Introduction

Chairperson, Members,

On behalf of the Health Information and Quality Authority, I would like to thank the Joint Oireachtas Committee on Health and Children for giving me the opportunity to present and discuss the findings of our Review of pre-hospital emergency care services to ensure high quality in the assessment, diagnosis, clinical management and transporting of acutely ill patients to appropriate healthcare facilities, which we published this morning. I am joined by Mary Dunnion, Acting Director of Regulation, and by Marty Whelan, our Head of Communications and Stakeholder Engagement. We welcome the opportunity to appear again before the Oireachtas Committee and to engage with Members.

Last year HIQA developed a three-year assurance programme, with the aim of providing assurance on the safety and quality of healthcare services in line with the requirements of the Health Act 2007; monitoring nationally mandated standards for health and social care services provided by the HSE and other specified providers. The focus of this programme is to find out how services are performing against the standards and to provide feedback aimed at improving services.

As part of our three-year assurance programme, HIQA had planned to undertake a review in the final quarter of 2014 of pre-hospital emergency services against the National Standards. Following a number of reported concerns, the then Minister for Health James Reilly TD asked the Authority to bring forward the review. Our work began last March.

The purpose of the review is to provide assurance to the public that the following are in place:

• clear strategic direction with implementation plans and control measures for the national service
• effective governance and leadership arrangements at all levels within the service
• clearly defined schemes of delegation
• appropriate controls in place through service level agreements with third parties delivering services on behalf of the national service
• appropriate quality and risk management arrangements
• workforce is well organised, skilled and there is a culture of continuous improvement
• The use of Key performance indicators to include response times and clinical outcomes and other quality assurance metrics to assure the public that the ambulance service is both safe and effective.

The review used a combination of interview, document assessment and on-site review of services for assessment, diagnosis, initial management and transporting of an acutely ill patient to an appropriate healthcare facility. The report contains recommendations which relate to important aspects of service provision in both the National Ambulance Service and the Dublin Fire Brigade. It is expected that on foot of the recommendations made in our report, both service providers will formulate quality improvement plans that will drive improvements in the quality and safety of the State’s pre-hospital emergency care services.

The establishment of the HSE in 2005 led to the creation of the National Ambulance Service. The National Ambulance Service provides pre-hospital emergency care services in the Republic of Ireland along with Dublin Fire Brigade’s Emergency Medical Service.

Over the past 10 years there has been a considerable progression of clinical competencies used by pre-hospital emergency care practitioners. The increase in numbers of paramedics and advanced paramedics, and the expansion in the treatment options that these healthcare professionals provide to patients at the first point of contact with the emergency health service, represent a major advance in patient care. The service providers, the practitioners themselves and the Pre-Hospital Emergency Care Council all deserve great credit for this advancement. However, many legacy issues associated with the former fragmented nature of multiple providers remain, and the National Ambulance Service has struggled to fully integrate as one entity.

Significant change to ambulance service provision in Ireland will be vital to improve services for patients. Our review identifies challenges in relation to:
- workforce and leadership
- the model of care
- fleet and fleet deployment
- clinical governance and risk management
- the relationship between the National Ambulance Service and Dublin Fire Brigade
- dispatch times and emergency response times

I will now briefly describe some of the main findings and recommendations of our review.

Our review found a number of challenges in the area of workforce and leadership within the services. As a result we believe that there is a requirement for more effective leadership, clear strategic planning and ongoing constructive cooperation between management and staff. This is not currently happening. Investment in management support and training; better management performance; and a more comprehensive focus on performance management and quality improvement, will deliver better services for patients. A lot of change has happened within senior management ranks, mainly through internal movement and promotion. Three different directors have been in position since the creation of the National Ambulance Service, with two in the last four years. Many managers outlined that they had changed roles with the service in recent times. Some of these staff reported to us that they did not have formal job descriptions which outline the specifics of their roles and the aligned responsibilities. More worryingly, some staff reported to us that while they had accepted new positions within the service, they did not have appropriate technical knowledge.

Our review concludes that strategic planning for the service will require consideration of plans for wider organisational and health system reform. The draft National Ambulance Strategy 2014 – 2016 does not fully reflect the impact of wider reform and how pre-hospital emergency care needs to complement new models of care provision, including the potential impact of the emerging hospital group structures and their delivery of unscheduled care.

When looking at the model of care, the Authority found that the number of calls received per year for ambulances in Ireland continues to increase, with a 10% increase reported by staff between 2012 and 2013. Increased call volume translates into an ever increasing number of patients being transported to hospital for treatment. This is unsustainable, and delays patient handovers at overcrowded emergency departments create an inability to rapidly turnaround ambulances in the emergency department.

The HSE implemented target times of 20 minutes for clinical handover of a patient from an ambulance to the emergency department and 30 minutes total turnaround time. The National Ambulance Service and many hospitals struggle to routinely meet these targets. The service model needs to be reviewed – at present, an emergency vehicle is dispatched to all calls, without examining the potential for treatment or triage over the phone. In addition, following arrival on scene, unless the patient refuses to be transferred to hospital, the vast majority of patients are automatically transferred to hospital emergency departments.

This model of care does not consider the potential for the transportation of the patient for treatment to a setting that may be more suitable to meet their needs such as a local injury unit, or indeed the possibility of treatment and discharge on the scene by the ambulance crew themselves. Both the National Ambulance Service and Dublin Fire Brigade must develop and implement an ongoing community education programme that would promote appropriate use of ambulances. Such public education should seek to reduce unnecessary requests for ambulances, and should increase public awareness and acceptance of the skills and competencies that paramedics possess The strategic direction of emergency ambulance service provision needs to be clearly articulated by the HSE. The flow of emergency medical admissions by ambulance should be monitored by all, but managed by the National Ambulance Service.

The clinical governance agenda is currently underdeveloped across both the National Ambulance Service and the Dublin Fire Brigade. It is the responsibility of everyone in the services to contribute to developing this agenda. The appointment of a full-time medical director in the National Ambulance Service has improved clinical expertise at a leadership level. However, effective clinical governance requires that there should be a collective leadership responsibility, rather than being siphoned into an operational silo. There is currently no clinical audit in the National Ambulance Service, so quality assurance of clinical care is very limited, especially for staff who have completed training. This is not acceptable, and need to be addressed.

The National Ambulance Service has only recently started to review adverse clinical incidents. A new policy which is aligned with best practice was introduced in 2011. The service has good visibility of severe incidents and thoroughly investigates these to identify potential for learning. The system works less well for more minor incidents and reporting of incidents is not operationally embedded.

Ongoing analysis of the collective experience of such events allows for the prioritisation of improvement efforts on the basis of risk, and is a crucial aspect of any successful risk management strategy.

• HIQA observed a fundamental disconnect in the internal organisational mechanisms that are used by the service providers for reporting of risks. It is clear that the current infrastructure for proactively capturing and subsequently managing risk in the National Ambulance Service is overcomplicated and it is ineffective in its ability to effectively escalate and rapidly address persistent issues.
• It is recommended that the National Ambulance Service should improve its patient advocacy approach, including its responsiveness in the handling of complaints.

When looking at the relationship between the National Ambulance service and the Dublin fire brigade we were concerned to note that there was no evidence of integrated management of pre-hospital emergency care in Dublin, the most heavily populated region of Ireland. The current governance arrangements between Dublin Fire Brigade and the National Ambulance Service is disjointed with inadequate quality assurance and accountability controls.

The provision of safe and effective pre-hospital emergency care services by two distinct agencies, with a critical interface, requires a rigorous service level arrangement, which clearly articulates governance responsibilities for both parties. Both service providers must address the operational inefficiencies that our report identifies and must publish an action plan outlining proposed steps to improve individual and collective performance in call handling, dispatch and coordination of calls between both services. For necessary performance improvements that are identified in HIQA’s review and which rely on cooperation between both services, a joint action plan between both service providers should be produced and published.
As a matter of urgency, both the National Ambulance Service and Dublin Fire Brigade must put the necessary corporate and clinical governance arrangements in place to provide a fully integrated ambulance service in the greater Dublin area. This should include a binding service level agreement that includes formal quality and performance assurance reporting mechanisms. In addition, the HSE and National Ambulance Service must immediately involve Dublin Fire Brigade in the National Ambulance Service Control Centre Reconfiguration Project to ensure a seamless and safe transition of services in Dublin.

One key issue we looked at in this review related to dispatch and emergency response times. HIQA supports the decision to move towards one national ambulance control centre, which will be located over two sites in Ballyshannon and Tallaght. Significant change in many other areas, as outlined in this report, will be vital to improve services for patients. Three different computer-aided dispatch systems were in use at the time of HIQA’s review, and these systems were not integrated, which meant that the National Ambulance Service continued to operate as six different services within defined geographical areas, rather than as one national entity. This means that there appears to be limited visibility of ambulance resources outside the geographically defined areas.

There is considerable potential for improvement in ambulance service response times if efforts are directed towards improving the operational efficiency of call handling and dispatch by control centres. In addition, both ambulance service providers could improve response times by looking to match available resources to anticipated demand over the calendar week, and through more tactical, dynamic deployment of resources away from station, based on predictive analysis of ambulance need.
Regular monitoring of the service’s ability to meet targets helps to deliver quality assurance, improvement and public accountability. Both the National Ambulance Service and Dublin Fire Brigade must monitor their performance through a consistent, reliable, accurate and balanced system of measuring and reporting against key performance indicators. These should include the 7 minute 59 second first response times for all ECHO and DELTA calls; specific response times for cardiac arrest, stroke and heart attack; and ambulance turnaround times at hospitals.

When examining issues concerning the ambulance fleet we noted a lack of ongoing investment increases the probability of an ambulance breakdown impacting on patient care in an emergency situation. The National Ambulance Service replacement policy – once a vehicle has been in use for seven years or has reached mileage greater than 500,000 kilometres – is in line with other ambulance services. However, despite this policy, 18% of the current fleet are eight or more years old.

Chairperson,

Geographical challenges in rural and sparsely populated areas will always present some difficulties for ambulance services that strive to achieve timely and appropriate responses to ECHO and DELTA calls. To achieve timely and appropriate responses to ECHO calls, which account for approximately 2,500 – 3000 of the services’ sickest patients per year, the National Ambulance Service must as a priority develop and support a comprehensive national programme of community first response schemes in all rural and sparsely populated areas. Efforts should be initially focused on those communities that are most challenged in achieving rapid responses, and do not have schemes in place. Extensive community involvement will also be critical to successful achievement of a more comprehensive national network of schemes.

Our report contains 12 crucially important recommendations which relate to aspects of service provision in both the National Ambulance Service and Dublin Fire Brigade. In addition, further areas that require improvement are also included throughout this report. It is expected that on foot of these recommendations, and this report, that both service providers will formulate written plans aimed at driving the necessary improvements in the quality and safety of the State’s pre-hospital emergency care services.

Eight of the recommendations relate to the provision of emergency ambulance services nationally, and must be addressed collectively as well as individually by the National Ambulance Service and Dublin Fire Brigade. Four of the recommendations specifically relate to the service that the National Ambulance Service provides, and these must be addressed by the National Ambulance Service and the HSE.

In conclusion, the Irish health service is undergoing a period of significant change. As the acute hospital service moves towards a model of hospital groups, ambulance services must be fully included in this strategic planning process, and must operate as a clinical service that is embedded in the unscheduled care system, and under the remit of the Acute Hospitals Directorate of the HSE. This change should be reflected in the strategic plans of both the HSE and emergency ambulance service providers.

There is scope within current resources for significant improvement for patients in pre-hospital emergency care services. Many of the required changes that this HIQA review outlines can be achieved with strong leadership, effective management, staff buy-in and a detailed and strategic approach. There is scope too for other changes which would make a significant difference to ambulance service performance. For example, with effective management and staff cooperation, improvement in operational efficiency in the practice of call-handling and dispatch, combined with dynamic deployment and more effectively matching resources to anticipated demand, could translate into measurably better response times within current resources. It is important that the HSE, the National Ambulance Service and Dublin Fire Brigade begin to act now to address the findings of this report.

I thank the Members of the Joint Oireachtas Committee on Health and Children for inviting us here today to discuss this report. I look forward to your questions and to your views on how HIQA can work with service providers and with this Oireachtas Committee, in the interests of improving the quality and safety of pre-hospital emergency care services in this country.

Thank you