Léim ar aghaidh chuig an bpríomhábhar

Joint Committee on Health díospóireacht -
Wednesday, 15 Dec 2021

Ambulance Services: Discussion

Today's meeting will be split into two sessions to discuss the issues facing ambulance services. In the first session, the committee will engage with representatives from SIPTU. I welcome from the union Mr. Ted Kenny, sector organiser, Mr. Geoff McEvoy, industrial organiser, Mr. Greg Lyons, ambulance sector president, Mr. Luke McCann, Dublin Fire Brigade, DFB, convener, and Mr. Peter Ray, president of the Irish Ambulance Representative Council, IARC.

Before we hear the opening statements, I point out to our guests that uncertainty regarding parliamentary privilege will apply to their evidence given from a location outside of the parliamentary precincts of Leinster House. If, therefore, they are directed by me to cease giving evidence on a matter, they must respect that direction.

I should declare an interest in that I am a member of SIPTU. I invite Mr. Kenny to make his opening remarks. He is very welcome.

Mr. Ted Kenny

I thank the Chairman and committee members for the invitation to discuss the challenges faced by our members working in the HSE National Ambulance Service, NAS, and the Dublin Fire Brigade, DFB, fire-based emergency medical services. SIPTU represents more than 1,600 members in the National Ambulance Service, all of whom are critical to the delivery of care in emergency services in our communities. The HSE National Ambulance Service provides the following supports to the public throughout the State: emergency ambulance service; immediate care transport; mobile intensive care ambulance; and neonatal intensive care ambulance.

In Dublin, a dual system is operated by the NAS and the DFB, which has served its residents well over many years. Dublin Fire Brigade ambulance service employs 110 personnel in all grades of ambulance professionals, inclusive of more than 80 advanced paramedics. Dublin Fire Brigade ambulance service requires back-up support from 840 paramedic first-response firefighters, backed up by 21 paramedic first-response fire appliances and two emergency fire appliances, offering a rapid first response deployment to any pre-hospital emergency.

Ambulance capacity in Ireland has been at a low level historically, with demand increasing over the years. For example, monthly demand in the second half of this year is at levels normally experienced in December pre-Covid. Covid has, obviously, affected all aspects of the health system, from primary care to hospital care. There are very high levels of hourly use of emergency ambulances and pressures on these areas of the system have had a knock-on effect on ambulance services. Hospital offload delays have increased in number and duration. Call volume to emergency control centres has increased, and the time duration of each call has extended due to the additional personal protective equipment, PPE, and effective prevention control measures that are required when managing Covid. Ambulance crews are experiencing the effects of lengthening response times, which in turn have an effect on the welfare of staff working in such a busy system, both in the control centres and operationally.

SIPTU representatives have expressed deep concerns over the high level of pressure on the ambulance service, with paramedics frequently having to be diverted from other parts of the country, under a system that has been widely criticised by staff and has resulted in many members suffering from burnout. Staff recruitment and retention in the service has become a serious issue. In Dublin Fire Brigade's fire-based emergency medical service, ongoing manning shortages have meant that, at times, up to 20% of front-line DFB fire appliances have been taken out of service, resulting in a corresponding reduction in the number of available paramedics.

In representing members in these vital services, we want to share our concerns about the effect this is having on the morale of our members who provide front-line ambulance services throughout the Republic of Ireland and the concerns our members have about the perceived lack of public confidence in an essential, life-saving service. As the Chairman and committee members will be aware, from both their work on the committee and their work in their constituencies, public concern has grown throughout the country as a consequence of several high-profile cases in which ambulance responses to a specific incident or event have been flagged in the media as a matter of concern. We are here to assist the Oireachtas Joint Committee on Health to examine all factors involved in the delivery of the ambulance services, to do what we can to establish the growing challenges confronting this essential front-line service and to assist the professional ambulance personnel committed to providing these services.

Ambulance professionals, in both the HSE National Ambulance Service and Dublin Fire Brigade, have a proven tradition of putting the care of the patient first, and this ethos has been well demonstrated by their commitment to developing the service from being a patient-transport service to a sophisticated first-point-of-control medical intervention. This has required the strategic educational development of personnel, whereby ambulance professionals are trained to the level of medical technician, paramedic and advanced paramedic, all of whom are equipped to deliver the earliest possible medical intervention, thereby giving the patient the best possible medical outcome. This also provides the added benefit of taking pressure off accident and emergency departments through earlier interventions. Our members are also committed to the bachelor of science degree programme in pre-hospital emergency medicine supported by University College Dublin and University College Cork. Those who deliver front-line emergency ambulance services are deeply affected when a failure to deliver the best medical intervention or to meet the recommended response times is linked to an adverse outcome for a patient, given many of our members who work for the ambulance services live in the communities they are deployed to serve.

Despite restrictions on resources in these difficult times, ambulance professionals continue to develop their skill set to serve in the interests of the public. SIPTU has been at the forefront of the development of the professionalisation of the ambulance services, which has evolved since 2001 and has been overseen and regulated by the Pre-Hospital Emergency Care Council, PHECC, which is also the licensing authority for all qualified ambulance personnel. In order for a proper discussion to take place on the resources required for the State's ambulance services, it is imperative the recommendations of the NAS capacity review be implemented.

SIPTU members are committed to working with any and all processes, including future capacity reviews, that will advance the ambulance service. The huge advances made by our members from the ground up are testament to our credibility in improving the ambulance service through the development of ambulance personnel and services.

I thank the Chairman and the committee for their consideration on this submission.

I thank Mr. Kenny. The first speaker is Senator Kyne, who has five minutes for questions and answers.

I thank Mr. Kenny for his presentation on behalf of SIPTU and I welcome him and all SIPTU members who have joined us today. I have good reason to thank the members of the National Ambulance Service in that on two occasions this year my uncle received wonderful treatment from paramedics and hospital staff. He is in a nursing home now, having suffered two strokes this year.

On the operating model, as part of a delegation from the constituency a number of years ago I visited the centre in Tallaght. There are some complaints in regard to ambulances being brought from one county into another. Is that process operating correctly or is there need for change in terms of improving efficiency of delivery of ambulances?

Mr. Ted Kenny

On the dispatch of ambulances, there have been times when, especially in rural Ireland, ambulances have been dispatched that are two and a half hours from a scene. An example would be from Castletownbere into west Kerry. Another example would be an ambulance from the midlands being sent into Sligo or as far away as to Galway. Improvements have to be made in those areas. Improvements are being discussed and negotiations are ongoing with management on how to alleviate those problems.

Is it impacting on response times? Obviously, it is a measure that has been put in place to ensure that there is an ambulance on the road to meet a patient but, unfortunately, if that ambulance has been taken away from its home area that means if there is an incident or a call-out in the home locality there will be no ambulance. If my understanding is correct, under the old methodology ambulances were provided in geographical areas and they were not permitted to operate outside of those areas. I can see that that might not have worked well either if there was a call-out on the border of a geographical area and the ambulance was elsewhere. In regard to the changes that are being recommended, will they improve delivery of the valuable services?

Mr. Ted Kenny

It is our belief that the changes that are being proposed and negotiated with the working groups and senior management within NAS will improve the current situation in terms of operations.

Response times in rural areas are poor for reasons of geography. They are particularly poor in the west of Ireland. There have been some improvements in terms of provision in Tuam and Belmullet and I understand there are plans for a new ambulance base in the Connemara region. Are there other geographical blackspots that SIPTU members have identified as in need of in-house services?

Mr. Ted Kenny

Any areas in the country that have been identified would have been identified by our membership and through local representatives and they have been addressed. As outlined by the Senator, a new ambulance station is being put in place in Connemara. It will have an additional 11 resources. In any areas that have been identified, management has been to the forefront with SIPTU members in trying to alleviate the issues.

In terms of the increase in call volume, as people are living longer is that increase in the main from the elderly population or are there problems within urban areas in terms of late night revellers and drink-related accidents? Are there incidents of ambulance staff being under duress, pressure or assault in some of these incidents?

Mr. Ted Kenny

That have been situations in which ambulance personnel across not only NAS but the DFB have come across late night incidents and have been victims of assault. On the issue of call volume and call times, much of the time paramedics are telling us that they are attending calls that there is no need for them to attend. I am sure my colleagues in DFB will agree with me on the need for an educational programme not only for the general public but for GPs in regard to what type of calls should be allocated to the National Ambulance Service.

What type of calls are being made that are not necessary?

Mr. Ted Kenny

Ambulances have been called out to incidents in areas where there are doctor-on-call systems. They have been called to attend in respect of a person with an eye infection or a broken toenail. These are matters in respect of which people could make their own way to accident and emergency departments. There are times when they do not have to attend accident and emergency and can be treated at home.

That is taking away from resources that could be best placed elsewhere. Is there a charge for unnecessary calls?

Mr. Ted Kenny

Not that I am aware of.

I note Mr. McEvoy is indicating.

Senator Kyne's time has expired.

Mr. Geoff McEvoy

On the Senator's question with regard to call volumes and late night revellers, that is a reality. Within Dublin Fire Brigade, the current system of resourcing previously operated at approximately 5,500 calls per month. Given the increase in the size of the city, that has increased to approximately 6,500 calls per month. During the Christmas period, that increases to approximately 7,500 per month as there are more people out and about generating more calls. The resources have not increased to match that demand and that is creating the problem. The level of resources that have been in place since the height of the Celtic tiger days are being stretched to meet the needs of a growing city.

I thank Mr. McEvoy. The next speaker is Deputy Cullinane.

I welcome Mr. Kenny and everybody else on the call. I want to start with the issue of staff burn-out as highlighted in Mr. Kenny's opening statement. It is an issue Mr. Kenny and I have discussed several times. What is the current level of staff burn-out? How bad is it and how difficult or challenging is it for paramedics across the board? I ask Mr. Kenny for a brief overview in that regard.

Mr. Ted Kenny

I will give two examples. The service operates on a two 12-hour shift basis, that is, 8 a.m. to 8 p.m. and 8 p.m. to 8 a.m. Owing to current call volumes, extended duties could run into 16, 17 or 18 hour shifts. We also have situations where paramedics who answer and are dispatched to calls, especially in rural Ireland, are being stood down when another ambulance becomes available that is closer to that call. That ambulance may then respond to another call only to be stood down again. We have examples of paramedics travelling nearly 500 km without ever attending the scene of a client.

What I have been hearing over the last few months is that there are issues around the long-distance calls, especially at the end of the shift, which can create real problems and that shifts are lengthy, breaks are short and staff are not able to take breaks at an appropriate time. Is that prominent right across the board?

Mr. Ted Kenny

It is. Working groups have been set up. It is hoped the recommendations of those groups will be finalised this evening. This work will, hopefully, go a long way towards alleviating those problems. Owing to extended duties we are experiencing high levels of burn-out throughout the staff population. I would imagine the same applies to personnel in the DFB.

Mr. Kenny mentioned the working groups. There are two main issues, one of which is the capacity review. There have been a number of capacity reviews in recent times, including a capacity versus analysis review which commenced in July on which we will engage with the National Ambulance Service and the HSE later. The capacity review has to look at increasing the staff complement, increasing the fleet and so on. If I am correct, the working groups will focus on the terms and conditions of employment and some of the other issues raised by Mr. Kenny.

Am I right in saying there is a number of them? There is one on the late finish, one on meal breaks, one on rules of engagement and one on emergency deployment points. Are they the four working groups that are in play?

Mr. Ted Kenny

They are the four working groups. There is also a working group being set up to look at the roles and responsibilities as well.

In terms of the late finishes, is Mr. Kenny saying that this working group or all five working groups will be concluded this week and there will be recommendations in all of them or some of them?

Mr. Ted Kenny

In all of them.

When the working groups have finalised their work, the health committee would like to see the details of that and get copies of those reports. Is Mr. Kenny satisfied that issues regarding breaks, late finishes, late call-outs and late discharges at the end of shifts will be covered sufficiently in the recommendations from the working groups?

Mr. Ted Kenny

Yes, we are quite confident that many of the recommendations that will emerge will help to alleviate difffculties. As it is an ambulance service, the ECHO and emergency calls will have to be responded to. There is no ambulance professional in this country who is not going to attend the scene of a cardiac arrest, regardless of meal breaks or anything else. That is imperative and all the staff in both the National Ambulance Service and DFB are committed to that.

What is meant by the rules of engagement?

Mr. Ted Kenny

The rules of engagement relate to the dispatching of calls, the type of calls that are dispatched to ambulance personnel and how they are properly managed.

Then that is the relationship between the call centre or dispatch centre and the ambulance paramedics.

Mr. Ted Kenny

That is correct.

Okay. In the previous contribution Mr. Kenny spoke about some of the call-outs not being calls that an ambulance crew should be responding to. There is a need for a public awareness campaign in that regard. How much of a difficulty or challenge is it, especially when there are major pressures on the system, if ambulance paramedics are being called out to calls they should not be called to perhaps because people cannot get access to out-of-hours GP services or whatever the issue might be that is driving that? How problematic is it?

Second, we have been hearing for some time about the treat and refer policy as well, where a paramedic would be able to manage a person in the home or wherever the person is at the point of the call-out and may not necessarily have to bring the person to an acute hospital, if possible. What is the position with that at present?

Mr. Ted Kenny

There are two pilot projects at present - one in Cork city and one that has started in Tralee - where those systems are up and running. It has alleviated pressure, as patients are treated at home and do not need to use an ambulance. It frees up spaces in the emergency department. We want to see the roll-out of that across the country, to be honest, because ambulances being dispatched to calls that do not necessarily need an ambulance is a core fundamental issue for our membership. The sooner we take them off the table and treat them either at home or by GPs, the sooner that will free up the ambulance for the emergency and urgent work that is needed.

I have two final questions.

Mr. McEvoy wishes to speak.

Mr. Geoff McEvoy

I wish to add the Dublin Fire Brigade context to the Deputy's question about burnout. The firefighters in Dublin Fire Brigade are facing a serious crewing shortage at present. As can be seen in our submission, that is resulting in, at times, up to 20% of the fleet not being available for service and scenarios where the fire brigade is becoming increasingly reliant on overtime to try to cover the city to the greatest extent possible. Potentially, up to 150 new firefighters need to be recruited into the service. All of this is having a massive impact on the morale of staff and their fatigue levels. It is becoming increasingly detrimental. However, I am sure the committee will join me in paying tribute to the personnel in both the Dublin Fire Brigade and the National Ambulance Service because despite those challenges, which are increasing, as the members of the committee will learn in the course of this meeting, they are continuing to make life-saving interventions and are saving lives in this city in the case of Dublin Fire Brigade and around the country in the case of the National Ambulance Service.

Absolutely, and I echo that. I have two brief questions before finishing. I will refer back to Mr. Kenny. There are the capacity reviews and there is a staff complement of just over 2,200 in the National Ambulance Service. Comparisons were made to Scotland, which some would argue is the best comparison that can be made to our service. That comparison would lead to a very substantial increase in staff numbers as Scotland has approximately 5,000. Is the review looking at the Scottish model or has it looked at it and what additional capacity is needed?

Second, I have received a great deal of correspondence, confidentially, from some ambulance paramedics. They have not made protected disclosures so I have to be careful how I present this. They are ambulance paramedics who are suffering from post-traumatic stress disorder. What industrial relations processes are in place to assist and support paramedics who have gone through that? Are they appropriate and are they working?

Mr. Ted Kenny

On the first question about the capacity review, Scotland has 5,000 personnel and the National Ambulance Service has just over 2,000 personnel. We want that to grow to double the number. We also want to see the number of ambulances extended by at least 100, if not 200 ambulances. We want that to be done in the next three to five years, at a minimum. The National Ambulance Service has been modelled on the Scottish system. We have been over to Scotland and seen how that works but, sadly, the investment in the national service in Ireland has not been to the same extent as it is in the Scottish system and we have fallen drastically behind.

I concur with what Mr. McEvoy said. The reliance on overtime in the National Ambulance Service and the DFB is causing massive burnout.

On the question relating to post-traumatic stress among our membership, there is a wide range of supports in the National Ambulance Service. I believe there are not enough and there should be a lot more. The professional ambulance personnel in this country are the first to horrifying scenes involving all ages, be it road traffic accidents or sudden cardiac arrests in young people or in all ages. There should be more resources for those personnel to help them recover after the call to such traumatic scenes.

Would Mr. McEvoy concur with that? Is there a similar problem or issue in Dublin Fire Brigade?

Deputy Cullinane has to conclude.

Mr. Geoff McEvoy

I concur.

Does Senator Black wish to speak now or later?

I will speak now, if that is possible because, unfortunately, I have to leave.

Go ahead.

First, I thank the witnesses for coming to the meeting today. I also pay a big tribute to the front-line workers who work in the ambulance service and the fire brigade. I do not know how they keep going, particularly in the current circumstances. Could Mr. Kenny give a little more detail about the investment in, and better staffing of, pre-hospital emergency care? There is no doubt that it could assist and remove pressure from the ambulance service.

With regard to supports for staff in general, mental health support is an area in which I have a specific interest. I believe that everybody who works in the ambulance service and the fire brigade needs that support, regardless of whether the person asks for it. I cannot imagine the trauma of going to work every day and having to face God only knows what. Can Mr. Kenny expand on the supports that are there?

Mr. Ted Kenny

There are two parts to the question.

The first has to do with the capacity review and what can be done to improve the current situation for paramedics. There must be a commitment by the Government that it will fully resource whatever the review's recommendation on numbers is. If we want to grow the NAS by doubling its staff over the next three to five years, funding must be made available not only for staffing, but also fleet resources.

The retention of staff is under consideration. It is a major issue. We have people coming into the organisation - Mr. McEvoy can comment on the DFB - who are not staying within the NAS. They are moving on, either into the wider HSE or to other jurisdictions.

Regarding burnout supports, there are in place employee assistance programmes which staff can attend. There are also occupational health services which they can seek. The mental health issue should be explored more and more resources should be put in place. Many paramedics whom I meet outside the job tell me about the horrifying calls they have attended and how, after returning to base, no member of management approached them to see how those calls went. Even though management and the call centres were aware of the calls, there was no follow-up with the paramedics, advanced paramedics and other ambulance personnel. This issue has to be examined.

I agree. Did Mr. McEvoy wish to respond?

Mr. Geoff McEvoy

I will speak to some of the points that the Senator raised. On investment in staffing and recruitment, there is a critical need for additional recruitment into the fire service in Dublin. This issue is impacting on ambulance provision, which is the subject of today's discussion, but also on the fire service. It is jeopardising the safe system of work under which firefighters need to operate and is creating health and safety concerns in that regard.

On early interventions and pre-hospital care, it is worth reminding the committee and anyone who is watching about the service that the personnel in the DFB and the NAS can provide. It is not simply that someone calls an ambulance, it arrives at the scene and the person is put into the back of it and taken to hospital. The personnel are trained to be able to deliver critical paramedic care as soon as they arrive. That is saving lives and producing better outcomes for patients but it takes longer. When we consider questions of response times, we also need to factor in the type of care and work that is going on during that time.

The Senator mentioned supports. I will not go into the details but perhaps some of my colleagues can provide them. It is the case that DFB crews see the worst that life in the city has to offer. They arrive on scenes involving road traffic accidents, domestic fires and incidents in the city centre. They deal with the absolute worst on a daily basis.

Did Mr. McCann wish to respond? I will make a comment while he unmutes himself. I can only imagine the trauma of what ambulance and fire brigade personnel must face on a daily basis. With my therapist hat on, we are committed to getting supervision for some of the work that we do. What we do is nothing compared to the trauma dealt with by ambulance and fire brigade personnel. Could supervision be considered? I understand that this all comes down to resources but it is vital that workers in this area be supported whereby they can have supervision and speak about the trauma they meet on a daily basis. They could encounter not one, but two, three or four major traumas per day. I cannot imagine how they do that and then go home and try to live normal lives. It is extremely stressful and should be addressed.

I see that Mr. Ray has raised his hand. Does he want to reply?

We are over time. I will let Mr. Ray respond but we need to move on.

Mr. Peter Ray

I will make a quick comment. The NAS also services Dublin city and faces the same challenges in terms of mental health and the calls its personnel meet. We often collaborate with our colleagues on the same scenes. We all share the same experiences, both in Dublin city and in the rest of the country.

I apologise. I must leave. I thank the witnesses for their wonderful presentations.

I welcome our guests and thank them for appearing before us. I congratulate and thank them for the work they have done over the past couple of years in particular but also on an ongoing basis. We must acknowledge that the public rely on them in the emergency situations to which they respond. It is appreciated.

Apropos of the questions on capacity and so on that have been raised, the witnesses will say that there is a requirement to improve capacity significantly, but do they believe it can be improved sufficiently to meet the kinds of exigency they have in mind in light of what has occurred in recent years? Will the augmentation be sufficient to meet those requirements?

Mr. Ted Kenny

It will if the numbers in the NAS and DFB are increased significantly but the problem throughout all of the health sector is the recruitment and shortage of staff. Not only has the NAS a problem in recruiting staff but we also have a retention problem. This is why there is a job in hand in the NAS in terms of roles and responsibilities. I have been dealing with the NAS as an official for the past 25 or 26 years. It is only recently that I took over the role of sector organiser dealing nationally with the Irish Ambulance Representative Council, IRAC, and the sectoral committees in trying to resolve those issues. We hope that the roles and responsibilities will be finalised next week.

There are not many people who are interested in becoming paramedics right now. Two issues are affecting this, the first of which is bad press about long distances. Why would anyone want to do a shift of 15, 16 or 17 hours? Why would anyone want to join an organisation where he or she cannot get meal breaks? These are fundamental issues. Another is that the rates of pay attached to the NAS have fallen far behind other health professionals' rates. The job in hand in respect of roles and responsibilities will address that. I hope that it will be accepted by the HSE, the Department of Health, the Department of Public Expenditure and Reform and the Government and that, whatever comes out of that work on roles and responsibilities, it will be supported by the Government in order to allow us to grow capacity within the NAS. It is all incorporated.

What is the rate of pay for a first-time applicant to the NAS or the DFB? It is becoming more difficult to source staff in services, manufacturing and almost all other areas of our economy. It is just a feature of the times. Will the witnesses indicate what the starter rates are?

Mr. Ted Kenny

I will ask Mr. Ray to come in on the rates of pay because I do not have them in front of me.

Mr. Peter Ray

Regarding the challenges on the rate of pay, for the training grade the salary is approximately €25,000. What has to be considered is that people are entering a bachelor of science degree programme over three years. The difficulty is that we generally get people into the organisation who have a bit of life experience. It is the type of profession where people need life experience. We cannot have school leavers coming into the type of job we do; that is not going to work. It can be economically challenging for a lot of people to consider this career. Starting on a salary of €25,000, getting a bachelor of science degree, moving to a salary of just over €30,000 after qualification and then having an 11-year wait to move through the pay scales is difficult. People may have a strong desire to enter this profession, but the difficulty is economic.

How often are the increments applied?

Mr. Peter Ray

For the first eight years they are applied every year, and the final long service increment has a three-year wait. It takes people 11 years to get to the top rate. There is nothing unique about this; it is linked to HSE pay scales. The difficulty is that the ambulance service looks for people with a significant amount of life and coping skills to ensure they are able to deal with what they will face. A lot of people who come into this job have families and we have challenges with relocation to anywhere around the country due to the fact it is a national service. We have tried to ameliorate the situation on a number of occasions, but there has been limited success.

Generally it takes people a bit of time to get back to where they want to be. The crippling costs of relocation post qualification in the National Ambulance Service are very economically and domestically challenging for a lot of people. Within the capital, there is a difficulty with rising rents and housing costs. We face the same challenges as all other professions. The challenge is whether people can live a comfortable life on the pay rate that currently exist. Unfortunately, the answer is "No" considering what people put into and get out of it.

Do the witnesses think that the infrastructure in the ambulance services generally, including the number, quality and condition of ambulances, is in accord with what one would expect in an ambulance service responding to emergency cases and the need to be ready and in tip top order at all times? I refer to how the ambulance service works nowadays. For example, ambulances had to wait at hospital when delivering patients and were ticking over while waiting to go to the next call. They were out of service throughout the waiting period at ambulance bays in hospitals. To what extent has that been eliminated?

Mr. Ted Kenny

On the first question, the National Ambulance Service has significantly improved its fleet. The ambulances are of a high standard. Waiting times in accident and emergency departments are a major issue and challenge for us on two fronts. Given the Covid pathway in accident and emergency departments, ambulances could wait for five, six or seven hours to get Covid patients through a department due to the availability of beds. There are now many protocols around Covid, PPE and cleaning and decontaminating vehicles and beds in accident and emergency departments and hospitals. They are all challenging aspects for the National Ambulance Service.

The waiting time for non-Covid patients in some accident and emergency departments can be anything up to two or three hours. That is an issue that has to be addressed. Scotland has hospital liaison officers attached to each acute hospital who liaise to free up ambulances. That is being considered by a working group. There is a belief that after its meeting later today there will be a recommendation that will help to alleviate the problem and free ambulances to go to the next available call.

I thank the witnesses.

I also want to thank the witnesses. Nothing can ever underestimate the amount of work our ambulance paramedics and fire service have done, in particular during Covid. It worries me that we are not giving them the recognition they deserve and that some are burned out. That is something we need to address. It is concerning. We know that there is a process of discussion with SIPTU through the IARC. Can Mr. Kenny tell us who elects the IARC and what it is? Does ambulance management ever talk directly to staff? Is there a process by which to do so? Can he explain how this works as a possible assistance in improving things? There are definitely huge issues.

Mr. Ted Kenny

The IARC is elected by our general membership. It is made up of not only SIPTU but the Unite trade union. SIPTU, Unite and Fórsa represent the National Ambulance Service. Fórsa represents the clerical staff and some officers, along with SIPTU. Unite normally represents paramedics and ambulance personnel in the Waterford area and certain parts of the north east and north west.

The IARC committee is elected throughout the Twenty-six Counties. There are 13 representatives in total and they are elected for a period of five years. That committee deals directly with management. Each IARC committee member feeds back directly to members in his or her locality. That is how the system operates. There are a series of general meetings with staff members and the officials.

I deal with the National Ambulance Service on behalf of SIPTU for all of the national issues. We have a number of local officials who deal with all of the local issues in various counties. They in turn meet members. Over the past 18 months to two years physical meetings have not happened because of Covid and a lot of meetings are now done through Microsoft Teams.

Does Mr. Kenny feel there is discontent within members who feel that they may not be listened to? Is there any way of improving that? I have seen this in different areas. Ambulance paramedics can address issues and problems they know about in their local areas. I welcome the involvement of management, but as the witnesses know paramedics know what is happening locally. If they cannot bring a particular issue to the attention of management or unions that then becomes a major issue. Do the witnesses have concerns about that? Do they feel there is another way to address members to ensure they have more of a say? Having spoken to paramedics, I feel that some of them want to be listened to. Do the witnesses think that can happen? How can we make those changes?

Mr. Ted Kenny

As I said to another Deputy, I came into this role on 1 July and have made substantial changes to how SIPTU runs its business. Within the general membership we are trying to get a shop steward set up in each ambulance base in Ireland.

We are in the process of issuing a newsletter to all SIPTU members outlining everything that has been achieved since we took over on 1 July, with all the concerns that have been raised across the country on behalf of our membership. If members in any part of the country have any issues, they will contact their local shop stewards, who will, in turn, contact their local official. If it is a localised issue, it will be dealt with locally and if it is a national issue, it will be referred to me and dealt with through the IARC.

Does Mr. Kenny feel there is consistency there with staff? Is there a lot of movement of roles from one area to another? That is another issue that might need to be looked at. Things are changing all the time. Many management posts and other posts are not permanent. There are part-time posts and whatever else. There is a lot of movement within the sector. Is Mr. Kenny concerned about that?

Mr. Ted Kenny

I do not understand what the Deputy means when she says there is a lot of movement. Is she talking about movement in the sense of staff relocating from one area to another?

I am thinking particularly of management. What is the situation with regard to management roles? Are there full-time management roles that are there constantly? Are there other issues? Is there movement from one area of the country to another, or whatever? Is there always someone in the base to represent the ambulance paramedics?

Mr. Ted Kenny

There is not. The situation is quite clear. Management of the National Ambulance Service operate 9 a.m. to 5 p.m. hours, Monday to Friday. No one is there after 5 p.m. until 9 a.m. the following morning between Monday and Friday. There is no one there from 5 p.m. on Friday until 9 a.m. on Monday morning. We represent the officers in the National Ambulance Service, along with our sister union, Fórsa. A business plan has been submitted to the Government and approved for an increase of approximately 136 officer positions in the National Ambulance Service over the next three years. That will necessitate 24-7 cover and that will come into being. Our officer grade members have issues around that. Those need to be addressed. However, that is a separate discussion to the discussion we are having today about delays on the road.

I thank our guests for coming in. We have all learnt a lot as a result of this morning's engagement. I have a couple of questions. What is the average call-out time, if our guests have that information? From the time someone requests the assistance of an ambulance, what is the response time? Have our guests the average response time for 2021 and can they compare that to the average time ten years ago?

Mr. Ted Kenny

I do not have that information, to be honest. All I know is there have been recent examples where people have been waiting for an ambulance for up to three, four or five hours.

That is something we might put to the representatives of the National Ambulance Service when they are before the committee later. My mother fell two weeks ago and broke her hip. The ambulance was there in 40 minutes. I am being told that is a good result, given the fact that people in a similar situation can be waiting up to two hours. The biggest problem is the reliance on overtime. That seems to be a major problem. Overtime should be considered a stopgap, something that is used in rare situations when required. It certainly should not be standard on a weekly basis. Are our guests aware of much absenteeism as a result of Covid-19? Have many members of our guests' organisations been hit with Covid? How has Covid affected our guests and the jobs they are doing? I know there is increased use of personal protective equipment and so on. Would many members of our guests' organisations feel they contacted Covid through their work? Have many been off sick with Covid? Are many of them now suffering with long Covid?

Mr. Ted Kenny

I will ask Mr. Ray to come in on that question.

Mr. Peter Ray

Covid has had a considerable impact on the ambulance service since day one. We all remember when that flight arrived from Bologna and the passengers on that flight were all contacted. I happened to be on duty at that time. From then, day one, there has been significant staffing resilience when it comes to Covid sick leave and all the associated matters. The same has applied to us as has applied to anyone else working in healthcare. The difficulty was that we did not have the back-up staffing resilience within the organisation to face the issue head-on. We redeployed staff to pop-up swab testing sites and vaccination teams. We were at the forefront and centre of that. The ambulance service traditionally has quite a gung-ho approach to atypical circumstances, as is true of all other emergency services. We took that approach without question, even though it had an impact on the delivery of traditional, day-to-day services. Covid has had an enormous impact overall. We do not know how long that will continue.

I thank Mr. Ray. Our support and solidarity go with his colleagues who have suffered from Covid. Of the ambulance bases around the country, which would our guests consider the worst in that it is not properly resourced and has the most challenges? Is there a particular black spot in the country that our guests would like to use this meeting to highlight?

Mr. Ted Kenny

To be quite honest, every ambulance base in the country is facing that particular problem.

I suspected that was going to be Mr. Kenny's answer.

Mr. Ted Kenny

I will give the committee a classic example. Using County Kerry as an example, we have ambulance bases in Tralee, Killarney, Dingle, Listowel, Caherciveen and Kenmare. A couple of weeks ago, all those ambulances were either tied up in the accident and emergency department of University Hospital Kerry or were out of the county. There was a road traffic accident in Slea Head, outside Dingle, and the ambulance sent to the scene was dispatched from Castletownbere, two and a half hours away. If there was an incident in Castletownbere when that ambulance was on route, an ambulance would have been dispatched from somewhere else. There is a triple effect all the time.

On that sombre note, I thank our guests for the work they do on our behalf.

I thank the Chair for facilitating me and I thank our guests for their presence. As others have, I thank them for all the work they have done, both seen and unseen, over the past year and a half, and for the essential emergency service they provide. Mr. Kenny spoke about Slea Head, an area I know intimately because my mother was from Ballyferriter. The idea that an ambulance would have to come from Castletownbere to Slea Head is pretty shocking.

I thank Mr. Kenny for his presentation. He has already answered most of the questions I was going to ask but there might be one or two that have not yet been answered. How effective does Mr. Kenny think a dispatch system is if it sends crews on a call from Donegal to Tipperary?

Mr. Ted Kenny

The problem with the dispatch system that is there is that it is all based on HIQA standards and response times. That is where the fundamental issue arises for our membership. Senator Conway asked how long it takes for an ambulance to be dispatched. He asked whether I know the average response time. I am sure management, who will be attending the following session of this meeting, will be able to give the committee those times. We have not been furnished with those times and have no access to them. Since the cyberattack, the HSE does not publish those details. The situation is quite clear. Once a call comes in, whatever is the next available resource is dispatched. As the Deputy said, that could well mean an ambulance in Donegal is dispatched to a call in Tipperary.

We have no hope of getting to that scene in any realistic time. It is only done just to keep the figures under HIQA standards on track. I am not sure about the incident the Deputy is talking about and whether the ambulance actually arrived on scene. If it did, I would imagine it would have taken anything up to five hours to get to the scene. Normally the ambulance would be dispatched and if another ambulance became available closer to the scene, the ambulance from County Donegal would be stood down and the other ambulance sent.

I have been given a scenario. Is this a regular occurrence or is it completely out of the question for a dispatch system to send a crew on call from County Donegal to County Tipperary that is diverted en route to Mullingar, then to County Mayo, and then to County Donegal? Is it completely out of the question that this could occur?

Mr. Ted Kenny

Not at all. It happens on a daily basis. As I said earlier, we have crews that have put up 500 km and in some cases 700 km in a day, being dispatched to calls and being stood down without actually arriving at the scene of any call. They have seen no patient in the course of their duties but they still put up 500 km or 700 km in that day. It is absolutely frightening what is going on.

What would Mr. Kenny say about reports that a third of ambulance delays last more than one hour and that this is a common experience in some counties?

Mr. Ted Kenny

That would be quite true, yes. The resources are not there. That is what we are saying about the capacity review. That is the fundamental argument we have. At the moment the National Ambulance Service has approximately 2,000 employees. Scotland, the nearest comparable service the NAS has looked at, has 5,000 personnel. We are behind. The investment in the service has not been there for the past six or seven years. It is shocking and to the detriment of the service that this has been allowed to happen.

Without being too explicit, can Mr. Kenny say for sure that these delays cause fatalities?

Mr. Ted Kenny

I have no doubt in my mind that delays have caused fatalities. I am conscious that we are in a national forum so I do not want to go into specifics. There have been incidents widely covered in the national media. A situation was described on Cork local radio, 96 FM, a couple of weeks ago, where a person was only 20 minutes from a hospital. I think it was his mother who went into cardiac arrest and the nearest available ambulance was two and a half hours away even though the hospital was only 20 minutes away. That individual was advised to transfer his mum to the hospital. Sadly she died in the car on the way.

The answer to the Deputy's question is "Yes", undoubtedly. It is happening across the length and breadth of the country. We saw harrowing testament in the National Ambulance Service. I am sure my colleague, Mr. McEvoy, or Mr. McCann in Dublin Fire Brigade have similar instances of that happening within Dublin city. My colleagues Mr. Ray and Mr. Lyons, who work with the NAS in Dublin city, will say the same.

I was responsible for ensuring that Dublin Fire Brigade and ambulance services were included today. I have had very close contact with them as a Deputy over the years. There are reports claiming that HSE figures show that ambulances turned up to life-threatening events more than an hour late on 300 occasions in the first six months of 2021. Is that accurate?

Mr. Ted Kenny

I do not know because we have no access to those figures. I would imagine management will be able to answer more categorically in the committee's next session. I see no reason to dispute those figures from my knowledge of what is happening in rural Ireland.

Councillor colleagues in Donegal have told me that delays in emergency departments are a significant issue in the availability of crews responding. Can Mr. Kenny elaborate on why emergency departments cause such delays?

Mr. Ted Kenny

I covered this earlier. When an ambulance arrives at an emergency department there are two pathways. First is a Covid pathway. If a Covid patient arrives, there could be a delay of anything between five and seven hours to transfer him or her from the back of an ambulance into the hospital. In normal situations where Covid is not a factor, it can take anything up to two and half or three hours to transfer a patient from an ambulance. That is all being considered at the moment in respect of working groups and that. We hope to have recommendations out this afternoon to address those issues.

The issue is twofold. We are relying on the handover from staff in the emergency department and they are under-resourced as well, there is no point saying any different. Because of the Covid situation there is a shortage of beds in acute hospitals. That is where the delays start. There have been times in acute hospitals where we could see between five and seven ambulances outside the emergency department, waiting for between two and seven hours. That has a knock-on effect when calls come through the national control centre for emergency work and there is no ambulance available. That is why we have an ambulance coming from County Donegal to County Tipperary.

If the system had all the resources Mr. Kenny wanted and was able to provide all the services and overcome all the obstacles, how long typically should it take for an ambulance once it arrives at the door of a hospital to dispatch its patient into the care of that hospital if everything was ideal?

Mr. Ted Kenny

I will ask Mr. Ray to answer that question.

Mr. Peter Ray

An accepted norm internationally would be within half an hour.

From arrival at the front door, as it were.

Mr. Peter Ray

From arrival at the front door to exiting and being ready for the next call, an accepted norm across the developed world would be 30 minutes.

This might be a question for management as they have the figures, but how often does that happen?

Mr. Peter Ray

We do not have access to those figures. We can see that our colleagues in the UK are suffering the same problems. It is a growing problem for ambulance services that are badly resourced.

That is all very useful.

I thank our guests for their presentation and for all the work they are doing. I am sure they are dealing with very challenging situations on a daily basis. I thank them for the care and service they provide.

I want to touch on two issues. One is turnaround times at hospitals. Does the ambulance service sit down and discuss the issues with management? Are the front-line medical people also involved in those discussions or is it just purely with management? I have heard of a number of cases where the ambulance service seems to have the answers and knows what the problems are but is not being listened to by the hospitals. What level of engagement is there and who is involved?

Does Mr. McEvoy want to come in first?

Mr. Geoff McEvoy

I had a few pieces to add in response to Deputy Lahart's questions about mobilisation and the queues at hospitals. From the Dublin Fire Brigade point of view, they allow for approximately an hour for an ambulance call-out from dispatch to delivery at the hospital and returning to duty. That factors in 20 to 30 minutes of a hospital wait time as per Mr. Ray's contribution. Before Covid there was a small percentage of hospital waits that exceeded 30 minutes - approximately 4% or 5%. That figure has tripled since Covid. The Deputy was asking about dispatch within an hour. If we are seeing ambulances that could be returning to service idling for an hour outside hospitals, that will clearly have an impact on the wait time for dispatch to the next call.

As Mr. Kenny said, we know the problems and the staff are under great pressure. However, because of the importance of maintaining the critical chain of care, ambulance crews must stay at hospitals until they can pass over to personnel in the accident and emergency department. Unless those structural problems facing our colleagues in accident and emergency departments in hospital environments are addressed, this problem will not be entirely solved.

On resources, there was reference in our presentation to unit mobilisation. That refers to the hypothetical maximum capacity if every ambulance in Dublin Fire Brigade was on the road 24 hours a day, 365 days a week. Dublin Fire Brigade is operating at approximately 85% of that capacity. Ideally, it should be between 45% and 55%. This shows that more ambulances are needed and more personnel need to be hired because the 85% figure does not factor in break times for crew or periods during which vehicles need to be serviced. For example, an ambulance involved in an accident may be out of commission. There is no capacity in the existing service without additional resourcing.

Deputy Burke's question might best be addressed to our colleagues in management because there is communication at managerial level between Dublin Fire Brigade and the National Ambulance Service. That question might be best directed to those colleagues. I note my colleague, Mr. McCann, wants to respond.

Mr. McCann's device is muted and we cannot hear him. Does Deputy Burke wish to come back in?

Yes. Would Mr. Kenny deal with the issue I raised about the link with hospitals? Is that link purely with management or are the front-line staff in accident and emergency departments such as the nurses and doctors involved in those discussions? I have heard from ambulance personnel that they have a solution but they are not being listened to.

Mr. Ted Kenny

At the end of the day, all stakeholders should be involved in those discussions. Various ambulance officers at ambulance bases attached to or in the area of acute hospitals with accident and emergency departments would liaise with managers in the hospitals when there are delays. In Kerry, where I am based, I have spoke to the general manager of the hospital more than once about ambulance waiting times outside the accident and emergency department to see what can be done. It is a challenging problem.

It is all fine engaging with management and ambulance personnel identifying solutions and conveying them to management, but are those solutions being conveyed down the line? Is there a three-way engagement between medical staff, management and the ambulance service? That is the question I am asking.

Mr. Ted Kenny

My understanding is there is not.

Is that not a real flaw in the system?

Mr. Ted Kenny

It is a real flaw in the system. We bring the concerns of our membership about waiting times in accident and emergency departments to management. Ambulance service management bring those concerns to hospital management, which will discuss them. There should be a co-ordinated group. The Deputy is right and we have asked for that. Meetings should be set up with all the stakeholders, namely, accident and emergency nurses, consultants, ambulance paramedics, advanced paramedics, ambulance management, hospital management and the unions to discuss all of that and draw up a template. That should be done not only on a localised hospital basis but for all hospitals nationally.

Is Mr. Kenny aware of that happening? He spoke about the situation in Kerry. Is he aware of that level of engagement in, say, Cork or Limerick?

Mr. Ted Kenny

Those engagements take place daily in all acute settings in the country on foot of our membership in the National Ambulance Service having raised concerns about the waiting times that have developed. I might get a call tomorrow morning to say that paramedics were delayed by five or six hours in University Hospital Kerry. If so, that would be addressed the following morning by ambulance management and hospital management to make sure the problem is alleviated. There is no national approach, however, which is a pity.

Does Mr. Kenny accept it would be better if there was joined-up thinking and management and the front-line medical people, namely, the nurses, doctors and care assistants in accident and emergency departments, also attended those meetings or at least part of them, rather than medical people being dealt with at third hand after the ambulance management talk to hospital management?

Mr. Ted Kenny

The Deputy makes a fair point. We have been endeavouring to get that involvement.

From the perspective of the National Ambulance Service, a hospital liaison officer should be deployed in hospitals. That would free up accident and emergency departments and deal with the issue of transferring patients from hospitals to free up beds. That approach works extremely well in Scotland. It was done on a trial basis in University Hospital Kerry and it worked well. It reduced the cost of patient transport for the hospital. The National Ambulance Service provided most of the transfers, which previously were provided by taxis and private companies.

Can I ask Mr. Kenny-----

I ask the Deputy to allow Mr. Ray to respond.

Mr. Peter Ray

If I could be helpful on that subject matter, there are three elements to be mentioned. Mr. Kenny spoke of a hospital liaison officer. In other jurisdictions that development has worked very well. The hospital liaison officer is on the bed management teams in hospitals and, therefore, is intricately involved and has an understanding both from the ambulance perspective and the hospital perspective. It is a good bridging mechanism between the ambulance service and the hospital. In addition, with control centres, other jurisdictions, including Northern Ireland, have a dedicated bed availability desk where they can see the availability across all hospitals they serve. That is another helpful element.

A third element is an expansion of the intermediate care vehicle, ICV, service. The more patients moved from hospital back to tertiary treatment - a lower level hospital or nursing home - following treatment, the better. We need an expansion of the ICV service to come under the remit of the National Ambulance Service. That service is somewhat lacking. It is a matter of attracting people into that service with the proper pay rates. Those are the solutions.

I have a further question on unnecessary ambulance call-outs. The figures from Dublin Fire Brigade show there were 8,532 calls in November 2020 whereas there were 12,657 in November 2021, an increase of more than 4,000. That is a substantial increase in one year for the same month. Is there any explanation for that dramatic increase in a 12-month period? Could some of those people have used a means of transport other than an ambulance to get to a medical facility?

Mr. Geoff McEvoy

As I do not have those figures in front of me, I cannot drill down into them in any detail. A number of factors are causing the increase in the number of calls. Demographic change is one. One of the challenges, which we referred to in our submission and my colleague, Mr. Kenny, also referenced, is with respect to the designation of urgencies in ambulance calls. We have an echo call for cardiac cases and a delta call for the life-threatening but non-cardiac cases. Delta calls account for nearly half the call-outs for Dublin Fire Brigade but there is no capacity to drill down into them in any more detail or to subdivide them further. As such, that becomes a less useful metric. When members speak to the representatives of management they will probably be able to give a much more detailed breakdown of the figures to which the Deputy referred.

From feedback from staff and colleagues, has Mr. McEvoy found that ambulance services are sometimes called out unnecessarily, with the result that much valuable time is being used in circumstances where people could have availed of other transport to reach medical facilities?

Mr. Ted Kenny

That is true. It happens daily. We see GPs and members of the public using, or trying to avail of, ambulances for incidents or illnesses that do not necessarily require one. The people concerned, or their relatives, could use their own transport to get to an accident and emergency department. Equally, it could be the case that there may be no need to go to an accident and emergency department at all and treatment might be possible at home.

We are aware of instances where ambulances have been sent out to people with eye infections and broken toenails, and absolutely crazy stuff like that. As I said earlier, there must be a media-driven campaign targeted at GPs and the public to clarify the circumstances in which an ambulance should be called. Ambulances should be called in an emergency.

I thank Mr. Kenny.

Mr. Ted Kenny

There is also a perception among the public that people who arrive in an accident and emergency department in an ambulance will be seen faster. That is not the case. Patients admitted to accident and emergency departments are seen according to the seriousness of their problems.

Fair point. I thank the witnesses.

Mr. Kenny has made an important point.

Before we move on to the management representatives in the next session, a point was made about staffing levels, a reduction of 20% in those levels and a reliance on overtime. Recently, we heard proposals from the Minister to fill vacancies. How would the witnesses respond to those proposals? Are they ambitious enough? Will they be sufficient to fill the gaps in the services?

In addition, regarding the joint emergency medical response model operating in the Dublin region, it has been suggested that paramedics be trained up in this regard. Donegal was mentioned earlier, and it has been suggested that this joint emergency medical response model should be replicated and rolled out across the country. Are staff skill sets countrywide sufficient to facilitate this model, or is the required availability unique to Dublin? Those are my two quick questions. Who would like to take them?

Mr. Geoff McEvoy

I will take the first part. The reality is that the proposals put forward thus far are not sufficient. As I said earlier, we need 450 firefighters to be recruited into the service. Each new intake of recruits will bring in 45 new firefighters. The educational process then takes about six months. Therefore, by the time those six months have passed, there will have also been six months of retirements, etc. At the rate we are going with recruitment overall, it will not be possible to catch up with the problem. We are so far behind now that recruitment must be drastically accelerated. In addition, a competition for promotion into officer grades is under way in Dublin Fire Brigade. That is fantastic. A panel will be created for the competition, and good luck to everyone on it. Equally, though, the vacancies created will need to be backfilled with extra firefighters. At the current rate of recruitment we are never even going to catch up with the problem, let alone get ahead of it. Rapidly accelerated recruitment will be required in the next one or two years to get staff levels up to where they need to be.

Regarding the joint emergency medical service provided for in Dublin and the co-operation that exists between the National Ambulance Service and Dublin Fire Brigade in that respect, one thing to add is that there are also staff who are retained firefighters who could enhance that service by answering medical calls. The main point to make about the service, however, is that it has been extremely valuable to the people of Dublin. The system's capacity to respond to medical emergencies and serious incidents is beyond comparison. I do not know if the capacity exists around the country to replicate the model, but it is one which has worked wonders and saved lives within Dublin city. It has ensured that a fleet of vehicles is available from the National Ambulance Service and Dublin Fire Brigade. Their facilities are already spread around the city. For example, there are 12 full-time fire stations and two part-time, retained, stations in the city.

The capacity to dispatch ambulances, paramedic crews and fire appliances to incidents means it is possible to intervene in the critical life-saving minutes, for example, if there is a cardiac incident. Equally, the capacity exists to deal with a serious incident or a road traffic collision in respect of creating a safe environment in which personnel can operate to bring people safely out of vehicles and transport them to accident and emergency departments, and then to reopen the area. I am not sure that the people of Dublin know or can fully appreciate the true value of all that is achieved by colleagues from different services working holistically together. I refer to the context in this regard of the training which exists within Dublin Fire Brigade. Working in conjunction with the staff of the National Ambulance Service, personnel arriving on the scene can attend to putting out a fire, rescuing people from vehicles, operating the equipment and working as paramedics. I am not sure if similar capacity is available across the country. Perhaps Mr. Kenny can speak to that aspect. I can only speak about what the model has achieved in Dublin. If it could be replicated, the outcomes for people countrywide could only be beneficial.

Mr. Ray wants to contribute.

Mr. Peter Ray

Regarding our collaboration with Dublin Fire Brigade, we face the same staffing challenges in the Dublin area. To address the Chair's question about skill sets, they exist within the National Ambulance Service and Dublin Fire Brigade in respect of advanced paramedics, etc. There is an eagerness to deliver the services that the people in the capital and around the country deserve.

The National Ambulance Service needs more staff than are graduating from the National Ambulance Training College. The Dublin Fire Brigade is in the same situation with its Fire Brigade Training Centre at the O'Brien Institute. We would also like to endeavour to increase our capital and estate footprint across the city. Every organisation realises that having more resources also gives rise to a requirement for a matching increase in related facilities. For example, the more vehicles available, the greater will be the need for locations to put them into, etc. Therefore, we share the same sentiments, and we work well together. Equally, we deliver, and endeavour to deliver, a premium service to the people of the capital city.

We rely as well of course in some areas on part-time firefighters. Does Mr. Kenny want the last word?

Mr. Ted Kenny

A capacity review of the National Ambulance Service is under way. As I said earlier, we want to increase the number of ambulance personnel to between 4,000 and 5,000 in the next three to five years. To do that, we must ensure that the job is made attractive enough to ensure that people will apply for the posts. The only way that can be done is through the roles and responsibilities and the rates of pay attached to the new job descriptions. We will only see people applying when those aspects are finalised for intermediate care operatives, paramedics, advanced paramedics, leading emergency medical technicians, clinical paramedic supervisors, and all that is accepted and agreed by the Government. It will then be necessary to address issues such as meal breaks, extended duties, etc. I reiterate that I hope we will have good, structured feedback from the working groups this evening and that implementation processes will be put in place. It will only be when all those aspects come together, under the capacity review, that we will be able to entice people with the required skill sets into the National Ambulance Service and to expand its operations.

I thank Mr. Kenny. I am conscious that it was mentioned that other unions are involved with these issues as well. We just did not have the space this morning to try to include representatives from all of them, but we will be glad to have their input into whatever future deliberations the committee has. I thank the witnesses for appearing before the committee today.

I apologise to those who had difficulty getting through this morning. Their attendance was welcome.

Sitting suspended at 11 a.m. and resumed at 11.09 a.m.

In the second session today, we will engage with service providers. I welcome the second group of witnesses to our meeting.

From the HSE National Ambulance Service, I welcome Dr. Cathal O'Donnell, medical director; Ms Emily Mahon, human resources manager; Mr. Liam Woods, national director, acute operations; and Mr. Robert Morton, interim director. From Dublin Fire Brigade, I welcome Mr. Dennis Keeley, chief fire officer; Mr. Martin O'Reilly, district officer; and Ms Una Joyce, senior executive officer.

Before we hear the opening statements, I will point out to our witnesses that there is uncertainty whether parliamentary privilege will apply to their evidence from a location outside the parliamentary precincts of Leinster House. Therefore, if they are directed by me to cease giving evidence in relation to a particular matter, they must respect that direction. I invite Mr. Woods to make his opening remarks.

Mr. Liam Woods

I thank members for the invitation to meet with the committee to discuss the National Ambulance Service, NAS. I am joined by my colleagues, Mr. Morton, Dr. O’Donnell and Ms Mahon.

NAS is the statutory pre-hospital emergency and intermediate care provider for the State. The service has more than 100 locations, in excess of 2,000 staff and a fleet of 630 vehicles. Since 2015, NAS staffing has increased by over 500. Since 2019, the NAS fleet has increased by 21%. The Sláintecare implementation plan acknowledges that there is an ever-increasing need to support healthcare in moving away from a hospital-centric model that results in high emergency department, ED, attendance and high hospital occupancy rates. The NAS strategy to 2020 focused on achieving a shift in the operating model from an emergency medical service to a mobile medical service. The NAS strategy to 2026 will continue to accelerate this shift by developing more services to treat more patients in the right setting, improving patient experience and clinical outcomes and supporting a reduction in pressures on EDs.

Additional funding is required to support this continuing transformation. NAS’s 2021 opening budget was €187.5 million. This represents an increase of €13.6 million, or 7.8%, and is the largest year-on-year budget received by NAS. In 2022, the total budget available to NAS is expected to reach €200 million. NAS will play a continuing role in the public health response to Covid-19 and will receive in excess of €10 million to recruit 160 dedicated posts in 2022 for mobile testing and outbreak teams. In 2020, NAS responded to more than 362,000 ambulance calls. Its intermediate care service transports approximately 40,000 patients per annum, co-ordinates and dispatches more than 800 aeromedical calls and completes 600 paediatric or neonatal transfers. In the Dublin metropolitan area, ambulance services are provided by both NAS and Dublin Fire Brigade, DFB.

NAS resources are dispatched to calls received by the national emergency operations centre, NEOC, which operates across two sites, Dublin and Ballyshannon, and represents a €50 million plus investment by the State. NEOC operates on a nearest available to the incident basis and not on a county boundary basis. NEOC represents international standards and best practice in clinically triaging and prioritising emergency calls. Therefore, life-threatening calls receive an immediate and appropriate response, while lower acuity calls may have to wait until a resource becomes available. Resources are dynamically deployed to areas where cover is required, or to respond to incidents as they arise, to ensure that the nearest available resources respond to emergencies.

The current deployment model is designed around international best practice and has eliminated previous practices where the nearest ambulance was not always dispatched due to former legacy boundaries. For example, an ambulance based in Killarney may be dispatched to a call in Cork, if it has just handed over a patient at Cork University Hospital and is the nearest available ambulance to the incident. In addition, NAS is expanding the hear-and-treat alternative care pathway for low acuity calls operated by doctors and nurses and, in due course, specialist paramedics, in NEOC’s clinical hub for patients not requiring the dispatch of an emergency ambulance.

Response time standards for life-threatening calls were first published by HIQA in 2011 and remain as recommended standards. The HSE adopted these as key performance indicators, KPIs, based on the following targets: 80% of echo calls at a national aggregate level to be responded to within 19 minutes and 70% of delta calls at a national aggregate level to be responded to within 19 minutes. The HSE service plan includes these KPIs on the basis that the expected volume of 112 and 999 calls, and ambulance turnaround times at EDs, will remain within expected tolerances as published in the plan. These calls account for approximately 45% of all emergency calls. All other emergency calls are not encompassed by any response time standard, target or KPI, which reflects their low acuity status.

Since the pandemic began, NAS has experienced longer offload delays at EDs. Infection prevention and control measures have increased the length of time spent dealing with patients resulting in longer call durations. Recruitment of paramedics and intermediate care operatives is an ongoing challenge both to fill existing vacancies and resource new developments. A NAS 2015 baseline capacity review found a significant number of additional staff would be required over the coming years to support NAS. Since 2015, NAS has increased its staff numbers each year. However, each year the level of demand for services is also growing. This year, recruitment to NAS is being outpaced by demand for our services, which has grown by almost 30%. There is no ready supply of paramedics in Ireland and NAS, for the most part, must educate its own workforce in its own college. The paramedic programme is degree level and represents four academic years completed over three calendar years. There are currently more than 200 student paramedics at different stages of the programme. The surge in demand for the service has come at a time when staff are working hard to support Covid-related activities. The level of demand now exceeds levels experienced in 2019. The pressure on everyone working in NAS has been immense. However, both our staff and our trade union partners have stepped up at the time of our greatest challenge. Their contribution has been enormous.

In the period 2017 to 2027, NAS predicts demand through 999 to increase by 107%. Given the rapidly widening gap between capacity and demand, NAS commissioned a new independent capacity demand analysis in July 2021, which is now well under way, to inform future workforce planning. The outcome is expected to represent a significant and sustained increase in NAS staffing each year over the next five years. This month, 80 paramedics will graduate from NAS college. In 2022, and in advance of the outcome of the independent capacity demand analysis, NAS is already planning to recruit 200 additional student paramedics and 200 additional emergency medical technicians.

Mr. Dennis Keeley

The DFB has provided an ambulance service to the people of Dublin since 1892. Firefighters are also trained paramedics and rotate continuously between firefighting and emergency medical service duties. I thank the Chairman and the committee for their invitation. I welcome the opportunity to attend and discuss the issues facing the ambulance services. I am the chief fire officer for Dublin Fire Brigade and ambulance service. I am accompanied by my colleagues, district officer Martin O’Reilly and senior executive officer Una Joyce.

Dublin Fire Brigade provides the function of the fire authority for the four Dublin local authorities, namely, Dublin City Council, Dún Laoghaire-Rathdown County Council, South Dublin County Council and Fingal County Council. The brigade operates a 24-7 fire, rescue and emergency ambulance service from 12 full-time and two retained fire stations. We also operate the east regional communications centre, an administrative headquarters, a fire prevention and enforcement section and a brigade training centre and logistics.

Dublin Fire Brigade provides emergency cover to Dublin city and county, a region with a population of more than 1.43 million or 28.5% of the total population, covering an area of 922 sq. km. In 2020, Dublin Fire Brigade processed in excess of 173,000 emergency fire and ambulance 999 or 112 calls. There were 31,723 mobilisations to fire and rescue calls and 96,000 mobilisations to ambulance calls. Dublin Fire Brigade is particularly proactive with respect to safety and has achieved international accreditation, and-or memoranda of understanding, for all aspects of its service delivery, including ISO 9001, ISO 45001, and an International Association of Emergency Dispatchers centre of excellence.

The service is guided by the range of policies and procedures issued by the national directorate for fire and emergency management, NDFEM, which sets the national policy for fire authorities, the Pre-Hospital Emergency Care Council, PHECC, and HIQA. The objective of Dublin Fire Brigade is to respond and deal with fire and medical emergencies as statutorily obliged. Our vision is to make Dublin a safe place to live, work and enjoy by being a modern, community focused and influential fire and emergency ambulance and rescue service. As part of my submission, I have also included a brief report that outlines the challenges faced by Dublin Fire Brigade into the future.

I thank our guests for their presentations and the work they do on our behalf. The reason we invited the ambulance services here is many of us have been receiving information from paramedics and ambulance workers throughout the country complaining about stress, fatigue, being worn out and constantly required to do overtime or essentially, pardon the pun, constantly firefighting.

We get many stories of situations throughout the country where no ambulances are available; the time between somebody dialling 999 and an ambulance arriving being anything up to two hours and situations where ambulances are parked up because there are no paramedics available to drive them. The weekend before last, in Athlone, there were no paramedics available to drive ambulances and that is just one of many examples we get. Obviously, that concerns us. We all understand there is a challenge in recruiting paramedics and that it is a challenge experienced not just by this country, but every country.

How short staffed are the ambulance services? How long will it take to get the critical numbers up to be able to provide a service where the system of the nearest available ambulance actually works? With the complement of paramedics and so on being so low, surely that system does not work. It can only work when the system is properly resourced. I ask for the witnesses' reflections on their reactions to what paramedics and ambulance workers are telling us the length and breadth of the country.

I will finish my comments by pointing out one thing that SIPTU said to us this morning. I asked SIPTU whether it could point to one particular black spot in the country that we could use as an opportunity to highlight. The answer was that every area, at this stage, is a black spot.

Mr. Liam Woods

The volume of demand for services is clearly a key factor and it is correct to say there is a significant pressure on services. We are seeing very significant growth in attendance at emergency departments and also in the requirement for paramedical services. I ask Mr. Morton to address this specific issue.

Mr. Robert Morton

I will reflect on 23 September. Our colleagues, Mr. Paul Reid, CEO and Ms Anne O'Connor, chief operations officer, HSE, were asked a similar question before the Committee of Public Accounts. At that time, Ms O'Connor indicated we needed approximately 90 extra ambulances. Some 90 ambulances throughout the country would equate to approximately 1,080 additional staff. That is what we believe is the current requirement, but the evidence base for that will very much be the capacity review to which Mr. Kenny and his colleagues referred in the session this morning.

In terms of how long it will take to get there, at present, we currently have the capacity to train approximately 200 to 220 paramedics every year. That is generally our current educational capacity. In that case, it would take us at least five years to recruit, train and qualify 1,000 staff, bearing in mind the people who start this year will not qualify for three years.

Is it Mr. Morton's view that because the system is so underfunded and under-resourced and the call out times then suffer, that people are losing their lives?

Mr. Robert Morton

If we look at how the performance of the service is at present, in Mr. Woods's opening statement, he touched on delta and echo calls as those that have response time standards. The standard response time is approximately 19 minutes. In 2021, the average response time for delta and echo calls throughout the country, but specifically delta calls, which make up the vast majority of calls, is 25 minutes in the south of the country, 22 minutes in the west, and 21 minutes in the east. Those are average times. In some cases, we respond much faster than the actual standard time and there are exceptional cases where we are very slow to get to patients. Sometimes, it takes us up to two hours to get to a life threatening, but not cardiac, call.

The average time is 21 to 25 minutes. If one was to extrapolate from that there is a degree of risk, the answer is "Yes" but broadly speaking, we would say our services are very safe. We deliver a high quality of care and measure the effectiveness and safety of the service through our quality and safety committee. I will ask my colleague, Professor O'Donnell, to touch on how we-----

Just before Mr. Morton does so, I have one final question for him. In a situation where a 999 call is received and one knows one cannot get an ambulance there for two hours, is a crisis management structure kicked in to try to assist the caller to get other assistance or help? What does one do if one knows an ambulance will not be there for two hours?

Mr. Robert Morton

That is a very good question. First, we have a safety netting process where we call back the patient to make sure his or her condition is not deteriorating. If there is an indication the patient's condition is changing, we will then upgrade the call and reprioritise a resource that might be on another call in the area at that time. We will also try to find a first response available. There may be a manager in the area. However, in extreme circumstances, we will look to other emergency services, as well. We will call the Garda. If it is a cardiac arrest, the Garda may have an automated external defibrillator, AED, in the boot of the car. We try to do various things to safeguard a patient in those circumstances.

Have lives been lost while that process is kicking in? Are there any examples of where, unfortunately, we have lost people, while that process is in operation?

Mr. Robert Morton

We have no reason to believe that is the case, because the sickest patients are always prioritised with the quickest response. However, that is why we monitor it very closely and why we have a quality and safety committee in place. It is one of the reasons we have a full-time clinical director who basically oversees the clinical governance of the organisation. That is why it is so important to have that position in an ambulance service. Effectively, the clinical director is the patient advocate in the service.

Does Mr. Morton's colleague want to come in?

Dr. Cathal O'Donnell

I will follow on from what Mr. Morton has been saying. Clearly, the time an ambulance takes to get to a patient is important, but we also need to balance that with what happens when the ambulance gets there and where we bring the patient after that. We have a very highly trained workforce. All of our paramedics are highly trained. It is exactly the same for Dublin Fire Brigade because we operate to the same standards. They are all very highly trained healthcare professionals and bring significant clinical assessment skills and treatments to patients.

I should preface that by saying that the treatment, in some cases, starts before the ambulance arrives because our call takers give what are called pre-arrival instructions to the caller in order that we can coach through the person on the other end of the phone, depending on the situation, to help the patient. The quality of the care we deliver when the crew gets there is as, if not more, important than how long it takes us to get there.

The other point is we have a very sophisticated system of hospital bypass procedures in order that we will bring the patient, not necessarily to the nearest hospital, but to the best hospital for their needs. For example, in the west of Ireland, if one is having a heart attack in Mayo, Castlebar is the nearest hospital, but one might be better served by going to Galway to the specialist cardiac unit there. We have procedures and protocols to do that and also access to a helicopter network that can get those patients to those centres in as timely a manner as possible. Without going on about it too much, the point I am trying to make is that speed of response is clearly important, but what happens when we get there is equally important and needs to be considered.

I have a number of questions to ask. I possibly will not get to all of them because our time is limited. I will direct each question at who best and appropriate to take it. If we can avoid multiple answers to the same question, that would help, because time is limited.

My first question is for Mr. Morton. Recently, the Minister for Health, speaking in the Dáil in response to a Private Member's motion regarding the National Ambulance Service, stated, "I am aware that ... the wait times for lower acuity, non-life-threatening calls have presented a particular challenge recently as the NAS has been experiencing unusually high demand [which we all accept]." I assume that relates to the Alpha, Bravo and Charlie responses. Our guests might forward to the committee a copy of the average response times over recent months, on a month-by-month basis, for this year. I do not have the time to go through it all because I want to get to the Delta and Echo response times, which are important.

Mr. Morton outlined the average time in the State in a previous response, which I acknowledge. I have submitted parliamentary questions on this issue, copies of which I have in front of me, but unfortunately the responses run only to May. Mr. Woods earlier stated that 80% of Echo calls and 70% of Delta calls should be responded to within 19 minutes. From January to November of this year, does Mr. Morton have the figures to hand, in respect of both Delta and Echo, for the percentage of calls that have come in on target?

Mr. Robert Morton

The latest figures run to the end of October, when the figure for Echo calls was 71% within 19 minutes, while the equivalent figure for Delta calls was 40%. In both categories of calls, compared with the previous year, there was a 38% increase in the volume of Echo calls within our overall call volume and a 30% increase in the volume of Delta calls.

To put that in context, the key performance indicator target and the HIQA standard that has been set for Echo calls is 80% and the figure that was reached was 71%, while for Delta, the target is 70% and the figure reached was 40%. Mr. Morton is saying that is down to the levels of increased demand on the system as well as not having the capacity he talked about earlier. Is that fair?

Mr. Robert Morton

Yes, it is a combination of factors. The most significant change we see relates to the overall job cycle time. The issue with the job cycle time is that it relates to mobilisation and journey times, which is a reflection of capacity and of whether there is resource displacement. If the ambulance is the starting point, that is the ideal, but it could be somewhere else. Arrival handover delays, obviously, are a feature of that. Another issue is on-scene time, which has become more pronounced because our crews now have to engage in PPE and much more infection prevention and control. It is a combination of factors but the main one relates to capacity.

I understand that. Mr. Morton might forward to the committee a month-by-month breakdown of the average response times for Alpha, Bravo, Charlie, Delta and Echo. That would be helpful for our future deliberations on this issue.

Turning to the capacity issue, a number of capacity reviews have been commissioned. Mr. Woods referred to a 2015 NAS baseline capacity review. I read last night about the National Ambulance Service fleet and equipment plan review. Mr. Woods spoke also about a new independent analysis of capacity versus demand, which commenced in July 2021. Is that analysis ongoing or has it been completed?

Dr. Cathal O'Donnell

It is ongoing, moving towards completion.

Why are there so many reviews? One issue I have picked up from speaking to paramedics is that there are not enough staff. Mr. Morton stated there is a 30% deficiency in staff and capacity throughout the system. As far back as 2015, there was the baseline capacity review, then there was the 2020 review of fleet and equipment and now there is the latest review. Mr. Woods indicated that more funding has been provided in recent years and more staff have come in. Will our guests directly address the 30% deficiency in capacity that Mr. Morton mentioned? In real terms, how many additional staff would be required to bring that up to a sufficient level?

Dr. Cathal O'Donnell

At the moment, there are just over 2,000 staff in the National Ambulance Service, so I believe that would equate to approximately an additional 600 staff, although Mr. Morton might correct me if I am wrong.

Let us assume that is the figure. How many staff are trained yearly?

Dr. Cathal O'Donnell

Between 200 and 220.

Some of that figure would include replacements, given that people retire. How long would it take us at that rate to get to the figure of 600, notwithstanding the ongoing review, which might call for even greater capacity?

Dr. Cathal O'Donnell

The Deputy is asking about the net additionality, that is, the figure after retirements. I do not want to take a guess if Mr. Morton might has a more accurate figure, but I imagine at least half will be replacements.

Mr. Robert Morton

When we talk about the 90 additional ambulances, that includes the net deficit at the moment. In 2022, for example, when we hope to start 200 additional student paramedics, that will include a backfill of vacancies. We will also hold promotional competitions, which will create some additional vacancies that will need to be backfilled. The figure also includes new developments, of which a range are planned in 2022, including both additional ambulances and additional community interventions, such as frailty teams or the expansion of our clinical hub. It is about standing still and getting to a good place with the 90 additional ambulances. The independent capacity review, which Mr. Woods referred to and which is due in the first quarter of next year, is likely to give us an indication of what sort of workforce we will require up to 2027. We expect that-----

I understand that and I have limited time. My point is it will take us a long time to get to where we need to get to, simply because of how many staff the HSE trains every year versus how many are needed, and that is my concern, not least because of the burnout and difficulties and challenges the service's members face. I have heard from many of them over recent months, in different parts of the country when I have visited various constituencies, that it will take an awfully long time to deliver on that. I will leave it at that because the prioritisation of resources is a political issue.

I raised this final point with the representatives from SIPTU. I engage with many paramedics and the vast majority love their job. They are working in very difficult circumstances at the moment and, obviously, Covid has made everything more difficult for everybody. There is considerable additional demand on the system and people are out sick. It is the same everywhere in healthcare; it is very difficult. I have also met paramedics who suffer from post-traumatic stress disorder and many of them have told me - I am relaying this to Mr. Morton and Mr. Woods - that their experience has not been good and that they have not been properly supported. What are the processes? We know how difficult and challenging being an ambulance paramedic is. They have to respond to very difficult calls and, at times, see children in great distress. They have told me they have had really bad experiences and some of them have left the job. Some of them have expressed hesitancy about going back on the front line after bad experiences without being properly supported. Will our guests explain the process in order that I can better understand it?

Mr. Robert Morton

There are two sides to it, namely, the formal and the informal levels of support. As for informal supports, the most important support available to any emergency medical technician, EMT, or dispatcher or call-taker in the National Emergency Operations Centre, NEOC, environment is his or her supervisor. The attitude, approach and level of support, psychological or otherwise, offered by that person colours the worker's experience of work every day. After that, there is the line manager. We consider those two supports together to be the most important informal supports.

Formally, if someone needs support beyond that, whether psychological or physical, the HSE provides a range of supports, including occupational health employee assistance. We have a joint partnership group with our trade union partners, known as the critical incident stress management committee, which focuses on creating an holistic network of peer support workers.

These are individual paramedics, EMTs, intermediate care operatives, call takers or dispatchers who have volunteered to act as a support to their colleagues. They receive specific training in critical incident stress management. We have been to the forefront in this area for probably the best part of 20 years and it has worked quite well. However, it is fair to say that the holistic range of supports are not necessarily holistically wrapped around the individual staff member. Our HR department has worked over the past two years to create a programme called WellNAS, which is widely promoted. One of the learnings from the programme is that we recognised that we need to better prepare our clinical staff and, broadly speaking, our operational staff for the job. For the past two years in particular, we have introduced personal resilience training for all new graduates coming into the NAS.

We hope these programmes are beginning to make a difference. We need more supports and we have plans to looking more at occupational psychology and more clinical psychology support but we recognise that the environment within which our staff work is changing dramatically and we need to increase the level and range of supports available. Importantly, we need to make sure that our managers and supervisors are focusing on supporting their colleagues. That is the most important intervention we could make.

I welcome all our witnesses. Mr. Woods mentioned a shift in the operating model during the last plan bringing us up to this year. I think it was for the period 2016 to this year. In terms of developing mobile service, what is the assessment regarding the progress made on that and its implications? How has this shift gone?

Mr. Liam Woods

There have been some very good initiatives undertaken by the NAS that are having a very positive effect. Overall, they are having the effect of providing service to people at or closer to home without in some circumstances having to come to the hospital environment at all. A project like Pathfinder is an example. It might be better for me to ask Mr. Morton to detail those.

Mr. Robert Morton

We are working on about five different initiatives. In total, the number of patients who have, thankfully, benefited from all of these schemes is approximately 10,000 to date this year. What this basically means is that the majority of those patients are captured at what we are calling the clinical hub. Effectively, it is where we review and triage a call and determine that there may be a better alternative for that patient. They will speak to a nurse or doctor. As a result, we have nurses and doctors working in our national emergency operations centre. What they are able to do is either discuss the patient's care, come up with alternative solutions or make an alternative referral. That is working very well. We have other initiatives, one of which is the community paramedicine project, which, again, is proving to be very effective. In the region of 50% of the patients that are being seen are staying at home or being referred to their GP. Those community paramedics have specialist training and undertake a master's degree programme. It is a joint programme. I might ask Dr. O'Donnell to touch on it because he was one of the leaders in putting the programme together. This model is operating in Donegal, Cavan, Monaghan, Tallaght in Dublin, Limerick and Cork. To put that model into every community health network in the country as it rolls out is part of the enhanced community care programme.

We also have the Pathfinder model, which is in operation in north county Dublin. As part of the HSE's winter preparedness plan, we are in dialogue about the funding to roll that out to nine further centres - six model 4 sites and three model 3 sites - in Kilkenny, Letterkeny and Tralee. Overall, we are going in the right direction. The main thing has been to prove the models worthy and safe. Now that we are satisfied that the evidence is there, we are moving an issue of scaleability. I might ask Dr. O'Donnell to touch on the clinical aspect.

Dr. Cathal O'Donnell

I do not have a huge amount to add. I think Mr. Morton has covered it very well. We target all of these at low-acuity calls. In particular, we are interested in the frail elderly because much the time patients would be better served by not going to a busy emergency department and they do not tolerate some of the delays we see in emergency departments well. In particular, the community paramedicine programme, the Pathfinder programme and what is called the alternative pathway programme in Cork are now transitioning from projects where we were testing the safety and effectiveness of them and we are now mainstreaming them. Pathfinder is a good example of that. It is a collaboration with Beaumont Hospital whereby we put an advanced paramedic and either a physiotherapist or an occupational therapist in a vehicle and they respond to low-acuity calls from the frail elderly. This has been so successful that we are looking at expanding it to eight further locations throughout the country.

One thing Mr. Morton did not mention that will also have an impact is the fact that the Pre-Hospital Emergency Care Council has finalised and released treat and refer clinical practice guidelines. The important thing about those is that they will apply to every single paramedic in the NAS and Dublin Fire Brigade and will allow paramedics to safely assess and not transport someone as per protocol.

What percentage of paramedics would be higher-qualified community paramedics?

Dr. Cathal O'Donnell

From memory, I think there are 12. It is a relatively small number. It started out as a collaboration with Northern Ireland Ambulance Service and the Scottish Ambulance Service and received EU funding.

Are there proposals to increase that number?

Dr. Cathal O'Donnell

Very much so. We are working very closely with the Pre-Hospital Emergency Care Council to finalise a clinical standard relating to it. Once the latter is complete, we will be very much pushing on with that.

Have training places been created?

Dr. Cathal O'Donnell

Our academic partner for the programme is UCC. It started off with Glasgow Caledonian University and was brought on-island at UCC.

How many additional training places have been created?

Dr. Cathal O'Donnell

Nine have been trained in Ireland on top of the three who were trained in the UK.

How many additional training places are there?

Dr. Cathal O'Donnell

The education standard has to be agreed and completed. That is not within our remit. It is within the remit of the Pre-Hospital Emergency Care Council. Once that is done, we will pushing forward with expanding the numbers.

So Dr. O'Donnell is talking about additional training places from next September or October.

Dr. Cathal O'Donnell

Yes, that is the plan.

How long is that additional training course?

Dr. Cathal O'Donnell

It is a master's programme. I think it is four semesters so it is just over a year.

So it will be some time before those people come on stream. Regarding resources and what Ms Anne O'Connor said about the need for 90 ambulances and 180 staff, to what period does that calculation relate? Is it to bring the service up to standard currently or to cater for the projected demand of 107%?

Mr. Robert Morton

There are 1,080 staff, not 180, so that figure of 1,080 staff is viewed as what is required to fill existing vacancies and achieve the current response time targets.

Over what period will that level of staff be required?

Mr. Robert Morton

They would be required straight away in an ideal world, but the reality is that it will take five years to get them in and train them.

There is a shortfall of more than 1,000 staff.

Mr. Robert Morton

That is our current estimation. I would stress that it is an estimation, which is why we commissioned the independent review to get some evidence.

In terms of projecting forward and the kind of increase in demand for service that has been set out up to 2027, which is only five years from now, what are the additional numbers that would be required over that five-year period? Has that been estimated?

Mr. Robert Morton

We can estimate it but it would only be an estimate. When we look at projections for future demand, we generally take a ten-year look so we have looked back at the trajectory from 2017 and are trying to project that up to 2027. Over that period, we estimate that there will be a growth rate of 107%. If we extrapolate from that, it would suggest we need 2,000 extra staff.

What are the plans for providing those 2,000 extra staff?

What is the timescale involved?

Mr. Robert Morton

Within our current financial envelope we aim to train 400 staff in 2022. That is 200 paramedics and 200 emergency medical technicians, EMTs. We need EMTs for our intermediate care service and on emergency ambulances. In 2022 we also need to begin to increase our educational capacity. One of our rate limiting factors at present is our ability to educate people. This includes internships. It means interns have to have one year's experience on an ambulance. There are only so many places in the country where we can put interns. As the capacity of the National Ambulance Service grows, its educational capacity grows with it. It will be an incremental process. This will not be quick. It will take at least five years to get well under the bonnet of this issue.

Is all training done by the NAS college or do other colleges provide the training?

Mr. Robert Morton

At present the majority of people, not all people, are trained in the NAS college. We do recruit some direct entry people when we can get them. We have a rolling advertisement every year. The University of Limerick is the only university with a direct entry paramedic programme. We are in talks with it about advertising for undergraduate interns next year. We would then be able to take in its graduates and provide an undergraduate internship next year as part of our workforce planning. We also propose to speak to SOLAS about an apprenticeship model. This conversation has already begun. We are also looking at a hybrid model with universities. The way we train will have to change. We have two streams and we need to increase this to four streams to try to accelerate our ability to acquire staff.

When does Mr. Morton expect to have plans finalised for an adequate number of training places?

The Deputy has five minutes and she is way over time. This is the final question.

Mr. Robert Morton

We expect to have a detailed workforce plan by the beginning of the second quarter of 2022, once the capacity review is finished. We expect it to finish in the first quarter. It will become the basis for which we will develop a workforce plan. This workforce plan will begin to feed into the Estimates process for 2023 from the third quarter onwards.

I thank the witnesses for their presentations and the work they are doing in this area. I want to touch on an issue I raised at the previous session on co-ordination between the National Ambulance Service and hospitals. The reply I received was that while the front-line ambulance personnel and their representatives communicate with hospital management it does not appear to be a three-way process as they are not able to communicate with front-line medical people in accident and emergency departments. Surely where ambulances find they are being delayed when they come to hospitals, any discussion should include all of the stakeholders, not only the hospital management but also the ambulance crew, people working in accident and emergency departments and people in the hospital itself.

Mr. Robert Morton

A range of conversations take place at various levels every day. Our front-line staff engage with doctors and nurses, clinical nurse managers, assistant directors of nursing at emergency departments on the hour every day. Our call takers and dispatchers deal with hospitals every day. Our NEOC managers and supervisors deal with hospitals every day. We have an escalation process in place for-----

That is not the question I am asking. My point is what happens after a problem with delays is identified where ambulances are held up in hospitals seems to be a two-way process between the ambulance and the hospital management. The front-line medical people do not appear to be involved in the discussion to resolve the problem.

Mr. Robert Morton

That is not the case. In fact-----

That is the evidence that was given to us this morning. The person who gave us this evidence is a front-line worker in the ambulance service.

Mr. Robert Morton

This afternoon, for example, Dr. O'Donnell will meet the medical staff in one hospital where we are having challenges with arrival handover delays. It does happen. The process I am referring to is a formal escalation process agreed between the hospitals and the National Ambulance Service. We follow a joint escalation process that involves our front-line staff. It involves our NEOC staff and managers. As it escalates through the various levels, various people become involved up to and including myself and Dr. O'Donnell as the clinical director. Perhaps Dr. O'Donnell might want to touch on this also. He is intimately involved in the subject matter today.

Dr. Cathal O'Donnell

I thank Deputy Colm Burke for raising this important issue. It is probably our single biggest patient safety issue. It is a huge problem. I have been in this job for 11 years and it is getting worse. I have to say that I fear for the winter ahead. I was looking at some figures before the meeting started. Last month alone, 17,000 ambulance calls had delays at emergency departments. The agreed handover time is 30 minutes. Of this, 20 minutes is for clinical handover and there are ten minutes to allow the crew to maintain the vehicle or restock. In October we failed to meet this key performance indicator 17,000 times. Every day, we lose between 5% and 10% of our capacity. Today we have 180 ambulances on duty. Roughly speaking, between nine and 18 of them are not available because they are held up at an emergency department. When we get a concentration in a particular hospital, which we do see because it is uneven, it can have a huge impact on our availability to respond in a timely manner to a call in the area with the hospital offload delay issue. As Mr. Morton said, we work closely with our hospital colleagues nationally and locally. At my level, I link in with clinical directors. There are no easy answers to this. It is a hospital-----

I apologise for interrupting but the evidence from the ambulance people this morning was that when a problem is identified, they deal with management only and there is not a three-way process. Perhaps this may be in only one part of the country; I am not sure. Is there a monthly meeting between people on the front line on the medical side, people on the front line on the ambulance side and management? It certainly does not appear to be the case.

Dr. Cathal O'Donnell

I heard that evidence. Let us take it down to brass tacks. A delay at a particular hospital where there are three, four, five or six ambulances held up is not an unusual occurrence. We have ambulance supervisors who are part of front-line crews and are part of our management structure. They engage there and then with nurse managers and doctors in the emergency department, as well as escalating the issue. Front-line staff in our organisation absolutely actively work to deal with such problems on the ground every day, as well as having the processes Mr. Morton and I are engaged in at regional and national level.

Does Dr. O'Donnell think more could be done in this area? From the evidence this morning, the indication that was given was that more could be done in this area.

Dr. Cathal O'Donnell

The fundamental issue is capacity. It is a hospital capacity issue that is bleeding into the emergency department and then out into the community. This is the long-term solution. I know it is an easy thing to say and it is a complex problem but this is the fundamental issue.

I want to raise an issue that I also raised earlier. It is with regard to demand for the ambulance service and a report from Dublin Fire Brigade. The number of call outs in November 2020 was 8,532 and in November 2021, the number was 12,657 call outs. This is an increase of more than 4,000. Is there any reason for such a change in the same month of the year?

There is such a change for the same month of the year. That is an increase of more than 50% on the previous year in one month. Is there a particular reason for that?

My other question follows on from that and relates to situations where ambulances are called out but people could have arranged their own transport to the hospital, without the necessity of an ambulance.

Mr. Liam Woods: I will respond to the first question. November last year would have been a time of societal lockdown. The data have been unusual for almost two years now because of the impact of Covid. The pandemic has had the tendency to both increase and decrease numbers. As Mr. Morton said earlier, we are comparing against 2019 numbers to get a sense of what is happening in the medium-term trend and the National Ambulance Service is well ahead of that. The trend between November last year and November this year is, in a sense, less meaningful because of the impact of Covid and the fact that society was in lockdown at that stage.

I will ask Mr. Morton to deal with the other issue raised by Deputy Burke.

Mr. Robert Morton

In terms of our experience in 2021, as the data indicate, in the week beginning 8 February we responded to around 3,800 calls. That figure seems low but on 6 September, which was probably our most difficult day so far this year, we responded to almost 5,000 calls. What we have seen this year in the data is about a 30% increase but, as Mr. Woods said, it is best to compare 2021 with 2019 because 2020 is very much a confounding year in terms of data. Against 2019, we are probably up about 6% to 6.8%. When we look back historically over ambulance demand, we generally tend to see an increase in demand of roughly between 4% to 6% per annum. We are seeing the expected rate of increase but we are also ahead of that expected rate of increase. Our sense of what is driving that centres on three issues. First, we are seeing a shift in acuity. When we look at the delta and echo calls that we responded to, there were more of them. Patients are sicker when we reach them and we are spending longer periods of time treating them. We also know that when they get to hospital, they are spending longer periods of time in the emergency department as well. That is not just because there is no bed availability but also because of the care they require in the emergency department. Acuity is definitely one issue.

The second issue is that we are seeing a step change in health seeking behaviour. One of the unfortunate successes of the National Ambulance Service during the pandemic is that it has been high-profiled so well. As earlier witnesses said, we have stepped up to whatever challenge has come along and have basically profiled ourselves in the public consciousness. We are up there now, front and centre, as a gateway to services. The third issue that we must reflect on is the fact that we are asking our GPs around the country to do an awful lot but they simply cannot do everything they are being asked to do. GPs are involved in vaccination programmes, a range of chronic disease programmes and so on. The number of GPs available is not necessarily growing and what we are seeing in our data is a shift in demand away from calls that would have traditionally come to us through GPs to calls that are now coming directly through the 999 system. That is what we are seeing in terms of what is driving the demand.

I have one last question related to the availability of GPs at night. This is a problem in some areas with the number of GPs available at night, whether through SouthDoc or other out-of-hours services in other parts of the country. Could we be doing more to make sure that GPs are available at night? Should we be employing GPs specifically to do night work because the current system certainly has its challenges at the moment?

Mr. Robert Morton

GP workforce planning is outside of our scope to some extent but based on our own experience, we would say that the availability of GP out-of-hours services is constrained because GP services in general are experiencing a very high level of demand. Bearing in mind that the majority of health professions are currently challenged at the moment in terms of overall recruitment, the solution probably lies in a hybrid model. Dr. O'Donnell might be able to say more about this but we are conducting some trials around telemedicine at the moment and are working very closely with colleagues in primary care. Our community paramedics work in GP practices one day per week as part of the practice team. In many ways the future model is not so much a separate ambulance service or separate primary care service but one under which these services come together, where we synergise and acquire the power of all of these people working together.

I have to move on. While we wait for Deputy Durkan, I wish to follow up on a point made in the previous session. A suggestion was made about the introduction of hospital liaison officers to address difficulties with accident and emergency departments in particular. We heard evidence this morning that people were waiting five or six hours at hospital accident and emergency departments. Do the witnesses have a view on that? Apparently it is working very successfully in Scotland. Do the witnesses believe it might work in Ireland?

Mr. Robert Morton

There are two aspects to that. While a dedicated liaison officer role, which is what the witnesses were referring to this morning, has proved relatively successful in the UK, it comes down to the personality of the individual doing the job. The role requires somebody who has very strong relationship building skills. The officer has to be able to build a relationship with colleagues in the acute hospital to effect the sort of changes that are required. Fundamentally, however, that role does not take away from the capacity challenges to which Dr. O'Donnell referred. Were we to introduce that role in Ireland, we would have to recruit 174 additional managers at a cost of €16.5 million. It would not be a simple solution. We are currently looking at a hybrid model. The witnesses this morning talked about 24-hour management. We are currently proposing to put in place a 24-hour management system across the NAS this year, involving shift managers in teams of six across the country. One of their duties, but not their only duty, would be to engage with the hospitals. We feel that will make some degree of difference but there are other measures that we can take and we are working with our trade union partners to develop some solutions.

I welcome the witnesses. I wish to return to a number of issues that were raised earlier. What is the simplest, quickest and most effective way to address the problem of waiting at ambulance bays at the hospitals for longer than expected periods of time?

Mr. Robert Morton

There are mitigation measures that we can implement. One such measure, which is frequently used outside of Ireland, is a process called cohorting. Effectively, if there are four ambulances parked outside an emergency department, two crews are asked to look after four patients and the other two crews are released. It does not fix the problem but it does mitigate the risk to the patient who is most affected, namely, the patient awaiting a response in the community. That is the patient we are aiming to get to all of the time. The patient in the back of the ambulance is experiencing some degree of risk, as is the patient who is waiting in the corridor in the emergency department, but the patient most at risk is the one who is waiting in the community for a response. That is just one of the measures we are considering.

We are also looking at things like rapid handover protocols and a process known as fit-to-sit. Under the latter process, we ask whether all of the patients that we bring to the emergency department really need to be on a trolley. That is something that we have to ask ourselves honestly and it may be more appropriate for some patients to sit in the emergency department rather than waiting for a trolley to be handed over. There are no immediate fixes, as Dr. O'Donnell said earlier, but there are some mitigation measures that we can take that we are actively working on at the moment.

The first proposal will release crews but it will not release the ambulances. Crews are important.

There is an acute shortage and difficulty in creating the necessary cover. What about the number of ambulances tied up in waiting bays? Is that at tolerable levels or does it create further problems for attendance at emergencies?

Mr. Robert Morton

Cohorting would also release the vehicles. We would have to make sure that we have spare trolleys available. That sounds easy, but it actually costs €12,500 to buy an ambulance trolley. They are not cheap. At the same time, we have to have spares. Some jurisdictions have put dedicated teams on the road with a van and extra equipment. In the event that the build-up of this problem can be predicted, with five, six or seven crews held up for hours, a dedicated team can be mobilised to go with extra trolleys and equipment, to provide the infrastructure to release the vehicles and crews to respond to calls. It is not easy but there are things that we can do. Those are the measures that we are exploring at the moment. It also requires a change in work practices.

How long will it take to go through the various procedures that have to be gone through and to do various consultations that have to take place? Can it be done before the end of the year? What is the situation?

Mr. Robert Morton

We are well advanced in our engagement with our trade union partners. We have been exploring, exchanged some documents and developed some protocols. Work is ongoing. We expect to use these procedures this winter.

Given the total dependence on emergency services when an emergency occurs, in the event of a major catastrophe requiring the call-out of all services, is Mr. Morton satisfied that the ambulance service can provide sufficient services to meet the normal demand at the same time as meeting the extra demand?

Mr. Robert Morton

There are probably two parts to that question. When we experience a surge in demand, we have the ability to meet the needs of patients who are acutely unwell. The consequence is that patients who are not particularly unwell, who are often referred to as lower acuity patients, find themselves waiting for much longer for an ambulance to turn up. The second area to think about relates to a major emergency, whether it is declared as a standby or an actual event is occurring. At that stage, the emergency services approach a state of being overwhelmed. The State's major emergency plans provide for a range of extraneous measures that we would not normally use. In our case, for example, we would call on voluntary organisations, the Defence Forces and private ambulance companies. We would set up casualty clearing stations and field hospitals, for example. In that sort of situation, there are active plans in place. Before Covid, those plans were regularly exercised. Covid has given us a different type of experience and we are far more practised now in measures that would be of benefit to those situations than we were previously. The plans are in place but I would be stretching if I said we would not be stretched. It would be a challenging situation for any emergency surface.

I thank Mr. Morton. That leads me to my next question. In the event of being in that type of fully stretched situation, does the ambulance service have the capacity to activate the entire emergency plan and ongoing plans to deal with routine requirements? Can all those procedures be activated together in a short time, without a waiting time of three, four or five hours before the plan is activated? In my previous experience on a health board, cold runs used to take place, where all the emergency services were called out and tested to see how fast they could react to a given situation. They tested those reactions to the best of their ability. Can the ambulance service call on all those in a short time? How short a time is it?

Mr. Robert Morton

The NAS is part of the health family. There are structured processes in place in the wider HSE. There is a national crisis management team, which would be called upon straight away, chaired by the chief executive. There are area crisis management teams, where the broader range of supports is brought into place, including acute hospital, public health and community health colleagues all coming together, as well as people involved in procurement. Whoever needs to be at the table is there. Every resource available to the HSE is called upon. In the event that the HSE needs to engage with other services, we do. The plans provide for that. The three principal response agencies of the State are the local authorities, the HSE and An Garda Síochána. They exercise their response through their principal emergency services, which are the ambulance service, the fire service, and the gardaí. Those plans are in place. They are well structured. We have a great degree of competence in our frequency of practice of those processes.

They can be activated quickly regardless of Covid.

Mr. Robert Morton

Absolutely. An advantage of having a national emergency operations centre is that we have that ability to do it in a way that we would not have had prior to 2014. We now have that national capability in place all the time.

I thank Mr. Morton. I congratulate him on the work that he has done during the pandemic and with all the other trying issues that arise regularly. As public representatives, we need to acknowledge the work that he is doing and wish him well in the continuation of that work, staying Covid-free as far as possible.

Mr. Dennis Keeley

I echo the comments that Mr. Morton made about the practising of the inter-agency co-ordination that the framework for emergency management provides for, which is done well. There are regular meetings, both regionally and locally, between the three principal response agencies. While Covid has had a detrimental impact on the level of that engagement, it continued throughout the Covid pandemic and it continues today. The requirement for each of the agencies to have their emergency plans practised, prepared and fit for purpose is a part that they all take seriously. We are well versed in the issue of emergency management in Ireland.

Who makes the call to call out the emergency services in those circumstances?

Mr. Dennis Keeley

The determination of a major emergency can be made by either of the principal response agencies. There are dedicated personnel within each agency to do that. Within the fire service, a senior officer grade can call it. There is a directive within the Garda and the NAS There are written procedures on who can do it. There is a formal structure for how it is done. Each agency is very much aware that either an impending major emergency or an actual emergency has occurred. This links in with the Deputy's primary question. When the resources of a particular agency are in serious jeopardy, that can be a deciding factor that it is becoming a serious emergency and we can no longer cope as a single entity.

Other members are looking to get in. We are having some technical difficulties. While we are waiting on them, I will ask a few questions myself. I am told that Dublin is one of the best cities to have a heart attack in, if there is any good place to have one. That is largely down to the network that Dublin Fire Brigade and the ambulance service have been able to build up. Does Mr. Keeley believe that this will be affected if Dublin Fire Brigade is removed from the equation and the joint response model is done away with?

Mr. Dennis Keeley

I am unaware of any discussion to do away with Dublin Fire Brigade as a contributor and provider of an ambulance service. I do not believe that is the case. We are in discussions about the model in future, with our colleagues in the NAS. Those discussions are looking for the optimal service model and how to deliver it.

The fire service's role in the network was mentioned. The service's contribution to pre-hospital emergency care in Dublin is well known and documented. As chief fire officer, I am very proud of the service we deliver. As mentioned, however, resources are, as is the case with the rest of the country, a significant issue for Dublin. Dublin Fire Brigade is suffering as a result of everything that was mentioned earlier. Handover delays at hospitals are something that we work to alleviate with colleagues in the NAS and with hospitals directly.

One thing that has not been touched on so far during this session but that was touched on earlier is recognition for our front-line staff. As chief fire officer, I acknowledge the tremendous work done within Dublin Fire Brigade but also by all emergency workers who have been working day in and day out, particularly during Covid.

We have heard that the system is overly reliant on overtime. We heard earlier about capacity, with between 200 and 220 staff being trained each year. Is there any possibility of that being increased? Is there any capacity in the system to upskill more people. We heard from the Minister that part of the delay has been due to Covid. Training was not happening. I believe it has now resumed. Is there any capacity in the system to increase the numbers. Do we need to increase the number of people on the panel if we are talking about bringing in significant extra staff over the next five years? What can be done to get the system ready if people are available? Is the system capable of facilitating more people training?

Mr. Dennis Keeley

I will answer from a Dublin Fire Brigade perspective. The Chair quoted figures which Mr. Morton and Mr. Woods related to the NAS. People will be aware that there have been ongoing staffing difficulties within Dublin Fire Brigade for some years. It is more complex than recruiting more staff. There are other factors that we are trying to work through with our colleagues in the trade unions. We have a class that will finish its training very shortly, at the end of this month, and will become available to Dublin Fire Brigade over Christmas. A new recruit class of 45 will start in February and there will be another class later in the year. We hope to advertise for another panel.

The complexity of training and its duration was mentioned earlier. It is very difficult. Dublin Fire Brigade has conducted training throughout the Covid pandemic. That presented challenges to the training centre, its staff and the students who went through it. Dublin Fire Brigade is trying to engage with the trade unions. Much of the question has been advanced and we want to get the final piece across the road which would allow us to release more personnel into the system. We hope to fast-track training for next year for the second class, which is so vital and badly needed. That has to be acknowledged.

I also thank the witnesses. I want to compliment our fire service staff and our ambulance paramedics. They must be recognised for the work that they do. They have always done a good job but during Covid they have excelled. It is important to recognise.

I am not a member of the committee. I am attending because I feel so strongly about the ambulance paramedics in my area and because I am really worried about this matter. We spoke about the ambulance services there. People in my area have had to wait for hours for an ambulance because one of our own ambulance paramedics could have been sent to Dublin or elsewhere. There could be an ambulance sitting at the base and there is no one there to take it out. I have a great concern in this regard. Has there been any consultation with the staff in order to try and improve the services? I am not happy with the new model. I believe there are many failings. I am wary of emergency centres where you lose the local contact. At the end of the day, it is all about local contact. You cannot beat that in an emergency or to make a plan. The new model is there but I am not happy with it. It is unacceptable to have anyone waiting hours for an ambulance and I have come across that on a good few occasions and I have reported them.

Is there any process to put permanent managers in positions regionally and nationally. So many managers are working in acting or part-time roles in the service. That can affect the running of the services when there is no clear decision on implementation. It could be changes in the roster or local problems. It all boils down to local. Similarly, how many officers are working in acting, part-time or temporary roles in the service, including senior management? Everyone is doing their best but a good system needs consistency. I can only speak about my area and the concerns I hear daily when people come to me. The model is failing.

From speaking to ambulance paramedics, I feel that they are not being listened to. We are all in this together, no question, but for us to make those changes, and we do need changes, that all of us have a role to play. We have to address the issues that I have come across in recent months. I compliment our ambulance paramedics on the great work that they have done but I just do not know about the system at the moment and I ask that it be re-examined.

I am concerned about the shortage of staff. We have been talking about a recruitment plan for 2022. That is a concern. Our ambulance paramedics are at burnout. They are doing such a good job. We are dealing with people's lives and I know that is a priority but it is very difficult to explain to someone that they cannot get an ambulance to them because I have sent it to Dublin and that is unacceptable. I have done a lot of work on this and I have made it a priority. I will continue to work on it and make sure that we look at this.

Maybe someone could come back to me with some answers. I again thank everyone for coming before the committee. I look forward to their answers.

Mr. Robert Morton

I picked out three questions. On consultation, the most important consultation that should take place is between the supervisor, the manager and the staff member. There are supervisors in Carlow and Kilkenny and there is a manager in the area. The first person that I would expect to listen to and to speak to the staff is the local manager. That is critically important.

The Deputy asked about whether managers are permanent or not. In order for that consultative relationship to be effective, you need stability of leadership. It is fair to say that the south east in particular - and, to an extent, the south west - has suffered from a fluidity in managers. That is partly because people have left the NAS to pursue other opportunities in the wider HSE or perhaps they have left the HSE altogether. While the NAS is a relatively large ambulance service in global terms, it is a very small service in the HSE. There are many more managerial opportunities for people to pursue their careers in the wider HSE. That has been one feature. From a management perspective, 2022 will be the year of stability. We have approval from the HSE and the Department for plans. It will be reflected in the service plan which the Minister will publish in the near future to bring about changes in the management structure which will stabilise and improve the position. The Deputy's point is well made.

I completely accept it in that a lack of stability in leadership has a detrimental impact on staff and whether they feel listened to.

The other issue to touch on is the local centre. It is probably important to reflect on why the centre arrangements changed. I am from Laois, as members can probably tell from my accent, but I have vivid recollections of the Carlow ambulance not going to Graiguecullen because it was in a different county. If you needed an ambulance in Graiguecullen, it had to come from Portlaoise. Likewise, if the ambulance in Carlow had gone to Kilkenny, the ambulance in Athy would not go because it was in a different county and under a different control centre. The national centre has got rid of all that. The fundamental reason the Deputy and her constituents are having the experience they are having relates to the capacity issue. If we address that, the national control model will come into its own and will prove to be the effective model we know it is nationally and internationally.

I thank Mr. Morton very much for answering those questions.

That concludes our business for today. I thank everyone for their contributions-----

I had indicated that I wished to speak.

I know but the meeting was to finish at 12.30 p.m. I apologise as I cannot allow the Deputy to contribute.

That is very frustrating.

We have been meeting all morning. I apologise, but I cannot bring the Deputy in at this stage.

I thank all the witnesses for their contributions and responses. I thank, in particular, all the front-line responders who have shown their commitment and dedication down through the years. They have shown particular dedication during the recent pandemic. It would remiss of us not to say that here this morning. I wish everyone a very happy and safe Christmas and a healthy new year.

The joint committee adjourned at 12.32 p.m. until 9.30 a.m. on Wednesday, 19 January 2022.