THERE HAVE been acres of newsprint and hours of radio debates dedicated to the ongoing reconfiguration or “downgrading”, as some would see it, of our acute hospitals. However, our ambulance services have also been undergoing an equally radical if more discreet transformation.
Since the HSE was launched in 2005, it has been working to bring together the ambulance services across the eight old health boards into a single uniform service, as well as reducing and improving the number of call centres, upskilling ambulance staff, and modernising and standardising the ambulance fleet.
In February this year, the HSE announced the appointment of Robert Morton as director of the National Ambulance Service (NAS). He says the key focus from 2005-2009 was to try and progress the concept of a national service “which was a considerable challenge” as each of the old health boards had their own ways of doing things, different types of ambulances and call arrangements and set geographical boundaries.
While there were several infrastructural elements that had to be put in place to achieve this, he says the key element was the move by the HSE to a central fleet procurement policy.
“So no matter where you are now in the country you will find one national standard of vehicle. On the back of that, we also had to work very hard to comply with a new European standard, which is referred to as ‘CEN’.
“The other big piece of work that was done in that period was adopting a national approach to equipment standards, information management-processing, the reduction of call centres, which at the all time high were 22. We’re now down to nine and are aiming to progress to two ,” Morton says.
The NAS has also had to deal with major changes in staff training and education standards, he adds.
The Pre Hospital Emergency Care Council (PHECC) introduced a system of professional registration at the end of 2006. In 2007, the training and education standards for paramedics were published, while the development of a national ambulance staff training college was also progressed during this period, so paramedic and advanced paramedic courses are now accredited by UCD.
The NAS now has about 1,300 operational staff, 1,080 of whom are trained to the 2008 paramedic level, while about 200 are trained to advanced paramedic standard (from 2007) and over 20 are still at the old EMT level, but are going through the process of being able to provide “intermediate care”.
Morton acknowledges these work-practice and training changes, as with most changes in the health service, have not been easy and were often affected by delays and industrial relations issues, but he insists the changes would make services better for patients.
“What we are now in the process of developing is a three-tier level of service; the first is intermediate care, that is a very robust and dedicated inter-hospital ambulance-based patient transport service ,” Morton explains.
“The middle level will be the paramedic level of service, and there is a significant body of that out there already, and they are able to deliver a significant level of care and can service most of the 999 calls we receive. They can administer life support, a certain amount of drugs, etc.
“The third level of care is the advanced paramedic, of which there are over 200 , and they are very much focused on delivering care to the very high acuity 999 calls, that is about the top one third of those calls. Those people are trained to an exceptionally high level . . . and can administer a significant range of medications such as penicillin to a child with meningitis, naloxone to someone with a heroin overdose, sodium bicarbonate to someone who has taken an overdose of antidepressants, and so on. They can intubate and administer drugs through an IV and they have significant clinical examination skills and focus on differential diagnosis,” he says.
Advanced paramedics are currently being deployed to areas with the greatest need for community emergency support services, including Roscommon, the midlands, west Cork and Dublin northeast, all of which have been affected by the HSE’s downgrading of local emergency departments.
Morton stresses that advanced paramedics are strongly linked to the nearby hospital services and are always able to talk to senior emergency doctors when needed, though a dedicated central number.
In line with all these developments, he says the NAS is “working hard” to change how its services are perceived and used by the public and also healthcare staff.
“The historical expectation and knowledge of the ambulance service was that it was a single level of service; predominantly transport and some treatment. Basically an ambulance went out, did some treatment at the scene – basic lifesaving skills – and brought you to the emergency department.
“By and large the expectation was that the NAS would continue to provide that function, so there has been a need for a cultural shift to get people to a point where they now understand the role of the NAS is not to primarily provide routine inter-hospital transport. It is still part of the role, but the principal role is to deliver an effective pre-hospital response. It has been a significant piece of marketing to get people to understand that.”
The NAS now aims to eventually reduce the number of emergency ambulances it has and increase the number of inter-hospital style vehicles and to modernise its communications infrastructure and technology in line with international best practice.
In accordance with the HSE’s move to treat more patients in the community and to avoid bringing patients to hospital where possible, the NAS will eventually roll out a major new national triage system, in which it will “categorise” the calls received and arrange for callers to be treated accordingly, whether that is through phone advice from a health professional, referral to a different service, or the deployment of an ambulance which may be able to treat the patient on site.
“So the number of patients we need to bring to emergency departments should be fewer. And if you look at international best practice, a good quality ambulance service should be able to reduce the number of 999 call patients that need to go to a hospital by 30 per cent.”
This new system, which Morton says is likely to take up to three years to be ready to be rolled out, will be underpinned by strong clinical governance as well as clinical audit.