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'Extreme risks' posed to National Ambulance Service due to management structures

A report obtained by The Journal reveals significant concerns for NAS management structures, staffing levels and funding.

AN INTERNAL AMBULANCE Service report has warned of “extreme risks” to the health service as a consequence of badly designed management structures. 

Documents obtained by The Journal reveal significant concerns for National Ambulance Service (NAS) management structures and also concerns around staffing levels and funding. 

Sources had told us that there were efforts underway in the HSE and NAS to redesign how paramedics were managed. 

In a Freedom of Information request we asked for documents, including correspondence, briefing documents and minutes of meetings discussing plans to redesign the service. 

In its response the HSE said that a lot of what we requested could not be located but we did obtain a withering internal report criticising the dangers posed as a result of NAS management systems.

A report entitled ‘NAS Organisational Redesign’ from 6 December 2022 was scathing in its criticism.

“The underdeveloped nature of the management structures in NAS has led to a number of significant issues creating a high and unsustainable level of risk exposure for the HSE,” the report author stated. 

NAS carried out an internal study on how the organisation is functioning – described as an Organisational Health Intervention in January 2021 – and this identified a series of significant risks.

These included under-resourced clinical governance, a lack of leadership and lack of resources to deliver strategic priorities – all made worse by an increasing service demand. 

While there is mention of the longer-term NAS Strategy covering 2022-2031, it said there was an immediate need for management systems to redesigned to deal with the crisis. 

cork-city-cork-ireland-05th-april-2020-a-paramedic-loads-a-gurney-back-on-to-his-ambulance-after-admitting-a-patient-to-the-mercy-hospital-on-grenville-place-in-cork-city-ireland-credit-david A paramedic works at his ambulance outside the Mercy Hospital in Cork. Alamy Stock Photo Alamy Stock Photo

The report added that in keeping with the Government’s Sláintecare policy NAS was transitioning from “its current model as an Emergency Medical Service to a Mobile Medical Service”. 

It added: “This transition will support the overall vision of Sláintecare: to move from an overly acute centric model to a more community based and integrated model of care.

“This significant change will require appropriate levels of leadership and management resource to effectively design, implement, manage, evaluate and support the new model of care.

“Presently, the NAS’s management structure is significantly underdeveloped and under resourced which has challenged the Service’s ability to evolve,” the report stated.

A review of the management structures was undertaken and six areas were classified as being “extreme risk” and “high risk”. 

These extreme risks included “compliance and standards” and said it was “highly compromised”. This is in reference to practices and procedures in how the NAS operates. 

Another area classified as extreme risk was a category entitled “adverse publicity and reputation”. 

“There is a risk of reputational damage and associated loss of public confidence/trust in the NAS and HSE as a result of prolonged issues of poor cultural indicators.

“The risk analysis indicates a score of 16 (extreme risk) that reputational damage to the NAS and the HSE is very likely and will result in major consequences. This would be detrimental to the NAS and the HSE in an environment which is already highly challenging,” the report stated. 

There was also an extreme risk and high risk finding across topics contained under the headline of ‘delivering projects’.

“This provides evidence that resources currently allocated to the NAS are at a risk due to a lack of management resources to effectively monitor and deliver against strategic projects and a lack of alignment with the HSE,” the report stated. 

The report also found that management structures were causing a “highly worrying” situation where there was an “extreme risk to safety and wellbeing of staff, management of performance oversight, quality of service delivery and the ability to deliver an effective service based on patient needs”. 

The trawl of documents received by The Journal also provided a picture of ongoing staffing and retention issues. 

In May of last year ambulance workers voted to go on strike over what they termed a lack of progress in implementing proposed changes to the National Ambulance Service (NAS), including revised pay scales.

At the same time Siptu-affiliated members of NAS personnel began a ballot for strike action in a dispute with the HSE.

The union said the row centred around a series of proposed reforms contained in a report which recommends the introduction of new grades of staff, new job descriptions and the upskilling of existing staff.

That dispute has not been resolved and as recently as January there were still industrial relations tensions between NAS and unions. 

Despite that a briefing note from 15 January 2024 cast a positive note on the issue stating that NAS had the lowest turnover of staff in the HSE.

A table contained in the report revealed that on average between 79 and 96 people left between 2018 to 2023 each year. The service, however, in 2022 suffered a spike of 138 resignations. 

Those were more than met with an average of 155 to 184 between the years 2018 to 2023 – 284 people joined the service in 2022.

A document, from March 2023, stated that NAS employed 2,267 employees. These fulltime employees were augmented by 231 volunteer Community First Responders in 26 counties. 

The January 2024 report stated that a key staff retention issue was around pay and allowances. 

“A key concern for staff is the value placed on their roles in terms of remuneration and while the NAS have collaborated on developing a joint business case to inform future pay talks, the setting of public sector pay rates for staff is not within the NAS span of authority to progress,” the report added.  

  • LIFE AND DEATH: Our Noteworthy team wants to investigate if lives are being put at risk in rural Ireland from ambulance delays. Support this project here.