An insider’s view of the latest problems with the Belfast Ambulance service

With the Northern Ireland Ambulance Service (NIAS) in the news once again, I wanted to take this opportunity to provide some insight into the ongoing internal problems within the service.

This time the spotlight has been shone on staffing shortages after it was revealed that 25 shifts lay vacant last Saturday night, the equivalent of 12 ambulances unavailable to respond to emergencies. Given that there are usually around 55 ambulances to cover the whole country this represents a significant reduction in service provision. This situation was common knowledge to staff in the middle of the week and barely raised an eyebrow as weekend cover is never much better.

Weekdays see fewer dropped shifts because vacancies are covered by staff doing overtime, without this undertaking the service would undoubtedly go under. However very few staff members are prepared to work overtime at weekends, especially nights, exposing the true magnitude of the problem.

The paucity of weekend cover is a symptom of chronic systemic failures within the organisation. I have posted twice before in this forum about the issues affecting ambulance staff in November 2014 and March 2015. Sadly many of these problems have still yet to be properly addressed with engagement from our managers remaining non-existent. Long-serving members of staff continually remark on how they have never seen the service in such disarray and it is hard to see how morale could get much lower.

The current staffing problems are the direct result of managerial decisions that border on negligence. They have allowed things to deteriorate to such a degree that you have to wonder whether there is any ministerial oversight whatsoever.

Emergency Medical Technicians (EMT’s) currently make up the largest group of vacancies within NIAS and an internal recruitment trawl was initiated late last year with another closing this week. In their desperation to save money, NIAS had attempted to replace EMT’s with unskilled, lower paid drivers. Their attempt to implement this model resulted in no EMT’s being recruited for almost 10 years.

Losing an EMT’s invaluable skill-set leaves the paramedic without vital support when it is needed most, undoubtedly affecting patient outcomes. Thankfully this was rightly recognised by the health committee who rejected the idea completely, but it is still frustrating to see how NIAS were allowed to let EMT numbers get so low in the meantime. It is also extremely concerning that, for the sake of saving the relatively small sum of £1.6 million over 15 years, NIAS were prepared to de-skill ambulances, disregard patient safety and leave themselves with problematic staff shortages in the process.

Paramedic vacancies are fewer but potentially represent a bigger problem. Staff turnover was 4% last year which is only impressive if you ignore the fact that paramedics here have nowhere else that they can utilise their very specific skills set within Northern Ireland. This is in sharp contrast to our colleagues in the rest of the UK who can move to neighbouring services or into other specialised postions.  However with Capita now aggressively recruiting paramedics for the role of Disability Assessor, offering similar wages for working 9-5 Monday-Friday, we have seen at least 30 paramedics leave the service from January this year. If there were permanent contracts on offer, or positions for EMT’s, then this figure would definitely be higher as so many staff feel unable to continue to work on the front line under such increasing pressure with no sign of relief.

Filling these positions will not be straightforward. The service is relying on a small group of recently qualified paramedics who were given positions as EMT’s instead due to the mismanagement of the most recent paramedic trawl. They have been invited to reapply for paramedic posts but it cannot be guaranteed that all these individuals will oblige, and this measure will still not fill all the empty positions even if the whole group were to be successful.

Unbelievably NIAS are now in a position of not being able to train their own paramedics. As of this year, to become registered as a paramedic you are now required to complete a course set at a higher level than that provided by NIAS previously. This requirement has been known for a long time yet NIAS have failed to recruit an academic partner to facilitate a new course, meaning that it will be at least 3 years before we are able to train our own paramedics in this country. In the meantime we will have to rely on people from Northern Ireland completing the degree course at a University on the mainland and then applying to work over here or else paramedics from other services transferring over.

Working for NIAS is not an attractive prospect for anyone currently working as a paramedic in England, Scotland or Wales. The workload is no easier and personal development is laughable compared to other services. We can only look on in envy as we see how these other organisations support their staff through degrees and other accredited courses. We have many frontline people who are hungry to learn more and desperate to deliver the highest possible level of care to patients but are denied the opportunity to develop their clinical skills. We want patients to reap the benefits of the advanced paramedic roles enjoyed by people on the mainland and at the same time give staff here something to work towards and keep them motivated. This lack of investment in staff is a key factor in the growing resentment and ill-feeling within the service, making leaving NIAS an increasingly attractive option.

Sickness has huge implications for service delivery and is almost considered an occupational hazard given that the nature of our job means that there will always be many reasons why front-line staff members are unfit for duty. There are numerous examples of ambulance staff suffering life-changing musculoskeletal injuries due to the cumulative effects of years of lifting heavy loads in awkward and uncontrollable environments or else in single episodes, where a staff member ultimately ends up sacrificing their own health for the benefit of the patient as the seriousness of their condition dictated the need for a speedy extrication.

Stress levels are high, but given the nature of the job they should really be much higher. On every shift we help people experiencing the worst day of their lives and as a consequence are regularly exposed to extremely traumatic events. We all live with the memory of particular patients we were unable to help but it is something that is rarely, if ever, talked about among staff. The deaths of young children obviously have a huge impact. In rare moments of candour between workmates it is clear that the entirety of our front line staff have been exposed to things that will undoubtedly affect their mental health.

It is testament to the dedication, resilience and courage of our staff that they continue to be able to provide high-level care to others every shift. Pastoral care in our organisation is non-existent, counselling provision is woefully inadequate and staff welfare appears to be secondary to performance targets. This approach can only lead to under-reporting and non-treatment of mental health issues. We are failing miserably in our duty of care to these staff members.

When you add in the ongoing problems with late and missed meal breaks, cancelled casual leave and late finishes that eat into valuable family time (14 hour shifts are not uncommon) you have a recipe for disaster. Increased stress inevitably leads to more sickness that puts extra pressure on an already creaking system with the remaining staff having no choice but to pick up the slack. This raises stress levels further still and ultimately leads to even more sickness. It is a vicious circle which our managers do not seem to want to address. The only time we hear them acknowledge the problems we face is on Nolan, Mitchell and Good Morning Ulster. Once the media storm has blown over the issue is never actually dealt with or discussed with staff, the relief from HQ almost palpable having dodged yet another bullet. The lack of engagement seems so chronic and profound that seems a conscious decision has been made not to engage with staff on any issues or to give us reassurance, empathy and a commitment to work with us. On Wednesday our interim Chief Executive issued a communiqué detailing how she intends to improve industrial relations, we can only hope that after all this time this is an honest gesture and not a cynical tactic with one eye on her upcoming interview for the permanent post.

Why do we feel you should care about all this? Vacancies, lack of cover and the resultant potential adverse effect on patient care are the products of a number of issues, some of which I’ve touched on here. ‘Human factors’ is a huge buzzword in medicine at the moment which the WHO recognises as the key aspect of most adverse events in health care. We proudly trumpet our response times, but they do not tell even part of the story. There is no point in a patient getting an ambulance in 5 minutes if they do not receive optimum care. The human factors approach recognises that tired, stressed, hungry, undervalued, demoralised and undertrained staff will inevitably make mistakes and it is the public who will suffer most. We want to be part of system that is fit for purpose but that means prioritising industrial relations and investing in staff. We want to be safe in order to continue to keep you safe.