COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Ambulance Services in the South West

11 December 2008

Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Mr Alex Easton
Mr Tommy Gallagher
Mr Samuel Gardiner
Mrs Carmel Hanna

Witnesses:

Mr Liam McIvor )
Dr David McManus ) Northern Ireland Ambulance Service
Mr John McPoland )

The Deputy Chairperson (Mrs O’Neill):

I welcome the chief executive of the Ambulance Service, Mr Liam McIvor, the medical director of the Ambulance Service, Dr David McManus, and the communications officer of the Ambulance Service, Mr John McPoland.

Mr Liam McIvor ( Northern Ireland Ambulance Service):

Thank you for your invitation to attend today’s Committee meeting. I welcome the opportunity to address the Committee on the subject of non-emergency ambulance provision in the west, and also to address issues that members have raised about delays in non-emergency ambulance transport.

I am conscious that the Committee has already visited our emergency ambulance control centre in Knockbracken Healthcare Park, which directs ambulance operations and targets resources where they are needed. I am pleased to invite members to visit our non-emergency control centre at Altnagelvin Hospital, which fulfils a similar role on the non-emergency side.

During the Committee’s visit to Knockbracken, I was able to brief members on our efforts to enhance the speed of ambulance response and the range of clinical interventions that are provided by ambulance paramedics who attend patients. I am pleased to report that since that visit, we have continued to respond more quickly to more emergency incidents throughout Northern Ireland. Those efforts have been supported by capital investment that is currently under way.

The quality and the range of clinical care that is provided by the Ambulance Service is being extended further still. Those developments have taken place in a challenging environment in which demands for emergency ambulance response continue to increase. Furthermore, the requirements for non-emergency patient transport become ever more complex as patients present to us with higher clinical dependency. Although the volume of patients may not be increasing, the demands of clinical dependency are growing.

I recognise that the main focus of today’s meeting is on ambulance transport for non-emergency patients, and, in particular, on delays experienced by patients in the west. From the outset, I wish to state that I sincerely regret any instances in which an Ambulance Service patient has a less than satisfactory experience. We work hard to minimise such instances, but we recognise that they can and do arise. We strive to provide a quality service for all our patients, which reflects their particular needs. It is a blow to all of us in the service when we do not succeed in that aim.

The Northern Ireland Ambulance Service (NIAS) non-emergency patient care service transports almost 250,000 patients a year. The workload ranges from outpatient appointments through hospital admission and discharge to inter-hospital transfers for scans and operative procedures. The ambulances cover in excess of two million miles per year, and the staff in that tier of the service are highly committed individuals who have recently extended their clinical competency to allow them to meet patient needs, such as the administration of oxygen and cardiac monitoring. That tier is being developed as well as the emergency tier.

We welcome feedback from patients on the service that we provide; typically, we receive it in the form of complaints and compliments. I welcome both forms, which are shared with the staff concerned to alert them to a job well done and to identify areas in which the service can be improved. If that awareness can be created at the coalface, it will have a greater impact as soon as possible. The complaints that we receive are fully investigated in line with our complaints policy and procedures, and a response is provided, signed by myself as chief executive, along with guidance on how to take the matter further if dissatisfied. We generally include an offer to meet a representative of the trust to address any residual issues.

We transported 128,000 non-emergency patients from April to October 2008. During that same period, we received 30 formal complaints relating to the non-emergency patient transport service. That equates to one complaint per 4,000 patients carried. That is not a cause for complacency for any of us, and I trust that what I have said so far indicates that we are not complacent in that regard. However, the volume of work must be set in context.

For each complaint we have received, we have sought to determine the cause of the patient’s dissatisfaction and to identify what we can do to address that and prevent recurrence, if possible. We share that with the complainant in our response, and offer a full and sincere apology for any failing on our part. Where the failing is attributable, in full or in part, to a third party, such as another healthcare provider, we incorporate that in our response and in our action to prevent recurrence.

We are presently introducing a range of measures that are designed to improve our non-emergency service provision, and I think that the Committee will be interested in hearing about them. Some stem directly from our analysis of patient feedback through complaints and compliments, and others from our assessment of how we provide the service. We are modifying our processes for handling requests for transportation made by clinical staff in hospitals and the community to incorporate mandatory data fields that provide relevant information to enable us to provide the most appropriate ambulance transport for the patient. We are trying to enhance the data that is given to ensure that it is meaningful and relevant to us, so that we can give the best service that we can.

That enhanced information gathering will help us to better manage conflicting demands for transportation by prioritising non-emergency ambulance transportation on the basis of clinical priority and the individual patient’s need. It is our organisation that aggregates the request; the people who make the requests see an individual, whereas we see a group of patients who need prioritisation.

We have already introduced, and continue to develop, a new command-and-control system. Importantly, that builds up a master patient index for the patients whom we have transported; we create a history for each patient. It stores key information such as the patient’s address and details of the patient’s needs, such as mobility needs. That prompts us to ask the person making a request for more details if they do not provide a full picture of the patient’s needs. For example, if a patient had previously required cardiac monitoring, we can then ask whether or not they still require that. Regrettably, we often get requests that do not provide full information.

We also continue to refine and improve the ambulance scheduling systems to maximise use of resources by breaking down the old divisional boundaries and barriers that we inherited from four services. For example, we are introducing automatic vehicle-location systems and satellite-navigation technology for our patient-care fleet to enhance the vehicle-location information. That will allow us to take advantage of vehicles en route with patients to provide a more flexible approach to dealing with late-notice requests for transportation, and also late changes to the requirements of patients. Thus, if a vehicle is already en route, it is no longer lost to us; we know where it is and can redirect it to meet the patient’s need more effectively.

We are also introducing automatic external defibrillators to the patient-care fleet to improve patient safety and extend the range of care our staff can provide. Importantly, that will also free up emergency ambulances that currently carry non-emergency patients purely because they require cardiac monitoring during that journey. Instead of tying up an emergency ambulance that could be responding to a life-threatening call, the new equipment and training mean that we can now move some of that work to the non-emergency fleet.

We are introducing new software to allow the hospital and community staff to make ambulance bookings directly, rather than having to phone or fax the ambulance control centre. We want to move to an internet-based system through which they can make a direct booking, which will reduce telephone requests and call queuing, and will also free up my staff to deal with urgent on-the-day enquiries regarding patients. The mandatory data fields will be a key element of that new system, ensuring that the booking system captures the relevant information.

Finally, it is worth noting that another intermediate care ambulance will be introduced in the south-west on the back of the Minister’s announcement about additional ambulance resources. The service will continue to press for additional non-emergency ambulance resources, particularly in areas where changes to acute hospital services impact on ambulance-patient flows. The service is in constant dialogue with healthcare trusts about planned changes in acute services in order to identify the impact on the Ambulance Service. In general, that is manifested by longer journey times and, potentially, more patients being carried, all of which must be managed in order to ensure that performance is maintained and that patients receive a good service.

Deputy Chairperson, I am happy to pause now or go on to address the circumstances of the specific incident that was raised by Mr Gallagher, whichever the Committee prefers.

The Deputy Chairperson:

Perhaps members would like to ask some general questions now. Thank you for the presentation. I welcome the measures that are being introduced. I assume that the biggest challenge is to secure funding in order to see through all those plans. I commend the good work that the ambulance personnel carry out. You said that only one in every 4,000 patients registers a complaint about the Ambulance Service, and that is good; I am glad to hear that.

Is there any analysis on whether more complaints are lodged from rural areas than urban areas? I also want to ask about clinical priority. I understand that there are big demands on the Ambulance Service and that prioritising is necessary in order to provide any sort of service. However, a lady in my constituency paid £100 for a return trip to Belfast in a private taxi because she could not get an ambulance — that was because she was not a renal, heart or cancer patient, who are top priority. As I said, I accept that there must be prioritising, but I believe that more resources are needed to provide for people who are on their own, without family support or friends, and who are not fit to travel on public transport.

I want the Committee to work with the Ambulance Service to increase the number of people that can be helped and to widen the service provision. As a matter of interest, are there more complaints from rural areas than urban areas?

Mr McIvor:

On the first point about funding, the Committee will not be surprised to hear me say that the Ambulance Service would certainly welcome more funding. Extra funding could be directed towards extending the time frame within which we offer the service and increasing the vehicle fleet, thus allowing a more individualised patient service.

The service has an issue with having to aggregate — having to transport as many patients as possible in a vehicle — which is not the most appropriate way for certain patients to travel. In recognition of specific needs, extensive use is made of the voluntary car service, particularly for cancer and renal patients. The service will happily work with the Committee on funding issues and the securing of new funding.

I return to the key determinant; where the service is changing, as a result of the actions of others, we want due cognisance to be taken by those involved of the impact on, and consequences for, the Ambulance Service. They must plan for the change to the Ambulance Service in order that the service can be part of that process and can prepare as best it can.

The Ambulance Service has not conducted an analysis of the ratio of complaints from rural and non-rural areas. I am happy to consider the extent to which that can be done and to share that information with the Committee. However, I have nothing to offer on that at present.

As regards clinical priority, the service must find a way to make very difficult choices. Priority is currently given to conditions such as cancer, renal, cardiac and fractures, which is consistent with ministerial priorities. An entirely warranted very high priority is given to the transportation of the terminally ill — although that is not specifically identified in any ministerial target, the service considers it the right thing to do. We must get to the point whereby more detailed information is available that allows for more refined choices, while recognising that there will always be limitations.

On the issue of funding, we intend to use the technology that we have, where appropriate, to transport as many people as possible on a vehicle, because that will free up other resources to deal with the unexpected or particular cases in which an individual needs to travel on his or her own — for example, if he or she has an infectious condition.

Mr Gallagher:

Thank you for your presentation, Liam. I agree with what you and the Deputy Chairperson said; we need to work together. Without question, you are doing very good work, and the Ambulance Service is working well. However, there seems to be a specific problem with non-emergency cover, particularly at Tyrone County Hospital in Omagh.

I welcome the database that you are working on. I want to mention the case of the 83-year-old man who was left at Tyrone County Hospital because an ambulance failed to pick him up. The 83-year-old man had certain medical conditions and was accompanied to hospital by his wife, because she had to look after his medicine. When he arrived at the hospital, the ambulance driver told him to ring for an ambulance to take him home again. However, the man’s wife made at least three telephone calls, and, despite having been told each time by personnel that the ambulance would be there in 10 minutes, it had still not arrived by 6.00 pm. It is clear that something is not right. In addition to the phone calls that the man’s wife made, some of the hospital personnel had phoned for an ambulance for him.

Furthermore, I discovered that another patient had the same experience the previous week. A member of Tyrone County Hospital staff had to leave that patient home because the ambulance did not turn up. There seems to be some sort of problem there. Given the distance that people must travel from parts of Tyrone and Fermanagh to get to the hospital in Omagh, the issue must be examined. I have not heard any more about that, and I am sure that you will be able to provide more information.

I wish to make other points about ambulance cover, particularly in rural areas, because people’s perceptions are sometimes based on misunderstandings. Recently, I encountered an elderly woman who had had a major heart operation in Belfast. She was called back for her first follow-up appointment, and she rang me a few days before it, because she could not get an ambulance to take her to the hospital. I checked the matter out, and found that it was not her GP’s responsibility; the woman had to arrange the ambulance with the hospital. It is not the fault of the Ambulance Service. However, the hospital told me that it could not provide an ambulance, because it did not get 48-hour’s notice. When I explained that to the woman and her son, they checked the appointment letter from the hospital, but it said nothing about 48-hour’s notice. There was a perception on the part of the patient that there was a problem with the Ambulance Service, but, in fact, the problem was a lack of communication between the hospital and the patient.

In the west, patients on the waiting list move up the list quickly by going to an independent clinic to which they are referred by the Western Health and Social Care Trust. However, I understand that the Ambulance Service’s remit does not extend to patients who receive treatment outside the trust area or at independent, private clinics. I understand why that is the case, and I think that the Health Service has a strategy to reduce the use of independent clinics. However, it contributes to the problem of patients saying that they cannot get ambulances. Those are the problems that I wanted to mention.

Mr McIvor:

I certainly appreciate your comment that the Ambulance Service is working well. We will continue to try to work better, harder and smarter. I would be very happy to pick up on some of those problems with you directly, to see how we can improve the service.

As a result of changes in the area, the non-emergency cover in Omagh has been increased. I am pleased to say that we engaged with the Western Health and Social Care Trust and the Western Health and Social Services Board, and extra resources were made available. Of course, that was linked to additional demand and additional workload. That demand now needs to be monitored on an ongoing basis to identify whether requirements have changed. Certainly, the cover in that rural area has increased. In Omagh, there has been an increase in the number of intermediate care vehicles, and those vehicles run until 11.00 pm.

You mentioned that patients must give 48 hours’ notice if they require an ambulance, and you are quite right to say that the hospital is responsible for making those appointments. The hospital is well aware of the requirements necessary for us to plan journeys to collect patients at a time that is appropriate for them. I hope that our recent work on the booking software will improve the service in that area. That system will depend on the people who are making the booking having access to it at the hospital site. Therefore, it will be made available to all hospitals, and, hopefully, be rolled out into the communities through GPs, enabling them to request appointments, too.

That software will flag up and synchronise the notification periods and the requirements of the patient. Basically, I want the system to be similar to an Easyjet booking system. The user will look at availability, and then set up an appointment. The closer we can get to that type of booking system, and the certainty that comes with it, the better.

Our remit does not extend to private clinics. However, in the past, when a hospital has made, for example, arrangements for a waiting list initiative, it has engaged with the Ambulance Service to provide the additional resources necessary to deal with the ambulance requirements. I am not aware that any such arrangement is in place at this point in time. However, depending on our capacity, we will continue to try to work with the hospitals.

Mr Buchanan:

First, I commend the Ambulance Service and its staff on the work that they do. Although we hear about the problems and difficulties that arise from time to time, I am sure that they affect the minority of cases. We perhaps do not hear so much about the Ambulance Service’s successes. We should not knock the Ambulance Service or its staff, but when negative incidents are brought to our attention, we must deal with them on behalf of our constituents.

What is the target response time for emergency call-outs in the Western Health and Social Care Trust area, from the moment the call is placed to the moment the ambulance arrives? We must take into consideration the fact that the trust covers a large, rural area. Have any target response times been set for non-emergency calls? I am thinking of, for example, a hospital patient who needs to be transferred to somewhere else, but whose condition is classed as non-emergency.

You may or may not wish to answer my next question. At the beginning of the month, a child in Aghyaran came off a quad bike. An emergency call was made, and it took an ambulance over 50 minutes to reach the child. The Minister is continually talking about improving ambulance services in the Western Health and Social Care Trust area, and there is mention of the base in Castlederg. Aghyaran is ten miles, or less, from Castlederg, yet it took the ambulance some 50 minutes to reach that child. Again, you may not wish to answer this question, but can you give the Committee a reason as to why that might have happened?

The Minister highlighted the investment that has been put into ambulance services in the Western Trust area, but has that yet been realised? What percentage of that investment has been actioned, or is it still all on paper? When I talk to the public and to ambulance staff in Omagh and other areas, I am told that they have not seen much of the investment realised on the ground. When will the investment be fully utilised?

Provision for after-hours services is another concern. I know of a case in which an elderly lady had to be moved from her home to Erne Hospital late at night, and no ambulance was available to bring her home again. Can a time lapse occur during a changeover in Ambulance Service staff’s shifts that would delay an ambulance from getting out?

Does the Minister’s announcement mean that enough ambulances will be provided to cover the Western Trust area and to provide an adequate service for the people who live there, given its geographical size? Given that County Tyrone has no acute-hospital facility, its hospitals depend solely on emergency ambulance cover.

Mr McIvor:

There is much to get through, so I will do my best. I welcome your commendation of our staff, and I will be happy to relay that to the front-line, control and training elements of our staff. You are correct to say that, sometimes, we focus too much on the bad news and do not hear enough about the success. When we receive compliments, therefore, I always endeavour to pass those on to the staff, who need to hear when they have done their job well.

Our staff are involved at the first part of a patient’s journey. At the end of that journey, the patient realises what he or she has been through and thanks everyone who has been involved, but our involvement is a long way from that. Therefore, it is important to pass on any compliments that we receive, and I thank you for those.

In his ‘Priorities for Action 2008-09’, the Minister announced that his target for the Western Trust area is to respond to 62·5% of category-A calls within eight minutes. Last year, we improved our performance from 51·3% calls being answered within eight minutes in 2006-07 to 59·5% in 2007-08. I do not have the most recent figures, but the overall figures for Northern Ireland have also increased. I am happy to provide those to the Committee if it feels that that will be helpful.

You asked whether enough ambulances and resources are available in order to meet the targets. We welcome the extra investment, and I will distribute any investment further and further into the community. The issue is then to do with the law of diminishing returns, but, in my mind, any extra resources will be targeted at areas in which I can see a cluster of calls that are out of standard.

The number of calls might not increase significantly, but an area could be addressed that was not being addressed previously. Increasing the cover of Castlederg to 24/7 will increase our chances of improving response times, because we currently do not cover there on a Sunday during the day. That is because the call volumes are low and because we did not have the resources.

Therefore, we will probably always campaign for more resources, because there will always be somewhere else where an additional ambulance or rapid-response vehicle could be placed to improve response times. However, the improvement that any vehicle makes will diminish over time, because it will address a smaller cluster of calls.

You asked whether any targets are set for non-emergency calls. There are no targets at present. However, we will set internal targets for ourselves via the improved data-collection system that we have put in place. The first stage is to start collecting data to establish a baseline and evaluate what can be developed.

That is a similar process to what we are currently doing with clinical-performance indicators in the emergency arena. We are anxious to introduce measures of clinical performance to sit alongside the measure of time that it takes to get to patients. We certainly do not envisage setting aside the response-times targets, because I have yet to hear a patient say that we got there too quickly; I have yet to hear paramedics say that they got there too quickly and that they wished that they had got there two minutes later. Invariably, the opposite is true — they want to get there, and we want to get there, as quickly as possible. However, we want to get there to deliver a set standard of quality clinical care.

We now aim to measure the clinical interventions that we make en route: whether we provided the patient with oxygen or aspirin on a cardiac call; whether we commenced CPR; or whether a bystander commenced CPR. We also aim to establish whether a positive outcome was achieved through our part of the patient’s experience; for example, a return to spontaneous breathing or circulation. That should all be recorded and measured. We started that process on the emergency side, and we develop internal targets on the non-emergency side.

It is very early days, but we are encouraged, and we will relay those measures of clinical performance to our staff so that they can take pride in the work that they do, and can measure their own performances and determine whether they achieved good results.

Our records show that the response time to the quad-bike incident in Castlederg was 38 minutes. I am very conscious that time flies in such a situation and is, therefore, very difficult to measure, but our response time is measured from the time that we receive the call to when the ambulance arrives at the scene. Our records show that our response time was 38 minutes, which is still an extensive time. The ambulance was clearly not responding from Castlederg, because the Castlederg ambulance was possibly deployed to Strabane or Altnagelvin, or because it was on another call — I do not have the exact details with me. Those are the kind of reasons for such a response time.

The target is set at a 62·5% aggregate of the whole area. One of the issues with a percentage target is that, even if we hit 62·5%, there is still a large proportion of calls that we will not reach within those eight minutes. That is a disappointment for my staff and me. The target is only a measure — our goal is to get to every call as quickly as possible and to provide the best care.

The Omagh investment is under way and a significant amount of it is in place. However, each additional requirement — the most recent being, at the start of this year, an additional vehicle for Omagh; an additional vehicle for Enniskillen; additional hours of cover in Castlederg; an additional intermediate-care vehicle in Omagh; and an additional deployment point in Irvinestown — means that our requirements for staff increase. Those staff are now being recruited and trained under a training plan.

However, it takes us three years to recruit and train a paramedic. We must recruit them and train them ourselves, so we cannot pick them off the street. It is not like nursing — we cannot go to an agency or a bank to draw paramedics from elsewhere. All our paramedics are contained in the Northern Ireland Ambulance Service.

In Omagh and elsewhere, we seek to provide cover by offering overtime to staff. It is the best that we can manage, but it is voluntary. I commend staff in the area who have risen to the challenge, because they are part of the community and they feel part of it. They have done their utmost to maintain high levels of overtime cover in that area, and I do not doubt that they will continue to do so.

We are currently recruiting staff, but it will be two or three years before all the paramedics are in place, provided that they all pass their training period and get their qualifications, but that is another issue.

You also asked about the time lapse in staff changeovers. Shifts generally run from 8.00 am to 8.00 pm and from 8.00 pm to 8.00 am. Therefore, there will be one crew on station, and then another crew will come in. There can be a time lapse when, for instance, a vehicle check is carried out at the beginning of a shift. However, if there is an emergency request, a vehicle will be allocated and the crew will respond. They may then ask to be brought back to base so that they can complete their check.

Ways in which we manage that include looking at staggered shifts and start times and finish times in stations in which there is more than one vehicle. However, there are stations in the west where there is only one 24/7 vehicle, but we dovetail vehicles.

The ideal situation would be to have an overlap, so, rather than having 24-hour cover, it would run to 28-hour cover. Therefore, there would be a two-hour overlap between one shift’s finishing and another one’s starting. That would then double the requirement for ambulances, but I do not have the ambulances to support that. That is how we operate at present. I hope that that covers everything.

Mr Buchanan:

I think that that covers everything. Thank you very much.

The Deputy Chairperson:

Well done for answering so many questions.

Mr McIvor:

We have received the complaint about the lady in Enniskillen, and we are working on it.

Mr Buchanan:

Yes, I wrote to you about that

Mr McIvor:

You will receive a response to that. There is a number of factors involved in that case, but the request for the ambulance was made in the early hours of the morning after the non-emergency-patient transport fleet had finished. Therefore, the patient would have had to travel in an emergency ambulance. We need to find out about the availability of ambulances, but I suspect that the controller made the call that there were insufficient emergency ambulances to reduce the emergency cover in order to allow that vehicle to make a non-emergency journey. However, I will get back to you directly on that issue.

The Deputy Chairperson:

Thank you for attending today. I am sure that we will see you again soon.