Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome Neil Sinclair and Maxine Paterson to the Committee. Thank you very much for coming and for sending your briefing notes, which were very useful. I invite you to make some brief opening remarks, after which we will go to questions from members.

Ms Maxine Paterson (Northern Ireland Ambulance Service): Thank you very much, Philip. The chair of our board would have liked to be here today as well, as was scheduled, but she had a conflict that she could not resolve.

The Chairperson (Mr McGuigan): You nearly caught me out on reading without looking. [Laughter.]

Ms Paterson: I will briefly take the Committee through some of the key themes from the written briefing, focusing in particular on the experiences of patients and staff and on the areas of greatest operational risk, as well as the actions that are under way to improve performance. Before I begin, I would like to acknowledge two things. First, many of our patients are waiting longer than we would want for an ambulance. Some are waiting in distress, and that is regrettable and not acceptable for patients or their families. Secondly, I would like to place on record my appreciation of the dedication and professionalism of our staff, who go above and beyond every day. They are working under really significant pressure, and they continue to provide compassionate care in very difficult circumstances.

Today, I want to explain why that is the case and what we are trying to do to address that. At the outset, the key point that I want to make is that ambulance performance reflects the pressure in the wider urgent and emergency care system. The Northern Ireland Ambulance Service (NIAS) sits at the front door of that system, so when pressure builds elsewhere, particularly in hospital flow, we feel it first. We are the most visible part of it, especially to the public. Our delays are directly linked to hospital discharge, bed availability and community capacity. While response times are what the public see and feel, they are symptoms of a wider system pressure.

We have given you some stats on how many patients we see every year. Our role is not simply about transporting patients. It is also about assessing and treating patients and navigating them towards the most appropriate care pathway, which improves their outcomes. That includes treating more patients at home and avoiding unnecessary conveyance to hospital. I want to be clear that that is a very deliberate shift towards improving patient care while supporting system sustainability.

Our performance does not meet national response time standards in any way and has not done so for a number of years. As per the briefing, our most serious call response times — for category 1 calls — average around 12 minutes. In category 2, our response time is significantly longer than the 18-minute target. At the time of writing, as per the briefing, that was, on average, one hour and 22 minutes. Our category 3 patients, who should expect an average response time of one hour and 20 minutes, are waiting hours beyond that time.

I want to be clear: those delays really do present a risk to patients. Prolonged waits are not neutral; they carry clinical risk. As waiting times increase, patients deteriorate and pain can go unmanaged. Our frail and elderly patients, who represent about 50% of the emergency calls that we get annually, face an increased risk of dehydration, pressure injury and, undoubtedly, deconditioning, which can impact their outcome. Therefore, this is a patient safety issue, not just a performance issue. Alongside that, there are the experiences of patients and their families. People are waiting, often in distress, and that is not where we want to be. Importantly, dignity can be compromised when waits are prolonged, not just in the back of an ambulance but in the community as well.

The single biggest factor affecting our performance is hospital handover delay, the impact of which is very direct. Delays at emergency departments (EDs) mean that crews are unavailable to respond to the community, and that leads to longer waits. This year, as per the briefing, we have lost over 25% of our capacity due to handover delays. In practical terms, that is equivalent to dozens of ambulance shifts from the system every single day not being available. It is important to recognise that the harm occurs in two places: first, in the back of the ambulance; and, secondly, in the community as a patient waits at home. It is not just about ambulance crews waiting unnecessarily. Rather, it reflects the pressures in our emergency departments and patient flow in hospitals and across the wider system.

At this point, I want to acknowledge the work of the emergency department teams, which are managing a really high level of pressure and high levels of demand with pressurised conditions, while continuing to provide care to people in that environment. The challenge is not isolated to NIAS or to one part of the system but is across the entire care pathway.

A regional approach to improving handovers has been agreed across the health and social care system. I emphasise that there has been clear alignment, at chief executive level, on the direction of travel and the importance of addressing the issue. Colleagues across the system recognise that handover delay is a patient safety issue and have committed to improving it. I need, however, to be candid with the Committee: we have been in this position for some time — there have been years of deteriorating performance — and have not yet achieved the required pace of improvement. Following our agreement, in August 2025, to improve hospital handovers, we saw some green shoots of improvement in October and November of last year that demonstrated that progress on performance is possible. That was not sustained throughout the winter period, however, when pressures on the system were at their most acute. The pressure that NIAS experienced, especially in the first two weeks of January, was unprecedented and extraordinary.

From my perspective, the key issue has not been lack of intent but the system's ability to deliver consistently under pressure and to get traction on this particular issue. The difference is that we have now moved beyond agreement of direction into a clearer operational grip and defined intervention. Following the winter, there has been a reset and a focus on grip across the system, including having clearer expectations for handover time frames, stronger system oversight and more consistent escalation when delays occur. Over the past few weeks, we have started to see a little bit of traction around that, but that does not take away from the really poor response times that we have had so far.

Critically, we now have an agreement on the introduction of a clinical safety valve. That is the new piece that has been agreed since the winter. It is anticipated that Release to Rescue, which is also called Release to Respond — in some cases, I have also seen it called the London model, because it was piloted and started in the London Ambulance Service — will go live in Northern Ireland from 27 April. We are very clear about the fact that the Release to Rescue process is not about withdrawal in isolation. It is a clinically led safety mechanism that has been agreed collectively with the other health and social care trusts. It is designed to ensure that ambulance capacity is made available to return to the community in cases where delays have been prolonged. That is an important inflection point in the journey that we have been on so far. It is a clear and consistent boundary in the system that has not previously been in place. To be clear, it will not resolve all the underlying pressures in our system, but it is a necessary step in stabilising performance while we get some space and clarity to create better conditions for further improvement. To date, progress is not what we would have wished it to be, but I am more confident now that we have alignment, a clearer grip and a defined set of actions that can begin to deliver some sustainability around improvement.

Building on that positive direction of travel, NIAS's workforce is also growing. We have increased front-line staffing overall, we continue to recruit, and we see progress on building our workforce pipeline. Alongside that, informed by practice and strategy in ambulance services across the UK and globally, we are reshaping how we use the workforce in anticipation of delivering more modern and sustainable care for our patients. The key issue is that our staff are doing that in a really challenging operating environment. The system pressures will impact on staff well-being, fatigue and absence levels. While we are growing the workforce, we are still supporting staff through this period of change and sustained pressure.

In part, that pressure means that we have been operating in action short of strike, with our unions, since November 2023. The issues that have been raised by our trade union colleagues are well understood and relate to the things to which I just referred: safe staffing, staff welfare and the impact of system pressures, especially delays. We continue to engage constructively with them through our partnership forum. Critical actions, such as Release to Rescue, would be expected to support progress on addressing the issues and challenges that our staff face. Our staff remain highly committed and continue to deliver compassionate care, but we are conscious of the impact that that has, particularly in terms of fatigue and moral distress.

We are also seeing increasing levels of violence and aggression towards our staff. I know that the Committee heard some evidence on the same last November. To give you a reminder of the scale, we recorded over 600 incidents this year. However, proportionately, taking into account the size of the workforce and the number of patients that we see, our figures for incidents per staff member are about a third higher than those of the next trust. We also know that staff do not even report about 25% of incidents, so we must consider that the number is much higher. It is a very serious issue, and we are taking forward a range of measures to support staff safety and well-being in that space.

I also want to highlight the role of our emergency operations centre (EOC) staff, our call-takers. They are often the first point of contact for patients in distress, providing a response and support over extended periods of time and answering many callbacks from distressed families who are wondering where the ambulance is. That is very challenging. We are continuing to invest in our workforce pipeline.

To conclude, alongside workforce growth, through our clinical model, about 11% of our calls from patients to our control room are dealt with on the basis of Hear and Treat. I have some information in the brief on that. Approximately 25% of the patients who call us do so through See and Treat. This is not just about managing demand; it is about delivering the right care in the right place at the right time, and it represents a fundamental shift in our service to a more modern, clinically led and sustainable model. While the pressures are real, we are not standing still. We are actively transforming the service to meet the needs of our patients now and into the future.

I would like to touch on our reliance on the independent ambulance sector. There has been quite a lot of conversation about that recently. That sector really supports us in some of our emergency activity and non-emergency activity. While that supports resilience in the short term and has been very much welcomed in the past number of years, it is not a sustainable, long-term solution. We recognise that. I think that it is important to provide a bit of context about why we have found ourselves in that position and why our use is at that level.

Our use increased significantly in 2021, and the reasons were twofold. First, it was during a period when we had a two-year gap in the establishment of our Bachelor of Science in paramedic science at Magee. We had a fallow two years, and, at that time, we needed to look at how we might compensate for some of the attrition and challenge in that space. We were using the independent sector to do that. Secondly, because of COVID at that time, for social-distancing reasons, we had to reduce the number of patients that we could take in a vehicle, so we had to increase the number of vehicles that we had available to transport patients. However, reliance on that sector was built at that time, and it continued to sustain our non-emergency service and patient-discharge capacity, through which we support the trusts in discharging patients home.

More recently, we have been able to focus on filling vacancies through each year's graduate cohort from Magee — the cohort was 48 students, and I am pleased to say that 65 students will now be available — and through targeted recruitment of qualified paramedics from the rest of the UK. That approach has gained some traction. We are not yet at the full-establishment stage that is outlined in the briefing, but we are certainly moving in the right direction. That reliance reflects a transitional period, and we expect, from next year, to see that significantly decrease, which is appropriate.

Moving forward on a strategy from a NIAS perspective, we have a clear plan, and, importantly, we are beginning to see that plan taking shape in practice. We did a demand-and-capacity review, and that provided a structured road map across workforce, rota reform, efficiency, and on how we might expand our clinical capability to support patients. It is not just an internal programme; it is aligned with the broader Health and Social Care (HSC) plans. The HSC reset plan encompasses elements that can be directly supported through our plans such as the neighbourhood model. The Big Discussion also has informed some of the work that we have done in our strategy. Ultimately, we are focused on delivering care in the right place, at the right time and by the right person. That represents a fundamental shift away from default conveyance to emergency departments and towards earlier clinical decision-making and stronger integration with community and hospital pathways. We are already seeing that through the development of alternative pathways across all of our HSC trusts, and I can give you some examples later if necessary. They are practical examples of how we can reduce avoidable hospital attendance and deliver better care for our patients. For that model to fully realise its potential, it must be supported by consistent improvement in hospital flow and handover.

It is not something that is binary; we require those things to make this work. It is not a choice between demand management or flow; we need to do them together.

There is a clear opportunity for ambulance services. That means delivering earlier, more-appropriate and more-person-centred care and evolving that to meet the needs of our patients now and in the future. Thank you.

The Chairperson (Mr McGuigan): Thank you very much, Maxine. That was useful. As I have said to all chief executives, there is no excuse for any violence against healthcare staff. It is important to put that on record. Our thoughts go out to any members of the Ambulance Service who have been subjected to physical violence or threatening behaviour. I thank your staff, who, as you said, are extremely committed — I have no doubt of that — for the work that they do.

I do not think that you tried to sugar-coat any of the issues in your presentation. Positive moves are afoot, but it is a pretty sobering assessment of where we are at. It is a very emotive issue for the public. You quite rightly said that the Ambulance Service is the most visible indicator of pressure on our health service, and that is true. It is the first port of call for people when they are in an emergency. We all, as MLAs, could highlight poor examples in which constituents in very distressed states have had to wait long times for the Ambulance Service to come, if it does come, to pick up family members.

Your waiting times are not particularly great reading. For category 1 calls, the highest category of emergency calls, the expected time is eight minutes, but the average time is 12 minutes. The category 2 times are worse: the expected time for arrival is 18 minutes, but the average time is an hour and 22 minutes. It just gets exponentially worse from there. That is where we are coming from. It is the Committee's job to try to interrogate how we can assist you to improve things. That is certainly our job.

You said that those figures, which are not good, along with some of the problems that you face as a service and the response times, can have a direct impact on patient safety. My first question is obvious: what is the assessment of patient safety and patient outcomes due to the problems that are currently being faced by the Ambulance Service?

Ms Paterson: I will start, and I may bring in my colleague Neil to answer further. First and foremost, we, as an ambulance sector, do not have access to patient outcomes. Our job is to get the patient to definitive care quickly, but I will come back to outcomes.

Ambulance handover performance has been an issue across the UK for the past number of years. In 2021, a review was conducted to look at the evidence of harm to patients who wait in an ambulance or in the community. It very clearly indicated that patients who waited for more than one hour to receive care were likely to receive some sort of harm. Patients who were over 65 — older patients — were even more likely to experience harm that might impact on their outcomes. That evidence-based study was used to support traction and improvement in the rest of the UK. There is clinical evidence behind it.

You referred to the category 1, category 2 and category 3 patients. Thankfully, our category 1 calls represent a very small proportion of the calls that we go to daily. Our category 2 patients are people whom we see experiencing the biggest impact from our hospital handover delays. Those are the people who we are trying to get to who may have chest pains or symptoms of stroke. We try to get to them within 18 minutes, because we know that minutes make a difference. Those are the patients who are more impacted by that. However, I do not want to miss the opportunity to say that our category 3 patients are generally our older patients. They may be frail and elderly. Those are the people who, unfortunately, could have had a fall, and they may wait many hours for us to respond and get them to definitive care. I wanted to give you an outline of the outcome basis for that.

The Chairperson (Mr McGuigan): There is some evidence to support your saying that there is harm associated with waiting for an hour.

Ms Paterson: Yes.

The Chairperson (Mr McGuigan): The average response time for category 3 patients is two hours and 52 minutes, and that can be correlated with harm. If it is correlated with the fact that the majority of those patients are older, and you said that outcomes for older patients get exponentially worse, that is not good.

Ms Paterson: Correct.

The Chairperson (Mr McGuigan): How can we create improvements? You have outlined a number of plans. Is there any difference across the trusts for the response times? Are some trusts better than others? Do some trusts have a particular problem that needs to be rectified?

Ms Paterson: With regard to response times, the NIAS is a regional service, and its resources cross trust boundaries. The challenges in one particular trust area will always have an effect right across the region. There are local challenges for individual trusts, and that exacerbates our ability to respond in the times we would wish. The handover times vary in each trust area every day, and they are not consistent. Generally, some trusts perform better or worse, but there are other factors that influence that, and it all contributes to our response times.

The Chairperson (Mr McGuigan): I have a simple, basic question. Danny and I visited Antrim Area Hospital one night during Christmas, and eight ambulances sat outside for a substantial length of time. Danny has the exact figures. If you could get patients to a hospital and do the handover quickly — in 30 minutes or 45 minutes — would you meet your category targets? Is it as simple as that?

Ms Paterson: It is a significant contributing factor that creates the delay, but it might not address the whole performance challenge. We are working to establish our core staff, and we need to make sure that we get our full staff complement. We also have to understand how the full staff complement, including the capacity that we would get back from handovers, will allow us to meet those performance targets.

The Chairperson (Mr McGuigan): You are working with the trusts to ensure that the limit is two hours, and Release to Rescue will commence in April. Will you explain the difference between the two-hour target and Release to Rescue?

Ms Paterson: There is an ambition to have a backstop of two hours to allow the NIAS to clear in two hours. Release to Rescue is an escalation protocol. After one hour, we will start to plan to ensure that the patient will be handed over in two hours. At the two-hour mark, we will be given leave to leave the patient at the hospital. That is a defined boundary that was not in place prior to the agreement in 2026, and it allows us to have a mechanism to get back out into the community rather than an unending commitment without a defined protocol to affect that.

The Chairperson (Mr McGuigan): The two hours is the time frame, and Release to Rescue is how you will achieve the two-hour handover.

Ms Paterson: I want to be very clear: this is phase 1. The national target, as you articulated, is 15 minutes for our staff to get to the hospital and hand over the patient, 15 minutes to clear, a backstop being 45 minutes. However, it is important that the trusts are given time to get that stability and consistency into their processes as well. They are not doing that in isolation. They are also developing alternative destinations, so that we can reduce the number of people that we take to their front door, allowing them to manage demand more appropriately. There is a two-pronged approach.

The Chairperson (Mr McGuigan): From my comment about the sobering narrative of where we are at, you moved on to the positive of what we want to achieve and how it will be achieved. Is it achievable? Obviously we want to see a better time frame, but given our current circumstances, come April, will we see the two-hour time frame being met right across the North?

Ms Paterson: I cannot guarantee that, Chair, but I have seen the clearest commitment and the clearest operational protocols to make it happen. I have seen significant system regional oversight from the strategic planning and performance group (SPPG) and the Department to ensure that it will be achieved. Between now and 27 April, we need to build to ensure that that can happen. We have certainly been raising that for a number of years in the Ambulance Service, and this is our most likely opportunity to achieve it.

The Chairperson (Mr McGuigan): From our point of view, we feel that it is critical —

Ms Paterson: Absolutely.

The Chairperson (Mr McGuigan): — when it comes to all the issues that we hear about weekly related to secondary care. We certainly want that to happen.

I have one last question. You are now taking patients from the South West Acute Hospital to Altnagelvin. Is that having an impact on local cover in County Fermanagh, for example?

Ms Paterson: It is our responsibility to ensure that we are able to respond appropriately and in the right time frame. We have been involved in the reconfiguration of services, not just in the south-west but across the whole region, and it is critical to have our plans and additional resources in that area to ensure that response times are met. We continue to work with the Western Health and Social Care Trust on any challenges that arise around that. It is not without challenge, but, operationally and strategically, we are meeting the teams to make sure that we alleviate any challenges that arise.

Mr McGrath: Thank you, Maxine, for your presentation, and thank you to all the team in the Ambulance Service for the work that you do. That is well recognised. I certainly acknowledge that, at times, the Ambulance Service is just being left to get on at the front of the order as the public face of a health service that is not functioning and is not able to get patient flow correct. You and your teams then have to deal with the longest waits. That is grossly unfair, and it is why I have always called for additional resources, help and solutions for the Ambulance Service.

I acknowledge what the Chair said, and I want to follow on from that. I am a representative of a rural community, and I feel that rural communities are feeling the pressure more than others. That is totally unfair. In my constituency, our category 1 response time targets are achieved somewhere in the region of 14% of the time. Unfortunately, that means that, as an entire health service, we are not reaching that target somewhere in the region of 86% of the time. That is causing problems. Could you give us a flavour of any issues related to that displacement?

In the South Eastern Health and Social Care Trust area, which I represent, there is only major hospital, and it is right on the border with Belfast. In fact, if you open the window in the room that you are in at the minute and throw a stone, you will probably hit the hospital — the Ulster Hospital — that is to serve all the way down to where I am in the Mourne Mountains region in Newcastle. Ambulances that are designated for areas such as Newcastle and Downpatrick go up to the Ulster and are then stuck outside there with a patient, but, once they are released, as they try to make their way back down to their base, they often get called off to other calls. How do you manage that process to make sure that, when the 999 call comes from somewhere like Newcastle, there is an ambulance available to deal with that?

Ms Paterson: Thank you, Colin. I will start and then bring in Neil, who is the expert. You are right. We have a regional service, and we distribute our resources across the five divisions, which are the five trust areas. It is anticipated that we should have enough in each of those areas to respond to the demand. As you rightly point out, the challenges with our handovers mean that our resources are responding from the hospital rather than from those areas. That undoubtedly creates challenges, especially in those very rural areas. I will bring in my colleague Neil to talk to how we manage that, if you do not mind.

Mr Neil Sinclair (Northern Ireland Ambulance Service): Certainly, Maxine. Thank you, Colin. As you outlined, it is a very challenging situation. Maxine mentioned our call handling staff in the control room. The other side to that is our dispatch and control management staff, who do a balancing act throughout the day to understand where cover is, how we can cover areas, what the neighbouring resources are, how we can spread the thin resource that we have as widely as possible and how we can provide the best cover. That is the best that we can do. There are also clinicians in the control centre. If a low acuity patient comes through the 999 system, the paramedics in the control centre will provide them with support prior to the automatic dispatch of an ambulance. We do the best that we can with our staff in the control centre. Ultimately, if the hospitals released our ambulances quicker, that would allow us to have better cover.

Mr McGrath: I appreciate that this is probably a terrible question, and it is not to put you on the spot, but if, for example, there is a queue of ambulances sitting outside the Ulster Hospital, including one that should be covering the Downpatrick and Newcastle area, and if, as that ambulance gets released, there are two patients sitting on your system with roughly the same type of condition, and it has to be sent to one of them, do you take the decision that it goes to the closer patient or to where the base is? If both patients have the same condition but one is much closer in somewhere such as east Belfast and there is only one ambulance that should be in somewhere such as Downpatrick or Newcastle, how do you decide where to go?

Mr Sinclair: Absolutely, Colin. That is the art of what our control centre does. There are two sides to it. The control centre normally works in chronological order through the categories. However, the clinicians in the control centre, specifically our new management layer of clinical safety managers, constantly review the waiting calls and identify who is the next priority rather just working on the historical chronological order. That is how we would manage that. A further challenge for us is the staff welfare element of ensuring that our staff have meal breaks and appropriate facilities and that they finish within a reasonable time of their shift ending in that scenario.

Mr McGrath: I remember having a conversation with the previous management team about the fact that long ambulance waits outside hospitals for prolonged periods can pose a difficulty and a challenge for staff, because they are not getting to use the range of skills that they have. Paramedics and other ambulance personnel are some of the most skilled medical interventionists that we have at our disposal to try to help people in their time of need. However, the issue is that, during their shift, they may deal with only one patient, who, by the time they get to a hospital, is deemed to have the least-serious condition in that area, because otherwise they would be in the emergency department. Everybody who is in an emergency department is prioritised as being sicker than the people outside, otherwise they would be in getting treatment. Are staff concerned about the fact that they are not getting the opportunity to use their skills in the way that they would like?

Mr Sinclair: Absolutely, Colin. It is a real concern. I will reflect on my career. When I started over 20 years ago, I conducted six, seven, eight, nine or maybe 10 patient journeys in a shift. We now know that the current NIAS average is three patient journeys per shift, so it is a real challenge. It is a challenge for our substantive staff to maintain their skills. It is also a challenge for our students coming through to make sure that they get enough exposure to fill their portfolios and to get the experience that they need. We address that in a couple of ways. We ensure that students have opportunities to work in response cars, which provide a little bit more exposure, to work in our control room and to work with our specialist resources. We have increased our education days from two to three days, so all our clinicians get three mandatory education days a year, which increases exposure. It is about how we solve the problem in the medium and longer term. It is also about providing further education and developing advanced paramedic roles in our career framework. We need to upskill paramedics to allow them to treat more patients in the community, which will, hopefully, solve part of the issue. However, I agree, Colin: it is a very challenging situation.

Mr McGrath: I have a final point for Maxine. Last week, I visited the North West Ambulance Service in the north-west of England. Alongside its ambulance service, it has a well-developed and well-delivered 111 service. You referenced your Hear and Treat and See and Treat pathways. One of the main ways to access the emergency-based service or emergency department is to ring the Ambulance Service, and it seems that you are dealing with a significant caseload that you should not have to deal with. Do you feel that, if there were other well-used and capable avenues alongside the Ambulance Service, it would assist you and your staff with your workload?

Ms Paterson: Yes. A number of services in the rest of the UK have 111 services that are aligned with their 999 service. They can pass patients between the two services and create a staff base to clinically manage and prioritise the 111 patients who are looking for access to care that they are not getting through any other means, as you say. It is an effective model. It is managing the community demand more effectively. That would be an opportunity for Northern Ireland as our system matures.

Mr McGrath: I could not recommend the service enough. You ring in and can get an appointment with your GP or the mental health team or in an urgent care centre. You ring in and get diverted to pathways. However, it seems that, here, it is a case of turning up at your ED or ringing for an ambulance. That seems to be where a lot of the pressure is. That is something that we might get an opportunity to look at.

Thank you, Chair, for the opportunity to ask those questions, and thank you, Maxine and Neil.

Mr Robinson: Maxine has covered a lot of what I was going to ask around the action short of strike. I will reframe my questions into one question, Maxine. Your paper has been very useful, as the Chair said. It highlights how action short of strike relates primarily to safe staffing levels and staff welfare. Your paper highlights that there have been efforts to increase staff. Some of those efforts have been positive: the number of staff available has increased from 645 in 2024 to 756 in 2025, and it is anticipated that that will increase to 806 during 2026. You highlighted other efforts that are being made to try to stabilise the service. Given the efforts that the Northern Ireland Ambulance Service is making to deal with the issues that the unions are highlighting, how close are we to a breakthrough? When do you expect progress to be made on action short of strike?

Ms Paterson: We have developed a good relationship with our unions around this space. We want our staff welfare to be supported. The safe staffing element is very much around and directed to the fact that over 30% of our staff are waiting for more than one hour at the end of their shift and not getting appropriate meal breaks because they are not at facilities that can accommodate their rest periods as they are waiting with patients. Over the past number of years, with our unions, we have developed opportunities to try to mitigate that impact on our staff. That has been very welcome, in both parts. However, I go back to my earlier statement. Critically, the thing that will potentially change the situation regarding action short of strike is the unions seeing a commitment to having staff released within at least the two-hour window that I talked about in the Release to Rescue process. That is critical for moving this forward in our relationship with the trade unions. I will continue to support their action, because it is right for staff. At the same time, they are working with us on the workforce plan and the like of our rota. We will get more progress on that if we can get some capacity back to give our staff that respite. We are working on that.

Mr Robinson: You referred to the reliance on the independent ambulance sector at a cost of approximately £10 million a year. How does the cost to buy in from the independent sector compare with the cost of NIAS? Is it more expensive to bring it in from the independent sector?

Ms Paterson: Buying in from the ambulance sector is fairly aligned with our resources. The main difference is that we have professional clinical supervision over our staff, and the independent ambulance sector is not supported in a regulatory way. Our direction of travel is to continue to build our staff and workforce. While we have been spending roughly £10 million a year over the past five years, we are forecasting £8 million to £8·5 million this year, and we expect that to reduce as we convert that revenue into our core vacancies and get our staff established. I hope that that answers your question.

Mr Robinson: Absolutely; that is very good. Thanks, Maxine.

Mr Donnelly: I reiterate the thanks to your staff over this period. The pressures over the winter in particular have been horrendous, as they have been for quite a few years, and it seems to be getting worse. I have spoken to quite a few of your staff. As Philip said, we went to Antrim Area Hospital. That was on Sunday 15 December, and, at 9.30 pm, we were told that flow had stopped at that hospital. Your ambulances were stacking up outside. There were six when we got there and nine when we left. The longest wait at that time was six hours and 21 minutes. That was someone with flu-like symptoms. There was quite a lot of flu at the time. The emergency department was full, so nobody else was getting in, and that wait was going to get considerably longer. The hospital was full, so nobody was moving on up from the department. As you said, it is a systemic issue. It is the whole way up. It backs up at the front door, and you are the most visible part of that.

You were involved in the winter preparedness plan's Big Discussion. Is that right?

Ms Paterson: That is correct.

Mr Donnelly: What was your feeling about that, and did anything positive come out of it for the ambulance service?

Ms Paterson: The Big Discussion offered us a different forum and place to collaborate across trusts to understand what we might be able to do differently, especially coming up to winter. I focused on the frail elderly falls pathway, which was one of seven work streams. Whilst, as I said, we do not have access to outcomes data, we were able to bring together the evidence and outcomes for a cohort of patients and understand what happened to them. We established that, although we brought the majority of those patients to hospital with the chief complaint of "falls", that was not why they were admitted. They were probably admitted for another reason, and that was illuminating for everyone involved.

To that end, we looked at how we establish —.

Mr Donnelly: Sorry. Typically, what were they admitted with? Chest infections or dehydration?

Ms Paterson: They were admitted for a range of things, and the majority of the patients who had fallen were older people. We got the most impactful evidence from the cohort of patients who were over 80. We established that, if you are over 80 and are brought to hospital under that pathway by ambulance, your average stay is 15 days. It is quite alarming that 80-year-olds will be in hospital for 15 days and treated for a range of things for which we did not initially bring them to hospital.

That set us on a path of looking at what we would do instead. A number of interventions were put in place through the Big Discussion on that specific work stream. They included clearer communication in signposting and engagement on a falls pathway in each trust. For example, each trust ED built a compendium of services for their staff and NIAS to ensure that the person whom we brought to hospital had been brought appropriately and went on to the appropriate care pathway.

Another thing that we got from that was a commitment from the trusts that some ED clinicians would come and work in our control room for a period. Unfortunately, due to the extraordinary pressures in January, that has not happened yet. It is a little bit like the 111 service in the north-west of England that Colin mentioned: if ED clinicians were in our control room, they might be able to suggest other, more appropriate pathways for the patients who are waiting in the community. That is the sort of thing that came out of the Big Discussion that we previously did not have access to or would not have thought about in that way. Whilst it did not help with the extraordinary pressures that we saw in January —.

Mr Donnelly: It did not help?

Ms Paterson: The extraordinary pressures still happened, but those things were in place and we might have seen worse performance in January otherwise. That pathway work has started and will continue past the conclusion of the Big Discussion.

Mr Donnelly: OK. It sounds similar to the mental health pathway that you had in your control room. We visited last year, and it was able to bring conveyance down by 25%, if I remember correctly.

Ms Paterson: It has reduced conveyance of our mental health patients by around 40%.

Mr Sinclair: That pathway continues. It is a great collaboration with the South Eastern Trust and continues in the same manner. As the Ambulance Service, and as paramedics, we have limited education around mental health. Bringing in expertise has allowed us to give those patients the best treatment and use our resources as effectively as possible.

Mr Donnelly: Fantastic. Thank you.

I am really interested in Release to Rescue, which is going live in April. Where do the patients go?

Ms Paterson: The patients who are being released?

Mr Donnelly: In the situation that you have described, where the department is full, ambulances are outside and an ambulance has been "released to rescue", what happens to the patient?

Mr Sinclair: My understanding is that, in the lead-up to Release to Rescue, there will be a couple of resets in community health and secondary care sites. The idea is that Release to Rescue will increase flow so that the hospital will not, as you experienced in Antrim, grind to a halt, for lack of a more articulate expression. We will get to that challenging position, though. That is our real challenge. If we had a full emergency department and, let us say, 110 patients waiting for us in the community, Release to Rescue would allow us to keep a patient on an ambulance trolley, take them into the emergency department and say, "We now need to go and respond to a patient in the community".

Mr Donnelly: So, after two hours, ambulances will leave their patients on a trolley in a full A&E?

Mr Sinclair: Obviously, that would be the worst-case scenario. The idea is that, hopefully, the system will become more efficient with the community reset and secondary care reset, and there will be enough flow throughout the system to allow us to have Release to Rescue as a worst-case scenario.

Ms Paterson: The work that is being done in the hospital trusts is about improving flow so that A&E will not be full. It is designed so that there will be capacity to enable handover. That parallel work is being undertaken to improve flow in the hospital, looking at discharges and community capacity. Therefore, just to clarify: it is not done in isolation; it should be done with a number of measures.

Mr Donnelly: I appreciate that. We have talked to trusts about patient flow, which is the biggest issue that is affecting secondary care. However, my concern is this: if the hospital is full, and you are just going to leave a patient, where does that patient go? Does that create extra work for an A&E department that is already full to capacity and where the staff are running around looking after patients? If hospital wards are full, with beds up and down the corridors, will there be a space to where those patients can be wheeled in?

Mr Sinclair: It is a balance of risk for us. That needs to be balanced across healthcare. We are talking about the risk that we hold. We have had significant challenges over, I guess, the past 12 to 14 weeks. Just to link back to your comment about seasonal pressures: if you look at historical data, you see that we would normally have a seasonal pressure blip of four to six weeks. This year, we had around 12 to 14 weeks of pressure. We did not foresee those pressures lasting for as many weeks. There were prolonged periods in which over 100 people were waiting for an ambulance. We are not going to just push patients into the ED. It needs to be done collaboratively with emergency departments. We do not want any conflict between our paramedics and ED staff. We are putting in place an escalation process to ensure that the issue can be escalated through the regional coordination centre (RCC) so that each trust's management structures understand that we have an agreement that we need to release to rescue within two hours because we have risk and known patient harm in the community. We need to work out how we will achieve that between us.

There is an agreement that we need to have flow. There needs to be a solution, which is flow out of the hospital into the community, and we need a robust stance on that. For us, there is so much hinging on that happening, including improving our response times; looking after our staff welfare; looking after patient outcomes and patient welfare; and our being allowed a platform to negotiate out of action short of strike, which we have been on for more than two years. I appreciate that there is a sharp point that we need to work around, but I think that we can work with colleagues and understand how we will achieve that.

Mr Donnelly: In your presentation, you mentioned that the Ambulance Service holds valuable data with health insights. Is that data analysed? Is it being collected? Is it going through any particular process that will be of use to the health service?

Ms Paterson: Absolutely. Over the past four years, we have built up sophisticated data. That data goes across demography and demand, looking at where our patients are and at areas of deprivation. The information is very rich. It is fed into the Big Discussion, which we referenced earlier, to understand where we should develop pathways — who we should target — and the capacity of those pathways. Think about a pathway such as Hospital at Home, which has been rolled out across the region. We have been using that most prominently in the Southern Trust. We should be able to use data to inform what the capacity of a Hospital at Home pathway should be, how we will use it and how we will manage demand more appropriately away from the front door of Craigavon, for example. That is just one example of how that data might work. It is being used in that way.

Mr Sinclair: I totally agree with Maxine. In the past three years, we have also set up a NIAS R&D department. It is a small department, but it is punching above its —.

Mr Donnelly: R&D?

Mr Sinclair: Research and development. Building on what Maxine outlined to the Chair about outcome data, we have aspirations that we will start to stand on our own two feet and understand our mortality and morbidity measures, which will allow us to nuance our response model in order to ensure that we are doing the best that we can for our patients with the resource that we have.

Mr Donnelly: Fantastic. Finally, Philip referenced the attacks on ambulance staff, which are horrendous — absolutely awful. We recently went to Antrim A&E, and it is rolling out body cams. Do you have any plans to do anything like that?

Ms Paterson: We have had body cams in place for at least two years.

Mr Donnelly: Apologies.

Ms Paterson: It is OK. In the first year, uptake was lower than we had anticipated, given the recognised evidence that use of a body cam by a staff member can de-escalate a situation. We are starting to see improvements in uptake. We are educating our staff in how they might de-escalate situations that they come across. About 50% of our staff check out body-worn video cameras on their shift daily.

Mr Donnelly: Is it up to staff to decide whether to wear a body cam?

Ms Paterson: It is up to staff to decide whether to wear a body cam, but they have clear guidance on how to use it, the protocols around when to use it and how it might help them to de-escalate a situation. However, a body cam is not the only answer. We need to do a number of other things to support staff to deal with violence and aggression, especially given the level that our staff see compared with other trust staff. A lot of patients who we see are under the influence of alcohol or drugs. That is just the nature of some of the work that we undertake.

Mr Donnelly: Are staff who are attacked following up with prosecutions?

Ms Paterson: We have had a number of successful prosecutions of people who have perpetrated violence against our staff. We welcome the work that the PSNI has done to support our staff on same.

Mr Donnelly: Thank you.

The Chairperson (Mr McGuigan): I have a supplementary question on Danny's point. It is important to understand the two-hour wait and where patients go. Am I right in saying that that is worked out in agreement with trusts, so trusts are aware of it?

Ms Paterson: Yes.

The Chairperson (Mr McGuigan): It is the job of the trusts, in the lead-up to April, to ensure that they have put in place procedures to help you to do it, because everybody recognises that it has to be done. Am I correct in saying that?

Ms Paterson: You are absolutely correct in saying that, Chair. We meet each trust biweekly, in what are quite full meetings, to talk about operational protocols; safety; who does what and when; and how it works. We have taken a lot of the evidence from protocols that have been effective in the rest of the UK — those that have seen traction and improvement. We use that evidence as a base, and we build our local arrangements around it.

The Chairperson (Mr McGuigan): Fair enough.

Mrs Dillon: Thanks to both of you for your presentation. I concur with a lot of the comments that have been made about the work that you carry out and, particularly, the comments about the unacceptability of attacks on any of our healthcare staff.

You are front-facing, out in the community, and I know that you face some very difficult situations. I have two questions based on that. First, you referenced staff health and well-being and where we are with that. There have been a number of really serious incidents in my area. The first people on the scene are Ambulance Service staff and PSNI officers. What support do your staff get after something like that happens, particularly if they are not able to remove themselves from a shift, and perhaps have to sit in a hospital all day, when all they are thinking about is what they saw that morning? We need some understanding of that.

Secondly, I want to return to Danny and Philip's point about Release to Rescue. Is there an evaluation process whereby you can ask, "Is this working? Is it putting patients in further danger? Is it putting EDs and hospitals under further pressure? Will it potentially mean ambulance staff having to make that decision under further pressure?". Is an evaluation process built into that to assess how things can be improved, but also whether there are hospitals that are doing it really well or not so well? How do we address that? How do we say, "Look, that hospital is managing to do it really well. What is it doing differently? Is it being resourced differently? What is creating that differentiation?"?

Ms Paterson: Thank you, Linda. Going in reverse order, I will, first, answer your question on performance — what I call surveillance. To go back to the point about data that we made to Danny: we have really clear data on this pathway. We are really clear about how many minutes it takes. We do a digital handover, not just a clinical handover, with our patient. The hospitals, obviously, have a lot of information about where the patient is and how long they have been there. You asked about where we can look to see what is effective, what is good and how we can share that information. Our regional forums look at where the best practice is; how we can learn from each trust and each ED; and see who is doing things really well. We have some really great examples, across Northern Ireland, of some trusts doing things better than others in different areas. That information is shared. I feel assured that additional learning will come out of that process and that that will be shared across the trusts.

Mrs Dillon: It is a constant evaluation.

Ms Paterson: It is constant.

Mrs Dillon: OK.

Ms Paterson: From a system performance perspective, SPPG collects all that data and uses it to inform what support is required for each of those localities, including for ourselves.

Mrs Dillon: My concern, with all things and not just the Ambulance Service, is about how SPPG uses the information to target resources and how quickly it uses it, but that is not for you to answer.

Ms Paterson: That is OK.

Secondly, you talked about our staff. Traditionally and inherently, the Ambulance Service is a first responder. As you articulated, very serious and tragic things happen, and our crews are normally the first at the scene. That generally means that staff in our service experience a level of trauma that is not seen in other clinical settings. That really influences our staff's ability to stay on shift.

Over the past number of years, we have recognised, learned about and tried to implement what we call a trauma-informed peer support model. We have peer support available for staff, especially those who indicate that they are having a challenge or struggle and that they need to be able to talk to somebody. We have a number of services in that space. Some of those services are independent, because, sometimes, our staff want such independence, and some of them are in-house. With those two avenues, we try to support staff through really difficult calls and experiences. It is not perfect. We have a small peer support team. Our ambition is to increase its size, if we can, over the next number of years. We are the only ambulance service with an internal peer support team. We recognise that it is a valuable and important asset for our staff. As I said, it might be that staff go to a scene or an incident and it is a number of hours, days or weeks later that they start to experience the post-traumatic stress and effects of having attended that call, so we have to be there when we can and when that might present itself.

Our sickness levels are sitting at just over 10·5%. The majority of the people who present in that space do so because of stress and mental health challenges. The Ambulance Service is funded up to 8%, which is greater than the other trusts. That is a recognition of the anticipation that our crews and staff will have higher levels of trauma and mental health issues as a result of the calls that they attend.

Mrs Dillon: Thank you.

Mr Chambers: I never miss an opportunity to put on record how grateful I am for the life-saving work that your staff do. During a typical peak operating shift, how many fully operational and fully equipped vehicles from your fleet are parked up in depots and not used?

Mr Sinclair: To be clear: we have an excess of vehicles. We have the vehicles that we run and a number of vehicles that we keep spare for resilience. We run 60 to 70 vehicles during the day and slightly fewer overnight. Is your question about vehicles that are not staffed?

Mr Chambers: Had you more staff, would you have the fleet capacity to put more ambulances out at any given time, or are you working at maximum capacity with your fleet?

Mr Sinclair: I do not think that there is a great deal of flex in our fleet. We have enough staff to service the ambulances that we have. Every development that brings more staff and grows the organisation needs to recognise estates, fleet and other support services.

Mr Chambers: A number of years ago, a great priority was placed on — quite rightly, I thought — first-response vehicles with one paramedic on board. Have you shifted away from that in any way? Have circumstances forced you to scale back that facility, or is it still a priority?

Mr Sinclair: We still have a number of rapid-response vehicles (RRVs). Historically, we operated a higher number of vehicles. We have recently realised that the evidence base, from our demand and capacity review and our benchmarking with UK trusts, demonstrates that a smaller number of RRVs is more effective, with a larger number of staff being put into double-crewed ambulances.

Mr Chambers: When I have asked this question, the answer has always been clouded in ambiguity. The answer usually depends on who I am talking to. When one of your ambulances drives through the front gates and into the hospital grounds and goes to the back of a queue of four or five ambulances that are sitting there, at what point does the patient in that ambulance become the responsibility of the hospital? While they sit there, who has lead responsibility for the care of that patient? Is any clinical triage carried out? Say that, in one vehicle, there is someone who has a broken hip and is in a lot of pain, but, in another vehicle further down the queue, there is somebody who has had a cardiac arrest and who you have defibrillated a couple of times during the journey: how is that dealt with? Would the person in cardiac arrest be brought in immediately, before the person who is sitting in an ambulance further up the queue?

Mr Sinclair: That is a very good question. Ambulance clinicians can call ahead if they have a patient who is very unwell. If a patient is in cardiac arrest and has been defibrillated, for example, they can be taken straight into the resuscitation room. That is standard practice. For the range of other patients who will not be taken to the resuscitation room, there is triage outside the ED. For example, if you are in the fifth ambulance in the queue, you might be the next one taken into the ED, depending on how unwell the patient is. Defined criteria and assessment scores are used. Most of the hospital sites use a similar scoring system. The paramedics have a similar nomenclature and scoring system that links with the hospital's system, so that there is a clear understanding of how unwell a patient is.

Mr Chambers: Does the hospital assume responsibility for a patient the minute an ambulance goes through the front gates?

Mr Sinclair: My understanding is that a letter from a previous permanent secretary outlined that position. At present, looking after a patient is a collaboration between the NIAS and the trusts until the hospital can accept that patient.

Mr Chambers: Thank you very much.

The Chairperson (Mr McGuigan): Maxine and Neil, thank you very much. It has been very useful. We look forward to seeing progress.