Value for Money Examination  20: Emergency Ambulance Service     Summary

Emergency ambulance services are provided by the eight regional health boards in their respective regions. In the Dublin city area, an emergency ambulance service is provided by the Dublin Fire Brigade on behalf of the Eastern Health Board.

The estimated cost of providing the emergency ambulance services was just over ?28 million in 1996, when almost 300,000 patient journeys were undertaken. At the end of the year, the nine emergency ambulance fleets consisted of 272 emergency vehicles located at 89 ambulance stations.

As well as providing pre-hospital emergency medical care and transportation of the seriously ill and injured to hospital, the health boards' ambulance fleets are also used to transport patients between hospitals for urgent or planned treatment and for more routine transport of patients to clinics and day care centres.

This examination was undertaken to establish the extent to which the emergency ambulance services are provided efficiently and economically.

Efficiency of the Emergency Ambulance Service

The systems in place in the health boards for measuring efficiency are underdeveloped. In some health boards, emergency call response times (a key indicator of efficiency) are not routinely recorded. In other areas, the times recorded may not be reliable because of the methods used to capture the data.

The examination found that, nationally in early 1997, 87% of emergency calls were responded to within 20 minutes. However, in the Midland, North Western and Western Health Board areas, less than 60% of the calls received were responded to within 20 minutes. Irish ambulances do not meet the standard of response time achieved by the ambulance services in England mainly because population and geographical circumstances are different and the resources provided for the services are considerably less.

No performance targets in relation to response time have been set at a national level or by individual service providers. Appropriate targets, which take account of the different circumstances faced by service providers, should be set as a matter of urgency.

A Review Group appointed by the Minister for Health recommended in 1993 that there should be a single command and control centre for emergency ambulances in each health board area to improve the efficiency of dispatch of ambulances. By October 1997, some health boards had not yet centralised their ambulance command and control.

Studies in the early 1970s concluded that in some health board regions, response times could be significantly reduced if extra ambulance stations were established. A recent initiative to improve the response time in more remote locations involves schemes where specifically trained general practitioners are dispatched as a first response while an ambulance is en-route. All initiatives to improve response times should be subjected to rigorous cost-benefit analysis before implementation.

Economy of the Emergency Ambulance Service

In order to overcome existing shortcomings, all the health boards should develop comprehensive costing and activity monitoring systems which allow them to identify clearly the full costs of patient transport services and to relate costs to identified activities.

The examination found that the cost of the emergency ambulance service in 1996 was m the range ?6.09 to ?7.32 per head of population served in most of the health board areas. The cost was significantly above the national average in the North Western Health Board, which spent ?11.29 per head. Even allowing for the fact that the population served is widely dispersed over difficult terrain and poor roads, it is surprising that the average speed of response to emergency calls in the region was the lowest achieved by any of the service providers.

One way of comparing economy in the use of resources is in terms of the average cost per hour that ambulance crews are planned to be on duty i.e. cost per rostered hour. The examination found that the range of cost per rostered hour was from ?16 in the Midland Health Board, to ?39 and ?24 respectively for the Eastern Health Board and Dublin Fire Brigade, where the fastest response times are achieved. The cost per rostered hour was between ?19 and ?24 in the other health boards.

The lowest unit cost was achieved in the Midland Health Board area largely due to nurses working in hospital wards being called on, when required, to act as ambulance crew members. As a result, it takes longer to get a fully crewed ambulance on the road, so the apparent economy is achieved at the expense of fast response times.

The number of emergency journeys in 1996 was in the range 16 to 29 per thousand of population in the health board areas, except in the Eastern Health Board area where there were 68 emergency journeys per thousand which reflects the higher density of population, higher traffic volumes and greater concentrations of industry.

Non-emergency journeys averaged 40 per thousand of population. However, in the Mid-Western and Western Health Board areas, the rates were much higher than the average -73 and 63 per thousand, respectively. While undertaking a higher level of non-emergency journeys improves the utilisation of resources, it may also reduce the ability of a service to respond to emergency calls. In considering options to improve response times, the feasibility and cost of undertaking non-emergency journeys using other, less expensive, forms of transport should be taken into account.

Strategic Issues

The 1993 Review Group report provided a good basis for the development of effective, efficient and economical emergency ambulance services. However, progress in implementing the report's recommendations has been slow. In part, this was due to industrial relations difficulties which were resolved only in April 1997. One of the recommendations involved the use of a standardised patient report form by all emergency ambulance services. The delay in its introduction resulted in the loss of information which could have greatly assisted the measurement of the effectiveness of the ambulance services and indicated areas where the delivery of medical care could be improved.

A National Ambulance Advisory Council, recommended in the Review Group report, was established in 1994 to ensure that uniform standards of service would operate throughout the country. Because it is an advisory body with no statutory powers over the health boards, the Council's ability to achieve its objectives was limited. The Department intends to review the structure of the Council to improve its effectiveness.

The planned introduction of clinical audit of the emergency ambulance services should strengthen the ability of the service providers to monitor the effectiveness of their activities. Clinical audit will also facilitate the setting of national standards for the quality of pre-hospital medical treatment.

The cost effectiveness of introducing priority based dispatch systems, which aim to  maximise the ability of the service to respond quickly to the most serious cases shouldbe examined.