I welcome Mr. Denis O'Sullivan, principal officer at the Department of Health and Children, Mr. Pat Clifford, assistant principal officer, Mr. Paul Robinson, CEO of the North Eastern Health Board, Dr. Jeff King, director of the Pre-Hospital Emergency Care Council and Ms Derval Cummins, consultant with Booz Allen Hamilton. I ask them to commence their presentation on the report on the feasibility of an all-Ireland helicopter emergency medical service.
Helicopter Emergency Medical Service: Presentation.
Mr. Denis O’Sullivan
I thank the Chairman. By way of introduction, I will provide for members a background to the report. We have distributed copies of the report to the secretariat and members may have had the opportunity to become familiar with its contents.
This report emerged through North-South co-operation between ourselves and our colleagues in the Department of Health, Social Services and Public Safety in Belfast. A decision was taken in the context of the Good Friday Agreement to develop a study, in an all-island context, on the costs and benefits of developing a dedicated HEMS or helicopter emergency medical service for the island. Booz Allen Hamilton consultants were commissioned to carry out the work for us and the study was published earlier this year.
Members will see from the contents of the report, which runs to over 100 pages, that its preparation required an in-depth review by Booz Allen Hamilton of the position internationally in respect of HEMS. In addition, we consulted widely with the public system and, in the case of the North, over 100 representative bodies were consulted in accordance with the legislation that prevails there.
The report considered a number of different options for a HEMS in Ireland and concluded that a dedicated inter-hospital patient transfer service would be most appropriate for the island. This service would be in respect of the planned transfer of patients between different hospitals. The report also recommended that the funding provided for HEMS should be additional to that being currently provided to support the development of the pre-hospital emergency care sector or the ambulance service as it is more widely known. The cost of introducing a helicopter dedicated to inter-hospital patient transfer services was estimated by the consultants at €12 million in capital, with annual running costs in the region of €4 million. The timescale for its introduction was put at approximately three years.
I will now deal with the developments that have taken place since the report was published. The current limited service that is in place is provided by the Air Corps and the Irish Coast Guard. This services is very much appreciated by the health sector. Following the publication of the report, the Department of Health and Children engaged in discussions with the Departments of Defence and Communications, Marine and Natural Resources on the capacity of the services under their remits to provide an air ambulance service. We have had further discussions with our colleagues in Belfast. As matters stand, we are finalising a service level agreement with the Department of Defence which is intended to formalise arrangements between the two Departments for the future provision of air ambulance services by the Air Corps.
The Air Corps is undergoing a significant fleet replacement programme. Tenders for six new helicopters have been received and they are being processed by the Department. Each new helicopter will have a specific air ambulance capability, which is significant. This is line with the Government's position outlined in the White Paper four years ago. The Department of Defence has confirmed that the fleet can be made available under the terms of the service level agreement. The new fleet will also have a greater flying capacity than is available currently.
The Department of Communications, Marine and Natural Resources confirmed that the Irish Coast Guard will continue to provide services to us. I offer apologies on behalf of the representatives of the Northern Ireland department. They were invited to send a representative to the meeting but they were not in a position to accept. Their priority is the need for further investment to improve the ground ambulance service.
Plans are also being developed within the voluntary sector for the introduction of a dedicated inter-hospital transfer HEMS, with a view to the service becoming operational in 2005. I do not have further details on the proposal but we will have discussions shortly with the people involved in this initiative to establish the progress that has been made and we will work closely with them to see if that service can be realised in 2005.
The introduction of HEMS is being considered in the context of the overall development of pre-hospital care services, including the Department's commitment to implement the strategic review of the ambulance service, which was prepared as a five-year report by the chief executives of the health boards and published in 2001. Three main issues are being progressed following the report. The first is the most significant development in the ambulance service for many years, the introduction of the EMTA programme for ambulance personnel. Legislation was recently passed in the Oireachtas to amend the pre-hospital emergency care council statutory instrument and that is the first step in the passage of legislation to provide for the introduction of this service. This will facilitate the administration of 18 additional medications by ambulance personnel, including cardiac and asthma drugs.
Second, the upgrading of the ambulance fleet is an ongoing requirement. It costs €7 million per annum out of the capital budget to replace 40 to 50 ambulances each year. The final issue is the elimination of on-call from emergency rosters of ambulance personnel and their replacement by full-time staff, which is also designed to improve the response capacity of the ambulance system. The cost of taking the ambulance service forward, excluding the HEMS, will be approximately €50 million over the next five years.
The Health Board Executive, in which Mr. Robinson is heavily involved, has been examining the future structure of the ambulance service in the context of the health reform programme. A key element of this work is the potential to improve ambulance response times through the provision of a national ambulance service and this work will be progressed next year under the aegis of the incoming Health Service Executive.
Booz Allen Hamilton has put significant work into the HEMS report, which sets and contributes to the policy agenda. It is accepted in policy terms by the Department as a desirable development. We are acting on it through our discussions with the Air Corps and we look forward to hearing about further developments in the private and voluntary sectors in 2005.
I thank Mr. O'Sullivan for his presentation. I congratulate Booz, Allen and Hamilton on its comprehensive report, for which numerous submissions were received. It is a rounded report and its conclusion is clear. I am glad the Department has finally accepted that an inter-hospital HEMS is the answer. It has been on the cards since 1993 when the ambulance report recommended an inter-hospital retrieval airborne service. This report rubber-stamps what was well recognised as being needed. I spearheaded the campaign on this issue for the past 11 years. The report came about because I met successive Ministers for Health going back to Deputy Noonan. I met the Minister, Deputy Martin, and Bairbre de Brún in Stormont. As a result, I met representatives of the North-South emergency care body set up under the Good Friday Agreement to examine pre-hospital care. A recommendation was made subsequently to the Council of Ministers for an all-Ireland feasibility study which was a joint effort between the Departments of health, North and South.
The report was commissioned in 2002. When was it completed? It was not published until this year and I would like to know the reason for the delay. We have an excellent ground ambulance service and the work of those involved often goes unnoticed. I compliment everybody involved. The funding of €50 million is necessary and it is not before time. Similar amounts have been spent on e-voting and Farmleigh House. However, this investment is badly needed because an essential part of a comprehensive pre-hospital and inter-hospital ambulance service is missing. Ireland is the only country in Europe that does not have this link, which is shameful.
I have always looked on this as an all-Ireland service. The air ambulance service is provided by the Air Corps. It takes 12.5 hours to get to a hospital to pick up a critically ill person who needs to be brought to the so-called centre of excellence within the golden hour. For instance, there is no neurological centre along the west coast. A man speaking on radio yesterday described how he was seriously assaulted on the streets of Dublin. He said if that had happened in Galway or Castlebar he would not have made it to a neurological centre because there is none on the west coast. That is why HEMS is important.
The Garda commissioned a helicopter because of the need for a dedicated service. The former Minister for Justice, Nora Owen, stated that when a crime is being committed, it is of no use if the Air Corps is doing another job. The Air Corps spends more time ferrying Ministers from A to B than on mercy missions. There is no point in making the Air Corps available for this service if it is deployed elsewhere. That has been the position. If the Garda can have two helicopters, why not provide a dedicated HEMS?
I have pushed for this meeting for a long time. The central issue is people are taken out of the hospital setting for 12 to 16 hours when being transferred and that is a dangerous time. International research has shown that patients need to be transferred to a centre of excellence for conditions such as severe trauma, head injuries, severe burns and cardiac disease. Children have died while being transferred from Kerry and Donegal. The hospitals along the west coast have helipads that can be used. However, even if this service was provided tomorrow morning, there is a deficiency in Beaumont Hospital because it does not have a helipad, which is urgently needed. The hospital is the national neurological centre and it would cost €1.5 million to provide a helipad. There is also no helipad at the Mater Hospital, which is the national spinal centre. However, I acknowledge that this cost, which is a pittance, is factored into the report. It would cost €16 million to set up the service and run it for a year. That is a pittance. The provision of €10 million for the operation of three helicopters is also a small amount.
I received information last night that the Tánaiste has stated the voluntary sector is now interested in getting involved and that the Department has been briefed on the matter. I have been approached many times by people in the voluntary sector who want to provide this service. I have nothing against people doing things themselves, but the type of system that would work best — I have studied systems from all over the world — would be one that co-ordinates best with the existing ground ambulance service. The helicopter emergency medical service should be owned and run by those running the ground ambulance services to ensure we have a properly co-ordinated system. I believe such a service would be best run by Government.
I would like to hear what Booz Allen Hamilton and the Department have to say on that matter. The amount being provided for the service is small in the scheme of things. The Irish Medical Organisation — I note Mr. Tony Healy is here — the Association of Ambulance Personnel and all those involved at the coalface know the value and importance of HEMS. We have waited a long time for this service. The former Minister for Health and Children, Deputy Martin, wanted to put his hands into the wound to feel the need for this service. The need for an inter-hospital HEMS is well documented in the report. The excuse has been made that one would not require a helicopter attendance at every emergency. That is not what people want. They want an inter-hospital transfer system.
Some 300 to 400 transfers occur annually. Approximately four people from the west coast of Ireland die each year following an accident and many are left permanently disabled. If one puts the value of a life at €1.25 million, as has been done in highway appraisal techniques, that sum more than takes care of the cost of a helicopter.
International research indicates that time spent in intensive care can be reduced by one third as a result of such a service as it leads to a better use of beds. When was the report finished? Why was it not published until 2004? If the Garda Síochána can have a dedicated helicopter service why can the health sector not have one? Can such a service be put into operation immediately? I am aware there is no helipad at Beaumont Hospital or the Mater Hospital but such landing areas should be available. Bringing people to Dublin Airport or Baldonnel, as currently happens, is better than nothing.
I am involved in the voluntary sector and I am very much a community person. Can the voluntary sector provide such a system? Is it not preferable to have a system that is owned and run by those currently operating the ground ambulance service, the Government?
Deputy Devins should speak to the issues before us.
I was not aware members were allowed to make Second Stage speeches at committee meetings.
I congratulate Deputy O'Connor on his appointment as convenor. I, too, thank the delegation for coming to the meeting. I have read the report and listened to the presentation made this morning. I am somewhat confused on what exactly is the position. The report states there is movement within the voluntary sector to supply HEMS. I believe that the Department is considering that option. Who will be responsible for the service? Will it be the voluntary sector or the Department?
The Department of Defence provides the air ambulance service. Given its helicopters are being upgraded, will HEMS be a dedicated service or will it be an add-on of that Department? Will the air-sea rescue service which is supplied on a contract basis through the Department of Communications, Marine and Natural Resources continue or will it also be moved? There appears to be an overlap in this area with no specific service being supplied. Who is responsible if there is a requirement to move a patient from one location to another? If the Air Corps is away on other business and the air-sea rescue service is busy on the Aran Islands, who will take responsibility for moving a patient from, say, Sligo General Hospital or Mayo General Hospital to the Mater Hospital or St. Vincent's Hospital? Are we to have a system that is second best?
My apologies for being late. Dr. Jeff King will know that I am very supportive of pre-hospital emergency care training which is ongoing. On reading the report I noted the famous words "Hanly report" are not included. Have the changes regarding the siting of accident and emergency units, as contained in the Hanly report, been considered?
My question also relates to the availability of landing facilities at Beaumont Hospital and other hospitals. How many hospitals are similarly affected? What would be the total cost of carrying out necessary works to ensure the availability of landing facilities at all hospitals? Am I correct in assuming that it would be better for a patient with head injuries to be transported by air as opposed to by road? I am not a doctor but that makes sense to me.
I presume, in terms of the level of international co-operation available to us, that we receive assistance from Scotland, Wales and England at various times. Perhaps the delegation will clarify that point. I welcome the introduction of the EMTA programme for the administration of additional medications by ambulance personnel. How long will it be before that is realised? The work done by our ambulance crews differs greatly from that done by such personnel in other countries. The introduction of that programme impacts greatly on the Hanly report. We cannot compare like with like.
Mention was made of inter-hospital transportation and landing facilities. What area would be required to allow for the landing of a helicopter close to a serious accident to provide immediate transport to a hospital? Would people still have to be transported by ground ambulance to the nearest hospital with a helipad? Is it realistic to expect a helicopter to land near the scene of an emergency? Can that be done?
I am sorry I was late for the presentation but I have read the document. My first question relates to the proposed arrangement with the Air Corps. Will the provision of six helicopters from the Air Corps, in terms of operating costs, amount to €24 million? The initial amount given for operating costs is €4 million. Will that money be paid to the Department of Defence?
My second question relates to a matter touched on by my colleague, Senator Henry. From my reading of the Hanly report, an issue that often arises is the transport of people over long distances. Does the delegation agree that if we are to properly implement the Hanly report the proposal today is an absolute necessity and that the Hanly report cannot be implemented without the introduction of HEMS?
Mr. O'Sullivan makes the point in the report that tenders have been sought for six new helicopters with specific ambulance capability. I am aware from my former life as an air traffic controller at Dublin Airport of the restrictions on helicopter flying. Will the service be restricted to day-time flying or is there capacity for night-time flying also?
Mr. O’Sullivan
I will deal with the last question first. My understanding, from information supplied by the Department of Defence, is that Air Corps capacity will include night-time flying.
Deputy Cowley's question related to the timescale for the report. I know he has taken a keen interest in this from both the parliamentary and public side. The Ombudsman asked previously about the timescale for completion of the report, on foot of a request from the Deputy. The position is that Booz Allen Hamilton was commissioned in April 2002 and its report was completed and handed to the steering group in December 2003. It was then the subject of discussion with the North and was formally published in April 2004.
That was a long time to wait, was it not? I had to go to the Ombudsman to ask for its release. It was not released until one year after it was done. There was talk that the Hanly report which was to be published in the meantime would hold it up. This of course made the necessity for it more critical. Can Mr. O'Sullivan explain the delay which has not been adequately explained?
Mr. O’Sullivan
From our perspective we do not accept there was a delay. As I said in my presentation, the process of consultation on the report involved, in the case of the North, requests for submissions from over 100 representative bodies. Over 88 public submissions were made in respect of the report. The consultants presented initial findings to the two Departments in late 2002, but thereafter the various inputs from the professional bodies and the public had to analysed, taken into account and reflected in the draft of the report. That is what the consultants did.
The Hanly report published mid-2003 was mentioned. In addition to doing some further research, its recommendations also had to be taken into account in the final proofing of the report. The questions that would have come to mind there were what were the respective benefits and roles of primary, secondary and tertiary response. Having looked at it all, the consultants concluded that tertiary response into the patient transfer service between hospitals was the most appropriate and desirable for Ireland. No doubt some people observing the Hanly debate would have wondered about the benefits and possibility of introducing a primary response. However, the international research did not throw up compelling benefits and advantages for going that road. That was the professional advice we were given on the issue in the context of the Hanly report.
The question arose as to whether, in policy terms, we would see an inter-hospital transfer service being critical to the development of Hanly. We would accept in policy terms that a more developed patient transfer service is desirable in any event, irrespective of the Hanly debate. The objective in terms of investing in pre-hospital care is to shorten response times, wherever patients are travelling from. This is what an air service does.
We are aware that the existing service provided through the Air Corps is limited. In some ways it is limited by the capacity of the Air Corps fleet to give that service. The fleet being replaced is very old. The Department of Defence has told us the capacity of what it is buying is significant in terms of flying hours and night capacity and that it has the potential to give us a much improved service over and above what we have. It is not a dedicated service because it is additional to the Air Corps core function and that is acknowledged. However, it has the potential to take us up significantly in activity terms.
The Air Corps currently flies at a low level of activity compared to what it was when Deputy Cowley would have been interested in its activities in the 1990s. Its activity level is low and we are concerned about that. We are told that the service it is in a position to provide will be much more extensive than it has been heretofore and we think we should take advantage of that as a State asset.
On the role of the voluntary or private sector in this area, I do not know enough about the proposal being developed. I understand it is being developed along the lines of the service that is provided in the United Kingdom, which is run on a not-for-profit basis by the voluntary sector in partnership with the state system.
On the matter of who would run the service, the Department would still be responsible and the HSE would be responsible for overseeing the delivery of all pre-hospital emergency care services either directly provided by the State or in partnership with the voluntary sector. That is not unique to the pre-hospital side.
Would Mr. Paul Robinson or Dr. Jeff King come in on this issue? If the ambulance service was running the service, it would be co-ordinated and would do the most good. If the Air Corps is involved, is it not a red herring to be talking about the Defence Forces running the helicopter emergency medical service, HEMS, or any sort of ambulance service? Recently it took five hours to come to a case. This is no fault of the Air Corps which has other jobs to do and the equipment it carries reflects its multipurpose role. It cannot be flying into this area as it should because of all the other equipment it must carry such as winches etc. that it needs for other jobs. It appears to me that the Department is fobbing the issue off to the voluntary sector after all this time.
I read Dr. King's curriculum vitae and know he has worked with helicopters in Australia. What is his view on HEMS? Will the continuation of a non-dedicated service by the Air Corps not just be more of the same?
Mr. O’Sullivan
I am happy to let Dr. King answer on that, but think it would be better to answer the first questions and then come to that.
I am happy enough with that.
Mr. O’Sullivan
On the landing facilities at Beaumont, the report in profile and the capital cost of what is required to develop a HEMS take account of what is needed in developing helipads across the system. That is reflected in the €12 million capital costs identified in the report.
I will ask Dr. King to speak in greater detail on the roll-out of the EMTA programme as he has been closely involved in it. The legislation and funding to allow training to commence in respect of the first cohort of EMTs to be trained up to the higher level has been provided and the training is under way. I understand that the service will be up and running by the middle of next year. Perhaps Dr. King has further details on that.
Dr. Jeff King
The Pre-Hospital Emergency Care Council, PHECC, is accredited to the national ambulance training school in association with University College Dublin to provide a course for EMTs. It has accredited that course. The first group of trainees are currently in training and will graduate in May next year — 16 people. The legislation to effect the statutory instrument has been amended to set up a legislative basis for the administration of medications by this first group of paramedics. There are still some changes required to the medicinal products and controlled substances regulations, but they will be in place by the end of May when this group graduates.
We have also been doing some spatial analysis work in examining where the first cohorts of advanced paramedics should be deployed to best advantage. There is often a feeling that urban areas are those that need these models first. However, what we are showing up, for example, is that most good would be done for the mid-west if these people were deployed in Ennis, Nenagh and Mallow. The first course graduates will be out in May and work is being done on deployment models to get the best outcome for most people in the community.
How many graduates are there?
Dr. King
There will be 16 from the first group and those 16 are trainers. Ireland is behind the United Kingdom, North America and Australasia in this regard, but in some ways coming from behind means that we can pick up on what they have done well and avoid some of their mistakes. Advice from the other jurisdictions that have put this system in place is that we should train the trainers first. In the first group we have trainers from all the health regions around the country, as well as the two recognised training institutions that PHECC recognises. That is not only the national ambulance training school with UCD, but also the Dublin Fire Brigade with the RCSI. Faculty members from both institutions and trainers from the services all around the country are in that cohort. By the end of May we will have a good training platform in place, which is important when introducing a completely new model. It is not unrealistic to think that the advanced paramedic model in Ireland will be a world leader in a short timeframe.
There will be another bottleneck here because we will not have brought through the legislation to allow the new trainees to give thrombolytics or opiates. Does Dr. King want to take a bet on that? I have been raising this issue for years and there is no legislation coming forward on it. I take a bet now that it will not be through by May and that will be our fault, not Dr. King's.
We can guarantee that.
Mr. O’Sullivan
The first part of the legislation has gone through the House, which was a significant amendment to the Pre-Hospital Emergency Care Council statutory instrument.
I really hope so but I have seen this so often.
Mr. O’Sullivan
Deputy Gormley asked a question about operating costs of the Air Corps. The operating costs for the new aircraft will continue to be borne by the Air Corps. Under the service level agreement being put in place with the Department of Defence, the intention is to that there will be a nominal charge levied to the health system.
How much will that be?
Mr. O’Sullivan
The cost for the Coast Guard is approximately €1,000 per flying hour. I think it is intended to be at around the same level.
So they undertake all the costs.
Mr. O’Sullivan
They charge at the marginal rate.
I am more confused now than when I asked my questions. The report indicates that inter-hospital transfers are required by the Department. Who will do this? Is it the voluntary sector, the Department or an amalgam of both or has it been decided? What role will be played by the helicopters belonging to the Department of Defence and the Department of Communications, Marine and Natural Resources? Will it be a continuation of the current situation where the inter-hospital transfer is way down the list or will it be a dedicated service?
Mr. O’Sullivan
As I said, it is not a dedicated service. Maybe the point has been lost in terms of the investment in the Air Corps's new fleet. One of the reasons——
If it is not a dedicated service, it will be more of the same. There is no point in having that figure——
Deputy Cowley, please.
There is no point in having that figure in the report.
Please, Deputy. Allow Mr. O'Sullivan answer the question.
The committee is not being given a straight answer.
We are.
Mr. O’Sullivan
I argue that the committee is getting a straight answer. The reason the service is so limited at the moment is because of the limited capacity of the Air Corps.
It is not dedicated because it is doing other jobs.
Please continue, Mr. O'Sullivan.
Mr. O’Sullivan
It is because of the capacity of the Air Corps to provide that service. It has a limited capacity and a very old fleet which it is in the process of replacing. In answer to the question asked by the Deputy about the position of HEMS in the context of overall policy and investment in pre-hospital emergency care, if €15 million or €16 million was available in the morning exclusively for the development of HEMS, that is where it would go. However, there is a very challenging and comprehensive investment plan for the pre-hospital side which I described earlier. The Tánaiste has said the priority is the development of the ground fleet and that is the approach being taken in Northern Ireland.
With respect——
Please, Deputy.
Mr. O’Sullivan
We would all accept that the policy agenda for pre-hospital care should be welcomed to the extent that it has been developed. It incorporates significant investment in the MTA rollout, in fleet replacement, in elimination of on-call, all of which are designed to improve response times, as is the HEMS. It would have to be accepted that they are all one and the same, forming an integral part of an overall service. The overall investment plan is running at about €65 million, through a combination of the investment plans for the ground fleet and in the HEMS.
What we have decided to do, and I think it is a sensible decision, is work in partnership with the Air Corps to develop a more extended service based on its capacity to deliver it. We are informed the Air Corps is in a position to provide a much more developed service because it has significantly increased flying time compared to the aged fleet that is now being replaced. Equally the Coast Guard is in a position to continue to provide services.
The voluntary sector has indicated it is joining the service at some point in 2005. That is how the service is delivered in the UK and it is a very comprehensive service. I am not sure what the point is about all this knitting together. Obviously it knits together in the context of the responsibility which the HSE will have next year for pulling the ambulance service——
Can I ask a question?
Please, Deputy Cowley.
I wish to hear some elaboration, on a point of information.
Deputy Cowley, please. Deputy Devins has a question.
I will try to be as clear as I can. The Air Corps was withdrawn from Sligo back to Baldonnel. The air-sea rescue service was put in place on a private contract with the Canadian helicopters and its prime responsibility is air-sea rescue. If there is a requirement for a patient to be transferred from Letterkenny General Hospital or Sligo General Hospital to wherever and the air-sea rescue helicopter is out on the Aran Islands, then there is no dedicated inter-hospital service.
Is the Department handing this duty over to the voluntary sector or will the Department put in place a dedicated HEMS? If a patient is in Sligo and needs to be transferred to Dublin, will the Department continue the current situation where the air-sea rescue service is contacted? If it is not available because it is doing its primary job of air-sea rescue out in the Aran Islands, then there is no inter-hospital transfer service and a patient will have to wait. It is a lovely report but will we still have the situation as it exists now which is unsatisfactory?
Deputy Devins says that tertiary transfers and inter-hospital transfers are needed. I have no problem with this. Why is HEMS not being proceeded with? What criteria were used? I understand what was said about investment. Why is not even the inter-hospital transfer part of it not going ahead? What is the reason for the delay? Whatever arguments may be made by the Department about picking up people from the side of the road, which is already done by the Air Corps and the air-sea rescue service to some degree, inter-hospital transfer is a vital part of the delivery of health care and this is being put on the long finger. Why is it being ignored?
Mr. O’Sullivan
I do not think the Department would accept that the implementation of the report is in any sense being put on the long finger. The majority of patient transfers, inter-hospital transfers, are obviously carried out and continue to be carried out through the ground fleet. It is either accepted or not accepted that we are progressing——
People are dying. That is why we are talking about a HEMS report.
Please, Deputy Cowley. Other members are asking questions. I will come back to you.
Mr. O’Sullivan
There is a judgment to be made as to whether people accept that the Department is progressing an overall agenda of investment in pre-hospital care, both on the ambulance side and in terms of the development of the HEMS. We are doing both. We are looking to develop both the ground fleet and the air service at the same time. We have not developed the ground fleet at the expense of the air service but there are acknowledged deficits which Mr. Robinson may wish to talk about in greater detail which require urgent remedial attention in the context of developing our ground fleet. A wide view of pre-hospital care is the approach being taken rather than just responding to the report in respect of air services. We hope to progress a wider investment across the pre-hospital side, not just in the context of air ambulances.
We still do not know what is happening to the inter-hospital transfer via air ambulance.
It does seem to have been put on the long finger. The Departments of Defence and Communications, Marine and Natural Resources are getting the funding for improving their helicopter services.
Mr. O’Sullivan
We are developing the ground fleet significantly and have invested €8 million in the last 12 months.
I apologise for being late but it was unavoidable. I do not intend any discourtesy. The dedicated inter-hospital transfer is a central issue of concern. The Department's statement says it is advised that plans are being actively developed within the voluntary sector and that the Department will be meeting this group which is developing the initiative. I would like some information about that group because "voluntary" can mean different things. Who is involved and what kind of voluntary organisation and initiative is it in this case?
Mr. O’Sullivan
We have limited information in terms of the proposal other than to say that we understand a group is being formed to operate the service on a not-for-profit basis, along the same lines as the service is currently operated in the UK. I do not know the individuals involved but I understand a group is being formed to look at the development and delivery of this service next year in a not-for-profit context and presumably with some nominal charging applying, similar to the position as it might apply in the case of the Air Corps or the Coast Guard. While I have no more information on the issue at this point, I hope to have more in the coming weeks.
Is Mr. O'Sullivan talking about a commercial approach in which the service is provided by a company operating similarly to BUPA, a not-for-profit organisation? I presume he has some knowledge of the issue.
Mr. O’Sullivan
My understanding is that it is intended to fund the service through private donation and corporate subscription. I do not have further details. The group would also apply for charitable status.
What leads Mr. O'Sullivan to the opinion that this proposal is of significance?
Mr. O’Sullivan
I have not been led to the opinion that it is of significance, other than that it is new information which has come to us recently in terms of interest in the development of the service. We will have to see how it pans out.
When does Mr. O'Sullivan expect to meet the group?
Mr. O’Sullivan
I expect to do so in the coming weeks.
I call Mr. Robinson.
As I must leave the meeting soon, I would like to ask Mr. O'Sullivan a question.
In that case, the Deputy will have to leave without asking a question.
Mr. Paul Robinson
One cannot operate a helicopter service separately from the ground ambulance fleet. They will have to be combined. The usual practice on an operational basis is that the hospital will request the ambulance service to make inter-hospital transfers, rather than calling in the helicopter service. A different practice always applies in emergencies. The helicopter service and ambulance fleet will be co-ordinated. In future, the decision on whether it is more appropriate for a transfer to be made by helicopter or a ground fleet will continue to be made primarily on medical grounds. The matter needs to be put in context. We started training emergency medical teams only in 1996.
I ask Deputy Cowley to show the committee courtesy by leaving the meeting. We are trying to obtain information and cannot, therefore, tolerate two meetings taking place at once. We facilitated the Deputy by starting the meeting early but it was not arranged for the Deputy alone.
I have waited a long time for this meeting and I am concerned that I have not received proper answers.
We have all waited a long time for the meeting.
I am aware of that but this matter has been on the agenda for 11 years.
I ask the Deputy to desist to allow members to proceed to get information.
Mr. Robinson
Since 1996, we have trained more than 1,000 people to paramedic level, which is the first stage. The advanced trainees are coming on stream now and, as Dr. King stated, we are examining how they will be deployed. The other issue which will probably affect response times to emergencies is the Health Services Executive, which will soon begin work. Until now, each health board ran a separate ambulance service. By the end of December, under the auspices of the Health Board Executive, HeBE, we will have recommendations in respect of command and control for the ambulance centres, of which there are at least 13. This means that each centre dispatches ambulances to emergency calls and hospital transfers. With modern technology, the number of centres will probably decline.
We are also examining the North-South aspect of the issue. The spatial analysis mentioned by Dr. King is that health board borders will no longer apply in this area. This will have a double benefit in terms both of calls made in emergencies and for inter-hospital transfers.
As regards helicopters, consideration of the recommendations I have received in meetings with the chief ambulance officers and so forth leads me to believe that they would not be too concerned about who provides the service, provided it is available when required and provided on the basis of an agreement. The service which probably works best at present is the coast guard provided service because one buys it in when required. It also works best from the point of view of protocols and so forth. As Mr. O'Sullivan stated, we will probably work towards the introduction of a system similar to the service agreement with the Department of Defence.
For Deputy Twomey's benefit, from personal knowledge many of the so-called voluntary services in place in the United Kingdom and elsewhere are run as trusts and do not make a profit. They provide the air ambulance and helicopter service but also work closely with the ground ambulance service. The key factor is the need to have only one point for calling in the emergency services. In other words, one should not have a separate control centre for the air ambulance service.
The deficiency under the current scheme is that the air-sea rescue service focuses primarily on air-sea rescue, while inter-hospital transfer is a secondary function. If the helicopter on duty is taking part in an air-sea rescue, no helicopter is available to carry out inter-hospital transfer, unless one is brought in from one of the other three locations. This scenario would result in a large section of our coastline being left exposed in the event of another air-sea rescue being required.
We are seeking a dedicated inter-hospital transfer system. I am as confused now as I was at the beginning of the meeting because I do not see any evidence that such a system is being established. Mr. O'Sullivan indicated it may be done by the voluntary sector. While I accept everything that has been said about the ground ambulance service, there is a deficiency at that level.
In effect, therefore, we depend on the Coast Guard, which is not a dedicated service. Nothing has changed.
That is understandable.
I thank the Chairman. I mean no disrespect to members of the committee but we have waited a long time for this meeting. This issue gives rise to a great deal of frustration. As a general practitioner, I am aware of people who would be alive today and others who would not be in wheelchairs if a dedicated service had been available. Every other country in Europe has such a service.
This report appears to have been subject to a major delay. The Ombudsman had to intervene to get it released. We have heard much talk about a helicopter emergency medical service. As far as I can gather, the Department is trying to fob off the issue and pass responsibility for providing a service to the voluntary sector. Would one fob off the essential work done by the ground ambulance service to the voluntary sector? The helicopter emergency medical service deserves to be allocated €50 million or more.
Ground ambulances cannot fly but circumstances arise when time is of the essence. This is known as the golden hour when it is vital to get patients to centres of excellence. The alternatives are to have perfect roads — even that would not solve the problem — or centres of excellence in every locality, which is not possible.
Will the delegation consider the introduction of a dedicated service? I am interested in Mr. King's response. The system will not work if the service is not dedicated. It was stated that €100 million would be spent in the Departments of Defence, Communications, Marine and Natural Resources and in other areas. Just as the Garda Síochána needs a dedicated helicopter, the health service needs a dedicated helicopter emergency medical service. We have waited a long time for a complete service. We now have an opportunity to introduce a proper service owned and operated by the same people who own and operate the ambulance service and in whom I have considerable confidence. A helicopter emergency medical service would work best in such a system.
Why should this be an either-or question? People deserve to have a proper ambulance service on the ground and in the air. The delegation referred to finite resources. The Government spent €50 million on electronic voting and a further €50 million on Farmleigh House. This issue relates to people and the reason I was elected to the Dáil was to speak up for people. I apologise for having to leave the meeting.
I am puzzled by the idea of using funding from public and private sources. While I accept that members of the public could make donations, why would the private sector get involved in such a service? What return would it get for providing funding? Will donations be sought or will the private sector get a return on investment?
Mr. O’Sullivan
The understanding is that such a service would operate as a charity. This appears to mirror the position as it applies in the United Kingdom. I responded earlier to the suggestion that the report was delayed and that an intervention by the Ombudsman was required to release it. That is simply not true.
We accept that is the position.
Mr. O’Sullivan
I have outlined the process which gave rise to the preparation of the report. It was comprehensive and involved wide consultation in the North and the South. Multiple submissions were received from representatives bodies and considerable deliberation was undertaken by the steering group which worked with Booz Allen Hamilton in finalising the report. I wish to place those matters on the record.
Given the number of submissions, I do not believe there was a time delay.
As regards the number of people who used the helicopter services, in 1991, the figure was 471, while the equivalent figure in 2001 was 700. What is the average annual figure? Is it possible to secure dramatic improvements by providing a better service?
Mr. O’Sullivan
According to the consultants, the projected activity of a dedicated helicopter emergency medical service is 400 to 600 missions annually. That would represent a significant increase on the current level of service provision. Roughly 100 missions are carried out between the Air Corps and the Coast Guard. The report outlined a mission projection of four times that. Ms Cummins may wish to comment on that. There was also a question for Dr. King.
How will the level of international co-operation be sustained and developed in the context of the report?
Mr. O’Sullivan
The discussions with the North will certainly continue in the context of the provision of an all-island service. The current priority for the North is the development of the ground fleet. Investment in a helicopter emergency service has not been prioritised in the North where a similar ground-fleet investment agenda is being followed to that in the South. We will certainly continue to talk to the North in the context of any further discussions we have with the voluntary and private sectors which will no doubt identify opportunities for all-island developments as recommended in the report. There is still significant potential to develop a helicopter service on a joint, all-island basis.
Perhaps the information was in the report and I missed it. How many calls per year would there be on such a service?
Mr. O’Sullivan
The projected activity level as set out in the report is 400 to 600 missions per aircraft.
Is that the figure for the country rather than simply per helicopter? Is it the case that a dedicated air ambulance service would deal with 400 calls per annum?
Mr. O’Sullivan
The projection is 400 to 600 calls per annum for one dedicated craft in a fully developed service. Ms Cummins may comment further.
Are not the Air Corps and coast guard answering more than 100 calls per annum?
Ms Derval Cummins
I do not have the numbers on that in front of me. According to page 100 of the report, which I have before me, an estimated level of demand of 400 to 600 missions is envisaged for a dedicated inter-hospital transfer helicopter emergency service North and South on the basis of the historical data on ambulance activity in Ireland, including long distance ambulance journeys and the activity levels of the specialist road-based transfer services operating across the island of Ireland.
Ms Cummins is saying the demand level is not per aircraft but across the service.
Ms Cummins
For the inter-hospital service for the island of Ireland.
That is a maximum of two calls per day.
Ms Cummins
Yes.
Would Ms Cummins say there would be no need for a dedicated helicopter emergency medical service if the Defence Forces and the Department of Communications, Marine and Natural Resources were able to answer one call per day each? That is how it appears to me. I am following Deputy Devins's line of thought on this, with which I agree. It appears we will not get a helicopter emergency medical service because the consultants have somehow reached the conclusion that it is not really necessary.
Ms Cummins
No.
Based on the figures outlined, there would be two calls per day. If that is the case, why are we talking seriously about a dedicated service?
We are talking a maximum of two transfers per day.
Mr. O’Sullivan
That was the analysis.
Dr. King
The Air Corps and Coast Guard figures aggregate currently to 100 per year. It is estimated that the inclusion of current road transfers would require 400 to 600 missions. This service level is seen as a justification for the report's conclusion that there is a case for a dedicated inter-hospital transfer service.
One helicopter.
Dr. King
Most likely based in Dublin. While that is its conclusion, the hand-in-glove aspect of the report is that one will still need to develop the service level agreement and the policies and protocols governing the use of Air Corps and coast guard assets to ensure that one obtains regional and primary response assistance as required. There is no evidence to support dedicated primary response models spread around the country. There is a need for strong integration with hospitals, co-ordination with clinicians and useful systems of operational tasking which are integrated with ambulance services. The system designed to achieve the latter would constitute a strong platform for the efficient use of a dedicated service. It is hand in glove. Buying a helicopter and parking it in Dublin does not provide one with a useful system of itself. One also requires the operational tasking component, integration with ambulance services and clinical co-ordination and integration with hospital clinicians.
The more Dr. King says, the more we get the answers. The figures show one helicopter would do the job and Dr. King says it would be based in Dublin. To get the best operational response for inter-hospital transfer, which we support——
Dr. King
One always needs options. Even if one has six helicopters in an area, something will happen. The more options one has available, the better. The level of service currently provided by the Air Corps and Coast Guard could be refined and augmented through better policy, procedures and a uniform understanding nationally of appropriate use. One must ask what sort of clinical conditions the service should address and what sort it should not. This is well enunciated in the report. To develop those systems would also provide a platform for a dedicated inter-hospital retrieval service out of Dublin.
I am still completely confused. Is Dr. King recommending a dedicated helicopter to provide an inter-hospital transfer service or is he saying he is happy to see the existing service provided by the Departments of Defence and Communications, Marine and Natural Resources continue in operation?
Dr. King
I am saying the report says both are required.
I do not understand. Does that mean where one has a dedicated service, one would use the Departments of Defence and Communications, Marine and Natural Resources as backup?
Dr. King
No. They would provide backup while fulfilling a different role. They would be used as required on a needs basis for different functions such as primary response work. Most successful primary response models have mixed roles which include search and rescue.
We are talking here about tertiary response, inter-hospital transfer.
Dr. King
The case is made for a dedicated inter-hospital transfer service as opposed to the provision of dedicated, primary-response, regionally-based helicopters.
Is Dr. King recommending that the current service be beefed up in terms of its primary response role and that while we must continue to rely on the current inter-hospital transfer service, he supports the provision of a dedicated helicopter emergency medical service to fulfil this role?
Dr. King
The report comes to that conclusion.
Dr. King sounds like a politician.
Dr. King
I was involved with the report, believe it is a fine document and support its conclusions.
Are we saying that while we recognise the funding which has been put in place for the ground fleet and will continue to rely on the Air Corps and Coast Guard, a dedicated helicopter service should be put in place to deal with two cases per day?
Mr. O’Sullivan
We are also being told the capacity of the Air Corps will be significantly developed.
That is the safeguard. The provision of the Air Corps with six new helicopters and increased capacity to provide backup services represents progress from the previous system. I reiterate that we are talking about the same fund base for ground fleet and air ambulance services. At least we know the report's conclusions. There has not been much progress on the development of a specific dedicated service. While the members of the committee recognise the need to maintain the current level of funding for the ground fleet, I am not sure we favour dividing the fund to cater for the air ambulance service. I thank the departmental officials and the consultants for their attendance and for outlining the report's recommendations in such a comprehensive way.
The joint committee went into private session at 10.40 a.m. and adjourned at 10.45 a.m. until 11.45 a.m. on Thursday, 9 December 2004.