Driven to the edge? An insider’s view of the Belfast Ambulance service

South Western Ambulance WA07RYP 612Due to the ambulance strike today we are republishing this post as it helps explain the background to the strike. We have also kept the original comments – feel free to add new comments.

Continuing our series on health, we hear from a paramedic about the challenges the service is facing.

As a Paramedic working on an emergency ambulance it was encouraging to read George O’Neill’s article on Slugger last week that recognised the vital role of the ambulance service in managing the future delivery of unscheduled care in Northern Ireland. I would like to take this opportunity to provide an honest assessment of the current capability of the ambulance service and it’s potential to fulfil this new role.

Emergency ambulances here are staffed by Paramedics and Emergency Medical Technicians (EMT’s). They deliver babies, pronounce life extinct and cover absolutely everything in between. They are consummate jack-of-all-trades. A Paramedic is licensed to independently administer 35 different drugs, manage major trauma, resuscitate you in the event of a cardiac arrest and stabilise many medical problems. We work in highly pressurised environments with minimal training and without the safety net of having specialist doctors and nurses nearby.

A typical shift could see us carrying a 20 stone patient having a heart attack down 3 flights of stairs, then being called to a house where an individual has suffered a sudden death, liaising with police and doctors and above all sensitively dealing with grieving relatives. We could then end up at a major road traffic accident before having to talk a suicidal person into travelling to hospital. And all before lunch!

This illustration is not exaggerated. The nature of the work, the diversity of situations, difficult working environments and the high range of emotions involved means we regularly put our mental and physical health on the line for the benefit of our patients. Yet one of the cardinal sins of ambulance work is acting as if what we do is a big deal.

Unfortunately, the problems highlighted in the media faced by our Emergency Departments are very much present within the ambulance service. A growing elderly population, many of whom have chronic conditions requiring frequent interventions coupled with the misuse and abuse of emergency ambulances by both the public and health professionals has led to a dramatic increase in 999 calls and is forecast to continue to rise for the foreseeable future. Budget cuts mean that ambulance numbers have been slashed leaving a service under mounting, and many would say unsustainable, pressure.

By rights Northern Ireland should have an ambulance service at the cutting edge of pre-hospital medicine. The man known as “The Father of Emergency Medicine”, Professor Frank Pantridge, was a cardiologist at Belfast’s Royal Victoria Hospital. He introduced the technique of CPR and mouth to mouth resuscitation for cardiac arrest and went on to develop the first portable defibrillator in 1965. Dubbed the “Pantridge Plan”, this protocol forms the basis for treatment of cardiac arrest around the world today and has saved countless lives . Unfortunately despite rapid uptake by countries such as USA, Canada and Australia, defibrillators were not installed in UK ambulances until 1990.

However, we have not capitalised on this fine heritage.

The service is now reduced to operating a maximum of seven ambulances to cover the Belfast area (approx 280,000 people), with the rest of the country no better.

The system works to capacity most of the time, with little slack, meaning that sustained seasonal pressures or major incidents cause serious problems for staff and unacceptable delays for patients. Given the sparsity of cover,  the trigger point for such major incidents is lower that you would expect, the Hardwell gig at The Odyssey being a recent example.

The increase in workload for crews means that we regularly go a 12 hr shift being stood down for only one 30 minute meal break, which can be as late as 7 or 8 hours into that shift. Even this can be disturbed if an emergency call needs to be answered. Finishing our shift on time is rare.

Forefront in our minds is the welfare of patients. If we go from call to call with no meal break until the last third of the shift, stress increases, performance decreases and mistakes will be made. I for one do not want to be lying in bed awake at night because I have caused a patient harm.

This plays out against a backdrop of a management team more concerned with crisis management and blaming staff instead of dealing with the root causes of the organisation’s problems.

Their obsession with response times has resulted in paramedics being taken out of ambulances and put into single man cars, solely as a clock stopping exercise and regardless of whether this is the most beneficial model for the patient. Despite this we still don’t meet response time targets but nobody really seems to care.

Holding the organisation together at the moment is the professionalism and goodwill of it’s front line staff. However this cannot go on indefinitely. Sickness rates are high due to stress and musculoskeletal injury. Staff shortages result in dropped crews and more work to be picked up by the rest of the workforce, as well as casual leave not being covered. It doesn’t take a genius to work out how this then leads to a perpetual cycle of stress and sickness.

I wholeheartedly agree with up-skilling paramedics to allow us to treat people in their own homes. This will alleviate pressures in ED’s but will do nothing to ease ours. We need investment in new skills but also more ambulances. We need a good foundation to build on for the future, not something optimistically tacked on to the existing creaking structure.

Above all we need a level of pay commensurate with the demands of the job. Paramedics will welcome the opportunity to enhance their professional practice, but before we ask them to become doctors on the cheap and take on even more responsibility we would need to see a matching financial commitment. Despite almost all job roles being evaluated under Agenda for Change when it was introduced ten years ago, our management have spent the last decade quibbling over minor details, seeking to deny us the points that would take us into the next pay band. A newly-qualified Paramedic (Band 5) earns a salary of around £21K,  receiving annual increments for seven years to reach a maximum of £27K. Achieving Band 6 would see our pay rise to £25-34K.

Too many people dial 999 who do not require an emergency response. This ranges from wilful abuse to unintentional misuse and is not isolated to any one section of the community. If the number of these unnecessary callouts could be reduced we would see some flexibility returned to the system, but how could we address this?

Charging people for calling out an ambulance inappropriately is a popular idea but it is fraught with complications. Many of the worst offenders would be unable to pay, and pursuing the non-payment of fines through the court system could potentially cost more than would be recouped. It would also send out the wrong message to genuine service users – call us out and you may be charged if your condition is not deemed serious enough. This couldn’t be further from the original ethos of the NHS. No-one in our line of work would ever support a system that could cause a patient to think twice before lifting the phone for help.

Currently we cannot refuse to take a person to hospital, no matter how trivial the complaint. Not taking certain patients to hospital seems an attractive option as it would reduce the amount of time an ambulance is unavailable to respond to other emergency calls. However I also think this suggestion is unworkable. Given the numerous atypical presentations of certain medical conditions any exclusion criteria used would be so restrictive that it would apply to very few people. Many Paramedics would probably not want to take the chance of leaving a person at home, as inevitably someone will fall through the net and not receive the proper treatment despite the protocol being followed correctly. Besides even regular abusers of the service will get sick sometimes.

I think the most realistic solution will be to improve education on how to properly use the service. Many people are either unsure about what alternatives are available or how to access them. We would never seek to deny an ambulance to anyone who needs one but we need the public to act responsibly when they require unscheduled care to ensure we can continue to provide the best possible outcomes for those most in need.

Sometimes the simplest solutions are the best, and whatever way you view the situation extra ambulances would help.

It seems unrealistic to expect an increase in the number of ambulances given the next round of swingeing budget cuts across most departments, but I would suggest that for short-term investment there could be long term savings. Patients could be treated at home by Paramedics in conjunction with GP’s and Allied Health Professionals at a fraction of the cost of hospital admission. But this model would seem unworkable given the existing number of ambulances.

The ambulance service desperately needs to change, both to respond to future challenges and also for the sake of it’s employees. The goodwill is evaporating, with many staff of the opinion that their commitment is not being reciprocated.  I am confident however that if you are ever unfortunate enough to need us you will always receive the highest standard of care possible. We act as the buffer between service reduction and patient safety and will continue to do so, but we would urge the department to recognise the dedication of all it’s frontline staff by alleviating these pressures, paying us for the job we do and above all giving us the tools to improve patient outcomes.

What do you think? Let us know your views in the comments below. We are keen to hear from other health professionals. If you are a nurse, doctor etc with a view on the health service, do feel free to contact us with your story

  • Korhomme

    It’s not so long ago that the only requirement for an “ambulance man” was a driving licence.

    I’ve been very impressed how things have changed, and the abilities of paramedics locally. ATLS was certainly a wake-up call for hospital staff, and proper paramedic training began at around the same time.

  • StretcherMonkey

    What about the EMTs waiting to get Band 5, it isnt all about the Paramedics you know.

  • Brian O’Neill

    Can you tell us more about being an EMT? Does an EMT progress into being a paramedic? What percentage of ambulances are staffed by EMT? Or do you pair up with a paramedic. Would appreciate you explaining to us lay people how it all works. Thanks.

  • Anon

    I’d say the service is heavier towards paramedic numbers as they didn’t hire EMTs for the best part of a decade there. Ideally it would be an emt & paramedic in a crew, but due to staffing issues it can be para & para or even emt & emt.

  • Anon

    This highlights a lot of the problems with the service. Everyone is feeling the pressure, from control staff to PCS, EMTs & Paramedics. A huge shake up is needed in management to address this in a caring way, much like the care that the front line staff give to the public on a daily basis. Frankly though, the workforce has little to no confidence in its management. People’s lives are being juggled by a service that has been cut back to less than adequate frontline numbers.

  • StretcherMonkey

    Anon has explained it, we are currently short of 100+ EMT positions and NIAS have just appointed some but not enough to fill the gaps quickly, they also are going to give PCS staff progression to EMT grade but this will take several months to get them appointed and trained up so it will still be bums on seats for the mean time and the overtime bill still continues to rise.
    Morale is low for many reasons but the main one is, as mentioned a 10 year banding process that has dragged on and we hear rumours weekly that its near completion but we dont actually hear proper news on ots progress, its a complete and utter farce and us A&E staff deserve a fair pay for the life and death decisions we make in work, seriously an admin person sitting in a nice warm office doing 9-5 gets more money that i get and im knee deep in stuff that cant be described in words, in a ditch working on a person in a car trying to treat and reassure them that theyre gonna live, there is no comparison at all.

  • Theelk11

    George’s original post contained some interesting but not particularly original ideas.
    EMT’s and paramedics have an expanding role and rightly so, where that role goes to is the question.
    George is a GP and is involved in commissioning of services. His blog was a barely disguised wish list allowing General practice to take over provision of emergency care with the money that would follow going into the pockets of general practitioners.
    It’s insulting to emergency medicine doctors and nurses that their training and expertise could be replaced by a (and it would probably be a locum) GP.
    The idea of EMT/paramedic staff assessing and treating patients at home at night and handing out pills for kidney infections when the underlying issues and pathology could be infinitely more complex is frankly ludicrous.
    GP’s used to fill this role until they managed to negotiate a contract which allowed them to opt out of out of hours care.
    George wishes to take over emergency provision while avoiding the hard yards. Paramedical staff need to be careful what they wish for, they could find themselves performing a high risk role with minimal reward.
    If you want to be a doctor go to medical school.

  • Deke Thornton

    Simple fact. There are hundreds/thousands of people who have the capability and would love the job advertised. It’s extremely well paid. If you don’t like it, leave for a much better paid job. There are plenty of people willing to take your place. It’s almost as good as the Fire (and rescue kittens) Service.

  • Guest

    Think you’ve missed the point of the article. Most paramedics love their job but see the current situation as endangering both patients and themselves. They have a duty to speak out. The money isn’t the whole picture. While it may seem an “extremely well paid” job when compared to an office or factory worker you would struggle to find any other role in the medical profession with as much responsibility for the lives of patients on comparable pay. There is a reason why we don’t pay Drs minimum wage. These hundreds and thousands of people coming in after us would soon see the problems faced

  • Guest

    Paramedics do not want to play at doctors, most are happy doing what we do, and doing it well. But these ideas seem inevitable considering the current proposals under TYC. Any treat and leave protocols would leave no room for ambiguity and would relate to simple presentations. Let’s not pretend doctors always get it right with all their resources and stunning intellects.

  • No mention of the private Ambulance Services doing the PCS jobs after PCS go home on the evenings? Lines of CPNI at Altnagelvin (Londonderry) & Pro Paramedics (Belfast). What about the fact no university in Northern Ireland offers Paramedic course, you have to go to England (any in Scotland??)

  • I did 5 week Ambulance Care attendant course last year (same course as NIAS) for private ambulance company CPNI who work out of Altnagelvin doing PCS type runs in the evenings that NIAS won’t do. NIAS paramedic staff trained us. You can progress from that to EMT but very difficult to progress to paramedic apparently and no paramedic degree courses offered in Northern Ireland.

  • You need C1 on your licence for Ambulance driver/Care Attendant/EMT which most under 30’s don’t have

  • Brian O’Neill

    So they have privatised parts of the ambulance service? Can you give us more details?

  • james

    As sombody who works front line ambulance service and also a retained firefighter the two are nothing alike!! Nobody joins the service for the pay we all love the job but that doesn’t pay the bills. The service needs more vehicles to keep up with demand plain and simple every trust has the same stories 12hrs shifts turning into 14 hrs, not getting a rest break until 8 hrs in, (most people have worked a day had an hour for lunch and gone home) driving 30/50 minutes on blue lights as your the nearest vehicle, people waiting hour’s for a ambulance. we are working under extremely pressure and responsibilities but getting a “better paid job” is not what were looking for your obviously not in the NHS if you were you would see the pay bands are not equel and not fare it pisses off with that attitude “get another job” get some facts before you comment!!!

  • Dereck

    You were going well there until you mentioned pay. Now the public wil think that the next ambulance person through their door is stressed out because he/she doesnt feel they are well paid. When in fact they are more worried about the cleanliness of the ambulance, will they pass out while treating a patient or crash the vehicle while racing through traffic for someone who fell over in a shop.

  • Deke Thornton

    Kenneth Clarke correctly called ambulance drivers as overpaid van drivers. In France, the army provide both fire crews and paramedic services as part of their basic job (roughly 18k a year). There is a huge number of people who would love to get such a cushy post. (minus the army bit). The retained Fire service spends most of it’s evenings sleeping or playing cards. Like I said, the numbers queuing up for the life of Reilly and big pay and pensions shaft your ‘overworked’ standard public sector retort.

  • Bazza


  • Noeleen McFall

    well paid I dont think so

  • StretcherMonkey

    Deke, you just dont have a clue what your talking about, an overpaid van driver is a total insult to anyone in our service saving lives each day, i just hope that you dont ever require the services of 2 van drivers in a big green van that has flashy lights and a fancy horn, you obviously werent intelligent enough to join the ambulance or fire service and it quite appatent your a total imbecile.

  • Bazza

    Brian, Emergency Medical Technicians ( EMT’S ) don’t have to progress onto become paramedics unless they wish to. They hold another job role and with it occupy 50% of all ambulance crews (if the balance is right)
    EMT’s and paramedics share the workload evenly, driving and attending and have their own protocols and drug therapies. The only time this changes is when a paramedics skills or advanced drug therapy protocols are called for.
    I would say 99% of ambulance personnel have always loved their job, but are increasingly annoyed by the people who govern them. Statistics have overall importance and this “DOES NOT” have the patients best wishes at heart. If a response time is met, even by a person or persons that are unable to transport said patient …… Then a box is ticked. It is then irrelevant what happens to that patient from a statistical point of view.
    We are part of a changing society, services are now run as businesses, squeezing as much work out of everyone for as little as they can …. “Agenda For Change” was introduced in 2004 as a new pay scaled system, pretty much everyone in the ambulance service have been evaluated and banded under the system ….. Except …… Wait for it …… Those members of staff who attend 999 calls from the public, treat them, and transport them to hospital!

  • Deke Thornton

    A frontline soldier in Afghanistan gets £17, 495 (no overtime or shift allowance for 24/7). If you get more than that for taxi duty you’re well paid. What is the pay for a St John’s ambulance crew (same job)?

  • james

    The pay in the UK starts at 17k, you can earn more stacking shelves. What exactly do you do for a living! Van drivers!! Wait until you or a family member need a ambulance for a real emergency then see if you think there just “van drivers. You can’t compare the UK service to France everybody.
    You have no clue about it pal and st John’s only pick up none emergency patients, the army is underpaid defenetly I agree (I’m ex forces ) the nhs has so many cut backs and the pressure this causes is pushed on to the the people at the bottom the argument is the ambulance service can’t cope with the demand and we need more staff at the same time pay for the job we supply isn’t matched but we don’t provide any less of a service

  • AndyB

    Brian, I don’t think (but am open to correction) that any part of NIAS has been privatised, nor that Ambulance Control would task a private ambulance to a 999 call. On the other hand, for example, the Odyssey complex has contracted with Pro Paramedics to provide dedicated Paramedic services.

    What in this context is PCS anyway?

  • puffen

    Just an idea, why not put bumper stickers on our big yellow taxis, along the lines of STOP THE 11 PLUS

  • puffen

    Watch this space, to-day crews were dropped, Belfast in the main, and coming up to Christmas it is set to get worse, this means that a/e cover is diminished, given previous trends, this is set to get worse,given demographics and the wrong skill mix of the Ambulance Emergency tier, be aware this not only lack of finance, but enept management

  • Both CPNI and Pro Paramedics provide the same services that NIAS PCS do ie taking patients between hospitals and/or collecting patients from home/old folks homes etc and back again

  • No but there are private Ambulance Companies that operate in Northern Ireland (CPNI & Pro Paramedics) that do runs for hospitals – ie CPNI work mainly out of Altnagelvin and run patients between Altnagelvin, Enniskillen, The Causeway and other NW hospitals and old folks homes – the same as PCS except the private companies will do the jobs PCS will not – ie runs at 7pm or 10pm when PCS have gone home.

  • AndyB

    Explains it. I expect somebody did the sums and reckoned it was cheaper to pay CPNI and Pro Paramedics to do a couple of runs a night than to employ additional full time (or even part time) drivers to work in the evenings – I wonder whether that actually works out in practice (I’m pretty cynical about the cost savings in contracting out!)

    What does PCS stand for anyway? Patient Care Services?

  • Connor Conway

    Ambulance drivers??? Do you have any clue what paramedics do? We provide life saving treatment, diagnose vast amounts of medical conditions, treat mental health, work as social workers, find relevant care and refer, provide treatment for acute and chronic conditions.

    If you think all we do is drive ambulance, then you are an idiot. Even more so if you think any tom dick and harry off a roadside can replace us. We are medical practitioners responsible for peoples lives. You’ll find out we are more important than van drivers when your family member stops breathing.

  • Connor Conway

    No paramedic degree in NI. I’ve been completing mine in England, yet cant start work in NIAS because they rather train their own medics rather than hire those with university degrees. We have some great skills and new ideas, but NIAS isn’t as welcoming as other services.

  • Connor Conway

    Paid 21k to deal with the same rate of PTSD as a soldier, more training than a solider, lives to save each shift, not make a single error or someone could be killed or disabled, drive after endless hours working, paper work to complete every job and that has to be perfect too, always doing overtime, having to carry loads that will do in our backs and leave us in chronic pain.

    You spend a week on the road with all that responsible, doing the work as a doctor and seeing as messed up shit as a soldier, then tell me we are paid alright.

    Its easy to judge others, until you are doing the role.

  • Dan

    Who would ever dare criticise the job that the paramedics do, day and daily?
    Everyone in the country should be, and most probably is, eternally gratefully for their assistance at some stage…I know I am.

    Yet, their insistence on strike action today is an outrage.
    The seething hatred and bitterness from the likes of Patricia McKeown this morning on the radio was disgusting. The crews don’t need to come out on strike and leave the public vulnerable to make their point. They have our support already, everyone wants improved conditions for them to deliver the service we all want.
    Their striking is a pointless, counter productive gesture….and that the Union leadership is too fking thick to understand that is sickening.

  • chrisjones2

    Forgive me but …..33 comments in…..the usual union navel gazing on terms, conditions, driving licences and carping about rivalries with doctors / GPS etc ……and almost no mention of the poor punters in the back

  • submariner

    Perhaps you should spend a shift with a paramedic rather than spouting shite on Slugger.

  • submariner

    So what do you suggest is their alternative Dan?

  • Dan

    Not sure how we’ll get a solution given the farce that is Stormont, but messing with the safety of the public in such a cavalier way isn’t going to help their cause,

  • puffen

    Fifteen to twenty per cent shortfall of crews most days, will have a direct impact on your chances of surviving a cardiac episode, I am not getting any younger and neither are you, in the matter of self interest , this could be very important, though I hope not.

  • chrisjones2

    an uncomfortable truth then forces you to resort to simple abuse …so perhaps those whining on here should focus on the patients in the back

  • submariner

    I suggest you read the piece again,there is plenty of concern for the guy in the back from the writer. The fact is that the funding to the Ambulance service like the rest of the health service has been drastically slashed by a bunch of multi millionaire Tory toffs in Westminster who are more concerned with giving their banker friends tax cuts and bringing about the privatization of the NHS. Yesterdays strike was not about wage demands but opposing the massive cuts imposed by the thugs in westminster. I hope that you are never in the position that you need an ambulance in an emergency only to find out one is not available because some tory wanker deemed it more important that millionaires need another tax cut

  • El_Commi

    “I am confident however that if you are ever unfortunate enough to need
    us you will always receive the highest standard of care possible”

    I have to say, I have only ever needed to call an ambulance once – it was when my 18 month old daughter ate some peanut butter and had a severe reaction. We were unaware she had an allergy.
    The one man car arrived in less than 10 minutes, with the bigger ambulance not far behind him.
    Those who attended to use weren’t able to do much at our home but got us safely to hospital. They were prompt, very courteous and unquestionably professional. I have never been so relieved to see someone.

    Ambulance staff do a hard job, it’s actually shocking to realize how low the pay is.

  • Johnnyhero

    Hi there, are you currently an ACA, working in Northern Ireland? I have just applied and was successful at interview, and am now on a waiting list. I would like to learn more about the process if you are any way able to help me? Regards

  • dave

    Pro paramedics are NOT paramedics they are badly trained first aiders. NIAS PCS are professionals. No comparison.

  • blinkers

    Why then do 2 paramedics crew one ambulances, best use of resources?. Why do paramedics drive ambulances, nias could employ drivers to do that job. A lot of paramedics time is spent standing around outside ea dept

  • blinkers

    How many paramedics actually did strike how many booked sick, and how many booked some kind of leave. How many stood at ea depts.

  • blinkers

    Ambulance crews especially paramedics have fi ally been exposed, driving ambulances, drinking coffee outside a&e putting time in avoiding calls. Yes there are the few dedicated numbers, but outweighed by those who avoid doing the work they are paid to do, and shout for more. How many took sick or took some sort of leave on day of strike, how sincere and dedicated is that?

  • Realist

    Get on with it, many unemployed would gladly do your job, driving about and waiting outside A&E drinking coffee

  • Realist

    Why then are you doing the job, if all you can do is winge, ambulance workers/drivers have a wire about themselves

  • blinkers

    Ambulance workers have a very high opinion of themselves, highly paid drivers. I’m sure there are plenty of taxi drivers who would take the training and do the job without winging. A lot of ambulances crawl keeping traffic back where’s the professionalism there

  • Realist

    NIAS Paramedics have such a big ego, they are merely people who have been given training at taxpayers cost to do a job and get on with it, instead of drinking coffee outside a&e, driving at slow speeds on roads, no blue lights, no horn, two crew in front of ambulance, holding back traffic, wasting and putting in time to avoid other calls. Time up boys and girls, do the job you are paid for, well supposed to be doing anyway.

  • blinkers

    Yea and plenty unemployed would do the job without wingeing, just give over the ego trip and do what you choose and hot free training to do.

  • Guest

    You haven’t got a clue what your talking about Deke, so pipe down, this so called “cushy post” you talk about is one of the most mentally hard jobs around, i bet you haven’t worked 78 hours in the last 6 days, well I have, don’t comment on stuff you knkw nothing about,