Embargo impacting NAS programme to mitigate ‘extreme levels of risk’

Catherine Reilly examines a recent report which highlights the effect the recruitment embargo is having on the National Ambulance Service

 A “redesign” programme established by the National Ambulance Service (NAS) to mitigate “extreme levels” of organisational risk is being hindered by the recruitment embargo, according to its Director.

In 2021 an analysis found “limited governance” and “low levels of assurance” in the NAS, which exposed it to “extreme levels of risk and staff to psychosocial harm”.

The analysis of leadership and governance arrangements found the clinical, operational, technical, and corporate governance structures were inadequate to meet the requirements of the NAS. This had contributed significantly to “poor culture” and an “unhealthy organisation”.

A three-year organisational “redesign” programme was initiated and led to “significant progress… achieved on Apex, Core, and technical structures in 2022”, according to a report presented by NAS Director Mr Robert Morton to the HSE planning and performance committee in November.

 However, Mr Morton’s report noted the HSE recruitment embargo “has had a significant impact on progress and early indications are that there is unlikely to be further progress in 2024”.

The report, which was obtained under Freedom of Information law, stated: “At this time, NAS has a core national level executive team, which oversees the delivery of services in six regions (HSE health regions) and four national level functions. The key impact of the current recruitment pause is predominantly on the absence of middle management and specialist expertise across core operational, technical specialists, and business support functions.”

Key strategic risks

The report also set out the “key strategic risks” for the NAS. These related to leadership and governance, capacity and access (including a need for 1,080 extra staff in the immediate term), finance and resourcing (a projected financial deficit of at least €17 million in 2023), and people and culture (“significant” industrial relations challenges).

The growth of demand greatly exceeded capacity, and the degree of “organisational stress” was impacting staff wellbeing, morale, recruitment, and retention.

According to emergency response statistics included in the report (Jan-Sept 2023), 72 per cent of ‘purple’ calls (immediately life-threatening) were responded to by a patient-carrying vehicle within 19 minutes (against a target of 75 per cent). The figure for ‘red’ calls (potentially life-threatening) was 46 per cent (against a target of 45 per cent).

Between December 2019 and December 2022 (37 months), there were 777,821 patient attendances by emergency ambulance personnel. Over one-quarter of attended patients had a life-threatening complaint or a condition that would result in serious ill-health in the absence of immediate on-scene treatment/stabilisation and immediate safe transfer to the appropriate acute hospital facility.

During this period, over 88 per cent of patients attended by emergency ambulance personnel were transferred to an acute hospital facility.

The report noted that increasing frailty and the incidence of chronic disease was presenting through the NAS caseload.

It outlined that population projections indicated a 38 per cent increase in the over-65 population by 2031 and a 68 per cent rise in the over-85 population. The report noted the “proven” value of community-based paramedic care and the merit of multidisciplinary staffing of the National Emergency Operations Centre Clinical Hub. It said the NAS was “ideally positioned” to scale-up the availability of such services subject to investment.

The continued development of alternative care pathways, specialist paramedic roles and progress towards meeting capacity and organisational improvements are emphasised in an NAS strategic plan approved by the HSE board in November 2022 and presented to the Minister for Health.

A Department of Health spokesperson told the Medical Independent a new NAS strategic plan was at “an advanced stage of development”.

“The Government is committed to investing in the continued strategic reform of the NAS from a conventional emergency response and patient conveyance service, to an agile and responsive mobile medical service that is well positioned to treat increasing numbers of patients in their home and community setting where clinically appropriate, which will reduce unnecessary pressure on acute hospitals.”

Mr Greg Lyons, Siptu Ambulance Sector President and Chair of the Irish Ambulance Representative Council (which comprises members of Siptu and Unite), said the longstanding failure to introduce appropriate recognition and pay grades for emergency medical technicians, paramedics and advanced paramedics has led to low morale.

He said there was a “long historical issue” in recognising the evolution of ambulance staff “from being drivers, basically, with nurses in the back, to being autonomous practitioners” administering medications and delivering life-saving care, and complex clinical decision-making, etc.

Last year, Siptu-affiliated NAS ambulance personnel voted for industrial action over the delays in implementing reforms, including appropriate pay grades. This action was deferred pending further discussions at the Workplace Relations Commission, but Mr Lyons said resolution of these matters is urgent.

He said understaffing and wider capacity deficits were also negatively impacting the mental health of ambulance staff and leading to exits from the service.

“The knock-on issues we have with delays in EDs is having an effect [on staff],” he noted. “Because the risk we hold is the patient we haven’t got to, not the patient we have got to. For all the times we are stuck in ED for long periods of time, there are calls outstanding, which means they are building up and building up, which ultimately means we don’t have rest or downtime, and are pretty much going for the minimum 12-hour shifts because there is no guarantee you will finish your shift after 12 hours.”

He said access to the HSE employee assistance programme and occupational health services was suboptimal, but acknowledged the NAS was developing an occupational health resource.

Mr Lyons said the community paramedic programme remained on a small scale and he underlined that the pay and conditions associated with these specialist roles would need to be made attractive to facilitate growth.

“If we support our staff, they will support changes to the service and continue to deliver a high-quality ambulance service that the people of Ireland deserve,” he said.

The HSE has previously acknowledged that NAS job descriptions/person specifications “have not necessarily been updated” to reflect current service care, delivery, and practice.

Commenting last month, a HSE spokesperson said the NAS was working to address these matters. In the past six years, the NAS had grown by approximately 23 per cent in terms of whole-time equivalents and a 2023 staff census showed it had the lowest turnover of staff across the HSE, it stated.