Northern Ireland Forum

for

Political Dialogue

~~~~~~~~~

THE NORTHERN IRELAND

AMBULANCE SERVICE

A Review by Standing Committee 'C'

(Health Issues)

~~~~~~~~~

Presented to the Northern Ireland Forum for Political Dialogue

on 27 March 1998

Adopted CR24

Note

DRAFT REPORTS

This report has been prepared by Standing Committee C for

the consideration of the Northern Ireland Forum for Political

Dialogue. Until adopted by the Forum in accordance with its

Rules, this report may not be reproduced in whole or in part

or used for broadcast purposes.

ACKNOWLEDGEMENT

The Committee is indebted to those organisations and individuals

who willingly and generously gave of their time and expertise to

make this study possible.

This report is itself dedicated to the hardworking and committed men

and women of the Northern Ireland Ambulance Service (NIAS).

Top: The Committee in session. L to R: Cecil Calvert, May Beattie, Sam Gardiner,

Joan Parkes (Vice-Chair), Tom Robinson, Gregory Campbell, Bob Coulter and

Denis Arnold (Secretary).

Bottom: Members chat with Gron Roberts, Chief Executive of EAS.

CONTENTS

Section Page

1. PROLOGUE 1

2. INTRODUCTION 3

3. BACKGROUND 5

History and Structure 5

Charter Standards 6

The New Standard 8

EU Funding 8

Throughput 9

Ambulance Fleet 9

Purchaser/Provider Split 9

Purchase of Ambulance Services 11

Contract Negotiations 12

Costs 12

Cost Improvements 14

4. SOME ISSUES 16

Financing 16

Capital Funding 18

Comparisons with Other Services 19

Some 'Little Local Difficulties' 19

Midwifery 22

Acute Hospitals 23

Strategic Review 23

Ambulance Stations 24

Building Standards 26

Training 26

Status of NIAS 27

Amalgamation with Fire Service 28

Early Retirement 29

Violence 30

Visit to England 31

CONTENTS

(Cont'd)

Section Page

5. SOME DEVELOPMENTS 34

Information Leaflets 34

Thrombolytic Therapy 34

Motorcycles 34

Helicopters 35

Paramedic Degree Course 36

Health Education in Schools 36

6. EPILOGUE 38

7. PICTURE GALLERY 39

8. LIST OF CONCLUSIONS AND

RECOMMENDATIONS 40

APPENDICES

Appendix A Remit of the Committee

Appendix B Committee Membership

Appendix C Record of Committee

Visit to Knockbracken

Appendix D Visit to Dungannon

Appendix E Visit to Castlederg and Omagh

Appendix F Visit to Downpatrick

Appendix G Visit to Strabane

Appendix H Visit to Londonderry

Appendix I Visit to Magherafelt

Appendix J Visit to The Beeches

Appendix K Record of Committee Visit to England

Appendix L Range of Commercial Activities in SYMAS

Appendix M Example of Headline News

Appendix N Compendium of Oral Evidence

Appendix O Strategic Objectives of NIAS

1. PROLOGUE

1.1 In the early hours of 16 November 1997 there was a house fire at

Glenowen, Londonderry in which four people died. The incident was

widely reported by the media. It was one of a series of incidents that

happened that evening in the Londonderry area which stretched the

Ambulance Service in the North-West to breaking point. On the same

evening there was a road traffic accident which was attended by the

RUC who, in the absence of an ambulance crew, of their own violition

following contact with Ambulance Service staff, took the casualty - a

pregnant lady - directly to hospital.

1.2 Other incidents involving ambulance personnel in the region that

evening included an attempted suicide and a serious assault. There

were two emergency vehicles in the city that night. One of these was

available for dispatch to the fire at Glenowen where a total of five

persons required resuscitation. A regular crew of two is capable of

resuscitating one person at a time.

1.3 Tragically only one of the five inhabitants of the house at Glenowen

survived the fire. This is not to suggest that had there been more

vehicles available the result would have been different - such a

conclusion would be far too simplistic and is not warranted.

1.4 Whatever the truth of the matter the incident was a serious one that

was to add a sense of urgency to an investigation begun only days

earlier by the Forum's Health Committee into the funding and operation

of the Northern Ireland Ambulance Service (NIAS).

1

1.5 The Londonderry incident was not a one-off event: there have been

many such serious incidents, both before that of 16 November and

since, in different parts of the Province.

2

2. INTRODUCTION

2.1 The Committee initially decided that the Ambulance Service would be

looked at as a special 'quick' exercise alongside the other work in its

agreed programme. It would be 'quick' because following incidents of

the kind that happened at Glenowen members felt that it was important

to get to the nub of the problems facing NIAS before there was a

repetition of the events of last November.

2.2 Evidence was sought from Mr Paul McCormick, Chief Executive of

the Northern Ireland Ambulance Service; from UNISON which

represents some 90% of unionised1

ambulance staff in the Province;

from the Health and Social Services Boards - these play a key role in

the funding of Ambulance Services; from ambulance staff themselves,

during a series of visits to stations and control centres around the

Province; and lastly through visiting Ambulance Trusts across the

water.

2.3 All of the visits are fully documented and appear as Appendices to the

Report.

2.4 Following this short introductory section the report delves into the

themes and issues that have emerged from the evidence. This element

is presented in two main sections that deal with Background and

Issues. Recommendations, also, appear throughout these sections.

The report then brings together a list of conclusions and

1 Approximately 80% of NIAS staff are unionised.

3

recommendations and these are followed by the usual annexed

supporting evidence.

2.5 During the course of this exercise the Committee visited England.

Parts of the visit were recorded on camera and the report contains a

somewhat light-hearted photo-montage of the Committee during the

course of this stage of its investigation.

4

3. BACKGROUND

History and Structure

3.1 The Northern Ireland Ambulance Service was set up as a Trust in

April 1995. It followed a merger of the existing ambulance

organisations within the Province. At formation there was already one

extant Ambulance Trust based in the Eastern Health and Social

Services Board area. The other organisations were the ambulance

elements of the other 3 Area Boards.

3.2 The Northern Ireland Ambulance Service is one of some 40

Ambulance Trusts within the United Kingdom. It is like Scotland (and

soon-to-be also Wales following amalgamations) a single territorial

service covering a 5,000 sq mile area. This makes it third largest in the

United Kingdom in terms of area (counting Wales as a single Trust

area). The Service is headquartered in Belfast and has a five-division

structure. Two Divisions are based in the Eastern Board Area (Eastern

City and Eastern Country). Each of the other three divisions covers a

whole Board Area.

3.3 It has some 30 ambulance stations where crews and vehicles are

housed. Seven of these are purpose-built. Operations are directed

from 4 control centres at Altnagelvin, Holywell, Craigavon and

Knockbracken representing the control centres of the Northern Ireland

Ambulance Service's predecessors. Some 60 staff work in Control.

5

Staff at stations are normally organised into two or three shifts in any

24-hour period.

3.4 The NIAS Training Centre is a shared resource located at The Beeches

in Belfast. The facility includes dormitory accommodation as much of

the training delivered is residential.

3.5 NIAS has 700 staff of which some 500 work in its emergency service

but this will shortly increase. There are approximately 230 paramedics

and it is a NIAS' aim to have one paramedic in each emergency

ambulance.

3.6 The Northern Ireland Ambulance Service has some of the best and

most experienced ambulance personnel to be found anywhere - not

least because of the history of the last three decades.

Charter (or ORCON) Standards

3.7 The NHS has a long and noble tradition of service-provision that is free

at the point of delivery. That delivery meets a need, otherwise it would

be pointless and wasteful. In the case of ambulance services the need

can be measured in various ways. The most telling measure is the

extent to which official operating standards are being met in various

parts of the Province.

3.8 The Government has laid down the operating standards that should

apply. These are known as Charter standards and are applicable to the

6

UK as a whole. Only some elements of the standard apply to Northern

Ireland. These are:

that an ambulance should be at the scene in 50% of emergency calls

within 8 minutes;

that an ambulance should be at the scene in 95% of emergency calls

within 18 minutes. This is known as the "rural" standard and is

applicable only in the Eastern Board area; and

that an ambulance should be at the scene in 95% of emergency calls

within 21 minutes. This is applicable in the rest of the Province.

3.9 Whilst the standards have been met globally within each Board area

with the notable exception of the Northern Board there are certain

individual stations which consistently fail to meet them, for instance at

Downpatrick, Enniskillen and Dungannon.

3.10 These standards, it must be said, are out of date with the current

thinking of policy makers and new standards will be introduced in the

financial year 2000/01. Under the new arrangements it will be

necessary for the Service to be able to respond to 75% of

life-threatening emergencies within 8 minutes. Research points to

perhaps only 40% at most of present 999 calls in fact being genuine

life-threatening emergencies.

7

The New Standard

3.11 The new standard will be based totally on a Priority Dispatch System

made up of a series of protocols that will allow for some basic facts to

be discovered about a given situation before decisions are made. The

system will also allow controllers to offer direct advice over the

telephone (controllers are at present neither empowered nor trained to

do this).

EU Funding

3.12 NIAS has successfully applied to the EU Special Support Programme

for Peace and Reconciliation in Northern Ireland and the Border Areas,

receiving a grant of £167,000. The intention is to:

make the best use of ambulance services in the border areas for

the benefit of everyone;

provide training for control staff;

make the best use of resources in emergency planning terms; and

educate the public in the best use of the ambulance service and of

first aid.

3.13 The Trust has appointed a Project Manager who will benchmark the

latest and best developments in England such as Priority Dispatch

8

Systems, Automatic Vehicle Location and high technology Control

Centres.

Throughput

3.14 In the past year NIAS has dealt with some 60,000 emergency (ie 999)

calls and 40,000 urgent calls. Urgent calls are normally when a GP

decides that a patient needs to be admitted to hospital. In addition a

non-urgent Patient Care Service (PCS) is provided for the

transportation of patients to and from out-patient appointments.

Ambulance Fleet

3.15 NIAS had a particular problem with its fleet of aged vehicles. This is

being dealt with partly through a substantial end-of-year windfall

investment by the Department and the Northern Health and Social

Services Board. Some months earlier NIAS had been given an

additional sum by the Department over and above its normal capital

allocation. The service's remaining vehicular needs will be met in

1998/99 through a Public Private Partnership (PPP) project.

Purchaser/Provider Split

3.16 The Committee has discussed the concept of the internal market within

the Health and Personal Social Services in some depth in its report on

Efficiency in the Health Service.

9

3.17 NIAS is a Health Service Trust and as such is primarily a provider of

ambulance services. The provision is directed at meeting the needs and

standards of the Area Boards as purchasers or commissioners of the

service.

3.18 It is the case that current and developmental expenditure by NIAS is

met mainly from Board funding. A small amount of the current funding

comes from provision of patient care services to the 9 Trusts in the

Eastern Board area. This came about in 1993 as part of a national

move towards disaggregating Patient Care Service monies from

Accident and Emergency (A&E) monies.

3.19 Capital expenditures, defined as any capital item over £5,000, attracts

direct DHSS funding. Present capital funding is running at £½m per

annum but this was augmented in the current year by an additional

once off in-flow of £2m. £1m came from the Northern Health and

Social Services Board and another £1m from the Department in two

tranches of £½m each. There were certain conditions attached to the

spending of some of the extra capital.

3.20 These capital sums are used to provide equipment such as vehicles,

telecommunication systems and defibrillators. The injection of extra

capital in the 1997/98 financial year was much needed and we believe

that the efforts of the Committee may have played a part in helping to

secure the extra funding.

10

Purchase of Ambulance Services

3.21 NIAS services are purchased by Boards on the basis of standing

Service Level Agreements (SLAs) which are reviewed and updated

annually. The Boards and NIAS meet regularly every few months to

monitor performance, plans and pressures. The Boards contract to

purchase three main types of service:

Accident and Emergency (A&E) or 'Blue Light' service;

Urgent calls by GPs for patient admissions, sometimes known as

'Doctors' Urgent';

Non-urgent Patient Care Services.

3.22 It is, we were advised, virtually impossible to disentangle these

services since they often use common facilities and staff, although it is

clear that the high dependency category accounts for the bulk of the

service with the 999 A&E category next.

3.23 In addition NIAS manages a voluntary car service which involves

volunteer members of the public giving up their free time to ferry

patients who have no transport of their own to, for example, clinics and

renal units.

11

Contract Negotiations

3.24 Annually the Boards as purchasers each issue a purchaser prospectus.

The Trusts, including NIAS, respond to this and as part of the process

of negotiation argue for enhancements to the specified services. Very

soon, it is widely speculated, all of this will change.

3.25 The exact details of the likely changes will not be known until the

Government publishes its Green Paper on Reform of the Health Service

in Northern Ireland. The combined Ambulance Services' budget for the

whole of the Province (all 4 Boards) is nearly £19m with the

percentage breakdown as follows:

36.3% Eastern Health and Social Services Board;

22.4% Northern Health and Social Services Board;

17.1% Southern Health and Social Services Board;

16.6% Western Health and Social Services Board.

The remaining 7.6% is income from the Eastern Trusts.

Costs

3.26 In an audit report on the Ambulance Service in 1996 the auditors

reported that within a sample of 16 ambulance services within the UK

the NIAS had the lowest cost per mile for emergency and

non-emergency journeys and the highest miles travelled. They have

amongst the lowest management costs of any ambulance service in the

United Kingdom.

12

3.27 NIAS patient activity rate is increasing annually. This follows a

national trend. Time spent by ambulances and staff out of their normal

areas of operation is resulting in increases in overtime and running

costs generally.

3.28 Changes occurring and planned in the acute sector are having an

adverse impact on NIAS. These changes have not been fully

evaluated. Examples of changes given were:

closure of A&E facilities at Larne and Newtownards;

increase in patient referrals to large hospitals for sophisticated

tests eg scans;

growth in renal services (the transport implications);

the absence of fracture services in certain areas and also the fact

that all long bone fractures in the Northern Board Area are dealt

with in Belfast;

the closure of small hospitals, eg Banbridge;

the closure of local maternity facilities eg at Ballymena and

Omagh.

3.29 A return journey from Enniskillen to Belfast for example can take in

excess of 5 hours leading to reductions in emergency cover and this

sort of journey is increasingly becoming a normal requirement.

13

3.30 Research in England shows that there is also clear evidence of abuse of

the 999 system by the public. This abuse is costly and measures need

to be taken to counteract it. There is a need for the introduction of

proven sophisticated and standardised interrogation techniques. These

are computerised systems that are utilised to obtain preliminary details

on which rational judgements can be arrived at by control staff. There

may be incidents where, as a result of this, ambulances will not be

dispatched and the caller advised where he/she may seek help or that,

in certain circumstances, an ambulance will be made available but not

on an emergency basis.

3.31 These are the facts that reflect the position on the ground. NIAS in

order to deal with them must be properly resourced and equipped. If

its budgets are concocted on high as it were and bear no relation to

what is happening on the ground it is almost inevitable that need will

not be satisfactorily met and this is a point we will return to.

3.32 We welcome the NIAS recognition of the need for computerised

interrogation system and its commitment to put such a system into

operation.

Cost Improvements

3.33 We are aware of the system within the Health Service whereby 1½%

of running costs are clawed back each year as efficiency savings and

we consciously make no comment on this in the light of the fact that

14

the system will not apply in the next financial year. We are also

cognisant of the impending Green Paper.

15

4. SOME ISSUES

4.1 What now follows is commentary on a series of matters that go some

way beyond questions of background. These are issues that the

Committee has encountered as part of the learning process. Each does

not necessarily attract a recommendation. What really matters is not

the number of recommendations, but their utility and quality.

Financing

4.2 The Prime Minister has stated that "The Government have already put

large extra sums into the NHS and will raise spending in real terms

every year ......." CM3811.

4.3 We do no know what the imminent Green Paper on the Health Service

here will offer and what affect it will have on the funding of NIAS but

the Prime Minister's statement is reassuring. What we will comment

on however is the process of funding itself. In the case of NIAS, the

funding has to be exacted from a multitude of different sources. The

framework is confusing and incoherent and leads to inconsistencies in

(a) funding levels as between funding bodies;

(b) the nature of contracts (different specifications for different

Boards); and

(c) purchases.

16

It would be wrong for us to come up with a pat answer on this single

issue when the Green Paper will look at the global situation across the

whole of the Health and Personal Social Services (HPSS). We would

however recommend the following guidelines on funding:

1. funding sources should be reduced to the minimum possible,

ideally one;

2. negotiations, if they are to continue to exist within the system,

must lead to decision-making on the basis of what is best for

the potential patient population. This is how 'need' should be

defined. We appreciate that NIAS is no more entitled to a

blank cheque than is anyone else but if the focus of need is

fixed on the community rather than on how best to carve up a

financial cake, a more appropriate budget can be evolved

from the bottom up;

3. need should, ideally, not have to be 'negotiated'. A hierarchy

of health service needs should be established, including the

needs that arise from the provision of an ambulance service.

This should be based on good 'honest broker' evidence from

informed and disinterested sources.

4.4 The present funding system is based on competition and this leads to

much conflict within the Health Service where in our opinion there

ought to be teamwork and pulling together. We are not alone in taking

this view. The Government reminded us in its Command Paper 3811

17

on the Scottish Health Service presented to Parliament in December

last that they:

"were elected on a manifesto which committed us to a

fundamental aim: to restore the National Health Service as a

public service working co-operatively for patients, not a

commercial business driven by competition."

Capital Funding

4.5 Before the advent of Trusts capital monies in relation to all those

services for which the Boards were responsible, including ambulance

services, were paid to the Boards by the Department through the

Health and Social Services Executive (HSSE). Once Trusts were

created their capital funding was paid to them direct by HSSE. The

amount of capital funding that a Trust receives has a direct

relationship with its income. It is in our view doubtful whether

there is a great deal of sense in linking current and capital funding

in this way and we recommend that funding is based on the only

criterion that makes sense namely, need. Demonstrable need that is,

as distinct from insatiable demand. The distinction must be drawn

between the two just as any purchaser faced with choices has to do.

4.6 At the very least we must move away from formula-based funding

particularly where the formula has apparently no regard to the needs of

patients.

18

Comparisons with Other Services

4.7 It is difficult when comparing levels of funding between ambulance

services to arrive at valid comparisons. There are a host of

variables, and in many ways engaging in this can be a futile

exercise: most funding currently is determined on the basis of

negotiation and success owes as much to the ability of the

negotiators as it does to valid argument based on sound statistics.

It is also interesting to note that funding has been known to appear

through the operation of the political process, for example in the

current financial year. This is very welcome when it does happen and

it only serves to underline that the current methodology does not

operate very effectively.

Some 'Little Local Difficulties'

4.8 We are aware that the NIAS Board has made a public statement to the

effect that it was concerned about ambulance services in the Western

Health and Social Services Board, particularly in the Enniskillen and

Omagh areas. They have stated that extra investment 'beyond a

shadow of doubt' is needed in these areas.

4.9 There is a particular logistical difficulty in providing an ambulance

service in these areas because of distances and the awkward

topography of the lakelands - this has to be recognised to a degree in

terms of funding. What militates against this region is its

comparatively low level of population.

19

4.10 We understand that there are also difficulties within the Glens area of

Co Antrim and in the Clogher Valley region largely because they are

designated as a sparsely populated areas. The problem here is similar

to Fermanagh although probably a little less acute.

4.11 We highlight these areas because they seem to suffer particularly from

the weaknesses of the funding arrangements for what is very much a

demand-led service. Lest we be called to book for failure to note other

areas let us say immediately that we know (through UNISON and other

evidence) of other localities where there is concern but we make

mention of the above areas because they require specific comment.

4.12 We took evidence from officers of the Western Health and Social

Services Board and their presentation was a very professional and able

one. We learned from them about some of the nuances of the funding

process and have felt able from this and from the evidence given by

NIAS and others to come to a view on the adequacy of funding in the

West.

4.13 It is fair to say that both the purchaser and the provider argued their

cases: the first maintaining that funding for Ambulance Services was its

top priority, but emphasising the pressures the Board was under from

competing demands and claiming that they had no money to spare; the

second maintaining inadequacy of resources.

4.14 We take a very simple view on all of this. The ultimate

responsibility for the provision of services should rest with the

purchaser. He must specify what he wants and what he will pay

20

and he must ensure that what he has sought is delivered. He has an

important responsibility in the whole business of funding and funding is

"To produce better care. Care when you need it. Care of uniformly

high standards." (Cm3811). In the case of ambulance services in

Northern Ireland the 'uniformity' required appears to be absent.

4.15 The same Command Paper also tells us that "A Trust's prime

responsibility is the provision of patient care of the highest quality ......"

This can only happen by means of a well designed and properly funded

package of delivery.

4.16 The Western Board maintains that it invested in its fleet when that was

under its control and that it ran a tight ship. UNISON disputes this. At

any rate what has happened in the recent past is, in funding terms,

'water under the bridge' - we cannot change it and we must come to a

realistic and fair conclusion on the matter. It is thus stated:

We are not satisfied with the ambulance provision in

the West and call upon the Western Health and Social

Services Board to take heed of the needs which we

believe the Board recognises, of the community there.

The WHSSB should ensure that it places itself beyond

criticism in contracting to meet these needs promptly.

4.17 If, as we were told, the Ambulance Service ranks first in the Board's

list of priorities, it should not be difficult (for the Board) to make the

necessary investment as it embarks on a new financial year.

21

4.18 We learned of difficulties in North Antrim from both NIAS

management and UNISON and we acknowledge the recent generous

action taken by the Northern Board to provide £1m extra capital

funding for NIAS services in that area.

Midwifery

4.19 Problems in the West as we have said are largely ones of population.

Numbers and distribution conspire to make service-provision difficult

to justify.

4.20 Another peculiar difficulty that has now surfaced in the Western Health

and Social Services Board Area is the absence of midwifery services

between 5.00 pm and 9.00 am. This is a serious problem since the

only maternity services available in Fermanagh and in South and West

Tyrone are located in Enniskillen.

4.21 It is an example of a situation where NIAS has been left quite literally

in some cases 'holding the baby' - their paramedics are required to fill

the 16 hour void. If these staff are to do so adequately they must most

definitely have proper training, and quickly!

4.22 Once again the funding agencies for paramedic training are the

Boards and we call upon them to make the modest amount of

money required available immediately to provide for the training

of paramedics in a specialist obstetrics module.

22

Acute Hospitals

4.23 The Area Boards are in the process of undertaking acute services

reviews. There is a possibility that this could result in a reduction in

acute facilities across the Province. There are many implications here

but for the purposes of this report we confine our remarks to the likely

effects of this on the ambulance service.

4.24 Any reductions in on-the-ground facilities inevitably places a much

greater burden on NIAS. Ambulances may have to travel greater

distances with perhaps greater risk of road traffic accidents, and of

course patients will be in the care of NIAS crews for longer periods.

Even with professional and highly trained ambulance personnel NIAS

cannot be expected to substitute for the sophisticated facilities of an

acute hospital. Additionally because ambulances spend longer on each

emergency the capacity of crews to deal with even the existing number

of emergencies is necessarily cut.

4.25 The problem of course is not confined to emergencies. It applies also

to a situation where a hospital doctor may, because of lack of facilities

at his hospital, have to refer a patient to another distant facility

necessitating the use of NIAS assets.

Strategic Review

4.26 We understand that the HSSE has agreed in principle to finance a

major strategic review of NIAS activity which would look at the

modelling of demand patterns and point the way to a more precise

23

priority-based system. The target date for the review's implementation

is currently autumn 1998. The review would take into account both

demographic trends and the relevant changes taking place within the

Health and Personal Social Services set-up here, and would look at

new technology available (see Appendix K - Visit of the Committee to

England).

4.27 We feel in light of the changes that will arise from the acute

services reviews and perhaps from the Green Paper that the

strategic review of NIAS activity is indispensable.

Ambulance Stations

4.28 During our investigation we visited a sample of ambulance stations and

the reports of these visits are shown in the Appendices. The reader

will see that the quality and quantity of facilities varied greatly. There

is no doubt that because of changes within the acute hospital sector

(eg hospital closures) the number and location of ambulance stations

has become a critical issue.

4.29 There is also a perennial debate on whether the activities of NIAS

should be conducted from ambulance stations or whether, as in parts of

England, the concept of 'out-stationing' or 'out-posting' should hold

sway.

4.30 At present crews are based in ambulance stations which provide

varying degrees of comfort and protection against the elements. The

drawback of this is that because ambulances are based at static points

24

they are at an in-built disadvantage in location when an emergency

occurs. This we believe is beyond dispute and was confirmed during

the Committee's visit to Great Britain where we found that most crews

are cab-based.

4.31 During our tour of stations we learned that garaging facilities were not

always very satisfactory. In the dead of winter we were told, problems

can arise in ensuring that garaged vehicles are roadworthy.

4.32 New technology such as Incident Risk Prediction systems which can

help in the prediction of accident locations allows managers to place

ambulances where they are most likely to be needed at any given point

in time.

4.33 The upgrading of stations that we have found defective in various

respects is a costly process which draws on precious public funds

(UNISON evidence suggests £4m). Management must take a view on

what is justifiable and what is best in terms of efficiency and

effectiveness. Whatever that view change, where it is needed, will

have to be brought about sensitively.

4.34 It is wrong for the Committee at this time to come up with a black

and white recommendation on stations that would influence or

even displace management's ability to manage. The policy at this

level is a responsibility of management working with the Trades

Unions and it is our concern only in that it may have an impact on

the level of service provided for the public.

25

4.35 We urge management to carefully consider the options; we are aware

that the value of its decision will be measured in the extent to which it

stands up to future external audit.

Building Standards

4.36 We found during our visit to stations that there was generally a lack of

sluicing facilities for the disposal of vomit and other body wastes

although it must be said that most sluicing necessarily takes place in

the A&E departments of acute hospitals. More advanced sluicing

exists at fire stations for chemical decontamination etc.

4.37 Government departments are currently considering a request from the

Ambulance Service's Association to equip ambulance services with

Personal Protection Equipment (PPE). This will provide protection in

cases of chemical accidents, spillages etc.

4.38 Capital restrictions have been an obstacle to improving accommodation

and any new developments must be accompanied by a business case.

With a total capital inflow of some £3m this year NIAS is in a

stronger position than it has ever been to turn its attention to

tackling building issues.

Training

4.39 Ambulance staff are trained under the standardised national syllabus of

the Institute of Health and Care Development (details are shown at

Appendix J). The Committee visited the NIAS training facility at The

26

Beeches in Belfast. The accommodation is shared with another health

service training provider and although this is not ideal the

arrangements, up until now, appear to have been workable.

4.40 It would in our view be helpful if NIAS could gradually work

towards the establishment of a dedicated Ambulance Service

Training Centre. Indeed if we follow the logic to its conclusion

there would be merit in housing all headquarter functions under

one roof as for the Essex Trust. We believe that there is an

abundance of health service accommodation that would facilitate

this economically.

4.41 We found during our visit to England that it was possible for

Ambulance Trusts there to sell their training services or to band

together to form training consortia. In this way they could either

generate or save money. There is less scope for this in the Province

but we urge NIAS Training to keep a close eye on developments in

Great Britain and ensure that no opportunity is missed.

4.42 We endorse the efforts already made by NIAS to exploit outside

training opportunities eg provision of skills for both dentists and

the Prison Service.

Status of NIAS

4.43 NIAS, like all other UK Ambulance Trusts, is classified as an essential

service, not an emergency service. This, it has to be said does not, for

27

all practical purposes, matter. It has no effect on funding levels and is

merely a technical definitional matter. We know for example that the

Northern Ireland Fire Service - an emergency service - has derived no

advantage from its different status and indeed is currently going

through a particularly bad patch in terms of financing.

4.44 We make no firm recommendation on the question of NIAS status. We

merely suggest that, if for no other reason than the raising of staff

morale, it might be useful for the Government to revisit the question of

why it differentiates between the 999 services, and to consider whether

there is any benefit in its continuing so to do.

4.45 Needless to say if a change in status of this highly valuable service

were to benefit its operations in any way we would without any

hesitation take a somewhat different view.

Amalgamation with Fire Service

4.46 We have not explored the question of amalgamation of duties within

the three 999 services here but are aware that this had taken place

abroad. Although the issue was broached at some evidence sessions

time has prevented us from looking at the possibilities and from making

the necessary contacts overseas.

4.47 For the present we take the view that the ambulance service in this

country is part of the National Health Service family of services -

28

something that does not exist elsewhere - and should remain where

it was originally conceived.

4.48 Any departure from the present arrangements would require a major

policy shift and so far as we can see there is no likelihood of this

happening in any other part of the United Kingdom.

Early Retirement

4.49 There can be no doubt that ambulance staff in Northern Ireland have

faced exceptional difficulties over the years because of the unrest. It

would not be difficult to catalogue many of the traumatic scenes visited

by NIAS staff but it is sometimes forgotten that human carnage and

serious injury of a more workaday kind can present an equally stressful

scene even to the hard-bitten crewman or woman who has 'seen it all'.

4.50 We were given evidence that an early retirement scheme for ambulance

staff has been in operation for the last three years in Great Britain. A

similar scheme has not applied in Northern Ireland for a number of

reasons. Much of what drives these schemes is to do with the

availability of cash. However the central issue for us is not economic

but social. It is about decency and fairness: it is whether ambulance

personnel should be required to work to age 65 while their counterparts

in the Fire Service and Police can retire much earlier. We feel that

NIAS staff in many ways undertake duties that are equivalent to those

carried out in the other 999 services.

29

4.51 We recommend that Government seriously consider reducing the

retirement age for ambulance staff. It is appreciated that we have

raised a national issue and would ask the Minister to ensure that it

is raised in the appropriate fora.

Violence

4.52 The Committee heard evidence of the difficulties crews often face

when they find themselves in the midst of violent situations and when

they and their vehicles come under attack. These incidents tend to hit

the headlines but thankfully they are not the norm. We heard evidence

from senior staff in South Yorkshire that they do not tolerate abuse of

their staff and press the police in that area to take any necessary action

to prosecute the culprits.

4.53 The situation however is very different in Northern Ireland and this has

to be recognised. We know that NIAS management at all levels takes

the safety and well-being of its crews very seriously and situations are

dealt with very effectively on their merits. We can only pay tribute to

the men and women of NIAS and its predecessors for their courage and

dedication to their calling over the last 30 years.

4.54 We welcome the announcement by the Secretary of State for

Health on 10 December 1997 that there is to be a review of

'violence to NHS staff'. This review will include NIAS staff and

will result in national guidelines for Trusts and their staffs in

managing the threat of such violence.

30

The Visit to England

4.55 Committee plans to complete fact-finding included the making of

comparative visits to two mainland Trusts. The first of these was the

Essex Trust - widely regarded as a leader among the Trusts in terms of

new initiatives and technology. It was one of the first wave of Trusts

set up by the previous government in 1991.

4.56 The Committee later visited the South Yorkshire Trust which, although

geographically smaller than Northern Ireland, was in budgetary and

resource terms closer to NIAS than Essex.

4.57 NIAS is beginning to move in the direction of the leading and

better-funded English Trusts in terms of upgrading its control training

and technology but has some way to go in developing its non-core

activities. These are basic activities which are on the peripherary of

what an ambulance service contracts with its commissioning body to

do. Examples are the selling of training provision to non-ambulance

personnel and the selling on of surplus maintenance capacity to the

private sector. The latter would be impractical for NIAS because much

of its maintenance is done by the private sector.

4.58 We find that there is a danger though that ambulance services cross?subsidise under-funded core activities by income-generating non-core

activities and thus mask the problem of under-funding. However we

feel that initiative deserves credit and if it is possible to bolster funding

to the public sector by way of these kinds of activities, then provided

they are kept in proportion they should not be ruled out.

31

4.59 Non-core activities carried out by NIAS have a turnover of around

£¼m per annum and profits of something of the order of £20,000

which are ploughed back into the service's core work.

4.60 Based on our GB findings we make the following recommendations.

4.61 We recommend that NIAS look at the possibility of increasing its

revenues through the further development of non-core activities

such as those identified during the Committee visit to England (see

Appendix K).

4.62 We also recommend that NIAS consider the introduction of a

Health Watch scheme. This is a scheme whereby local volunteers are

recruited, given training and equipment, and then linked with

Ambulance Control staff who dispatch them to deal with 999 calls in

their locality ahead of an ambulance.

4.63 We further recommend that NIAS consider the introduction of a

category of specialist cleaning staff within the Service in order to

make for a better use of scarce resources (see Appendix K,

page 14).

4.64 We recommend, on the basis of our enquiries in England, that

NIAS consider rationalising of control systems now that it is the

sole ambulance service in the Province. The existence of 4 control

centres is a relic of the past and it should now be possible, in the

public interest, to reduce the 4-site model.

32

4.65 We have made recommendations in relation to a reduction in Funding

agencies. Linking this to our recommendations on Control we feel that

the areas of operation of ambulance crews should not, by and

large, be associated with Board boundaries - these are entirely

artificial and should have no bearing on NIAS operations.

4.66 Before making this change however it would be most important for

NIAS to ensure that there would be no diminution of service provision

as a result and indeed that an improvement would be achieved. We

would also anticipate that a properly funded NIAS would in time

expand and allow for redeployment (or early retirement as

recommended earlier) of excess Control staff.

4.67 We recommend that NIAS should further recognise the fact that it

is now a uniform service by moving towards manpower planning

policies and structures that are centrally controlled in the way that

they are in South Yorkshire (see Appendix K, page 13). We

recognise that this has partially happened with the employment of

a Resource Manager in the Eastern Division and wonder whether

it would be feasible to extend this on a very gradual basis to other

parts of the Province.

33

5. SOME DEVELOPMENTS

Information Leaflets

5.1 NIAS is developing a public information booklet on the use of the

Ambulance Service by the general public. It will also be seeking to

advertise on television. Once again this has been funded by grant.

Thrombolytic Therapy

5.2 The Ambulance Service here is embarking on an exciting and

innovative project which will look at developments in thrombolytic

therapy (clot-busting drugs). The project will include the use of ECG

telemetry whereby paramedics on the ground are linked to coronary

care units by a telephone line.

Motorcycles

5.3 Motorcycle paramedics are used in parts of the United Kingdom

notably London and Greater London and this is helpful where it would

be difficult to get to patients by other means. The results have been

mixed - the injury rate to the motorcyclists is high as is the staff

turnover rate (not in the literal sense we hope).

5.4 An added problem has been pilferage of the contents of compartments

on the bikes and damage being done to the machine while the

paramedic has attended victims. These machines are very expensive

34

and would at present be a highly doubtful investment for the Province's

ambulance service. Whilst paramedics have the ability to stabilise

victims the use of expensive motorcycles of this type does not obviate

the need for an ambulance that is capable of carrying a patient to the

hospital. The bicycles look like police motor cycles and in the local

context this could present extra difficulties for crew.

5.5 The issue of motor cycle deployment is for NIAS management to

consider and we are satisfied that they will do so methodically.

Helicopters

5.6 At present the size and composition of the military garrison here

ensures that there is a relatively large number of helicopters in the

Province and these are often multi-functional.

5.7 The use of dedicated helicopter ambulances is at this time extremely

expensive and cannot possibly be justified in terms of public finance.

They are a luxury, and are a poor investment that the taxpayer should

not be asked to fund. However there are two points worth reflecting

on: firstly technology moves on apace and it is possible that costs will

reduce in the longer term and so we must always keep an open mind on

these things; secondly we were made aware during our visit to

England that there may be alternative means of funding helicopter

services, eg through public subscription or even public lottery. We

know that NIAS is actively looking at the possibilities of helicopter

35

ambulances for Northern Ireland. We concur with what is being

done and will go no further in this report.

Paramedic Degree Course

5.8 We welcome the interest of the NIAS in pursuing the possibilities of

establishing a paramedic degree course in Northern Ireland. This is an

imaginative initiative akin to that under development at the University

of Sheffield which we learned about during our visit to South

Yorkshire. The skills and competencies offered by paramedics

need recognition and we believe that there is scope for the

development of a paramedic-practitioner role within the Health

Service here. Development would have to be gradual and there should

be full co-operation with medical and allied professions.

5.9 We would however not wish to see an academic take-over of the

essentially practical and professional role of the paramedic. There

will always be a pivotal role for the trained and skilled

ambulance-borne paramedic within the Health Service. A primary

training objective must be to see that this continues and does not end

up maintaining any academic establishment that could siphon off vital

and limited Health Service funds from where they can do most good.

Health Education in Schools

5.10 In the last 3 of the Committee's reports Health Education in Schools

has been touched upon. It seems that every time the Committee looks

36

into a general health-related issue that this aspect necessarily and

unerringly crops up. Once again evidence taken shows that there is

a need for Health Education to become a subject of study within

the school curriculum. Its value is in its practical application, not

only to the individual pupil or student, but also to society as a whole.

5.11 We believe from our examination of the Ambulance Service that if, for

example, basic first aid and a knowledge of healthy lifestyles were

taught in schools there would be a massive return on the investment.

Like all worthwhile investments it is long-term and the sooner action is

taken on this front the better for all concerned.

37

6. EPILOGUE

6.1 Returning once again to the City of Londonderry where our story

began. As recently as the end of February a further series of incidents

occurred which put additional pressure on the ambulance service there.

On the morning of 28 February 1998 eighteen people were involved in

a serious road traffic accident at Claudy. At the same time there were

separate calls on the service to deal with two persons suffering from

smoke inhalation and with two stabbings. It was necessary to bring in

vehicles from the surrounding area some 25 miles distant.

6.2 Fortunately the end result was different to the night of

16 November 1997. However that day's business was potentially more

serious than the earlier one and incidents of these type seem to

continue to recur all too regularly for comfort. Nor of course are they

confined by any means to the Maiden City.

6.3 We must not lose sight of the fact that we need an ambulance service

that is up to the task and able to deal with these incidents which seem,

more and more, to be a growing part of the job. A paramedic's lot is

perhaps, at the moment, 'not a happy one'.

6.4 We have presented throughout this report a series of recommendations

that are calculated to change things for the better. Let us put them to

the test and see.

38

PICTURE GALLERY

39

LIST OF CONCLUSIONS AND

RECOMMENDATIONS

We welcome the NIAS recognition of the need for computerised

interrogation system and its commitment to put such a system into

operation. (Para 3.28)

We would however recommend the following guidelines on

funding:

1. funding sources should be reduced to the minimum possible,

ideally one;

2. negotiations, if they are to continue to exist within the system,

must lead to decision-making on the basis of what is best for

the potential patient population. This is how 'need' should be

defined. We appreciate that NIAS is no more entitled to a

blank cheque than is anyone else but if the focus of need is

fixed on the community rather than on how best to carve up a

financial cake, a more appropriate budget can be evolved

from the bottom up;

3. need should, ideally, not have to be 'negotiated'. A hierarchy

of health service needs should be established, including the

needs that arise from the provision of an ambulance service.

This should be based on good 'honest broker evidence' from

informed and disinterested sources. (Para 4.3)

40

The amount of capital funding that a Trust receives has a direct

relationship with its income. It is in our view doubtful whether

there is a great deal of sense in linking current and capital funding

in this way and we recommend that funding is based on the only

criterion that makes sense namely, need. (Para 4.5)

It is difficult when comparing levels of funding between ambulance

services to arrive at valid comparisons. There are a host of

variables, and in many ways engaging in this can be a futile

exercise much funding currently is determined on the basis of

negotiation and success owes as much to the ability of the

negotiators as it does to valid argument based on sound statistics.

(Para 4.7)

The ultimate responsibility for the provision of services should rest

with the purchaser. He must specify what he wants and what he

will pay and he must ensure that what he has sought is delivered.

(Para 4.14)

We are not satisfied with the ambulance provision in the West and

call upon the Western Health and Social Services Board to take

heed of the needs, which we believe the Board recognises, of the

community there. The WHSSB should ensure that it places itself

beyond criticism in contracting to meet these needs promptly.

(Para 4.17)

41

The funding agencies for paramedic training are the Boards and

we call upon them to make the modest amount of money available

immediately to provide for the training of paramedics in a

specialist obstetrics module. (Para 4.22)

We feel in light of the changes that will arise from the acute

services reviews and perhaps from the Green Paper that the

strategic review of NIAS activity is indispensable. (Para 4.27)

It is wrong for the Committee at this time to come up with a black

and white recommendation on stations that would influence or

even displace management's ability to manage. The policy at this

level is a responsibility of management working with the Trades

Unions and it is our concern only in that it may have an impact on

the level of service provided for the public. (Para 4.34)

With a total capital inflow of some £3m this year NIAS is in a

stronger position than it has ever been to turn its attention to

tackling building issues. (Para 4.38)

It would in our view be helpful if NIAS could gradually work

towards the establishment of a dedicated Ambulance Service

Training Centre. Indeed if we follow the logic to its conclusion

there would be merit in housing all headquarter functions under

one roof as for the Essex Trust. We believe that there is an

abundance of health service accommodation that would facilitate

this economically. (Para 4.40)

42

We endorse the efforts already made by NIAS to exploit outside

training opportunities eg provision of skills for both dentists and

the Prison Service. (Para 4.42)

For the present we take the view that the ambulance service in this

country is part of the National Health Service family of services -

something that does not exist elsewhere - and should remain where

it was originally conceived. (Para 4.47)

We recommend that Government seriously consider reducing the

retirement age for ambulance staff. It is appreciated that we

encroach on a national issue and would ask the Minister to ensure

that it is raised in the appropriate fora. (Para 4.51)

We welcome the announcement by the Secretary of State for

Health on 10 December 1997 that there is to be a review of

'violence to NHS staff'. This review will include NIAS staff and

will result in national guidelines for Trusts and their staffs in

managing the threat of such violence. (Para 4.54)

We recommend that NIAS look at the possibility of increasing its

revenues through the further development of non-core activities

such as those identified during the Committee visit to England (see

Appendix K). (Para 4.61)

We also recommend that NIAS consider the introduction of a

Health Watch scheme. (Para 4.62)

43

We further recommend that NIAS consider the introduction of a

category of specialist cleaning staff within the Service in order to

make for a better use of scarce resources (see Appendix K,

page 14). (Para 4.63)

We recommend, on the basis of our enquiries in England, that

NIAS consider rationalising of control systems now that it is the

sole ambulance service in the Province. The existence of 4 control

centres is a relic of the past and it should now be possible, in the

public interest, to reduce the 4-site model. (Para 4.64)

We feel that the areas of operation of ambulance crews should not

by and large be associated with Board boundaries. These are

entirely artificial and should have no bearing on NIAS operations.

(Para 4.65)

We recommend that NIAS should further recognise the fact that it

is now a uniform service by moving towards manpower planning

policies and structures that are centrally controlled in the way that

they are in South Yorkshire (see Appendix K, page 13). We

recognise that this has partially happened with the employment of

a Resource Manager in the Eastern Division and wonder whether

it would be feasible to extend this on a very gradual basis to other

parts of the Province. (Para 4.67)

The issue of motor cycle deployment is for NIAS management to

consider and we are satisfied that they will do so methodically.

(Para 5.5)

44

We know that NIAS is actively looking at the possibilities of

helicopter ambulances for Northern Ireland. We concur with

what is being done and will go no further in this report. (Para 5.7)

The skills and competencies offered by paramedics need

recognition and we believe that there is scope for the development

of a paramedic-practitioner role within the Health Service here.

(Para 5.8)

We would however not wish to see an academic take-over of the

essentially practical and professional role of the paramedic.

(Para 5.9)

Once again evidence taken shows that there is a need for Health

Education to become a subject of study within the school

curriculum. (Para 5.10)

45

Top: Members consider the way forward.

Bottom: Members inspect a single-trolley ambulance.

46

Members and staff of Essex Ambulance Service.

47

Two of the more sprightly members of the Committee, Rev Coulter and Cecil

Calvert, both expert motor cyclists, road testing machines in the 1000cc class to

destruction at EAS.

48

Top: 'In the driving seat'. Sam Foster with Tom Robinson co-piloting.

Bottom: Members and staff at EAS Control.

49

Top: Members inspect maintenance facilities in Doncaster.

Bottom: Members inspect one of the new smaller and cheaper vehicles at EAS.

50

Members are briefed by senior staff at Rotherham Ambulance Station.

51

'Reviewing the Fleet' South Yorkshire.

52

The Committee in South Yorkshire admiring an Emergency Tender.

53

Top: 'Women Drivers'.

Bottom: 'Preparing to go home to the wife'. Cecil Calvert models a complete set of body

armour. Colleague Gregory Campbell 'in reflective mood' looks on.

54

Hugh Smyth - Thoughts of Shankill

55