COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Efficiency Savings

26 February 2009

Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill

Witnesses:
Mrs Sharon McCue )
Mr Liam McIvor ) Northern Ireland Ambulance Service
Mr Brian McNeill )
Ms Roisin O’Hara )

The Chairperson (Mrs I Robinson):

We now have an evidence session with the Northern Ireland Ambulance Service on efficiency savings. The meeting was arranged to consider the trusts’ proposals on efficiencies, following media reports about ambulances being replaced with rapid-response vehicles, and as part of our meetings with each trust.

It is my pleasure to welcome the representation here today. I welcome Liam McIvor, the chief executive, Roisin O’Hara, the director of human resources, Brian McNeill, the director of operations, and Sharon McCue, the director of finance. I invite you to make a short presentation, after which we will invite questions from members. I will allow up to one hour for the evidence session.

Mr Liam McIvor (Northern Ireland Ambulance Service):

Thank your for the invitation to give evidence today. I propose to outline briefly our proposals for efficiency savings and comprehensive spending review investment, along with the consultation process in which we have been engaged, after which we will be more than happy to take questions, to which we will do our best to respond.

The Northern Ireland Ambulance Service (NIAS), as with all the other trusts, is required to make efficiency savings during the 2008-2011 comprehensive spending review period. The savings for NIAS amount to approximately £8·5 million over the three-year period, increasing from £1·2 million in the current year to £4·5 million by 2011. The final cumulative figure of £4·5 million represents around 10% of the revenue budget on which the proposals are based.

To put that into context: that figure represents more than the Northern Ireland Ambulance Service currently spends on training and administration combined. It represents more than we spend on the ambulance control function, which deals with all emergency and non-emergency calls and provides the dispatch function for the ambulances. Indeed, it is more than we spend on staff to provide non-emergency patient transportation for more than 200,000 patients. Therefore, it is a sizeable sum for the organisation.

The consultation document that we have provided outlines the level of savings to which I have referred and the process by which we considered our full budget to develop our savings proposals. The proposals that we have outlined cover the key areas of expenditure and take account of previous efficiency savings, and they are extremely challenging. They also reflect the fact that a high proportion of the Ambulance Service’s budget is spent on front-line personnel who staff the emergency and non-emergency ambulances, and the ambulance control centre, which I am pleased that the Committee has had the opportunity to visit.

Efficiency savings cut across all aspects of the service. By the final year, absence management will account for savings of £500,000. We seek to improve the efficiency of the non-emergency transportation of patients by transporting more patients per journey in patient care service (PCS) ambulances and our voluntary car fleet.

We intend to introduce in-house servicing of our fleet — for a proportion of the fleet, whichever is appropriate and suitable — and the resulting savings will amount to £110,000 by year three. We also aim to reduce our administration costs and, by introducing new methods and technologies that are less labour-intensive, our training spend. Finally, we plan to reconfigure the emergency ambulance hours, to which you referred. That issue has caused the greatest concern and media interest, and resulting savings would amount to £3·489 million by 2011, by which time efficiency savings will total £4·449 million.

We continue to work with local managers and trade union representatives to review our current expenditure, and we have established an internal group to do precisely that: to identify alternative proposals for savings with a view to releasing funds to reinvest in front-line services, if possible, and to consider and further refine the proposals that we developed internally. It will be challenging to deliver 3% savings across the board.

I will now address the issue that has attracted the most attention — the reconfiguration of emergency ambulance provision. As an organisation, NIAS is faced with challenging, but welcome, targets to improve its response to category A, which are potentially life-threatening 999 calls, within eight minutes across Northern Ireland. I describe the targets as welcome because they represent a drive to get to more potentially life-threatening calls more quickly than before. The service is all about getting to the patient and providing paramedic care as quickly as possible. It can mean the difference between life and death for the patients whom we attend, and that is what drives us.

However, we also welcome the priority placed on getting to those life-threatening calls more quickly by the Department and the Assembly, because that provides the basis on which we can bid for extra resources. Without that measurement of performance, we would have a difficult task in convincing others that we must invest in getting to more patients more quickly and providing the best possible care.

On that basis, NIAS has secured extra funding through the comprehensive spending review to meet those targets and, more importantly, to get professional ambulance care to more patients more quickly than before. The extra income that we have identified amounts to £12 million over the three-year period: £2·5 million in year one; £4·4 million in year two; and £5·5 million in year three.

In developing our proposals for efficiency savings, we have specifically referenced the proposals for investment alongside the proposals for efficiency, because the two are necessarily linked. We are seeking to modernise the service, and, in so doing, we want to become more productive and effective. We also want to ensure that the investment that we have secured is used as wisely as possible.

To divert slightly: when it comes to the spend per head of population or per square mile, we are not a well-resourced ambulance service in comparison with other UK services, such as that in Wales and comparable English services. I have provided Members with several slides from a report by the Wales Audit Office. They illustrate the income levels for a range of ambulance services that the Wales Audit Office selected, of which NIAS was one, and we were happy to provide that information.

It is, therefore, all the more important that we use the funds available to us as effectively and efficiently as possible to deliver care to the patients who need it most. In essence, our proposals are to invest in alternative care pathways to prevent unnecessary attendance at accident and emergency departments, or transportation to those departments by ambulance when it is inappropriate and unnecessary.

The UK Department of Health has suggested that up to 50% of ambulance transportation to hospital is inappropriate. The Ambulance Service aims to reduce 999 transportation by 10% in the first instance, to bring it into line with the practice in the rest of the UK. That is targeted particularly at the lowest-priority calls — those that are classified as category C, which do not involve life-threatening situations, and are not urgent.

That would be achieved through measures such as the introduction of clinicians in ambulance control to provide call triage, and also by paramedics attending calls, assessing patients, and identifying alternative care pathways at the scene for those patients. Those care pathways would allow patients to remain in their home and community, and prevent them from making an unnecessary and inappropriate trip to an accident and emergency department.

As a consequence of the planned 10% reduction in the requirement for emergency ambulances to transport patients to hospital, the Ambulance Service proposes to reduce the planned hours of emergency ambulance cover by 12% — 70,000 hours over the CSR period. I stress again that the aim is to reduce the need for ambulances to transport 10% of patients, and, as a result, the planned hours associated with that will be reduced.

The Ambulance Service further plans to invest in additional rapid-response paramedics to improve overall paramedic cover, and to increase that cover from the current 48,000 hours for rapid response to almost 180,000 hours by the end of the CSR period. That will be a very significant improvement in paramedic response to the most needy patients. It will improve both the level and the spread of the cover, will enable available response resources to be distributed as effectively as possible, and improve the timeliness of the response to patients, and, ultimately, the care that is provided, as a result.

Again, I refer members to the slides that I have provided, which illustrate an improvement in the performance of the Northern Ireland Ambulance Service last year compared to the previous year. It has improved the timeliness of its response to category-A calls throughout Northern Ireland; at a Northern Ireland level, at a health-board level, and at a sub-health-board level in each of those areas. We are continuing to seek to drive that performance up further.

In conclusion, I realise that this is necessarily a brief report to the Committee, but I hope that it illustrates that the Ambulance Service is seeking to link the delivery of efficiency savings to the investment in the service through the comprehensive spending review programme in order to modernise the ambulance service, and specifically, to reduce inappropriate attendance at hospital accident and emergency departments. That benefits the whole health economy.

We are all very aware of the pressures that accident and emergency departments have been under over the Christmas period, but the proposed changes will reduce the requirement for ambulance transportation for patients, while also providing the patient with a more appropriate alternative in relation to the care that they require for their condition.

The proposal is to reduce the requirement for transportation by putting in place suitable alternatives for the patients — alternatives that have been tried and tested elsewhere. We propose to monitor the impact of those changes to ensure that they deliver the goal of faster paramedic response to life-threatening calls throughout Northern Ireland, and also to monitor the provision of targeted, timely emergency ambulance response, and transportation for patients where it is necessary and appropriate. It is not just about getting there quickly; it is about the whole continuum of care.

The proposed changes will result in additional investment in the Ambulance Service, which will create jobs and increase the number of skilled paramedic ambulance personnel in Northern Ireland. We will continue to work with our colleagues and our staff to manage the change process, which, we acknowledge, will be challenging — change is always challenging. In doing so, the Ambulance Service will seek to fulfil its responsibilities in relation to its staff and its patients.

Thank you for your time. I am happy to take questions.

The Chairperson:

Thank you for that clarity. The public hears about reductions, and about fleets being changed. The rapid-response vehicles will have one person on board.

Mr McIvor:

The vehicle will have one paramedic on board.

The Chairperson:

An ambulance carries two personnel on board, so there is a fear that something could happen to the rapid response vehicle en route, and, indeed, accidents have occurred, which could put the person who is waiting for the emergency response at risk. Someone sent me a copy of your report anonymously, and it states:

“The draft proposals outlined above are a work in progress. The target CSR efficiency savings for each division are in the region of 60 hours per week A&E reduction in year two, and a further 120 hours per week A&E reduction in year three. This is in line with overall CSR efficiency proposals of a reduction of 17,520 A&E hours in year two, and 35,040 A&E hours in year three. The totality of A&E hours outlined above falls short of these totals by around 9,000. The additional investment in rapid response vehicle hours is designated to mitigate the proposed reduction in A&E hours in two above. These will amount to an additional 43,800 hours in year two and a further 43,800 hours in year three.”

I am very concerned that the cover for A&E will be so dramatically reduced that it almost beggars belief. Obviously, it is driven more by monetary considerations than by the quality of the service to the person who needs help, that is, the person who needs to be brought to hospital urgently. I have had a huge mailbag concerning this issue, and I am sure that other members have had many concerns expressed to them about the change of vehicle and about it having only one person on board — albeit a paramedic. The hours reduced at A&E will not really give us the cover that we need, especially when there are already concerns that it is very hard to get an ambulance within the stipulated time.

We met with the British Heart Foundation this morning, and we were taught how to give resuscitation. We were also told that vehicle response time is about eight minutes. I do not know whether someone who has already suffered a major heart attack would feel confident that, if they were to suffer another heart attack, the rapid response team would get there in time, or whether they would fall victim and die because of the time factor and lack of provision that you are proposing. I know that it is only a draft outline, but can you understand people’s concerns about all the hours of cuts for efficiency savings? Sometimes, efficiency savings do not really mean that the service is efficient — it simply means that you have cut back.

Mr McIvor:

I fully understand what you are saying. In relation to the last point, the response to a cardiac arrest is the type of life-threatening situation that we are seeking to respond to more quickly, and we are succeeding in providing care to those patients more quickly. We are getting a paramedic — which is the highest level of care that we can provide — to 70% of those life-threatening cases this month across Northern Ireland. That figure has increased on previous years, and we continue to increase it this year. Therefore, we want to reassure the public that we have increased our performance in relation to response to those life-threatening calls. Those measures are designed to enhance that even further by allowing us to further concentrate our resources in that area.

The advice that you were given by the British Heart Foundation is welcome — it is important that as many people as possible get that advice. We have worked with the British Heart Foundation on how to develop measures to get such advice to the community. The British Heart Foundation is particularly strong on school visits in that regard, and we have linked up with it to discuss how we do our school visits.

The other key point is that, when a call is identified as life threatening, our ambulance control staff are trained to provide guidance over the telephone, because of the technology that we have introduced. Therefore, those who have not had the benefit of the training that the Committee received today are directed on how to give bystander CPR. That is a zero-second response and can be supplemented further by public defibrillators, such as those provided by the Cormac Trust and at sports grounds. Our staff are trained to ask if a defibrillator is available.

After giving a zero-second response and getting CPR commenced immediately, the next step is to get a paramedic on the scene with a defibrillator and the necessary drugs as soon as possible. You are correct that the target time for that is eight minutes — we all want that target to be reduced further, but we also want to spread our resources so that we adhere to that eight-minute target as many places as possible.

I accept what you say — none of us wants to reduce the number of ambulances. I referenced the investment in other ambulance services, because I welcome the application of benchmarking. There is more scope for investment in the Northern Ireland Ambulance Service. However, if I am required to reduce spending, I want to target that reduction at resources taken by patients who present with non-life-threatening conditions.

We have the technology to assess a call and categorise it as immediately life-threatening; urgent but not life-threatening; and neither urgent nor life threatening. Calls from patients with neither urgent nor life-threatening conditions number 20,000 a year. I have researched how other ambulance services in the UK deal with such calls, and they transport 50% of patients in that category to hospital. In contrast, we transport between 80% and 90% of patients in that category to hospital. We want to offer an alternative so that ambulances are not involved in the transportation of patients in that category to hospital.

I want to ensure that we free up resources currently used by patients with neither urgent nor life-threatening conditions, because that will free the ambulances for the life-threatening emergencies. For example, I have doctors and GPs in my control centre, so when a call is received from someone with a non-life-threatening condition, it can be immediately referred to a doctor who engages with and assesses the patient. The doctor may offer the patient an alternative, such as a visit from a rapid-response nursing team or a crisis-response nursing team. The doctor may even advise the patient to visit his or her GP the next day and offer to smooth the path for an appointment. Importantly, the message will be that the patient does not need to go to a busy accident and emergency unit, because that would tie up an ambulance and take it out of its response area.

Those are the areas that we are targeting. From the feedback in the consultation, it is clear that we still have work to do in conveying that message to the public. Our work in conveying that message has not been helped by some of the stories about rapid-response units in England — rapid response is a different animal here.

We have very deliberately stated, and held to the point, that rapid response in Northern Ireland is by paramedics. It is a paramedic rapid-response service. Other services have put non-paramedics in rapid response, and the emphasis there is on getting to the patient quickly. The emphasis here is on getting there quickly with paramedic personnel, and with the equipment and the drugs to intervene and make a difference in the most life-threatening cases.

The next stage that we want to develop is to be able to say that, if we have got enough paramedics, we want them to attend some of the non-life-threatening calls. A face-to-face consultation with a paramedic opens up further avenues, which may mean that that patient’s illness could be managed at home, and may prevent them from making an unnecessary trip to hospital.

The reduction in hours that we seek to achieve is inextricably linked to the non-emergency patients currently being transported to hospital by emergency ambulances when an alternative exists and we can access and build on that alternative. We could have a whole system geared towards appropriate care; maintaining the patient in their community and in their home, and caring for them there.

The Chairperson:

Liam, six members want to ask questions, but, leading from the point I made about having only one person in the rapid-response vehicle: how are we going to reduce the 80% who are dependent on transport at the moment? What other transport can one use apart from the Ambulance Service which has been utilised heretofore? Will members of the Ambulance Service become unemployed through the reduction of the rapid-response crews from two to one?

Mr McIvor:

If there is an accident en route — and you are quite right; none of us know what the road conditions will be — we have automatic tracking systems that can identify if the vehicle stops unexpectedly or inadvertently. That situation would be flagged through to control. More importantly, the radio communications in place include an emergency button on the radio which, if pressed, would override other radio traffic, and alert the control room to an emergency.

It would also alert those of our staff in the nearby area of an emergency, and has a failsafe of 30 seconds of open air. If the person is unable to communicate effectively and press that emergency button, the person listening in has 30 seconds to hear what is going on. Through the pressing of that emergency button, we can identify from the automatic-tracking system where the vehicle is, and seek to get a resource to it. In doing that, as soon as we become aware that an ambulance or a response vehicle is, for any reason, unable to respond to a patient, we will send the nearest emergency ambulance to the patient, so that the patient would not suffer. Those failsafe mechanisms are in place.

A big driver for us will be providing alternative transportation of patients, which means that they will not need to go to the hospital at all; that they can be given advice to manage their condition at home; or that we can request a rapid-response nurse team or someone else to come to the patient’s home and provide them with appropriate care.

There will be occasions when a patient still needs to go to hospital, but does not need to go in an emergency ambulance. If, in that case, we can identify that they are suitable for travel in a non-emergency ambulance, we would seek to move them in that non-emergency ambulance, if there is one available. If there is not one available, then the fall-back position will be to use an emergency ambulance. There will be a range of stages in between in an effort to ensure that emergency ambulances are available for, and targeted to, the transportation of patients who are in a life-threatening or urgent condition, rather than those cases that are not urgent.

In relation to employment, we are fortunate in that the investment that we are getting in the Ambulance Service exceeds the efficiencies coming out. However, we recognise that the investment is reliant on the efficiencies being made, but it means that we have got the opportunity to invest in our staff. By developing additional paramedic response staff and additional paramedic clinical supervisors, we will increase the number of positions in the trust and the opportunities for internal promotion within the trust.

That is why we are working with the trade unions. There is no need for staff to be made redundant as a result of this process. Some staff might be unable to adapt to the change; we want to work with them sensitively and offer and develop alternatives for retraining. This is a tremendous opportunity for our staff to develop their skills; to become paramedics; to spend more time in direct patient care with the patients who need them most; and to spend more time and be more visible in the community. That is part of our programme to develop additional appointments. I hope that that will raise community confidence. We must be more vocal in demonstrating that we have driven up our response performance across Northern Ireland.

Mr Easton:

I will be quick, because I know that we are running out of time.

The Chairperson:

We can extend it a little.

Mr Easton:

Would the Ambulance Service have made those changes if it had not been asked to make efficiency savings in the first place? Is the service losing any staff in any other areas under those new arrangements? Will there be a reduction in hours of — I hope you do not mind the expression — proper ambulances, and will any of those ambulances be lost? Given that reduction in hours, does the service have enough cover to deal with a disaster such as the Omagh bomb or an airliner crash? In the light of the loss of 70,000 ambulance hours, rapid-response vehicles will be used in emergencies initially. Only one individual will attend such emergencies; sometimes, however, two people are needed in a medical emergency. Is the service adequately covered to deal with such situations? In theory, could that also mean that while waiting for a proper ambulance to arrive, people could be lying by the roadside for a long time?

Mr McIvor:

The use of the phrase “proper ambulance” is an issue. Perhaps “traditional” is a better word. I will ask my colleagues to answer some of those questions. Would we have made changes anyway? Yes; the modernisation of the service is essential. Demand is increasing year-on-year, and given the economic situation and the history of investment in the Ambulance Service to date, we must take steps to manage demand. However, the management of demand requires us to categorise and interrogate it so that we know where the most urgent cases are, and what they are. We must be in a position to dedicate our response resources to those most urgent cases, and to provide appropriate alternatives for non-urgent cases.

In short, we would have been moving towards a modernisation programme anyway. I would have preferred to have been modernising purely on the back of investment, as any chief executive would say. That is not within our gift, however — that is not where we are. The modernisation of the Ambulance Service in order to provide a rapid paramedic response to the patients who are most in need, and targeted ambulance transport and response to patients who do not have life-threatening conditions, is the way forward.

I will ask Roisin O’Hara to talk about staffing levels.

Ms Roisin O’Hara (Northern Ireland Ambulance Service):

I shall make a few comments. The Ambulance Service has no intention of making redundancies throughout the service at the moment. As members can see in our written submission, there have been some reductions in administration. It is important to say that our administration-to-staff ratio is very small compared with other healthcare trusts in Northern Ireland. We are running at just under 4% of the ratio at present. I am aware of the ministerial target to reduce to 19·5%, but our administrative base has been withdrawn and de-layered through the years.

As far as changes are concerned, we are using some vacancy control. For example, we have quite a few vacancies for administrative and clerical staff at the moment.

We will use agency staff slightly less and look at recruiting permanent staff where possible. There will be no redundancies in that area either.

Mr McIvor:

When you asked about the reduction in ambulances, did you mean the physical vehicles?

Mr Easton:

A proper one.

Mr McIvor:

Setting aside the CSR, with that big capital investment we will seek to replace ambulances. I am certain that that news is very welcome. We have been struggling with that area for quite some time. At present, we run a fleet of 132 emergency ambulances, more than 60% of which are more than five years old. There is a risk associated with an older vehicle.

Through investment on a continual year-by-year basis, we will replace those ambulances — at rate of roughly 20 to 22 emergency ambulances a year — until we get a flat profile of ambulances. We envisage that that replacement strategy — to ensure that there are no peaks and troughs in the ages of the ambulances — will take five years. We will then move to reduce our base from 132 ambulances to 110 ambulances. That will be a challenge, but we will monitor it over the course of the strategy.

It is a necessity that the replacement strategy be fluid, so that we can also react to acute-service changes such as in Omagh and Enniskillen, where investment in additional crews necessitates increasing the fleet. Although we seek to rationalise the service and to reduce the overall number of ambulances, we also have to be very careful to point that we have to add on two or three ambulances to reflect that acute-service change.

If, as a result of acute-service reconfigurations, other service changes are made at, for example, the Mid-Ulster Hospital, we will press to ensure that the impact of those — ambulances making more journeys, having longer journey times, or taking patients to different areas — on our service is clearly recognised and identified. Although the local trust will lead those changes, I have argued consistently that there must be recognition of the impact of those on other stakeholders, such as the Ambulance Service, which is a probably a primary stakeholder.

Service changes might also affect the flow of patients from, for example, the Mid-Ulster Hospital to Craigavon Area Hospital —which will impact the hospitals themselves — or indeed, from Whiteabbey Hospital to the Mater Hospital. Those changes will hit both the Ambulance Service and the hospitals.

Those changes must be managed, so that their consequential impact on other stakeholders, such as the Ambulance Service, is fed into the equation. I am sorry that I have rambled on about this matter. The short answer is yes. We propose to reduce the physical number of ambulances. However, the reason for that is more related to the current age profile of the fleet, because 60% of our ambulances are more than five years old and have significantly high mileages.

Once we have a fleet of younger ambulances with lower mileages, we will seek to reduce the number of ambulances that we run with. We will monitor that on a monthly basis. The fleet strategy has a built-in a process to monitor and deal with the regional health board and to regularly update it on our progress.

We have a major incident plan that incorportes escalation measures to ensure that available resources are deployed to deal with an incident and other ongoing work. Reduction in cover is linked to a reduction in demand, and, therefore, has a neutral effect. In broad terms, we will have the same capacity as we do at present.

If you were to ask me now whether we have enough resources to deal with an emergency, I would have to say that it would depend on the nature and scale of the emergency. We have a plan that we exercise and test. I assure you that all available resources that we have would be directed to deal with a large-scale emergency. Any additional resources that were made available would also be directed to dealing with the emergency and to managing its consequences. The issue will be how quickly we can manage and deal with the consequences of an emergency. More pressure would be placed on resources if there were a major incident, such as 7/7 or 9/11, or a multi-area incident. In that kind of scenario, we call on resources from beyond the Ambulance Service.

Indeed, we were engaged in the evacuation that took place at Drumaness earlier this week. An old people’s home nearby was at risk. Emergency planning officers and local ambulance officers were present, and an emergency ambulance was one of the earliest responders to arrive on the scene. We also dispatched several patient care ambulances, because they are the most appropriate type to move a large number of old people. Importantly, we liaised with the Fire and Rescue Service and the Police Service. Translink was also brought in to move patients. Therefore, in that context, it became a multifactorial and multi-agency event.

We exercise such events with the police, the Fire and Rescue Service, the coastguard service, the Territorial Army and a range of other partners. A short while ago, there was a big operation on the Boucher Road that involved Translink as well. It was a valuable exercise because we learned a lot from it. We always hope, however, that we will never have to put it into practice, but, if necessary, the procedures that we have in place will be put into action. A range of measures will be escalated through the plan.

One person in the rapid-response team deals with the other situation that was mentioned. I will ask Brian, the director of operations, to pick up on that.

Mr Brian McNeill (Northern Ireland Ambulance Service):

A patient’s outcome will not be determined by the type of vehicle that responds, but rather by the speed of the response and the arrival of a paramedic as quickly as possible. With that in mind, I will describe how that will be realised when the proposals come into play.

Traditional accident and emergency vehicles will work as part of the system, which will have 131,400 additional hours of rapid-response-vehicle cover. Recently, we invested in new technology that will allow control staff to see quickly, when someone makes a 999 call, where that person is calling from on the map on the console, and also the location of the closest available response unit. In some instances, that may be a traditional accident and emergency vehicle, while in others, it may be a rapid-response vehicle. In some cases, it may be one of our uniformed officers in a car. The controller will immediately dispatch the closest available unit to that patient.

We know from experience that certain categories of calls will require a traditional accident and emergency vehicle; as you say, quite rightly, for more hands, and also because there is a high expectation that the patient will require transportation. Reasons for that include: cardiac arrest; trauma; and road-traffic collisions. Therefore, in the event that we send a rapid-response vehicle as the first response unit, the control team will immediately look for the closest available traditional accident and emergency vehicle, and deploy it as well. Therefore, in some cases, there will be a dual response. We make no exception for that because we know our business, and we know that that will be required.

I do not anticipate that anyone will be lying by the roadside, as you put it. Our plan is to get help to patients as quickly as possible. When we know that a patient will need transportation or that the crew will need additional help, we will get that to them. Quite often, we send a rapid-response vehicle or, indeed, two accident and emergency vehicles to some road-traffic collisions, based on the information that we get from the caller.

Dr Deeny:

I am sure that you will not mind me saying, Madam Chairperson, that the issue is crucially important for all of us, including the Ambulance Service. I welcome you, ladies and gentlemen.

As a front-line health professional, the matter is extremely important to me. At the outset, I must comment that you have a big job of work out there on communication. People do not understand what rapid-response vehicles do. The implications of those changes must not only be explained to front-line healthcare professionals but to patients and the public as well. I am reassured by some of the comments that have been made. I have heard that, already, ambulances are being used more in my area, which, despite its being the largest of the Six Counties, has, this week, lost the last remnant of its lifesaving services.

Therefore, I am particularly concerned about ambulance cover, and some of my GP colleagues are also expressing concern. I understand, and I think that people should know, that a rapid-response vehicle does not take a patient to hospital. I also want to be reassured that a doctor takes every decision on whether to send a rapid-response vehicle. You talked about doctor triage.

Mr McIvor:

The doctor triage is for non-life-threatening, non-urgent calls — category C calls. That is where doctor triage comes in.

Dr Deeny:

Who decides to send a rapid-response vehicle?

Mr McIvor:

The officer who is manning the rapid-response desk does that on the basis that a 999 call has been received and on which nearest response unit can get to the scene.

Dr Deeny:

It worries me because, as a doctor, sometimes I know, on the strength of a phone call, whether a patient should go to hospital; however, often I do not know until a patient is assessed. Therefore, it worries me that a rapid-response vehicle is dispatched when an emergency ambulance is available, even though it is known that that person — without being assessed — will not be taken to hospital.

Mr McIvor:

If you, as a doctor, have a patient about whom you are worried and you phone through a request for an ambulance to take that patient to hospital, you will get an ambulance to take that patient to hospital. We will ask you to explain the nature of the call, the time frame within which the ambulance is required, and the ambulance will be sent.

Dr Deeny:

I am not talking about a doctor ringing in. I am talking about a 999 call that someone has taken requesting a vehicle, and the person who has taken that call decides to dispatch a vehicle that will not take that patient to hospital before he or she has been assessed. That worries me.

Mr McIvor:

The person who takes the 999 call asks a series of targeted questions in order to determine very quickly if the patient is conscious, if he or she is breathing and to establish other symptoms. If the patient is not conscious or not breathing, the default scenario is that that phone call concerns a potentially life-threatening condition, and the nearest paramedic rapid-response vehicle or accident and emergency ambulance is sent.

Therefore, that call comes in, and it is treated as category A — life-threatening. We send the nearest response unit, and we do not delay the ambulance because a rapid-response vehicle is being sent; we send both. If there is no rapid-response vehicle near enough — if it is busy or it is not available — the nearest ambulance is sent. If there is a rapid-response vehicle, it and the nearest ambulance are sent. We deliberately do not delay the dispatch of the ambulance. I cannot make it any clearer than that. That is what happens.

Dr Deeny:

You talked about monitoring, which I believe is very important. The Ambulance Service must receive feedback from the front-line professionals. If that feedback is negative, and GPs say that there are major problems, you must take those on board.

A response time of eight minutes was mentioned. I know that that cannot be done. Some of my patients would be lucky to be seen in 18 minutes. Therefore, it is extremely important to have facilities that enable patients to be stabilised at the scene. At present, there are no lifesaving services in County Tyrone. Alex is quite right, and there are more incidences than he has described. I know of many instances in which two people are needed to stabilise a patient, and that is what will save lives in the future. I have tended to patients suffering from conditions such as a seizure, and they had to be stabilised at the scene. I could not have stabilised those patients without help. It is important that there be stabilisation at the scene. Therefore, that question is about ensuring that there is feedback.

There should be a protocol for defining what type of cases a rapid-response vehicle will be sent to. That would benefit front-line healthcare professionals, including emergency nurse practitioners and GPs. Such a protocol must also define cases that rapid-response vehicles should not be sent to. I am reassured by the fact that rapid-response vehicles will be backed up by emergency ambulances. However, it is important that the Committee realises that, once a rapid-response vehicle is sent out, the decision has already been taken that the patient is not going to hospital. That is the way that it appears. Let us work on those protocols.

I am trying to clarify the matter. If you think that, in instances when a patient may need to be hospitalised, a rapid-response vehicle may be sent out because it is nearest and it will be followed by a back-up emergency ambulance, that is fair enough and is reassuring.

We do not want an inappropriate vehicle to be sent out to sick patients, because we do not want to look back and think that a patient should have been admitted to hospital, but it took 20 minutes for a rapid-response vehicle to arrive and another 20 minutes before an emergency ambulance arrived, which resulted in the death of a person who had had a major life-threatening event. The procedure must be streamlined.

Mr McIvor:

You are quite correct. We need feedback from the front line — that is, from our staff and from other healthcare professionals. The area that Dr Deeny represents is one example of an area where the co-ordinator whom we have in place is getting daily feedback. Dr Deeny’s assessment is that ambulance activity has increased in the week since the changes have come into place; I am pleased about that. As would be expected, I have been monitoring the situation and have found that the response times are also up, which encourages me because it means that the people whom I have put in place are doing the right thing.

There are two aspects to a protocol for rapid-response vehicles. One is to provide reassurance that, if the presumption is that the patient will be going to hospital, an ambulance will follow up the rapid-response vehicle and that it is a paramedic response. Our emphasis is on getting paramedics to the scene of an incident as quickly as possible so that they can assess the patient and determine their needs. Dr Deeny is quite right; there will be occasions on which paramedics determine that they need further assistance, and, in that scenario, the investment that we have made in mobile radio communications is critical.

Until about two years ago, the only radio communication devices that paramedics had were in the vehicle. We have now equipped all emergency ambulance personnel with hand-held devices so that they can remain in communication with the control centre. Those devices also allow paramedics and other staff to request assistance when they need it and indicate the priority assigned to the incident. Importantly, they can also give clear directions about where they are, because, once they leave the vehicle, the tracking goes.

The second aspect of the protocol is the suitability of the cases that rapid-response vehicles go to. Protocols and procedures are already in place for us not to send rapid-response vehicles to incidents where we consider that the staff are at risk of physical violence. If we are sending rapid-response vehicles to such locations, the protocol is to request PSNI assistance or for the staff to assess the situation and report before they actually engage. None of us wants the paramedic to wind up as a victim, along with the person who needs care.

Dr Deeny:

What are your plans for informing the public? They do not know about this issue; they see the efficiency savings as cuts. I could not agree with you more that we must have more efficient use of our ambulances — there is no doubt about that. Too often, over the years, the Ambulance Service has been abused because ambulances have been used for purposes for which they should not have been used. It is fine if we do things more cheaply, as long as clinical standards are maintained. It is important to get the message through, not only to healthcare professionals but to our public. How do you envisage doing that?

Mr McIvor:

The consultation is now closed, but it has given us a tremendous opportunity to provide feedback, demonstrate clearly that we have listened to what has been said in the consultation and take that on board, so that we can present it in a way that will be understood by the public. When undertaking the consultation, we engaged with Mencap to produce an easy-read version of the document. We made that effort in order to make a difficult topic somewhat more manageable.

Now that the consultation period is over, we need to go to the next stage and build relevant and effective measures, which go beyond the speed of response and deal with what happens when a vehicle arrives at the scene of an incident. That will cover procedures such as the administration of oxygen, the administration of aspirin, the application of face, arm, speech, time (FAST) tests to identify and determine the occurrence of a stroke, and what we do thereafter to provide the best care for the patient. We should also compare our performance in procedures such as the return of spontaneous circulation with performance elsewhere, although we have seen an improvement in that.

We should also examine our performance in matters such as the frequency with which we deliver paramedic thombolysis and have a good outcome by ensuring that patients survive to reach a hospital as a result of their being administered clot-busting drugs within 15 or 20 minutes rather than the time that it would have taken if we had to take them to hospital first. We have to use the opportunity of the feedback and consultation to convey that information to the public. We should also engage with people such as Dr Deeny and other GP professionals and ask how they can assist us and how we can do this together.

We must be very clear — as we have tried to be today — that this is not about delaying the traditional ambulance response; it is about providing a rapid paramedic response that is supported by the capacity to transport the patient as well as directing those response vehicles to the patients who need them most to try to give the best possible care.

We are keen to become involved in longitudinal research on the outcome of patients. However, a great difficulty is that we do not have a phone number for a patient whom we pick up from the side of the road; if we are lucky, we may have a name and address. Therefore, we want to find ways to tie our information, which is patient specific but not individualised, to the information that the hospital has to see whether we can track the outcome of that patient. We may have a relatively modest impact at the outset; however, we want to measure that impact and see what happens thereafter.

Mr Gallagher:

In common with other members of the Committee, I have been to Knockbracken Healthcare Park, and I was very impressed by the way in which its operations are run. Liam has already answered some of my questions about non-life-threatening situations. However, can you assure us that that will always be decided by a GP? Will a GP be available, 24/7, to assess which calls go into that category? I am sure that we all agree that a call concerning, for example, a sore heel is easy enough to adjudicate; however, most of the time, it will be more difficult than that.

One does not want to send an ambulance out needlessly, and the advice to callers in those non-life-threatening situations might be to contact their GP, or, if necessary, the out-of-hours service. In the west, the out-of-hours service for Fermanagh is based in Enniskillen. Therefore, it can happen that a patient may ring up from Rosslea, some 30 miles from Enniskillen, to be told that the doctor is on his way to Belleek, which is 30 miles in the other direction. The doctor has to complete the call in Belleek, spend 15 to 20 minutes with that patient, get back to Enniskillen and then travel to Rosslea.

When the system is introduced, the doctor at Knockbracken in Belfast — if it is to be a doctor who will make the decision — must be aware that, in rural areas, under the out-of-hours arrangements, there can be quite a delay before a patient is seen. I am interested to hear your views on that because I am a bit worried about such situations.

Mr McIvor:

Currently, a GP is involved in call handling. That is a pilot scheme, and we will assess its suitability. The scheme has been running since January, and the initial impression is that we are very pleased with it. As part of that, we will measure the cost-effectiveness of the service and decide whether it is effective to continue to use a GP. There are other ambulance services in the UK in which that task is undertaken by nurses or paramedics, and that will form part of the evaluation.

At this point, however, we are using GPs; part of the reason for that is that referral services here are not as well developed as elsewhere. There are some referral services that will accept a referral only from a GP. That is why we were quite specific in saying that, at this point, we want to run the service with a GP. As the service develops, crisis response nursing teams may be content to accept referrals from, for example, paramedics. However, at the minute, we are not. That is why I would not rule out the development that it may be someone other than a GP providing the service.

Currently, the service is provided 16 hours a day; it is not 24/7, and that reflects in the profile of the calls. The number of calls drops considerably in the early hours of the morning, as one will know from GP out-of-hours cover. We are targeting 16 hours a day. However, in the future, we would have to consider whether there are other appropriate alternatives to that.

There is no requirement for an ambulance to attend a patient who has requested a GP out-of-hours service. However, a patient is involved who needs assistance. That is a tremendous opportunity for further development of the paramedic in the solo vehicle. If a doctor is on his or her way to Belleek and then has to go to Rosslea, which is a 60-mile round trip, there is an opportunity to see whether someone else can undertake that face-to-face assessment on behalf of the GP and report back and have communication with the GP. If we can create and encourage far stronger links between ourselves and the GP out-of-hours service, there are synergies that we can exploit, and we can become the eyes and ears, and, on occasion, the hands of GPs and provide a more immediate response to the patient.

However, that will be another development of paramedic rapid response. It is not just about going to life-threatening calls; there is an opportunity for them to go to non-life-threatening calls, conduct a patient assessment and offer an alternative. That would lead to future development potential. Of course, I would then be seeking additional resources to support that. Nevertheless, the question is whether paramedics can go to some of the calls currently being attended by GP out-of-hours services, do it more quickly, report back and work with the GP.

To give a further degree of reassurance: where the doctor in control feels that it is appropriate for a patient to make an appointment with GP out-of-hours service, he or she can follow that up by saying that, if the patient’s condition changes or deteriorates, or if the patient feels the need to come back to the doctor, he or she should telephone again. The doctor is at the end of the telephone and can engage further. It would entail a straightforward 999 call, which would bring the patient back into the system, where he or she could re-engage with the GP who made the first assessment in the control centre. It is relatively straightforward for a patient to come back to us.

Mrs Hanna:

The Committee’s visit to headquarters was worthwhile. We have a better understanding of how your operation works, and a better understanding of the work that is done by your operators. They are skilled in handling calls and obtaining as much information as they can in order to make decisions.

I appreciate that you have to manage demand, and that is happening throughout the Health Service. Categorising is appropriate; we all know of occasions of an ambulance going out unnecessarily, when it could have been used elsewhere. There are also hoax calls and attacks on staff. All of that must be taken into the mix. The service will always have to be efficient. However, if the Ambulance Service did not have to make these 3% savings, you would be using the rapid-response vehicles anyway. However, would you be using the ratio that you will now use?

What is the main saving? Is it in having one person rather than two, or is it in having the different vehicle. Would there be the same saving in having a paramedic in the rapid-response vehicle as opposed to having two people in an ambulance? Should paramedics have the same level of training? I take on board everything else that you said about getting more information on the way to the scene and then assessing whether an ambulance is needed urgently and ensuring that it will be made available.

First and foremost, the real concern is for people who are in life-threatening situations. It is very important that they are reassured that target times will still be met. I realise that there is a huge difference between people who live in Belfast and people who live in the rural west, and we must always bear that in mind. If someone has a heart attack in Belfast, he or she will very quickly be taken to Belfast City Hospital or to the Royal Victoria Hospital, but it is different for a person who lives in Fermanagh.

Where will the main savings be made? If you had a choice, would you still change the ratio between ambulance and rapid-response vehicles, or would the change be more gradual? Are you still meeting your target times?

Mr McIvor:

I will answer some of those questions, and I will pass on others. The main savings are in reducing the requirement to transport patients. Investment in the rapid-response vehicles will improve our cover and performance, and will maintain cover. That is the biggest area. It is about assessing how we reduce demand on the service, particularly the demand to take patients to hospital who could be treated alternatively. Investment in rapid-response vehicles is a key part of that strategy because the rapid-response staff will undertake face-to-face consultations. They will speak directly to the patient and offer an alternative, as will the paramedic staff in the ambulance if they arrive first.

Mrs Hanna:

The out-of-hours doctor also does that over the phone.

Mr McIvor:

That is correct. As far as training is concerned, the ambulance paramedics and the rapid-response paramedics both go through the same training programme. Currently, the rapid-response paramedics have a higher level of training because they are being trained in the administration of the thrombolysis drug and the equipment that allows them to do that.

It is important to note that that training is provided for paramedics throughout Northern Ireland. We want to extend that because, up until now, out-of-hospital thrombolysis has been largely dictated by how close the patient was to a hospital from which the team was dispatched. We want to move beyond that situation so that rapid-response vehicle paramedics are equipped to perform thrombolysis.

To date, thrombolysis has successfully been provided in Enniskillen and Londonderry, which is very pleasing. Next year, we intend to have all our paramedics equipped with 12-lead defibrillators — with telemetry, so that the paramedics are able to communicate with the hospital — and with thrombolytic drugs, so that the paramedics in the traditional ambulance and in the rapid-response vehicles can provide thrombolysis to patients who have suffered heart attacks. We want the first paramedic to arrive to be equipped to deal with that situation.

You sought reassurances that the target times were being met. We monitor those more than daily. Pagers will, no doubt, go off before very long to tell us where we are currently. We have driven up our response times for life-threatening, emergency, category A calls year after year.

We aim to reach those targets as quickly as possible, so a secondary benefit is that the response times for all 999 calls are dragged up on the coat tails of the target times. That is also positive, and we will continue to monitor both situations. We have said that we will continue to monitor the arrival of the traditional conveying ambulances to ensure that they reach the scenes in a reasonable time frame. I do not want paramedics to be delayed; I want them to be released as quickly as possible.

Mr McNeill:

It is important to point out to Committee members that rapid-response vehicles are not new to our service; they have now been in operation for the past four years, with a great degree of success, particularly over the past year, in which the number of units in the system has increased from 12 to 22.

It was always in our plans to change the ratio of ambulances and rapid-response vehicles. Since the review of the service in 2000, it was our plan to complement the existing accident and emergency ambulances. The efficiency savings are a different debate. The rapid-response vehicles improve outcomes; if a paramedic arrives at a scene with a defibrillator and drugs in less than eight minutes, it improves the arrest patient’s chances of survival by 43%.

Recent data indicates that rapid-response vehicles arrive first at the scene 85% of the time. There is no doubt about the clinical efficacy of their being on the ground.

We would be changing the ratios anyway, to answer your question. More paramedics on the ground and faster response times mean better outcomes for patients.

Mrs Hanna:

It is very important to get the positive messages out there, because as you are aware, the negative messages take legs.

Mr McIvor:

You have made a very good point. Our staff constantly tell us that they want to deal with the patients who need to be dealt with; not with those for whom an alternative exists. This will be the proof of that, and it will be very important that we assess the patients that are seen by the GPs and report back rapidly to our staff. Our assistant medical director is dealing with that now. For 25% of the first 600 patients, no ambulance was sent: an alternative was provided. For 15%, an emergency ambulance was not required, and an alternative ambulance was provided.

We will be feeding that back to our staff very quickly to tell them that this is what they have been asking for — a system which allows them to deal with, and focus on, the people who really need their care quickly.

Mr Gardiner:

Being last in line, I am sure that you have covered quite a lot of what I had indicated that I wanted to ask earlier. You have said that there are alternatives for the patient in relation to transport, and I know that you have covered quite a lot of them, but can you elaborate a wee bit more on what the alternatives are for the patients?

Mr McIvor:

There are two key areas; one question is whether the patient needs to travel in an emergency ambulance, or whether they can travel in a non-emergency ambulance. We have emergency ambulances with a paramedic and a technician, and we have non-emergency ambulances with ambulance care attendants: ambulance drivers with some attendance skills. Those are further sub-divided into the ones with seats or those with a stretcher. There are some occasions when we would say that there is no requirement for an emergency ambulance; that the patient could be picked up by a non-emergency ambulance and transported to hospital. That is an alternative that we can bring in —

Mr Gardiner:

But it is an ambulance?

Mr McIvor:

Yes, it is an ambulance, but it is not —

Mr Gardiner:

It is just that, when you said “alternative transport”, I was beginning to wonder whether a neighbour or family member would have to drive the patient to hospital.

Mr McIvor:

If the GP has assessed the patient, and there is no urgent need or requirement, then it is a bit like the GP out-of-hours service. There will be occasions when patients will be told that there is no requirement for them to travel by ambulance or to go to hospital, or if they do need to go to hospital, that there is no requirement for them to travel by ambulance. In that case, they would be asked if they have an alternative way to travel. That would have to be done on an individual, face-to-face, case-by-case basis. The other alternatives would be around not going to hospital at all, if we could bring something from the healthcare system to the patient to enable them to stay at home.

Mrs McGill:

I share the concerns raised by Tommy Gallagher and Dr Deeny about the west — the Omagh and Strabane areas particularly. The figures show that local performance measurement in Omagh was 52·9% response within the eight-minute limit in the year 2007-08. In Strabane, that figure was 45% response within eight minutes. Brian, you have said that speed is the key. Currently, the situation is not good in the areas that I represent. I know that the EQIA deals with the different categories of Section 75, but what about rural proofing? Will these figures improve, and where is the nearest rapid-response vehicle to Strabane?

Mr McNeill:

There is no doubt about it: providing an ambulance service, especially an emergency response in a rural environment, is very challenging. That was recognised in the PFI target, whereby this year, the Minister has specifically identified a 62·5% target for rural areas, rising to 65% in the year to come. That has been helpful for us in being able to have debates with commissioners about resourcing those particular areas, and was part of the success for Omagh where we were able to get an additional 24/7 vehicle into Omagh and to Enniskillen, and increase cover to 24/7 in Castlederg.

However, the resources for rapid response in rural areas are managed by each control desk. A desk controls the Western Board area and, depending on the activity on a particular day, the control team determines where rapid-response vehicles, and accident and emergency vehicles, will be located. Their job is to respond to calls and to move patients. I cannot give you a specific location for a particular vehicle at any given time. I can only say that all available resources in the area are utilised to try to achieve the best possible performance. I accept, however, that we face a major challenge.

Mrs McGill:

In the west, will that figure of 62% be achieved in the Strabane and Omagh district council areas? How many of the vehicles are based somewhere in the west and in the Strabane and Omagh district council areas in particular? Are they based at Altnagelvin Hospital or Omagh Hospital?

Mr McNeill:

Each station has a complement of vehicles for each shift. In Omagh, for example, we have three 24/7 vehicles and one day vehicle. We also have some alternative transport vehicles, such as the intermediate care vehicles. Vehicles are based in two sections of Omagh town to try to improve performance; there is a deployment point in Omagh town as well as at the station. Vehicles are also based in the Strabane and Castlederg areas and a complement of vehicles work out of Enniskillen station. Thus, there are vehicles based at stations and additional specific deployment points at, for example, Irvinestown and Fintona. Where we have more than one vehicle available at a station, we move the remainder into the rural community to try to improve response times in the area. Where the vehicles are based depends on the demand at a given time.

There are also vehicles that move within the system: for example, as Dr Deeny said, the recent changes mean that a vehicle may pick up a patient at Omagh and take him or her to Altnagelvin Hospital. However, as the vehicle is returning towards Omagh, it may be redeployed to Enniskillen to cover for a vehicle that has left that area. It is a matter, therefore, of maintaining cover in the different areas as well as moving patients.

Mrs McGill:

Are the vehicles travelling most of the time?

Mr McNeill:

Yes, and that is exactly what we want. From experience, the more time the vehicles spend moving, the better their response time, because we do not have to mobilise them from the fixed location of a station.

Mrs McGill:

What figure have you achieved in the Strabane and Omagh areas, and has it improved?

Mr McIvor:

As the figure of 62·5% is measured at board level, there will be variation, as is the case in the Eastern Board area. Up until last year, our performance was measured at a Northern Ireland level, but there is now differentiation at board level. If you want to take it a stage further, the question is whether to go down to local care group or council area. The resulting figure would not be 62·5% because there would be a range, but it would be reasonable to set meaningful targets at those levels.

Rather than simply focusing on targets for response time, I am anxious that the service starts to move towards more clinically oriented targets and to measure the clinical performance at each incident: did staff use defibrillators, administer oxygen, administer the appropriate drugs, and so forth? That would mean that both elements of response were being measured. I am not trying to diminish the importance of response times, but we need to move forward on several fronts.

Mrs McGill’s last question was whether performance had improved. Performance is variable, but there has been a general improvement of between 5% and 6% so far this year, and, in the past month, we have managed to deliver performance at 68% in the west, which is close to our target for Northern Ireland of 70%. I am afraid that I do not have the figures for Strabane with me.

The Chairperson:

I thank Liam and the other witnesses for coming along today. I do not want you to go away thinking that we do not appreciate and applaud the work of the Northern Ireland Ambulance Service. It is simply the case that, as elected representatives, we have concerns that we have the best provision possible for the people who elect us and whom we all serve in different ways. Thank you for your presentation and for all your answers.

Mr McIvor:

I really want to thank the Committee, because the questions have been searching, very pointed and intelligent, which indicates to me the interest that you show in the service. That interest can only be to our good as we move forward. I appreciate the time and effort that you have put into considering us.

The Chairperson:

You are very welcome. Thank you for your presentation.