy Sorca Clarke

I add my voice of thanks and commendation to the tireless workers from the National Ambulance Service and our paramedics. It is very clear that lives are being put at risk because of the Government's failure to resource the National Ambulance Service and support our paramedics. The HSE's own standards provide that 80% of life-threatening incidents should be responded to by an ambulance within 19 minutes. In the midlands, that response time has increased by 53% to 29 minutes since 2019. Every ambulance region is further away from meeting the targets that it was in 2019 and this trend needs to be reversed. The outcomes must improve and that needs a multi-annual capacity and workforce plan to meet the needs of patients and improve the ability of the National Ambulance Service to do the job we are asking it to do.

The ambulance service is under serious strain and pressure and this is exactly what the paramedics have said would happen for years at this point. The service has approximately 2,000 paramedics and its own workforce plan lays out the need for more than 1,300 additional staff by the end of next year. It needs to double the staffing complement to more than 4,000 by 2026. The Minister should do the maths. Only 181 patient and clinical care staff started in 2022 and the college has started to train just 472 new recruits since 2019, which is less than 160 per year for a three-year programme. We need to double the number of paramedics in training and engage with qualified paramedics who no longer work in the ambulance service to try to bring them back. Paramedics are burning out. They are absolutely exhausted and that is what makes retention critical to meeting these targets. However, retention plans will fail unless there are more paramedics in general to share the burden.

I have read the amendment tabled by the Government which refers to the established number of alternative care pathways. The Minister failed to mention the record overcrowding and growing waiting lists. He mentioned that parts of the country are not yet seeing improvements. Which parts of the country is he willing to sacrifice?

Deputy Réada Cronin

Most of us have a story about how brilliant our ambulance paramedics and personnel are. They are the men and women we hope to never meet but when we need them we want to see them as quickly as possible. I know my local ambulance base in Maynooth very well. I campaigned about it having its hours cut during the austerity Government of Fine Gael and the Labour Party in 2012. Ever since then Maynooth and the surrounding towns of north Kildare have no ambulance operating from the Maynooth base every Thursday from 7 a.m. until 7 p.m. If an ambulance is requested in our area during those hours on a Thursday it has to come from further afield, from west Dublin or Tallaght. It has even come from as far away as Cavan. This has drastically increased response times and as the Minister is aware, response times are critical in cases of acute emergencies.

As a result of the ambulance cuts some of us got together to found the Maynooth community first responders in my town a few years ago. The local ambulance personnel in Maynooth were of great support to us, along with the National Ambulance Service, NAS. I pay tribute to our ambulance personnel, both the front-line paramedics and the operational staff in Kildare North for what they do. They are certainly not valued by the Minister for Health and his Government. That is what they say to me. That failure can be seen in the way our ambulance personnel cannot respond in the way they wish to and as HIQA recommends that they should. The target is that 80% of life-threatening emergencies should be responded to in 19 minutes. We are simply not meeting that target. As already outlined by our health spokesman, an Teachta Cullinane, the Government neglect of this essential service has seen that percentage fall through the floor. The NAS says it needs to double its staffing complement by 2026. It also needs to increase paramedic personnel by more than 1,300 paramedics in that same period. We know, because we listen. In the last budget, the Minister did not listen to NAS. It told the Minister it wanted a multi-year capacity and workforce plan. This is what we are calling on the Minister to provide in this motion. It needs this in order to plan for the future, to meet the emergency health needs of citizens throughout the State. The Minister has to start looking after the people who matter.

Deputy Aengus Ó Snodaigh

I commend the professional and compassionate manner of those in the ambulance service in particular in Dublin where I had a number of interactions with them over the past few years in regard to family members. They are absolutely brilliant. During Covid-19, the care, attention and compassion they showed in how they dealt with people is a testimony to the gift they have. What they want to do is save lives. However, there is frustration. There is stress and they are stressed themselves. They can see the solutions but they are not getting the answers. This Government and the last Government have failed them because the solution has been outlined quite clearly. There is a need to address the fact that ambulances are stuck at hospital accident and emergency departments where in many cases the turnaround is slow. Also, there are not enough vehicles and not enough recruitment. They cannot get to problems that arise. When an old woman falls on the street and cannot get up, and neighbours think she is having a heart attack or a stroke they are told to leave her, not to move her, then 40 or 50 minutes later an ambulance comes. It would have been easier for me or some of the residents to put that woman on my back and walk to the hospital. I would have been there more quickly, but we are told to leave her. That is an old woman on the cold road in the middle of winter. The fire station is 300 yards away but has no ambulances because they are stuck in the hospital or because there are not enough of them nor enough crew. We have the figures about how bad it is becoming. We cannot continue in that vein because lives are being lost. Lives are being lost because we do not have enough ambulances or crews. Something has to change. The change has to be proper investment and a proper recruitment drive.

Minister for Health (Deputy Stephen Donnelly)

I move amendment No. 1:

To delete all words after "Dáil Éireann" and substitute the following:

"notes:

— the vital role played by the National Ambulance Service (NAS) in Ireland's public health service;

— the vital role played by the NAS throughout Ireland's response to the Covid-19 pandemic;

— that ambulance services have been experiencing a significant increase in demand in recent years with a record 389,764 emergency ambulance calls received from the public in 2022, a 6 per cent increase on the number received in 2021;

— that the Government invested a record amount of over €200 million in the NAS as part of Budget 2022, and this represented an overall increase in NAS annual funding of approximately €30 million since 2019, with a further record investment for the NAS being allocated as part of the 2023 Health Service Executive (HSE) National Service Plan;

— that NAS staffing levels have increased from 1,933 whole-time equivalent (WTE) in 2019 to 2,125 in 2023, a 10 per cent overall increase in WTE, with further expansion of this workforce expected in 2023;

— the significant progress made under the previous NAS strategy 'Vision2020', to commence the transformation of the NAS from a conventional emergency medical service to an agile and responsive mobile medical service, and to enable patients to be treated at the lowest appropriate level of acuity;

— the significant modernisation and development of the NAS operational fleet of vehicles, including critical care ambulances, emergency ambulances, intermediate care vehicles, rapid response vehicles and a range of specialised support vehicles;

— the establishment of a number of alternative care pathways, designed to treat patients at the most appropriate level of clinical need, in the right care setting, while avoiding the unnecessary use of emergency resources where there is no medical requirement;

— the development of the NAS clinical hub 'hear and treat' service at the National Emergency Operations Centre, the pathfinder 'see and treat' model of care, and the establishment of the NAS Intermediate Care Service, which undertakes low acuity inter-hospital transfers to help free up frontline emergency capacity;

— the expansion of the successful Medical Assessment Unit (MAU) pathway pilot project, first trialled in North Cork and Mallow General Hospital in 2022, to the MAUs in Ennis, Nenagh and Roscommon;

— that the MAU pathway results in patients receiving medical treatment in a hospital closer to their home, reduces patient presentations to emergency departments and releases ambulances more quickly to respond to other emergency calls;

— that the NAS has developed a Human Resources People Plan 2022 – 2025, to further support staff retention, and the overarching purpose of this plan is to enhance employee experience, optimise the NAS working environment and meet expectations of health policy in Ireland;

— the Department of Health and the HSE are working to finalise a new NAS strategic plan to 2031, and this plan will facilitate a strategic organisational redesign and continued focus on key priorities including alternative care pathways, specialist paramedic roles and progress towards meeting capacity requirements and performance targets; and

commends the NAS for recent improvements in response times, noting:

— the key performance indicator is for 80 per cent of all ECHO (life-threatening cardiac or respiratory arrest) emergency responses and 50 per cent of all DELTA (other life-threatening incidents) to be responded to within 18 minutes and 59 seconds; and

— the latest figures for January 2023 from NAS show that 77 per cent ECHO and 48 per cent DELTA were responded to within the target time; and acknowledges that certain parts of the country are not yet seeing the improvements in response times that are required, and commits to on-going support for the HSE and NAS in investment and reform, to ensure targets are met both nationally and regionally."

I welcome the opportunity to address the House on the delivery of emergency care by the NAS. Deputies will be aware that in parts of Dublin, ambulance services are provided by Dublin Fire Brigade and my comments this evening apply to both groups of healthcare professionals, both Dublin Fire Brigade and the NAS. I meet with ambulance staff throughout the country. I am always impressed by their professionalism, their passion and dedication to providing the best possible care to their patients and by their fierce pride in the NAS. The women and men of our NAS and Dublin Fire Brigade were some of the heroes of Ireland’s Covid-19 response. They were regularly first on the scene with teams for testing, patient isolation, treatment, transport, vaccines and much more. In recognition of this and in response to it the Government recently sanctioned an additional rapid response force for the NAS of 200 healthcare professionals.

Our healthcare professionals in the ambulance service also deserve great credit for the improvements being seen throughout the country in regard to response times and new services. The Sinn Féin motion would have you believe that our NAS professionals are failing in their jobs, that they are failing to improve services for patients, to get to patients quicker, when nothing could be further from the truth. Our ambulance teams are responding quicker. They are arriving with highly trained emergency medical technicians, paramedics and advanced paramedics. They are providing new services including access to nurses, doctors and health and social care professionals. Last year the average response time was 25 minutes. In January this year they had that down to 22 minutes. Last January, out of 30,000 calls, 35 people waited more than 2 hours. That is 35 people too many, but it has fallen from last January to this January from 35 people to 30 people. Last January 114 people waited more than 1 hour. Again, that is too many. However, this year the ambulance services brought that down from 114 people to 81 people. They are absolutely committed to bringing those numbers further and further down.

The target for echo calls, that is cardiac and respiratory emergency responses, is that 80% of those calls be responded to within 19 minutes. Last year they were at 71%. This January they are up to 77%. That is very close to their 80% target. The delta call target, which is the other emergency calls, is that 50% be responded to within 19 minutes. Last year they were at 43%. This January they were up at 48%. As people working in the ambulance service will confirm, January is often the most difficult month of the year.

Sinn Féin acknowledges none of this in its motion. It says nothing of the improvements that our healthcare professionals are making to response times. It says nothing of the upskilling and advanced training of ambulance crews and nothing of the new services being rolled out. It gives no credit to our ambulance workers for the invaluable progress those healthcare professionals are making.

The Government has a different view. The Government acknowledges and supports the progress being made. We are investing in our National Ambulance Service at record levels and we salute those working in our ambulance service for using the funding with which they have been provided to improve response times, to expand the workforce, to modernise the fleet, to upgrade the bases and to provide new services for patients.

There is more progress to be made. Some parts of the country are not seeing the national response times that are needed. Many bases throughout the country need to be upgraded. We need to expand further the workforce. Deputy Kerrane quite rightly pointed to a workforce recruitment challenge in the midlands. I have discussed this in recent days with the director of the NAS and the service is aware of those recruitment challenges. It is aware that there is regional disparity. It is focused on bringing standards up across the country. In light of these various challenges, some time ago I asked the director of the NAS to develop a new strategy. The HSE board reviewed the draft plan in the past two weeks and it is now with my Department. The plan provides a path for ongoing investment, growth and modernisation with patients always front and centre.

Years ago, as we all know, the ambulance service was concerned mainly with getting patients to hospital. We now have a service that is clinically led, deploying highly trained crews onsite.

The new plan seeks to continue this journey and evolve from an emergency response service to a mobile medical response service. The ambulance service is now treating more patients over the phone, at the scene and in their homes. These are patients they would have had to bring into the emergency department in previous years.

Last year, the Government invested €200 million in the National Ambulance Service, an increase in funding of around €30 million since 2019, with additional funding being allocated on top of that this year. Staffing has increased by nearly a fifth since 2016. Is more needed? Yes it is. Do we need to train more paramedics, advanced paramedics and emergency medical technicians, EMTs? Yes we do. Do we need to address some of the regional recruitment challenges? Absolutely we do.

Additional clinical capacity in the national emergency operation centre, NEOC, in Tallaght has introduced new care pathways which are very good to see. These "hear and treat" and "see and treat" pathways allow the ambulance service to assess and treat many patients at the lowest appropriate level of care. Additional investment in the NEOC clinical hub means that a growing number of callers who are clinically triaged do not require transfer to hospital. Since October 2020, nearly 50,000 patients have been treated through this new pathway, 19,000 of whom did not need to go to an emergency department.

The pathfinder model has been rolled out in Tallaght, Limerick and Waterford. Additional sites are currently being identified for this year. The service aims to ensure individuals aged over 65 can avoid a visit to a busy emergency department, where clinically appropriate. The National Ambulance Service is assessing over the phone whether it is appropriate to send out a team that might include an occupational therapist or physiotherapist. It is engaging with the patient in his or her home and is able to tell a patient it does not need to bring him or her in, but instead needs to provide supports in the home. People are being made stable and treated at home, and are linked into the new specialist teams in the community.

Another recent initiative developed by the ambulance service, in collaboration with hospital groups, has been the medical assessment unit pathway. This was trialled in Mallow General Hospital in Cork last year. It has been rolled out in Ennis, Roscommon and Nenagh and we are considering more sites to roll it out in later this year.

Substantial funding has been allocated to increase the number of student paramedics training at the National Ambulance Service College. The recruitment programme last year was successful, with an intake of 135 students on the BSc programme in paramedic studies.

Colleagues will be aware that we are in the middle of a fundamental shift in how healthcare is delivered in Ireland. Over the past three years, we have built a new enhanced community care service comprising 96 primary care teams, 94 of which are now in place. There are 60 specialist teams supporting older people and those with chronic diseases. There is a new modern network of primary care centres with enhanced supports for GPs, including direct access to diagnostics. I, and, critically, the National Ambulance Service believe they are well-positioned to play a major role in this fundamental shift in how we deliver care. Its proposed plan, which we are reviewing at the moment, has a vision for the ambulance service playing an ever greater role in treating patients in the community and in their homes, in particular focusing on the elderly population where it will be able to add more and more care and treat people at home and in the community.

The Government is committed to supporting the National Ambulance Service as it grows and innovates. I want to acknowledge again that there is work to do. It is by no means all perfect. We and those working in our service are acutely aware that people are still waiting too long for an ambulance and that there are recruitment issues in some parts of the country. Some of the ambulance bases are, quite frankly, not fit for purpose and we investing in rebuilding them. Progress is being made at pace. Response times are getting better. The workforce is expanding.

Deputy David Cullinane

That is not true.

Deputy Stephen Donnelly

New services are being delivered. I want to finish by again acknowledging that all of this is happening through the tireless efforts, dedication and professionalism of the men and women working in our ambulance services.

Deputy Paul Donnelly

The simple fact of the matter is that, as the Minister has acknowledged, the ambulance service is under great pressure. Nobody outside of the Chamber would ever criticise any of the workers. In fact, we have all been exceptionally supportive of them and that is why they have engaged with us on this matter.

When a person fell ill recently in this building, I called the ambulance service at 11 a.m. At 4 p.m. I received a call from the ambulance service and from Dublin Fire Brigade to apologise and I was asked whether we still needed an ambulance. I had a conversation with the service and was told it was stacked up by the dozen. That was in Dublin, which is not a rural area. There is a fire station five minutes' walk from here. That was the call I received at 4 p.m.

This is one of many first-hand experiences we have with the ambulance service. My mother was left waiting for hours for an ambulance. She lives in East Wall and the Mater Hospital is only up the road. These are the experiences we are talking about. There are dozens of other experiences from people in the Chamber and throughout the State.

We have had extensive conversations with Dublin Fire Brigade, DFB, regarding the recruitment and retention of firefighters and paramedics. Any firefighter who is a member of the ambulance service will tell us quite clearly not only that are there not enough staff, but also that there are not enough ambulances.

Today I raised the change in the children's urgent care centre from a walk-in service to an appointment-only service. One of the biggest issues parents in Dublin West are talking about is the fact that this decision will put great pressure on the ambulance service. People cannot get appointments for GPs and will now have to go online to make an appointment for an urgent care service in the children's department in Connolly Hospital. We are heaping more pressure on people and parents, in particular. As someone who has used the children's hospital on many occasions, I know that when a child is sick a parent will not go online and self-triage, which is what the system involves. A parent will call an ambulance and go straight to Temple Street.

Deputy Johnny Guirke

Sinn Féin commends the tireless work of the front-line paramedics and operational staff who keep the ambulance service running without proper support from the Government. In a National Ambulance Service plan presentation, the service stated it has an urgent need to recruit additional staff as recruitment efforts are being surpassed by service demand. Dublin Fire Brigade has said that demand for ambulances is continually identified as being far in excess of capacity.

The National Ambulance Service currently has 2,000 paramedics and its workforce plan lays out the need to double the staffing composition to more than 4,000 by 2026. It also states that the ambulance service needs more than 1,300 more paramedics by the end of 2024.

SIPTU, not Sinn Féin, has said the National Ambulance Service is at breaking point. Increasing numbers are attending accident and emergency departments across the country which has severely impacted turnaround times, with crews having to wait hours on end to hand over their patients because of a lack of beds, as was the case in Drogheda when 13 crews were left treating patients in the back of ambulances as no beds were free. In my county of Meath, Navan is being bypassed and people are very concerned that they will wait hours to be admitted to Drogheda or Connolly hospitals.

Last month, paramedics in Navan said most runs were going to Drogheda with few or none staying in Navan. Having been seen by a consultant, patients were then sent back to Navan. That seems outrageous and must add to the ambulance service's workload. We need extra beds in our hospitals so that patients can be admitted in a timely manner which will, in turn, improve turnaround times. We need to more than double the number of paramedics in training and engage with qualified paramedics who are no longer working for the ambulance service to try to bring them back. Paramedics are burned out and exhausted, which makes retention critical to meeting these targets. Retention plans will fail unless there are more paramedics to share the burden.

Deputy Maurice Quinlivan

Too many aspects of our health service are failing. In my city, the emergency department in University Hospital Limerick, UHL, is under significant pressure, as are mental health services, particularly youth mental health services. According to the Irish Examiner today, 700 patients in Limerick, Nenagh and Ennis had operations cancelled in the past six weeks alone.

Other challenges facing our hospitals in capacity and staff retention are also facing our ambulance service. Everywhere we look there are challenges and at every turn, the Minister has fallen far short in addressing those. Like far too many of our health professionals, our ambulance staff continue to do tremendous work with limited resources and with limited support from the Government.

The paramedics and the operational staff deserve tremendous credit for their performance and the reality is there is just not enough of them. Regardless of what figure you look at, it seems that the trends are going in the wrong direction. Response times have increased by 50%, with the national average response time to call-outs now standing at 27 minutes. The ambulance service has advised that it urgently needs to recruit staff as demand for its services is increasing. The ambulance service employs 2,000 people and its workforce plan advises that this needs to be doubled by 2026. Scotland, which has a similar population to Ireland, has 5,000 people employed in its service. Our ambulance service has been run into the ground over the past ten years and this is showing as average response times and patients' experiences have worsened. The unavoidable reality is that emergency call-outs are taking longer because the ambulance service is understaffed.

I have met the NAS and unions representing their members with our health spokesperson, Deputy Cullinane. They explained to us that paramedics are burnt out and totally exhausted. The ambulance service spent €18.8 million on overtime in 2021, with two thirds of paramedics working significant overtime every month. There is an urgent need to address training places for paramedics and invest in ambulance services to recruit and retain paramedics. Without an uptick in recruitment, we simply will not meet the 2026 target of doubling the current NAS staffing levels. The problems in our hospitals are contributing to the issues in our ambulance service. The offload times in hospitals are being prolonged and this is contributing to the capacity and staffing issues in our hospital workforce. The number of people being treated on trolleys in my local hospital, UHL, stands at 1,561 for the month of February, which is a truly shocking figure. In February, an average of 82 people on trolleys every single day was recorded. The accident and emergency department at UHL cannot cope with the influx of patients, with an average of 240 people presenting daily. The causes of the crisis in our health service are multifaceted and this Government shows no sign of being able to deliver. The staffing response times in our ambulance service are putting patients at risk. Our trolley crisis is putting patients at risk.

Deputy Ruairí Ó Murchú

Our health service is in crisis, our hospitals are under pressure and our staff who are working in the ambulance service are under severe pressure. We commend the work they do but they need support. We need the capacity in the plan for the Government. I thank the Dundalk Democrat for dealing with this issue:

As many as 163 ambulances dispatched to non-cardiac life-threatening emergencies in Louth in 2022, took longer than one hour to get to a patient, shocking new figures have revealed. The figures are almost four times the number of calls which took longer than an hour to respond to in 2021. National Ambulance Service guidelines state that an ambulance should aim to arrive at the scene of an emergency non-cardiac incident within 19 minutes. However, 163 patients were forced to wait longer than an hour for an ambulance to arrive last year, according to information released to the Dundalk Democrat under the Freedom of Information Act. The longest wait time for a non-cardiac life threatening incident in Louth in 2022 was four hours and 50 minutes, with ‘Volume of Work’ given as the reason for the lengthy delay. Life threatening calls are split into two categories: Delta/Red (non-cardiac or respiratory arrest life threatening calls) and Echo/purple (life threatening calls relating to cardiac or respiratory arrest). In total, 111 Delta ambulance calls were logged as taking over one hour to arrive at their destination due to the ‘Volume of Work’; 37 were delayed due to ‘Distance Involved’; ‘Other’ was logged as the reason for delay in eight calls; while four cases which took over an hour were logged as ‘Slow Crew Mobilisation’; with two further delays logged as ‘Difficulty Finding Location’; and the remaining case logged as ‘Slow rate of Response By Crew.’

I will detail the overall figures, as cited in the Dundalk Democrat:

62 people experienced a response time in excess of 60 minutes and less than 75 minutes. 40 experienced a response time in excess of 75 minutes and less than 90 minutes. 17 experienced a response time in excess of 90 minutes and less than 105 minutes. 13 experienced a response time in excess of 105 minutes and less than two hours. 31 experienced a response time in excess of two hours.

I will leave it at that. The Minister has gone into some explanation of the improvements that have been made. There would want to be a hell of a lot of improvements to ensure next year's figures are not the same or worse.

Deputy Duncan Smith

I thank Deputy Cullinane and Sinn Féin for bringing this motion and this issue for discussion before the Dáil again in their Private Members' time.

Before I get into the motion itself, I would like to pick up on what the Minister said about the many things that are being delivered, including a national "modern network of primary care centres". When will we get a primary care centre in Swords in Fingal? It is the largest town in Ireland without one. It serves a growing population of more than 60,000. We are no closer to having a primary care centre than we were when a former Fine Gael Minister for Health put up posters all over the constituency saying he was going to deliver one. We are the largest town in Ireland without one, to add to us being the largest town in Ireland without a rail link. We need it. There are children's disability network teams, CDNTs, that need to be housed in modern facilities. Our primary care centre is Beaumont Hospital, and that is not appropriate. It puts undue pressure on an already stressed accident and emergency unit and hospital in Beaumont.

I welcome the equity the Minister showed at the beginning of his contribution when he said his comments this evening apply to both NAS workers and DFB workers. It is important to acknowledge, at least in a Dublin context, that we have both services and that they have quality workers and workforces. However, both are under great pressure. Both require the investment and the resources this motion speaks to, although the NAS is the focus of this motion. While the Minister's response to the motion was robust, it still did not speak to the main charge of the motion, which is that we do not have a workforce plan for the NAS that will deliver the 1,300 additional paramedics who are needed by the end of 2024. They will just not be delivered. We need to double the staffing composition to more than 4,000 by 2026, which is a very short period of time. The NAS needs more than 3,000 paramedics in only four years. That is just not going to happen if we maintain the current recruitment levels associated with current recruitment drives.

We have seen reports on this issue and it has been discussed before the health committee. Every local newspaper all over the country and all the national media have highlighted on many occasions the wait times that are being experienced. The trolley crisis still has not ended because there are between 550 and 600 people on trolleys each day. At the peak of the crisis, in early January, one ambulance crew spent its entire shift at the accident and emergency unit of a Dublin hospital. That is something that nobody could stand over. These are the realities faced by this workforce, which is under intense pressure and is under-resourced. The investments and resources that are coming its way are not meeting the demands of an ever-growing population.

Today, SIPTU has unequivocally called for support for this motion, as well as the motion that will be before the Dáil tomorrow. While we can all articulate political support in this Chamber, SIPTU has said that the appropriate first step would be the implementation of the independent review of NAS roles and responsibilities, which dates back to 2018. Its members and HSE management have called for the implementation of the review in order to assist with alleviating the crisis in ambulance services. These are the practical things that the unions are calling for in this area.

The Minister mentioned the echo and delta calls in his response to the motion, but they are still not meeting the targets. We have the figures that have been reported and the Minister has come back with figures that are slightly higher. However, they are still not meeting the target and we are still not confident that is the trend. We hope it is, and we hope it meets and exceeds the target. However, given what we are seeing in the throughput of people going into training and coming into the workforce in this area, we are not confident that meeting and exceeding the target will be a trend. It gives us in opposition no joy whatsoever to say that.

In relation to the Dublin Fire Brigade, we really need to get a handle on this. Most people in politics speak in support of the DFB. The support at local authority level from local authority members is incredible, and that is where the majority of the funding for the DFB service comes from.

Nevertheless, a recent report by Dublin City Council stated no additional funding had been secured from the HSE towards the cost of the Dublin Fire Brigade EMS in 2022 or 2023. The Department of Housing, Local Government and Heritage has made €8 million available towards the cost of the service in 2022, in addition to €1.9 million, or just over 50% of the unfunded cost of the service, towards payroll costs, and there is no commitment to maintaining this funding in 2023. There is agreement between the two agencies and the two Departments to establish an HSE-DCC joint ambulance service delivery task and finish group, to be chaired by the chief executive of DCC and the national director of acute operations in the HSE, to see whether the outstanding service delivery and funding issues can be resolved.

They need to be resolved. Successive Ministers for Health and HSE management continue to express public support for the involvement of DFB in the provision of emergency ambulance services but continue to starve that very service of the funding it requires. When we speak of why we need a strong Dublin Fire Brigade as well as a strong National Ambulance Service, it is because we need a strong paramedic service. The end users of these services are people who are sick, and in many circumstances, critically ill. They do not really care who turns up, whether that is a NAS or DFB ambulance. They just want one to turn up quickly and for the paramedics in those vehicles to have been trained and be skilled, as they are. There are not enough of them, however. We are not bringing enough of them onstream and they are not being supported.

We cannot allow this continued uncertainty in the provision of the service by Dublin Fire Brigade to continue. We need certainty. The fire brigade is a trusted service the people of Dublin value and hold dear to their hearts. We need proper action to ensure that service will be sustained and that the investment needed in the NAS, as set out in the motion, will be delivered.

Deputy Róisín Shortall

On behalf of the Social Democrats, I welcome this timely motion from Sinn Féin, which we support strongly. I pay tribute to the staff of the NAS and Dublin Fire Brigade for the essential work they do, which is a matter of life and death. That work is made significantly more difficult, however, due to the severe shortage of staff, vehicles and infrastructure generally.

At last week's meeting of the Joint Committee on Health, the scale of the crisis in ambulance services was laid bare. The gap between demand and capacity is widening and this requires an urgent response from the Government because lives will, undoubtedly, be lost. The newly published response time figures should act as a catalyst for change because they simply cannot be defended. Last year, only 72% of life-threatening cardiac or respiratory arrest cases were reached within the agreed time of 19 minutes, which was eight percentage points off target. For other life-threatening illness or injury, only 41% of cases were reached within that key 19-minute period, representing nine percentage points off the target figure. As outlined in the motion, the average ambulance response time has lengthened by 50% since 2019. That is a shocking figure. As for hospital turnaround times, the figures supplied by DFB are just as worrying. The average turnaround time for Dublin hospitals was 39 minutes, up ten minutes from 2020, while 16% of incidents took more than one hour to turn around, again a ten-minute increase on 2020.

This steep dip in performance must be reversed urgently. The situation is especially bad in some parts of the country, including the west, parts of the south east and Dublin city and county. In Dublin, for instance, serious questions hang over the governance structure of ambulance services and, unfortunately, that is borne out by the figures. Last year, Dublin Fire Brigade sought assistance from the NAS more than 63,000 times, only to be told no ambulance was available on 76% of the occasions. That is a truly shocking statistic. No ambulance was available 76% of the times DFB requested one.

Earlier this month, Paul Cullen of The Irish Times examined this issue in great detail, and his work has been helpful in this regard. He had to jump through hoops to get his hands on the 2016 Brady-Flaherty report, almost seven years after its completion. It still has not been published. What is the delay for that? Just today, I requested it. It has been known for a long time that there are serious problems here, and two people with expertise in the area were recruited to carry out a study on that. The study was completed in 2016 and its publication was blocked. Why was that the case? There is no point in doing these things unless we are going to learn from the expertise that has been brought in. It is unforgivable that the report has not been published. I hope it will be made available now, given it was finally released under freedom of information, FOI. It required an appeal to the Information Commissioner for Paul Cullen to get his hands on it. It should be published now.

I tried to get to the bottom of this at last week's committee meeting but none of the representatives of NAS or DFB could say when the report would be made publicly available. All they could say was they understood it was jointly owned by the HSE and Dublin City Council. That, frankly, is not good enough. We need more than piecemeal information. Will the Minister enlighten the House about this? Why has the report not been published and when does he intend it will be? We should not have to chase this. The people of Dublin and their elected representatives deserve to know the full scale of this problem. After all, it is their lives that are being put at risk by suboptimal ambulance provision.

We need to find out where the logjam exists. Is it in the HSE or the local authorities or, more likely, is it in the two parent Departments, namely, the Departments of Health and Housing, Local Government and Heritage, given they are the bodies that hold the purse strings? Those Departments must take ownership of this problem and take responsibility for guaranteeing people that there will be a properly functioning ambulance service. As I said, it is a matter of life and death and we cannot afford not to fund those services properly.

I appreciate that a task and finish group has been established and met for the first time only last week, but we have been told it will be another six months before it finishes its work. In the interim, we need to know what steps the Government is going to take to increase service provision and improve governance. We need answers to that now and we cannot wait any longer. These problems have been highlighted for more than 20 years. The Government has had the report since 2016. We need answers now. The problems have existed for two decades. They are not new; they have just worsened under successive Governments.

It is clear the vision of healthcare outlined in Sláintecare should be the guiding principle for reform, but political will is needed to get that up and running at a proper pace. Alongside scaling up the capacity of the ambulance service, alternative models of care, located in the community outside overburdened emergency departments, are an essential part of that reform. While I recognise progress has been made on putting in place alternatives to acute hospitals, it is terribly slow. There are significant problems with the recruitment of staff and with alternative services being available, not least out of hours. A reference was made earlier to Blanchardstown and the urgent care arrangements there, which are getting worse. Now, appointments have to be made. It was supposed to be an alternative to the overcrowded children's hospitals but now there are problems there.

This needs to be dealt with on a whole number of different fronts. Both the NAS and DFB detailed a number of initiatives that they are keen would be fully implemented but there appears to be a lack of joined-up thinking. A case in point is the ridiculous situation surrounding UL paramedic graduates. Last month, I raised this with the Minister for Further and Higher Education, Research, Innovation and Science and I raised it again at last week’s meeting of the Joint Committee on Health. However, I am still at a loss to understand why this has not been resolved to date. Every year, the UL students are sent abroad to complete their one-year internship because the NAS does not have the capacity to take them on. That is a crazy situation. There is a dire shortage of staff and students are in UL doing the course, yet they cannot get clinical placements in the NAS. That is just nonsense. It does not make any sense whatever.

To make matters worse, once these students have completed their internships, most of the graduates find it difficult, if not impossible, to secure employment with the NAS. I have received a number of emails from UL graduates since January. They are justifiably frustrated with the current application process. I understand work is underway to resolve the internship issue, albeit late in the day, but I see no evidence that the NAS or the Department of Health is dealing with the application issue. We are told that 3,000 additional staff are needed, yet we are freezing out a whole swathe of graduates who would be very well qualified to take up employment. The central issue seems to be with the application process and in particular, phase 1, which is a multi-choice questionnaire. According to a submission to the health committee, in the past seven years 405 Pre-Hospital Emergency Care Council, PHECC, registered paramedics completed the multiple-choice questionnaire but only 75 passed. That is a mere 18%. Of those, 56 got onto the employment panel to await a job offer for which the average time was a staggering 300 days. As of last November, only 37 had been offered a post. That is a no-brainer. That needs to be dealt with urgently.

I ask the Minister to please prioritise the whole question of resources, deal with the issue in UL and ensure that there is an adequate supply of ambulances. We cannot afford to let this go on any longer.

Deputy Bríd Smith

I thank Sinn Féin for tabling the motion. I thank friends and comrades in the NAS and Dublin Fire Brigade for talking to me in the last while and sharing notes with me. I am proud to say that I have got to know many of them very well over the past few years, particularly since I was a councillor. DFB was and still is run by the council. It is still under-funded. It always has been. I forget the year, but at one point the city manager, as he was then called – he is now called the CEO, which is a set of words that should not be lost on anybody and indicates that the city is run as a sort of company rather than for the services of the people - was trying to move away from the provision of the ambulance service and the Dublin Fire Brigade service because it was so expensive. A service like that is expensive and should be and must be expensive if it is to be good, of high quality and the staff are to be well trained, well paid and well looked after and if it is to respond to the emergency needs of the citizens, both of the cities and the rural towns and areas in the country.

The NAS is similarly way underfunded and understaffed and workers in that service have had quite a long struggle to get trade union recognition for the National Ambulance Service Representative Association, NASRA. We have been in this Chamber arguing for that trade union recognition for them and got a motion passed that the Government would seek to discuss this with the HSE so that it would recognise NASRA’s rights, talk to the workers and recognise their role in all this. In the meantime we had Covid and now we have a crisis in the delivery of the ambulance service. What I find interesting in how the workers view this is that they recognise that while they are underfunded, under strain and understaffed, this is intrinsically linked to the crisis in the health service, etc., because, they say, even if the ambulance service was fully staffed tomorrow; there would still be a failure insofar as there would be a lack of GPs, bed capacity and nurses, and there will always be backed up queues for the services when ambulances arrive at emergency departments. If the ambulances were at full capacity, inevitably they would be left waiting outside emergency departments in the current climate and result in stagnant response times. This is compounded by the failure of the Government and the Department to fully resource the service, particularly in rural Ireland where many of the hospitals that closed have left a void and it takes much longer for ambulances to reach the point where they should be able to deliver a patient safely.

I want to talk for a minute about the work they do. My brother was an ambulance driver and a paramedic. Unfortunately, he is gone from this world quite a long time but every year they write to the family and ask us to go to the annual mass. I am not into religion but I do go to the mass out of respect for him and the workers. It is quite impressive to see how proud they are of what they do, of the service they deliver, of the job and the employment they have and the comradery between each other and for each other, and for the patients they look after. In that sort of a job that sense of solidarity and comradery is important to have because, as they say themselves, the sort of sacrifices they put up with, particularly when the service is under pressure, means they consistently put their own welfare to one side. They often work for five, six or more hours after shifts are finished; they repeatedly skip meals and rest times; they sacrifice family events and their life-work balance; and ignore their own mental and physical health needs. This applies not just to the National Ambulance Service but to the paramedics and the men and women of Dublin Fire Brigade as well. They shoulder the burden of the criticisms of the community and when people cannot get an ambulance and they are waiting for ages for one, what they see is the ambulance driver and the paramedic, not the Government or the Minister for Health and those in the Department who are failing to deliver a service for the community. I, therefore, welcome this motion. We fully support it and we would like to request again that the Government act on the motion that was passed without opposition some time ago in this House, the details of which I can send the Minister, particularly where it states that the Government should act on talking to the HSE to push it to discuss the question of trade union recognition with the branch of the psychiatric nurses union, known as NASRA, which has been trying to get the recognition that it deserves for ten years.

Deputy Mick Barry

I want to pick up on the point at which Deputy Smith left off. More than 500 paramedics in the National Ambulance Service have chosen to join the National Ambulance Service Representative Association to represent them. NASRA is a branch of the Psychiatric Nurses Association, the PNA, which is a recognised trade union with a negotiating licence.

The HSE continues to refuse to recognise the PNA and to allow it to negotiate on behalf of its ambulance membership. It refuses to recognise it for purposes of negotiations on behalf of the ambulance membership. This is despite the fact that the PNA contains within its ranks at least 30% of all NAS paramedics. This is far more than other unions recognised by the HSE as representing ambulance personnel. If it does not make the PNA the largest union among ambulance staff, it certainly makes it the second largest among the two big unions. I am surprised and a bit disappointed that the Sinn Féin motion makes no mention of this issue in its text because it is central to the points and issues that are being debated here. Why is the NAS so chronically understaffed? Why are ambulance personnel so chronically overworked? Why is there such a major shortfall in the number of ambulances available to the service compared to the numbers needed by the service and the public?

The answer to all these questions is, of course, that successive right-wing Governments have failed to invest in public services at anywhere near the level needed. However, a factor in the equation has undoubtedly been a lack of sufficient pressure for real change, including by what is probably the largest union in the service recognised by the HSE. It would appear that the HSE is choosing to recognise the union that does not put it under too much pressure for change and refusing to recognise the one it fears might do so. Despite a unanimous vote by Dáil Éireann that the PNA be recognised, it is clear at the very least that the HSE is not under any real pressure from the Government on this issue.

Recognition of the PNA is not simply an issue of democratic rights, although it is that; it is also an important democratic issue. It is an issue in the sense that if we want a properly resourced ambulance service, we need to listen to those front-line personnel among those pushing the hardest for it. This union should be recognised now and the Government needs to get off the fence regarding this issue.

I do not have sufficient time available to fully develop other points I want to deal with, but let me refer briefly to a point raised by Deputy Shortall on the UL course and its graduates. The latter could be a tremendous resource for the NAS and bring great skills to the paramedic service. The fact is that obstacles are being placed in the way of these graduates to join the service when it needs 3,000 staff. That is wrong and needs to be changed. The Government should address it and feel under pressure to do so based on this debate.

Deputy Peter Fitzpatrick

New figures from the HSE reveal that the National Ambulance Service is not meeting the response time targets for emergencies throughout the country. While it is outrageous that 62 ambulances dispatched in County Louth to deal with life-threatening emergencies in 2022 took more than an hour to arrive at the scene, I commend the tireless work of front-line paramedics and operational staff for dealing with increased demand and limited resources. These timelines are not a reflection of the work put in by NAS staff but of a service that is under-resourced and under-appreciated.

The longest waiting time for a non-cardiac life-threatening incident in Louth in 2022 was four hours and 50 minutes, with the volume of work given as the reason for the lengthy delay. On the back of such figures, the HSE has confirmed there is a significant gap between demand and capacity.

Recruitment and retention issues related to recognition, pay, resources, working hours and poor working conditions, which I have raised numerous times regarding service providers such as gardaí and military staff, now apply to our National Ambulance Service providers. NASRA warns that the service is under significant strain, with pay and conditions so poor that it losing in the region of ten staff per month. Is it any wonder that under the Health and Social Care Professionals Act 2005, the paramedic profession is not even recognised as a profession? On top of this, paramedics do not even get recognition from the largest employer of paramedics within the State, the HSE. This lack of recognition limits career progression, negatively affects retention, restricts alternative pathways of care and, in the case of HSE employees, limits access to health and social care professional education opportunities within the HSE. As a result, the retention of employees within the field of paramedicine generally, and within the NAS specifically, is an area that needs to be addressed. Since 2019, the National Ambulance Service College brought in 472 staff who commenced training under the three-year paramedic studies programme. Of these, 55 dropped out. That amounts to fewer than 160 recruits a year. With the NAS estimating a requirement of more than 3,000 paramedics within the next four years to meet its workforce plan targets, these numbers of recruits are abysmal. Yet, this is a familiar tale.

Concurrently, emergency service demand is significantly increasing. For example, the number of emergency calls in 2022 was up 15% on 2021. As the "twindemic" hit in December, 2,000 people a day were looking for an ambulance. At one stage in December, 11 ambulances were parked outside the emergency department of Our Lady of Lourdes Hospital, Drogheda, and could not leave because there were no beds or trolleys inside for their patients. Some paramedics were left waiting for five hours before their patients had a place in the hospital due to an extreme lack of planning. Ambulance crews treated patients in the ambulances; however, because they could not offload, none of the ambulances could leave and respond to other 999 calls.

The reality is that if recruitment targets are not met and demand continues to rise, performance will continue to decline and people will die. Patients have unquestionably suffered harm due to ambulance delays. Clinical outcomes are being put in jeopardy as a result of these delays, and this is the real way that this needs to be evaluated. The appropriate measures and steps need to be taken to protect lives.

We need to implement solutions within our entire healthcare system rather than put a plaster over one issue only for another to explode. For example, Cork University Hospital has dramatically improved ambulance turnaround times due to a strategy whereby, if the acute phase of care – initial diagnosis and management, stabilisation and referral to an inpatient specialty – is complete, the patient is moved to a corridor inside the hospital rather than being left in a corridor in a crowded emergency department. This has reduced the ambulance turnaround time from half a day to 20 minutes. However, it has drastically increased the workload of already-overburdened inpatient ward teams and nurses, in particular.

Another potential solution would be to treat stable medical patients who meet the agreed clinical criteria in hospitals closer to their homes, such as model 2 hospitals. This pathway would reduce patient presentations to emergency departments and release ambulances more quickly. I would push for the reopening of Louth County Hospital. There is infrastructure and capacity available immediately that would alleviate the pressures on our other hospitals and ambulance services. The Report of the National Acute Medicine Programme 2010 outlined the need for smaller and larger hospitals to operate as a single local hospital group, resulting in the downgrading of Louth County Hospital and the advised closure of the Navan hospital emergency department. However, 13 years later, it is evident that our ambulance and emergency department services are struggling.

Overall, we need to overhaul the delivery of the pre-hospital emergency care services, having better training for staff in schools and childcare facilities and an expanded role for paramedics, helping to reduce the numbers of patients attending emergency departments in the first instance. However, to succeed we need to consider the career recognition of paramedics, the recruitment and retention issues, and the training issues of paramedics and the community. We need to act now before patients die.

Deputy Peadar Tóibín

Cuirim fáilte roimh an rún seo ó Shinn Féin.

In fairness to the Minister for Health, I have to hand it to him for managing to deliver an upbeat speech on the current situation in the health service. It takes a phenomenal level of optimism, or maybe disconnection, to give an upbeat speech in that manner. In his response, there was an element of Comical Ali defending the Iraqi war effort while bombs were landing behind him all over Baghdad. What is happening throughout the health service is heartbreaking.

This a record-breaking Government for all the wrong reasons. We have record-breaking numbers of people on trolleys in recent years. Last year, well over 100,000 people were on them. We have had record-breaking waiting times in accident and emergency departments right around the State, with many waiting at least 13 hours to be treated. We know this policy is actually killing people. I use that word advisedly. Often we say lives are lost because of the Government's policies, but lives are not just being lost: decisions are being made that lead to people's deaths. It is estimated that 1,300 people lose their lives annually because of Government-related overcrowding in accident and emergency departments. It is heartbreaking to see this happen. A hundred people per month lose their lives in this country because the Government will not reform the system. It is not for the lack of money because today we also learned that the budget in the health service is 21.5% of all Government expenditure. Never before has so little been achieved by a Minister for Health with so much taxpayers' money.

A particular issue on which I want to focus is obviously the wait times for ambulances for people. On 6,200 ambulance call-outs last year, it took more than an hour for the ambulance to respond to life-threatening emergencies. Only in 72% of life-threatening cardiac emergencies were people reached on time. We are learning that response time is actually lengthening by 50%. There are a large number of reasons for this. I want to focus on something that none of the other political parties are focusing on, however, and that is the relationship between the crisis in the ambulance service and the crisis in accident and emergency departments. If the Government keeps closing accident and emergency departments, it will take longer for an ambulance to get to an available accident and emergency department because it will have to travel further. If we keep closing accident and emergency departments, more and more people will be forced into fewer accident and emergency departments. We have ambulances waiting outside accident and emergency departments trying to deposit their patients.

The average turnaround time in Dublin is now 39 minutes. Just before Christmas, there was a phenomenal crisis outside Our Lady of Lourdes Hospital in Drogheda when 11 ambulances were forced to wait to deposit their patients in the accident and emergency department. The Government and HSE turned the hospital car park into an ambulance car park. The paramedics waited for five hours to deposit their patients in the accident and emergency department. As a result of the ambulances being tied up at the hospital, no ambulances were available on the night in question in the whole of counties Cavan, Monaghan, Meath and Louth. As a result, if someone had a heart attack or stroke, it was tough luck, you had it on the wrong date. That was the situation the Government created.

How do we imagine the Government would respond to a car park full of ambulances outside the hospital in Drogheda? Would it be to have ambulances bypass the Navan accident and emergency department? We would imagine the answer to that would be "No" but that is exactly what happened in the immediate aftermath. We now have the incredible situation whereby patients are being picked up in Meath and ambulances are bypassing Navan accident and emergency department and dropped them off in Drogheda. They are triaged in Drogheda and in many cases the consultant decides to send them back to Navan for treatment. The ambulance then has to make a third journey back to Navan to bring the patient for treatment. If an ambulance is not available, the patient must be brought back by taxi but because the patient is ill, a healthcare professional has to travel in the taxi. After dropping the patient off in Navan, the healthcare professional then has to get a taxi back to Drogheda. What would be an emergency involving two journeys becomes one involving four journeys because of the dysfunction of this Government. This is leading to a crisis. I appeal to the Government to stop ambulances bypassing Navan accident and emergency department.

Deputy Michael Collins

I thank all the ambulance personnel who work all over this country, including Cork South-West, for their tireless work. The level of ambulance cover available for west Cork has deteriorated to such an extent that it is now actively endangering the lives and health of residents and causing severe levels of burnout and exhaustion among ambulance and paramedical staff. That view does not come from me but from the staff themselves. When I raised this matter recently with the Taoiseach during Leaders' Questions he said he would have the Minister for Health, Deputy Stephen Donnelly, engage with me to attempt to address the series of concerns that were being raised. Nothing has changed, however, and people are losing their lives. The Minister did not contact me and the Taoiseach did not get back to me.

On paper, there are four ambulances serving west Cork. These are based in Clonakilty, Castletownbere, Bantry and Skibbereen. The reality, however, is that, at best, we have two part-time ambulances because the Clonakilty ambulance spends the majority of its time in Cork city and county, while the Castletownbere ambulance is routinely tied up serving parts of County Kerry. The Bantry ambulance is often held up due to the delayed transfer of patients meaning that it too is unavailable for considerable periods of time. This is creating the terrifying scenario whereby the entire west Cork area is being left without any effective cover. This often forces people into taking understandable but high-risk actions such as putting sick and injured loved ones into a vehicle because they cannot wait the length of time needed for an ambulance to arrive.

In 2013, the people of west Cork were promised a 24-7 rapid response paramedic vehicle and the necessary staff to man it. Fast-forward one decade and here we are with only a daytime rapid response vehicle, which I was informed was out of action for at least 94 days last year. This skeleton service would not be tolerated in any other area of the country and it will not be tolerated in west Cork. The Government and National Ambulance Service need to address this matter urgently before we lose the remaining excellent staff we have to exhaustion and before more lives are placed on the line because people cannot access timely care or transfer to a hospital. This is a very serious issue. It is coming from people I know on the ground, not from me. That is the seriousness of the situation. We are losing staff due to exhaustion, which is unfair.

Deputy Mattie McGrath

I, too, am in favour of this motion. This situation has gone from bad to worse. A paramedic told me at a retirement do one night a number of years ago that he left the service because of the disgraceful call-outs and the utter confusion and ridiculousness involved. He was called out one day to leave Clonmel and head for Carrick-on-Suir. When he reached Carrick-on-Suir, he was told to head on to Waterford. When he got to Waterford, he was told to carry on to New Ross and when he reached New Ross, he was told to drive on to Enniscorthy. He was almost within five minutes of Enniscorthy when he was stood down. That is a journey of 100 miles. It is the triage system that is being doing over the phone, or whatever kind of triage system is being used to assess patients. He did not know that a man had fallen in the street in Enniscorthy and was waiting two hours for an ambulance. That causes such trauma and anguish.

The Minister and Ministers of State with responsibility for health should be utterly ashamed of themselves. They know better than anyone that this is going on. They just want to have the trick of the loop, however, that once a call has gone in at two minutes past nine, the ambulance is dispatched at four minutes past nine. It is a paper exercise. The ambulance could be 200 miles away. It could be going from Galway to Tipperary or Tipperary to Sligo. That is how ridiculous the practice is and it is burning out ambulances.

I salute the paramedics and their professionalism. They work long hours and then when they have almost returned home after a long shift, they get a call to go elsewhere. They are being blackguarded and bullied and their morale is being destroyed by abuse. The working time directive to give respect to people who are working in jobs is not being implemented. The system has failed utterly and so has the Government.

The Minister came in like Comical Ali - someone said he is comical every day because he answers no questions - and the Ministers of State lined up with him. I do not know what way to describe them. I better say nothing or I might end up at a tribunal. The way they are treating the paramedics is ridiculous and scandalous. Above all, they have contempt for their electorate in east Galway, west Galway, Roscommon and all over the country. It is nothing other than contempt for the people who voted for the Minister of State and Minister. I know they have got in on late counts but they will not look after the people. We need to get rid of this Dublin control. When we had local controls and when Tipperary had its own control, we managed fine and the ambulances did a good job with a timely response. Everybody was reasonably happy. Now, it is a centrally controlled disaster.

Deputy Danny Healy-Rae

I, too, thank Sinn Féin for tabling this motion. Until around 2011 or 2012, the ambulances were controlled locally but then a centralised service was brought in by the HSE which operated from counties Dublin and Donegal. There were two centres in total. Since then, the whole thing has gone wrong.

Before I go any further, I want to thank all the ambulance drivers in County Kerry and our paramedics. Anything that is wrong with the ambulance service is not their fault. We have a number of ambulances in County Kerry. Let us consider what happened two weeks ago. The ambulance from Kenmare was deployed and sent to Clonakilty. It took a patient to Cork University Hospital and was sent from there to take someone to the hospital in Dungarvan. It then made a second run from Dungarvan to the hospital in Waterford. It was then delegated to go to Tipperary and finished up around Clonmel. After 13 hours' service, it was told to come back home to Kerry. In all that time, the whole district of Kenmare was left without an ambulance if something had happened. That is what is happening.

The busiest urban centres are benefitting because when the ambulance leaves the Cork hospital after dropping the first patient, the paramedics have to press a button to say they are available for work. They can be sent to Midleton, Carrigtwohill, Kinsale or anywhere. The ambulances that leave Kenmare, Killarney or wherever it may be in County Kerry are gone for the whole time they are up in Cork.

The Dublin centres are benefiting and it is the places in rural Ireland and places far away in Kerry that are left behind. Those people are struggling. That system must be reversed.

I also want to speak today about our air ambulance. We must ensure it is properly funded. In the past four or five days, the air ambulance has been called to County Kerry for crashes and different things. We appreciate it very much.

Deputy Carol Nolan

I welcome the opportunity to speak in this debate on a motion on the ambulance service and, in particular, its call on the Government and NAS to urgently review the adequacy of the spatial distribution and coverage of the ambulance fleet to ensure an equitable distribution of services across regions, to reduce reliance on overtime and long shifts and to reach response time targets.

Before I make any further points, I commend our paramedics who do an excellent job. They are, however, caught in a broken system, one that is unfair and not fit for purpose. I know that many paramedics are demoralised. Among the few that are still there - many of them have left - morale is at an all-time low. We need to ensure there is fairness and that lives are protected through there being a fair and sensible system in which every region and town has its own dedicated ambulance service. That is a very reasonable ask.

I raised this very issue during Leaders' Questions in November when I highlighted that the ambulance station in Tullamore, County Offaly, had been closed a number of times for an entire day shift or night shift. This would have been unheard of previously. On top of this, despite the lack of cover in the midlands, the ambulances that are available are regularly drawn into other areas. The Edenderry crews are regularly in Dublin, Kildare or the north east. The Birr ambulance crew spends most of its time in Tipperary or Limerick. The Portlaoise ambulances are frequently in Wicklow, Kildare or the south east. In addition, the Tullamore ambulances are normally picking up the pieces in Laois, Westmeath, Birr, Edenderry and everywhere else around. This has to change to protect lives and to be fair to our paramedics.

I have also repeatedly called on the HSE and the NAS to place a renewed focus on supporting schemes that ensure greater numbers of people can act as community first responders. That could well be part of the solution here. This is particularly vital in counties such as Laois and Offaly for echo calls, which are life threatening cardiac or respiratory arrest, and delta calls, which are life-threatening illness or injury other than cardiac or respiratory arrest emergency calls.

From my experience of engaging with ambulance staff, I note that something more fundamental has gone wrong within the work culture of the NAS. We need to change this fast.

Deputy Thomas Pringle

I am happy to support this motion and I commend Sinn Féin on bringing it forward. Like every other part of our health services now, the ambulance service is in crisis. I wonder at this stage if it is deliberate on the part of the Government. Is it preparation for privatisation that we are seeing in such inaction across the board? It is rule 101 in the privatisation book that one runs down services so much that citizens will accept anything as a solution, including that the private operators will surely do it better, except they do not and ultimately what they do it is more expensive as well. Some people have said the problem is simply the Government trying to live within totally unrealistic budgetary constraints. I cannot figure out which is worse at the moment.

It is shocking to see that the workforce plan outlines the service will need 1,300 more paramedics to meet demand by the end of 2024. In Donegal, we need three extra ambulances and crews to meet the need we have. Killybegs ambulance station definitely needs another crew on duty. A call-out to Glencolmcille can barely meet the call-out requirements when there is a crew based in Killybegs, never mind if that crew is covering Donegal town and is based there, as often happens. Extra crews are needed in Inishowen and Letterkenny or Ballybofey.

The queuing of ambulances at Letterkenny University Hospital is continuing but now the ambulance service has employed someone to try to move them on. The hospital is unable to take patients quickly enough. The impact of this is that it delays ambulances at the hospital. Paying the cost of another officer will not solve the problem as far as I can see. The manager of Letterkenny University Hospital told a meeting recently that 70% of the ambulances were moved out within one hour - or some similar time - but the problem is the 30% of ambulances that take hours to get back and then be rostered again.

One good development to emerge over the past few years has been the community paramedic. This person diverts patients from casualty and enables many patients to remain at home by giving a higher level of care in the community. This role needs to be rolled out on a service-wide basis. It would actually save money overall for the health services. A patient who can be treated without going to casualty is the cheapest patient in the health service. One would think the bean counters in the HSE and Department of Health would at least see that.

The Government response to the motion appears to recognise some of this but that is hard to make out from the gobbledygook. Maybe that is part of the problem. They speak in tongues and no one understands what the intention is.

Deputy Marian Harkin

I thank Sinn Féin for bringing forward this motion on the unacceptable situation in the National Ambulance Service, which is completely stretched across the country. The service is at crisis levels in certain areas where wait times are simply unacceptable.

Last week, Mr. Robert Morton, the director of the NAS, gave evidence at the Joint Committee on Health. When he was asked about response times and geographic locations he said:

... we conducted a demand and capacity analysis. We commissioned it in July 2021 and it reported in May 2022. It highlighted a number of key areas of deficit. To the best of my recollection, the area of greatest deficit was County Sligo and the area east of Enniscrone was the most difficult in which to mount an effective response.

That is a pretty shocking picture for those who live in that part of Sligo. Indeed, many of my constituents have contacted me over a period of time about these totally unacceptable delays in ambulance response times. I am pleased to see, however, that since January of this year, Sligo now has a three-day, two-night crew. It used to be two and two. This is a start but it is my understanding that a four-day, two-night crew is the absolute minimum requirement for Sligo. It is absolutely essential that this minimum is put in place. I ask the Minister of State, Deputy Rabbitte, for a commitment on this.

We need a community paramedic in Sligo-Leitrim. As Deputy Pringle said, there is one in Donegal. It is essential that this badly needed service is extended to Sligo-Leitrim.

I heard the Minister for Health speak earlier about the pathfinder model, which is a pilot programme. That too should be rolled out in Sligo-Leitrim. I believe it is to be rolled out in Letterkenny towards the end of this year but we especially need it in Sligo-Leitrim because of the existing deficit. Under this programme, an advanced paramedic, an occupational therapist and a physiotherapist can work with patients over the age of 65 on low-acuity calls. I put it to the Minister of State that this would help to alleviate some of the very significant pressure at Sligo University Hospital, SUH. Just today, I received an email from a GP practice signed by eight doctors setting out again the stark realities of the severe pressure being placed on patients and staff at SUH. The Minister of State will be aware that towards the end of last year, more than 50 consultants at SUH signed a similar letter.

As I have said about ten times previously in this Chamber, the reality is seen in the trolley numbers in all the large hospitals as against the numbers of beds, or the bed stock, in those hospitals. Figures from the Irish Nurses and Midwives Organisation, INMO, for the first ten months of last year show us the comparisons. Cork's trolley numbers were some 10% of the bed stock; St. Vincent's Hospital trolley numbers were 10.6 % of its bed stock; University Hospital Limerick trolley numbers were about 20% of its bed stock; and Letterkenny University Hospital trolley numbers were 17.3% of the hospital's bed stock. However, Sligo University Hospital trolley numbers were 24.7% of its bed stock, which means the hospital is under the greatest pressure. Obviously, it is a long-term solution to build the new block, about which I will not go into detail today. In the context of today's discussion, ensuring that Sligo and Leitrim were part of the pathfinder scheme would, in the short term at least, take a little pressure off the most pressurised hospital in the country.

I ask the Minister of State to please bring that to the attention of the Minister.

Plans for a new ambulance base in Sligo are currently at design stage and the project will be in for capital submission early next year. It is crucial that it is approved speedily and that the base is built as soon as possible. In addition, the proposed new national college to train paramedics must be located in Sligo along with the new ambulance base, ready to start training paramedics by 2024 or 2025 at the latest. These are some of the minimum requirements we need.

We have heard from many colleagues this evening about blockages in the system. Deputy Shortall clearly outlined the crazy situation in UL. There are many other issues I wish to raise but time does not permit me to do so. I will simply once again refer to the remarks of Robert Morton at the health committee last week, when he said, "There is a growing gap between demand and capacity." It is up to the Government to bridge that gap.

Deputy Michael McNamara

I thank Sinn Féin for tabling the motion, which highlights the completely unacceptable wait times for ambulances and the fact that not alone are targets being missed in many cases, but more of them are being missed than was the case previously. In December 2019, ambulances reached 69% of cases of cardiac and respiratory arrest within the target time of 19 minutes. That had fallen to 59% by December 2022. In other emergency cases, it fell from 54% to 43%, which is less than half. That is simply unacceptable. There are a number of reasons for it, none of which can be blamed on the excellent staff of the ambulance service and the paramedics who are doing their very best in a chaotic system.

Centralisation works badly in most services but it has had catastrophic effects in the ambulance service. Ambulances from County Clare are being sent all over the place. Last year, an ambulance was sent from Ennis to Enniskillen, resulting in there being no ambulance in north Clare. I have driven from Ennis to Enniskillen. You would not be driving up to Enniskillen and coming back down to work in Ennis thereafter. If it is not working, it simply needs to reviewed, and I believe it is not working, despite the best of intentions.

I reiterate the point raised by Deputy Harkin and others in respect of the paramedic training course at UL. Notwithstanding that these people have been trained and could provide an excellent service, they cannot get into the NAS thereafter, largely because of a typically Irish battle of egos, it seems. That must be stopped.

We were led to believe that the protocol under which ambulances would go to Ennis hospital would improve matters. Instead of ambulances queueing outside UHL for patients to be admitted, they would go to Ennis hospital, where there would be a faster drop-off. In the first six weeks of the protocol, however, only 29 ambulances went to Ennis hospital, so that is not a panacea either. The situation needs to be reviewed.

Minister of State at the Department of Health (Deputy Anne Rabbitte)

It is evident from the debate this evening that Members across the House share a commitment and motivation to ensure the ambulance service has the requisite support and resourcing to allow for the delivery of the best possible level of care for patients that is appropriate and timely. There is general consensus that this is achievable with an ambulance service that is appropriately resourced and structured to work as part of a wider system to meet national healthcare policy needs. I reiterate that the Government is committed to continuing to support the NAS with the necessary funding throughout this transformative period to allow for an expansion and development of patient care services, as the Minister outlined.

The significance of the role played by the ambulance service in the delivery of care has never been more prominent. Ambulance services are evolving and growing capacity to meet the future service needs. This is most notable in the area of alternative care pathways and mobile medical services. Paramedics are at the forefront of the interface between community care and hospital services and their position offers real opportunity to effect considerable benefits for patients and the wider healthcare system.

Through the development and expansion of its suite of alternative care initiatives, the NAS will play an ever-increasing role in relieving the pressure on hospitals and aiding in the reorientation of healthcare. It is worth reiterating the point raised earlier by my colleague, the Minister, that between October 2020 and October 2022, the NAS treated nearly 50,000 patients through an alternative care pathway. Of those patients treated, over 43%, or nearly 19,000, did not need subsequent conveyance to a hospital emergency department. The NAS estimates that in the region of €3.7 million was saved in the care of these patients as a result. These are very small numbers in the context of the wider healthcare system but the potential for further development and expansion of initiatives like the clinical hub and the pathfinder model of care could yield significant gains in the numbers treated outside of emergency departments and the potential savings that could be accrued. I take on board the point raised by Deputy Harkin regarding Sligo-Leitrim and will bring it back to the Minister.

The continued implementation of Sláintecare reforms means that community-based care options will continue to expand and the NAS will be centrally involved in delivering these patient care options as conveyance to hospital increasingly is no longer considered the most clinically appropriate default solution. I emphasise to the House, therefore, the scale of reform and modernisation that has already been achieved within the NAS in recent years. Such innovations include those aimed at providing alternative pathways of care and helping to improve resource availability and response times. Although current capacity issues in the ambulance service and across the wider hospital system are certainly affecting the level of response provided, I am reassured by the significant funding commitments we have been able to make in recent years to progress initiatives and increase capacity in the medium and long term.

As noted by the Minister, a new strategic plan is currently in development. The new strategy will set out the strategic aims of the service in the coming years to enhance staff experiences, further utilise technology and update organisational structures to ensure the patient care provided is aligned with the Sláintecare goals of the right care in the right place at the right time. I hope that will consider providing that a central ambulance base deployment system would be more on a regional basis than a national one.

I will briefly address other initiatives the NAS has undertaken to improve response times and resource availability. It has established a significant number of voluntary community first responder schemes to provide a high level of initial cardiac response within local communities. A total of 275 schemes had been established prior to the outbreak of Covid, when a temporary stand down of these groups was put in place due to the pandemic response. The majority of the schemes have since returned to full operation. As stated by the Minister, a collaboration between the NAS and a number of hospital groups throughout the country has resulted in the expansion of the successful medical assessment unit, MAU, pathway pilot. This project was first trialled in north Cork at Mallow General Hospital in 2022 to the MAUs in Ennis, Roscommon and Nenagh. This MAU pathway will reduce patient presentations at emergency departments and release ambulances more quickly to respond to other emergency calls.

Following a HIQA review in 2014 into pre-hospital emergency care services, the NAS set out to implement a number of key recommendations for improvements. One of these recommendations was to use a dynamic deployment model. Dynamic deployment allows staff at the HSE national emergency operations centre to see all available resources and prioritise their allocation to higher acuity calls that require immediate emergency response. This model represents international best practice and was highlighted by HIQA as a way to improve response times and NAS performance generally. I assure the House that the NAS has been continuously working with stakeholders to introduce changes to its ambulance deployment model which reflect the reality of current capacity challenges while seeking to reduce demands on ambulance staff. That takes on board what many Members have stated this evening.

Ambulance services in Dublin are delivered by the NAS and Dublin Fire Brigade. There is a high level of co-operation between the HSE, NAS and Dublin Fire Brigade on day-to-day operational matters.

This collaborative relationship was further strengthened during the Covid-19 pandemic and efforts are ongoing to build on this co-operation to strengthen arrangements for the delivery of ambulance services in Dublin into the future. I am aware that the first meeting of a task and finish group - formed following agreement between my colleagues, the Minister for Health and the Minister for Housing, Local Government and Heritage, to identify an ambulance service delivery model for Dublin took place in the last fortnight. I look forward to seeing the results of the group’s work in the coming months, which I am sure everyone in the House will agree can only be beneficial for the citizens of our capital.

The well-being of NAS staff is a priority both for the Department of Health and for NAS and HSE management. The NAS has developed its HR People Plan 2022-2025 to enhance employee experience, optimise NAS working environments and meet expectations of health policy in Ireland. In 2020, the NAS launched its holistic model of staff support, WellNAS, which details the range of supports available to support the well-being of staff. In 2022, the NAS was also allocated funding to strengthen 24-7 management and governance arrangements, and plans to further strengthen management, technical and business functions as part of the new service development plans for 2023.

As part of budget 2022, an additional €8.3 million in development funding was invested in the NAS. This funding was used to build upon the significant process of modernisation the NAS has achieved in recent years. Specifically, the funding provided for: increasing paramedic whole-time equivalent, WTE, staffing levels to meet identified capacity requirements in support of improved performance and service delivery goals; adding clinical capacity within the hear and treat service in the National Emergency Operations Centre to advise lower acuity patients of appropriate alternatives to hospital transfer; and implementing an organisational redesign to enhance governance arrangements and improve the NAS's ability to integrate with strategic developments across the health sector.

I would contend that notwithstanding the considerable challenges of record patient demand outlined by my colleague, the Minister, earlier today, our ambulance services have continued to deliver a high-quality, patient-centred service, even against the backdrop of similar record levels of hospital and ED activity. The Covid-19 pandemic forced us to change the way that our health services operate, and the way patients interact with our health services. Our ambulance services continue to adapt to these changes. The transformation outlined will lead to a service that is better able to deliver on the future requirements of the wider healthcare system. Despite the challenges that have been experienced over recent years, the strategic aims for our ambulance services remain clear, as does our firm commitment to delivering on them. A number of Deputies brought up the issue of UL students. I will bring that back to the Minister. I cannot, for the life of me, understand how those students in the masters programmes are not getting the opportunity to practise their profession in an environment where they are trained to do so.

Deputy Louise O'Reilly

I want to start by acknowledging the really good and hard work done every day of the week by workers in the Dublin Fire Brigade and the NAS. Despite this Government, they are holding the service together with their hard work and dedication. Even in a well-staffed service and a service where Government provides leadership - unlike in this instance - those workers are under pressure. Their work environment is naturally a pressurised one and it is made worse by the lack of leadership from the Government. Short-staffing, as the Minister of State knows, compounds the pressure that these men and women are under every day of the week. The tactic of attacking Opposition politicians is not going to work. I note that the Minister for Health is not here, but I did hear his contribution. I must say, there is something more than a little bit pathetic about trying to point fingers at Members of the Opposition and trying to twist our words. The workers in the Dublin Fire Brigade and the NAS know damn well who is on their side. They know exactly the names and, indeed, the parties of those who cut their pay when their backs were to the wall. They know exactly who imposed a recruitment moratorium from which they are still trying to recover.

On Christmas Day a relative of mine fell and hurt herself. We did not know at the time, but she had broken her hip and her femur. At 7 p.m. we called the ambulance. By 8.30 p.m., the ambulance had not arrived. We spoke to fantastic people on the line who stayed with us right the way through. They advised us not to move her but it was freezing cold and raining, and we had to move her. The woman had a broken hip and a broken leg. I drove her to hospital that night and I was terrified. My sister and I spoke to people on the phone. They did everything they could, but the resources were not there. I just want the Minister of State to know that as a member of the family who was there, it was absolutely terrifying. You do not realise how much you depend on the service until you pick up the phone. The person on the other end of the line did everything they could, but they could not dispatch an ambulance. That was the key. It was terrifying not just for me, but for all the other members of my family.

In my final moments, I wish to state that men and women working in the retained fire service in Skerries and Balbriggan did medical work during Covid and have been locked out of the Covid payment because they are members of the retained service. I implore the Minister of State to discuss this with the Minister for Health to try to see if good sense can prevail in this instance.

Deputy Seán Crowe

The chief fire officer for Dublin Fire Brigade told the Joint Committee on Health last week that the combined resources of the NAS and Dublin Fire Brigade cannot meet current ambulance demands in Dublin city and county. I sat through the meeting so I know what he actually said, which seems at odds with what the Minister was saying. You would think that would be a wake-up call for the Government that there is something very wrong with the way it is resourcing our ambulance services. Dublin is a growing and expanding city and we are simply unable to keep up with demand. Ambulances are only able to respond to less than half of non-cardiac life-threatening situations within the target time of 19 minutes. Every minute is vital in these situations. We are failing both the ambulance and fire crews, and the people who need them, by putting them in impossible situations like that.

The health committee was also told about the value of programmes like the pathfinder service, which aims to treat people, and particularly the elderly, in their own homes as a means of keeping them out of hospital in the first instance. That was mentioned by a number of speakers. I fear we are too slow in recognising the value of programmes like that and rolling them out right across the wider health service. I think the Minister of State would probably agree with me on that.

The training sector also needs to see a very large investment as, currently, we are simply not able to get enough newly trained paramedics into the system to cope with the demand and the people who are leaving or retiring. Currently, we are sending paramedics over to Britain for placement, and many of them just do not come back as they are snapped up by the NHS. If we could train more of them at home we might reduce the brain drain.

The logjam in our EDs plays a very significant role in the problem. If ambulances are stuck outside hospitals while the staff inside grapple with the overcrowding and the lack of beds, then they are not on the road, heading to where they are needed to actually save lives. We need to see greater investment in training and new vehicles and we need to roll out programmes like the pathfinder service. What we need most from Government is to take the situation seriously before it gets even worse, with the harm and loss of life that we heard about. We are all agreed that we need to do more.

Deputy David Cullinane

It takes a bit of a brass neck to deliver the speech that the Minister for Health delivered earlier today. It is so full of inaccuracies and mistruths, it is hard to know where to start. I will start with the first one, where he said that the Sinn Féin motion would have you believe that our NAS professionals are failing in their job. In fact, the very first line of our motion "commends the tireless work of front-line paramedics and operational staff in dealing with increased demand without proportional resource increases". Last week, senior personnel of the NAS and Dublin Fire Brigade told the Joint Committee on Health that demand is outpacing supply in ambulance capacity, and that people are waiting longer for ambulances for emergency and non-emergency call outs.

The second mistruth in the Minister's written statement which he read into the record of the Dáil is that response times are improving. I do not know what planet the Minister is on but I will list the response times again in the Minister's absence and let them ring loud in his ears because he really needs to take his head out of the sand when it comes to the NAS.

I am talking about the life-threatening calls, the echo and the delta calls. Let us compare them from 2019 to 2022 and for each region. In the east region, in 2019, the average response time for life-threatening call-outs was 15 minutes; in 2022 it was 22 minutes, an increase of seven minutes or 47%. In the midlands, in 2019, it was 19 minutes; in 2022 it was 29 minutes, an increase of ten minutes or 53%. In the mid-west, in 2019, it was 16 minutes; in 2022 it was 25 minutes, an increase of nine minutes or 56%. In the north east, it was 18 minutes in 2019; in 2022 it was 26 minutes, an increase of eight minutes or 44%. In the north west, it was 18 minutes in 2019; in 2022 it was 22 minutes, an increase of four minutes or 22%. In the south east, where I come from, in 2019, it was 21 minutes; the south east now has the highest wait time of 33 minutes, despite the fact that we do not have emergency cardiac services operating on a 24-7 basis, as the Minister of State will know. That is an increase of 12 minutes or 57%. In the southern region, the average wait time for life-threatening calls in 2019 was 18 minutes; in 2022 it was 31 minutes, an increase of 13 minutes or 72%. In the west, it was 19 minutes on average in 2019; in 2022 it was 26 minutes, an increase of seven minutes or 37%. Those are all figures produced by the Minister in response to a parliamentary question. Then, when we look at the percentage of calls which were responded to in the 19-minute timeframe for both echo and delta, we see a decrease year on year from 2019.

How, then, can the Minister say in his scripted speech this evening that response times are improving? Improving from when, exactly? The evidence is there in the data which are presented to us from the National Ambulance Service and the Dublin Fire Brigade. In fact, the Dublin Fire Brigade told the Oireachtas health committee that in 2020 the average hospital turnaround time in Dublin for patients being offloaded from an ambulance into a hospital was 29 minutes, with 6% of ambulances experiencing offload delays in excess of 60 minutes. In 2022 the average offload or hospital turnaround time in Dublin was 39 minutes - it went from 29 minutes to 39 minutes - with 16% of incidents having a turnaround time in excess of 16 minutes.

We are getting data from the HSE, from the National Ambulance Service and from the Dublin Fire Brigade all telling us that the wait times are going in the wrong direction, and we have a Minister for Health who has his head in the sand and who comes in here, does not address any of the issues, does not give us any sense that there is any urgency, attacks Sinn Féin and the Opposition for tabling a motion which sets out the facts and, it strikes me, is going to go off, as he always does, with his head in the sand and do absolutely nothing. As Deputy O'Reilly said, he is not fooling anybody. He most certainly is not fooling patients, who are waiting longer for ambulances. He most certainly is not fooling those ambulance paramedics whom we praised in our motion, rightly so, for the work they do, and they are doing it on the back of great pressures and overtime. Some in the Dublin Fire Brigade had to wait, and some are still waiting, for their pandemic bonus payments, another slap in the face they were given by the same Minister for Health. His speech today was absolutely appalling and shameful, he should come back and correct the record of the Dáil for some of the inaccuracies and, I would argue, mistruths that were in his statement this evening.

Amendment put.

An Cathaoirleach Gníomhach (Deputy Marian Harkin)

In accordance with Standing Order 80(2), the division is deferred until the weekly division time tomorrow evening.