ࡱ> ^   X Y Z [ \ ] ^ _ ` r^Stk)KJUWn $$$$$$N'''''''+++++++w. bjbj hI-: : }}8$= I D""""(''4'c<E(&('((}}""]a666(R}8""6(66~t~"B^`. {6w0@{N1l~~~d((6(((((6((((((((((((((((: C:  Proposals for Efficiency Savings and Comprehensive Spending Review Investment 2008 2011  Consultation Document including Equality Impact Assessment November 2008 Freedom of Information Act (2000) Confidentiality of Consultations Northern Ireland Ambulance Service (NIAS) will publish an anonymised summary of responses following completion of the consultation process; however your response, and all other responses to the consultation, may be disclosed on request. We can only refuse to disclose information in limited circumstances. Before you submit your response, please read the paragraphs below on the confidentiality of consultations and they will give you guidance on the legal position about any information given by you in response to this consultation. The Freedom of Information Act gives the public a general right of access to any information held by a public authority, namely, NIAS in this case. This right of access to information includes information provided in response to a consultation. We cannot automatically consider information supplied to us in response to a consultation, as information that can be withheld from disclosure. However, we do have the responsibility to decide whether any information provided by you in response to this consultation, including information about your identity, should be made public or withheld. Any information provided by you in response to this consultation is, if requested, likely to be released. Only in certain circumstances would information of this type be withheld. Acknowledgements The Northern Ireland Ambulance would like to thank the Statistics and Analysis Branch of the Department of Health Social Services and Public Safety (DHSSPS) for their help in producing data for this document. We would also wish to thank the following organisations for contributing to our pre-consultation in order help inform the Equality Impact Assessment included in this document. Disability Action Carers NI Childrens Law Centre Unite Unsion NIPSA CONTENTS SectionTitlePage No.1Executive Summary62Introduction 133Background164Why is the Ambulance Service changing?195What services are changing?236How are RRVs used?257Introducing alternatives to ambulance response and transportation Managing demand for ambulance services 298What specific changes are being proposed and where?339What will this mean for patients?4010What will this mean for our staff?4211What information did we consider to conduct our EQIA?4412What does this information tell us about people in S75 categories?4713Assessment of impacts- what this information tells us about the impact of the proposals on Section 75 groups6014Rurality and Deprivation6415Measures to mitigate against impacts and consideration of alternative policies how will we manage the impacts of the proposals?6616What happens next?6817How can you comment?6918Publication of results of the EQIA70Appendices 1 EXECUTIVE SUMMARY 1.1 The Northern Ireland Ambulance Service (NIAS), along with all other Health Trusts in Northern Ireland, is required to deliver an average 3% per annum cash releasing efficiency savings over the next three years. In the financial year 2008/09 the saving is 1.236 million, rising to 2.719 million in 2009/10, and increasing again to 4.449 million by 2010/11 from a baseline budget of 49.436 million. A range of measures have been developed, following detailed consideration and review of the existing budget and expenditure to deliver the required savings. 1.2 Consistent with the direction of the Health Minister, the challenge for NIAS has been to develop proposals, which do not represent a reduction in the service currently provided to patients and carers, and which are consistent with the delivery of a modern ambulance service, supporting ministerial priorities of rapid clinical response to life-threatening calls and extension of life-saving interventions, such as thrombolysis. 1.3 We have developed a number of proposals to achieve required savings including: The application of absence management measures including new rostering technology, reducing spend on overtime cover. The application of recently-introduced technology to increase the number of patients carried per non-emergency journey for PCS ambulances and Voluntary Cars. The in-house servicing of the Trusts fleet where possible and appropriate, such as servicing of cars and non-emergency ambulances and ancillary components. System review to reduce spend in Training and Administration with an emphasis on use of new and existing technology to reduce non-payroll expenditure. 1.4 However, it is proposed that the majority of efficiencies would be released through the reconfiguration of front-line emergency resources resulting in a reduction in planned emergency ambulance hours of cover. Comprehensive Spending Review investment will be used to increase the hours of paramedic cover provided by Rapid Response Vehicles. This document includes an Equality Impact Assessment of this proposal and seeks views particularly in relation to the potential impact of the proposal on specific Section 75 groups. An Equality Impact Assessment (EQIA) is an in-depth study of a policy or decision to assess the extent of the impact of the policy on equality of opportunity for the nine equality categories identified by Section 75. 1.5 NIAS intends to re-profile planned hours of Ambulance Paramedic Response cover by reducing emergency ambulance response hours of cover, while increasing the proportion of paramedic rapid response hours to emergency ambulance hours. Overall there will be more ambulance paramedics spread between emergency ambulances and single-paramedic rapid response vehicles available to respond to emergency 999 calls. This means: We propose to reduce the hours of cover, currently provided by traditional A&E emergency ambulances, by 70,080 hours over the three year period a reduction from 490,560 hours to 420,480 hours. We propose to use Comprehensive Spending Review (CSR) investment to increase hours of Rapid Response Vehicle (RRV) Paramedic cover by 131,400, hours from 48,180 to 179,580 hours. We further propose to use CSR investment funds to introduce clinical triage into NIAS Ambulance Control centres, to offer clinically appropriate alternatives to ambulance attendance and transportation to hospital for 999 calls, where the patient does not present with an immediately life-threatening condition. 1.6 The net result will be: An increase in the number of planned paramedic response hours to deal with life-threatening and non-life-threatening 999 calls. A reduction in the number of ambulance journeys undertaken for non-life-threatening 999 calls. A consequential reduction in planned emergency ambulance hours to deal with remaining 999 calls requiring ambulance attendance and patient transportation. Clinicians in ambulance control providing advice and support to 999 callers with non-life-threatening conditions and offering appropriate alternative care pathways for these patients who may not require emergency ambulance or hospital A&E department attendance. 1.7 The aims of this proposal are to: Protect and enhance the capacity of the ambulance service to provide rapid paramedic response and treatment to emergencies. Deliver efficiency savings in line with Health Department requirements. Support and sustain improvements in response times recorded in 2007/08. Facilitate service plans to extend provision of paramedic thrombolysis throughout Northern Ireland. Transform the service from a model prioritising patient transport to a more patient focused clinical model of pre-hospital care where the most clinically appropriate care options are provided for patients promptly, including emergency paramedic response, clinical treatment and ambulance transportation, where appropriate. 1.8 NIAS has examined a range of data in order to assess the potential impacts of these proposals. The Trust has categorised those potentially affected by the proposals into three main groups: Local populations in the areas where the reconfiguration of A&E Services is proposed to take place in Year 1. NIAS A&E Staff who will all be affected by proposals over the three year period. Patients seeking ambulance assistance through 999 calls in Clinical Priority Categories A, B and C. We have also considered previous consultations we have done and had some conversations with some Section 75 representative groups and trade union representatives. 1.9 The table below describes the potential impacts we believe the proposals may have on groups covered by Section 75. Section 75 CategoryDifferential/adverse Impact identifiedCommentReligious BeliefDifferential impact.54% of the populations in the areas identified by NIAS to be affected by these proposals in year 1 are Roman Catholic. 59% of A&E ambulance staff are from the Protestant Community, 39% from the Roman Catholic Community. As previously mentioned religious belief is not currently monitored specifically. Political OpinionDifferential impact.27% of the populations affected is classed as Unionist, 35% as Nationalist and 38% as other or not known. Data relating to the Community background of staff indicates that potentially the majority of staff affected may be from a Unionist background.Racial GroupNone identifiedAgeDifferential impact57% of patients who access A&E are over 50 and are therefore more likely to be affected by these proposals. Marital StatusNone identifiedGenderDifferential impact 78% of A&E staff are male.DisabilityNone identifiedDependantsPotential Adverse Impact in respect of A&E staff.Changes to shift patterns which may result in staff being required to move to work from a different station may have an adverse impact on those with caring responsibilities.Sexual OrientationNone identified 1.10 Shift working is a fact of life within a 24/7 service and changes to shift patterns and movement of base locations are in line with contractual arrangements for operational ambulance staff. In terms of mitigating the potential adverse impact on staff who have caring responsibilities we are in the process of implementing a computerised rota system called PROMIS (Personnel Rostering Overtime Management Information System) to better plan the allocation of duties for all staff which will improve the degree of predictability for staff. In addition we have a number of Work Life Balance Policies. In particular we have a Carers Leave Policy to cover short term leave to respond to the immediate needs of carers arising from unplanned and unforeseen circumstances. Mileage payments will be made to staff who are required to move base locations in accordance with terms and conditions and we will monitor the impact of the proposals as they are implemented. 1.11 NIAS is of the opinion that the introduction of proposals to make 3% efficiencies involving the reduction in A&E hours cover alone would have reduced its capacity to respond to emergency calls and therefore, potentially had an adverse impact across the Section 75 categories. However coupled with the CSR investment, which will be used to provide increased numbers of Rapid Response Vehicles and enable us to modernise and improve our service, we believe the net result of these combined proposals is a positive one. 2 INTRODUCTION 2.1 The Northern Ireland Ambulance Service Trust (NIAS) was established on 1 April 1995. NIAS employs over 1,100 staff and operates on a regional basis across five divisions, providing ambulance services to over 1.7 million people in Northern Ireland, with an operational area of approximately 14,100 square kilometres. Our mission is to deliver effective and efficient care to people in need and improve the health and well-being of the community through the delivery of high quality ambulance services'. NIAS provides a range of ambulance response and transportation resources dealing with emergency calls, urgent and non-urgent calls. All emergency calls are assigned to a category reflecting potential clinical urgency: Category A (immediately life threatening), Category B (non-life threatening but serious) or Category C (neither life threatening or serious but requiring some form of clinical intervention). A significant proportion of NIASs workload which is undertaken by emergency ambulances, arises from the treatment and transportation of patients referred by GPs known as Urgent Calls. 2.2 NIAS has experienced significant growth and demand for emergency 999 response calls over recent years with activity increasing by approximately one third since 2001. We are one of the six Health Trusts in Northern Ireland and are funded to provide ambulance services throughout Northern Ireland by a Commissioning Group for Ambulance Services (CGAS) comprising representatives from the four Health Boards in Northern Ireland. 2.3 Section 75 (1) of the Northern Ireland Act 1998 requires NIAS, as a public authority, in carrying out its work, to have due regard to the need to promote equality of opportunity: Between persons of different religious belief, political opinion, racial group, age, marital status or sexual orientation; Between men and women generally; Between persons with a disability and persons without; Between persons with dependants and persons without. In addition Section 75 (2) requires NIAS to have regard to the desirability of promoting good relations between persons of different religious belief, political opinion or racial group. An Equality Impact Assessment (EQIA) is an in-depth study of a policy or decision to assess the extent of the impact of the policy on equality of opportunity for the nine equality categories identified by Section 75, listed above. This EQIA has been prepared by NIAS to assess the impact of proposed measures to (1) deliver efficiency savings which NIAS is required to deliver and (2) target investment through funding provided by the Comprehensive Spending Review. In line with Practical Guidance on Equality Impact Assessment produced by the Equality Commission for Northern Ireland, this document will: Define the aims of the policy to release efficiency savings and target CSR investment through the reconfiguration of frontline services. Consider available data and research. Assess the impacts of the proposals on Section 75 groups. Consider measures which might mitigate any adverse impacts and alternative policies which might better achieve the promotion of equality of opportunity. We will also explain how we intend to consult on the proposals and how we will publish the results and monitor for adverse impact in the future. 3 BACKGROUND 3.1 A Strategic Review of the Northern Ireland Ambulance Service, Mapping the Road to Change was published in February 2000. The Department of Health Social Services and Public Safety (DHSSPS) developed an Implementation Plan for the Strategic Review of the Ambulance Service and this was the subject of a DHSSPS EQIA in 2001. This work set out the key priorities and proposals for the future direction and modernisation of the ambulance service. The key areas of progress since this have been the introduction of: The Regional Emergency Medical Despatch Centre in Belfast and the Regional Non-Emergency Medical Despatch Centre in Londonderry; The Regional Ambulance Training Centre based at NIAS Headquarters. An Advanced Medical Priority Despatch System (AMPDS) which enables NIAS control staff to assign clinical priority to emergency calls, despatch the appropriate response and provide on-line clinical advice to callers; A modern computerised communications system that improves NIASs ability to manage and deploy its resources effectively. This includes the introduction of Digital Trunk Radio (DTR) which has been rolled out to the police, fire and rescue and ambulance services, which has improved communications throughout Northern Ireland and between the emergency services; The introduction of Automatic Vehicle Location Systems (AVLS) and satellite navigation in September 2008; An increase in the Patient Care Service (PCS) fleet to reduce the inappropriate use of A&E ambulances for non-emergency work; (NIASs PCS is the non-emergency tier which provides transport for patients with a clinical need for transportation). The development and roll out of Rapid Response Vehicles (RRV); Alternative Care Pathways for Category C calls. This work will be developed further with the use of CSR investment to include clinical triage of calls in the control room, the introduction of protocols to ensure appropriate treatment and if necessary, referral for patients who may not require transportation to hospital. 3.2 NIAS has also continued to strive to improve its performance in response times to emergency calls. Our key aim when dealing with emergency calls is to get to the patient as quickly as possible, to enable early clinical intervention and improve outcomes for patients. During 2007-08, NIAS delivered a 6% improvement in Category A, life-threatening emergency calls, responded to within 8 minutes, averaging 62% against a target of 65% for Northern Ireland. Peak response was in February 2008, with 69% of Category A calls responded to within 8 minutes, against a target of 70% for Northern Ireland. 3.3 The Minister for Health has outlined specific priorities in his Priorities for Action (PfA) related to the Programme for Government. The immediate priority for NIAS remains the requirement to deliver a response to life-threatening emergency calls within 8 minutes as often as possible with the resources available. The Ministers current target is that NIAS should; Deliver Enhanced Emergency Response to achieve 70% of Category A calls within 8 Minutes for Northern Ireland, rising to 75% by March 2011 and deliver baseline Category A response at Board level of 62.5% within 8 minutes, by March 2009. In addition, Priorities for Action also specifically stipulates: The Northern Ireland Ambulance Service should ensure that, by March 2009, paramedic-administered thrombolysis is available throughout Northern Ireland. 4 WHY IS THE AMBULANCE SERVICE CHANGING? 4.1 In line with the other five Health and Social Care Trusts, NIAS has been charged with realising, an average, 3% cash releasing efficiency savings each year over the next three years. The amount of savings to be realised has been set at: 1.236 million in 2008/09 2.719 million in 2009/10 4.449 million in 2010/11 To make these savings, NIAS is required to make the current system more efficient in terms of operational productivity. It is also expected to re-shape and change current service provision in directions that meet the requirements of those who use our service and are of equal, or better, clinical effectiveness. 4.2 In order to decide how best to achieve these efficiencies, NIAS undertook an examination of each area of its budget. Expenditure in 2006/07 was analysed to identify prospective areas for efficiency savings. It is worth noting that the vast majority of the Services budget relates to salary costs: It is apparent from the exercise that the bulk of NIAS spend is in payroll which accounted for 82% of total expenditure and the greatest spend within this is on front-line A&E ambulance personnel (approximately 27.87 million). There is very little scope to deliver further efficiency savings from non-payroll expenditure as it is predominately demand-driven and heavily influenced by activity related to patient interaction. A clear example is that spend on fuel represents the biggest area of non-pay expenditure (excluding capital charges and depreciation) at 1.368 million. This analysis has been shared with key stakeholders including Health Boards (CGAS) and there is broad acceptance that options for efficiency savings of the order required in NIAS are very constrained and rest predominately in payroll.  Following detailed examination of the expenditure profile and consideration of ways to deliver the efficiency savings, we have developed a number of proposals to release efficiency savings. Table 1 below outlines the efficiency proposals developed. NIAS Efficiency Proposal2008/09 m2009/10 m cumul2010/11 m cumulReconfiguration of Emergency Ambulance provision  .856 1.794 3.489Enhanced Absence Management  .250 .500 .500Increasing number of patients carried per non-emergency journey in Patient Care Service non-emergency vehicles .050 .200 .200Reduce Voluntary Car Costs by carrying more patients per car journey .025 .050 .050Increase In-house servicing of fleet .010 .075 .110Reduction in Training expenditure  .025 .050 .050Reduction in Administrative Costs  .020 .050 .050Total: 1.236 2.719 4.449 Table 1 NIAS Efficiency Proposals for Years 1, 2 and 3 Items 2-7 relate to fairly traditional and generic types of saving including: the application of absence management measures, including new rostering technology aimed at reducing spend on overtime cover (Item 2); the application of recently introduced technology to increase the number of patients carried per non-emergency journey for PCS ambulances and Voluntary Cars (Items 3 & 4); the in-house servicing of the Trusts fleet where possible and appropriate, such as servicing of cars and non-emergency ambulances and ancillary components (Item 5); System review to reduce spend in Training and Administration, with an emphasis on the use of new and existing technology to reduce non-payroll expenditure (Items 6&7). Item 1 proposes that the majority of the efficiencies (3.489 million) will be released through the reconfiguration of front-line emergency resources and a reduction in planned emergency ambulance hours. Some key actions are proposed to manage and mitigate the impact of this specific proposal: NIAS would propose to increase paramedic RRV response hours to offset the reduction in emergency vehicle ambulance response capacity and increase paramedic response cover overall. NIAS would propose to introduce clinicians to ambulance control to provide alternatives to ambulance response and transportation for specific non-emergency 999 callers, for whom appropriate alternatives exist, thereby reducing existing demand for emergency ambulance response and transportation. NIAS would propose to avoid any requirement for redundancy in Year 1 through vacancy control and offering opportunities for staff to re-skill to become paramedics, using the proposed investment to identify opportunities to redeploy staff. NIAS is committed to seeking ways to improve and modernise the delivery of its service. Bids submitted through the Comprehensive Spending Review (CSR) process have secured additional investment funds of 14.5 million Capital and 12.1 million Revenue to support service improvement and modernisation over the CSR period 2008-2011. 5 WHAT SERVICES ARE CHANGING? 5.1 NIAS intends to re-profile planned hours of ambulance paramedic response cover, by reducing emergency ambulance response hours of cover while increasing the proportion of paramedic rapid response hours to emergency ambulance hours. Overall there will be more ambulance paramedics spread between emergency ambulances and single-paramedic rapid response vehicles available to respond to emergency 999 calls. This means: We propose to reduce, over the three-year period, by 70,080 the hours of cover currently provided by traditional A&E emergency ambulances a reduction from 490,560 hours to 420,480 hours. We propose to use Comprehensive Spending Review (CSR) investment to increase hours of Rapid Response Vehicle (RRV) Paramedic cover by 131,400 hours from 48,180 to 179,580 hours. We further propose to use CSR investment funds to introduce clinical triage into NIAS Ambulance Control centres to offer clinically appropriate alternatives to ambulance attendance and transportation to hospital for 999 calls where the patient does not present with an immediately life-threatening condition. 5.2 Other ongoing initiatives such as increased use of Intermediate Care Vehicles to support the A&E fleet will contribute to ensuring more appropriate treatment and transport of patients. These measures are also designed to reduce the number of patients unnecessarily transported to hospital by emergency ambulance. 5.3 The aims of this proposal are to: Protect and enhance the capacity of the ambulance service to provide rapid paramedic response and treatment to emergencies. Deliver efficiency savings in line with Health Department requirements. Support and sustain improvements in response times recorded in 2007/08. Facilitate service plans to extend provision of paramedic thrombolysis throughout Northern Ireland. Transform the service from a model prioritising patient transport to a more patient focused clinical model of pre-hospital care where the most clinically appropriate care options are provided for patients promptly, including emergency paramedic response, clinical treatment and ambulance transportation, where appropriate. 6 HOW ARE RRVs USED? 6.1 Response delivered by paramedics operating in Rapid Response Vehicles (RRVs) is a recognised method of delivering early clinical intervention throughout the UK. NIAS has successfully utilised RRVs since early 2003 and RRVs provided a significant contribution to the improvement in NIAS Category A performance figures in 2007/08. If a patient has experienced a significant accidental injury or has a life-threatening medical condition that could lead to cardiac arrest and death, then early clinical intervention is absolutely crucial. A very significant proportion of calls attended to by paramedics operating in RRVs receive a response within the 8 minute target by which NIAS is measured. 6.2 When an RRV is despatched to a life-threatening emergency call, an emergency ambulance is also sent. The RRV paramedic can undertake any and all of the skills available to any paramedic and will provide life sustaining care including defibrillation, airway protection and drug administration until the emergency ambulance arrives. This early intervention may well make the difference between life and death and will certainly ensure that patients and their relatives are confident that all that can be done is, or has been, done. Paramedics operating in RRVs also have a key role to play in managing demand; not only are they frequently well positioned and effective at providing the early and crucial clinical intervention in the case of immediately life-threatening calls, but they are also able to attend our Category C less serious calls and arrange for a more appropriate care pathway for the patient, including transportation, if required. An analysis of the two principle response options, emergency ambulance and RRV, is useful in understanding the operating environment. Emergency Ambulance VehicleParamedic Rapid Response Vehicle (RRV)An emergency ambulance has a stretcher and two ambulance crew members, one of whom should be a paramedic. This ambulance contains a variety of essential equipment and supplies including oxygen, life-saving cardiac and pain-relieving drugs, equipment for airway protection, ventilation support, circulation protection and - most importantly for people in cardiac arrest a cardiac monitor / defibrillator. An emergency ambulance can be tasked to emergency calls; to Doctors Urgent calls (transporting ill patients for planned hospital admission); can undertake patient transfers between hospitals and also to discharge patients home. An RRV is a smaller car or jeep type vehicle which carries ALL of the equipment contained within an emergency ambulance except for the stretcher. It is staffed by one experienced paramedic and attends only emergency calls. RRVs work closely with emergency ambulance resources rather than as an alternative to them they complement each other. Often arriving first, the RRV remains in the area and is immediately available for the next call once the emergency ambulance has left with the patient. The key difference between an Accident and Emergency Ambulance and an RRV is that the RRV is not equipped with equipment for moving patients nor does it have a stretcher for transporting patients. RRVs will treat patients at the scene and normally do not transport patients. 6.3 The perceived benefits of RRVs are: RRVs are mobilised and ready to respond to 999 calls more quickly than emergency ambulances. RRVs achieve a sub-8 minute response time to 999 calls more often than emergency ambulances. The RRVs are only unavailable while awaiting an ambulance. Once it has arrived the RRV Paramedic may stay and help but is effectively free to respond to any other 999 calls in the area. An RRV Paramedic can prepare a patient for transport - thus the ambulance is on-scene for a shorter time and is on the call for a shorter time. An RRV is on a call for less time than an emergency ambulance which has to transport the patient to hospital before it can be considered available again. Consequently the RRVs are actually available to 999 calls for a greater proportion of their working day. Often an RRV paramedic will attend a patient who does not need to travel to hospital by emergency ambulance. Following assessment and discussion with the patient the emergency ambulance can be cancelled and alternative arrangements made. 6.4 Following are some practical examples to illustrate how RRVs operate as part of the whole emergency response regime. 1. An elderly lady from Newtownards fell in her bathroom and fractured her hip. Unable to get up again, she used her help-line button to call for help. On receipt of the 999 call, ambulance control located the nearest RRV as being in Bangor, approximately eight minutes away. However, an accident and emergency ambulance was also available just three minutes away at the ambulance station in the town. Subsequently, the ambulance was dispatched to the call and the RRV was relocated to Newtownards to provide cover in case of any further emergencies occurring in the town. 2. A Rapid Response Vehicle was travelling along the Lisburn Road in Belfast when a collapse call came through for a lady in a residential home, also on the Lisburn Road. The patient had choked and had stopped breathing. The vehicle tracking systems in the control centre identified the RRV as the closest available resource and the call was immediately passed to the RRV paramedic who arrived on the scene in less than a minute and successfully resuscitated the patient prior to the arrival of the emergency ambulance. 3. A call was received for a two-car road traffic collision outside Crossgar, County Down. The initial call indicated that three people were injured. The nearest available ambulance was at Downpatrick, with the next available vehicles being in Belfast. A rapid response car travelling between Ballynahinch and Crossgar was activated and arrived on scene six minutes before the first ambulance. The crew assessed the situation and was able to stabilise the most serious casualty and report that only one emergency ambulance was required to transport this person, standing down the two extra ambulances from the call. 7 INTRODUCING ALTERNATIVES TO AMBULANCE RESPONSE AND TRANSPORTATION MANAGING DEMAND FOR AMBULANCE SERVICES 7.1 Demand for ambulance services is increasing every year. A recent report Taking Healthcare to the Patient: Transforming NHS Ambulance Services (DoH 2005), suggests that up to 50% of patients transported by ambulance services are taken to hospital inappropriately. 7.2 A recent analysis identifies that NIAS transports a much higher proportion of 999 callers to hospital than other ambulance services throughout the UK. NIAS currently transports 82% of Category A patients, against an average figure of 78% patients transported by English Ambulance Trusts. NIAS currently transports 81% of Category B patients to hospital against an average of 68% in English Ambulance Trusts. NIAS currently transports 85% of Category C patients to hospital against an average of 61% in English Ambulance Trusts. Achieving current UK transportation rates for Category B & C patients would reduce NIAS transportation of non-life-threatening 999 patients to hospital by 10%, or 11,000 patients. If we try to keep up with demand and we carry on transporting all our patients to hospital then patient care, particularly for the most clinically urgent Category A 999 callers, may be compromised by the requirement to transport inappropriately. What we must do is assess our patients immediate needs, provide clinical care early and then decide on the most appropriate care pathway. This may be transport to hospital, referral to another destination e.g. GP surgery, or for our paramedics to treat and then leave the patient at home. 7.3 We propose to manage demand through the introduction of clinicians into ambulance control centres to triage non-life-threatening 999 calls, thereby determining and offering the most appropriate care pathway for the patient, including ambulance transportation to hospital if appropriate. 7.4 The importance to patient care should not be underestimated, as reducing the amount of inappropriate patient journeys results in greater availability of emergency ambulances for life-threatening calls. The wider health service benefits from this model of care in many ways not least of which is that it may reduce pressure on A&E departments. 7.5 What follows are some examples of 999 calls we have received which have resulted in emergency ambulance attendance and transportation to hospital, but which could, in the future be handled differently, to preserve and maintain capacity to respond to life-threatening 999 emergencies. These are examples of real calls we have received but some minor details have been changed inorder to ensure individuals cannot be identified. 1.An ambulance was called to a house in Bangor. When the crew arrived, a sixteen year old girl walked down the front path towards them. Her father walked from behind her, handed over a bag of toiletries to the ambulance attendant and said the girl needed to go to hospital for stomach pain. He said he would follow over in the car. The young girl stepped into the ambulance and on examination nothing untoward was noted. She had seen her doctor the previous week who had diagnosed her as having constipation and the problem was persisting. She had normal vital signs and no other medical history of note. The girl could have re-attended her own GP or travelled with her father to hospital. But under current arrangements the crew was obliged to take her to the Accident and Emergency Department. In the future, with appropriate care pathways in place, the call would be passed to a clinician in ambulance control who would assess the situation and offer the patient advice. In a case like this, the clinician would advise the patient to make an appointment with her own GP or, if necessary, recommend her family take her to hospital instead of by emergency ambulance, which was not required. 2. An ambulance crew is frequently called to attend a patient with a long history of social problems. On the latest visit they found the man in conditions of absolute squalor. He claimed to have back problems and to be unable to bend down. Under current arrangements, the crews only option was to transport the man to hospital, even though he had no acute medical problems or recent injury to report apart from his long-standing back pain for which the Accident and Emergency Department could offer no ongoing treatment. In the future an RRV paramedic with access to social services or a rapid response community nursing team could refer the man to a care pathway more suited to his ongoing social and physical needs rather than him being repeatedly taken to an already busy Accident and Emergency Department. 3. A 90 year old lady fell out of bed in the middle of the night in Enniskillen. She was found four hours later by a neighbour who phoned 999. While the lady was distressed, stiff and sore and had difficulty getting up, she was uninjured, fully conscious and determined she wanted to remain at home. But under current arrangements the emergency crew who attended the incident had no option but to take her to hospital from which she was discharged a few hours later with no acute medical problems or injury being found. In the future an RRV Paramedic could be sent to the scene to assist the patient and undertake a thorough and focused clinical assessment. With access to social services or a nursing care team and not obliged by protocol to transport the patient to hospital, an RRV Paramedic could deal with this situation far more appropriately than removing a 90 year from her home unnecessarily. 4. An ambulance from Omagh received an emergency call for a young man with a low blood sugar. When they arrived he had recovered with the help of some food and fluid with high sugar content. He was known to have Diabetes and had clearly suffered a minor diabetic hypoglycaemic event. The emergency crew had to take him to hospital where he was discharged a short time later with no further treatment being necessary. Under future arrangements such a call could be passed immediately to a clinician in ambulance control who would consider the blood sugar levels and decide on the appropriate way forward. This could be either advising the patient over the phone, with him being left in the care of a competent friend or relative and follow up review arranged if necessary. Alternatively, if the clinician in ambulance control deemed this necessary, an RRV paramedic with appropriate protocols could be sent to treat, assess and advise the patient and then discharge him at scene into the care of a competent friend or relative. 8 WHAT SPECIFIC CHANGES ARE BEING PROPOSED AND WHERE? 8.1 NIAS has determined, following discussion with Health Board Commissioners, that these proposals should be applied across Northern Ireland, shared across each Division and Board area. The key objective for NIAS is to modernise service delivery by focusing upon providing rapid paramedic intervention to critical, life-threatening incidents. Timely ambulance transportation of patients to hospital, where necessary and appropriate, remains a priority element of the ambulance response and will continue to be provided in line with DHSSPS guidelines. However, through this modernisation process we will seek to prevent unnecessary and inappropriate ambulance response and transportation by offering relevant alternatives to those requesting ambulance assistance. 8.2 The key principle being applied to deliver the modernised service as efficiently and effectively as possible is that of matching demand and supply. Demand analysis matches demand on an emergency ambulance service against the resources available to service it. Its purpose is to inform the scheduling of those resources effectively to meet clinically sound service delivery standards. It is a support to the judgement of experienced managers and staff; not an absolute prescription. Demand on an emergency ambulance service, in this context, is all patient related activity undertaken by Accident and Emergency Crews, whether it is emergency, urgent or non-urgent. Emergency demand is measured using calls activated. The table below identifies the peaks and troughs in ambulance activity across Northern Ireland over a typical 24 hour period based on data from April to June 2008.  Table 2: Average A&E Ambulance mobilisations over 24hrs for NI April - June 2008 8.3This is a typical demand pattern for ambulance services nationally reflecting peak demand at midday, falling off at 19:00 hours with further increase in activity up to 02:00 hours particularly at the weekends. Over the three-year CSR period, NIAS propose to remove 70,080 hours of cover, currently provided by the equivalent of eight 24/7 emergency ambulances, to achieve efficiency savings and to put in place 131,400 hours of cover provided by the equivalent of fifteen 24/7 Paramedic RRVs, using CSR investment funds. This will have a net result of increasing the number of hours when paramedics will be available to respond to 999 calls. 8.4 Using its comprehensive information systems, NIAS will continuously monitor the use of the available Accident and Emergency hours and RRV hours available to ensure that the greatest number of resources is available at times of peak demand, while also providing sufficient resources at times of low demand. This is a process which will be subject to continuous review and adjustment as we seek to plan for and respond to, changes in the pattern of demand for ambulance response and transportation. 8.5 We will seek to manage demand by: Applying clinical prioritisation to calls, based on information secured from the caller, to target the most clinically urgent calls. Introducing Clinical Triage of non-life-threatening 999 calls to provide clinically appropriate alternatives to emergency ambulance response and transportation. Extending the capacity of ambulance paramedics at the scene of incidents to safely treat and leave patients at home or refer them to a more appropriate health care provider. We will seek to match supply with demand by: Realigning the shift start and finish times of ambulance personnel with demand patterns. Reviewing shift duration to maximise efficiency and effectiveness. Reviewing the Patient-Centred Deployment Plan to make best use of available resource through deployment to locations based on predictive analysis of past incidents. Reviewing and revising as necessary current ambulance deployment locations (to include stations, substations and deployment points). Immediate Actions 8.6 In year 1, 2008/09, NIAS has used the following criteria in order to determine where and to what extent, planned hours would be revised in order to minimise any potential risk and maximise benefits: Revised hours will be during the hours that RRV will operate most effectively and the hours when non-emergency 999 calls will be subject to clinical triage in ambulance control. Revised hours will be in locations where there is more than one emergency ambulance currently available twenty-four hours per day. Revised locations should be in areas where there is potential for support from neighbouring ambulance locations. Revised locations will take account of requirements to meet other PfA priorities while continuing to provide other essential services, such as non-emergency GP calls and inter-hospital transfers. We will continue to monitor and assess the impact of this service delivery model and make adjustments to ensure it is effective. 8.7 The reduction in emergency ambulance hours of cover will therefore be directed at areas of relatively high ambulance activity, in close proximity to hospital services, which are supported by NIAS patient-centred strategic deployment points. 8.8 Applying these criteria, using activity analysis and looking at demand for services, the Trust has identified a number of stations where this re-profiling would be implemented in Year 1. These are Altnagelvin, Ardoyne, Downpatrick, Ballymena, Armagh, Dungannon, Craigavon, Omagh, Ballymacarrett and Newry. 8.9 The table overleaf outlines the number of hours of emergency ambulance and RRV cover which will be re-profiled within the proposals, in order to work towards the figures targeted. DivisionStation/Location and Efficiency Ambulance Hours removed:Station/Location and Paramedic RRV Hours introduced:Total increase in paramedic emergency response cover hoursNorthBallymena 2,085 hoursBallymena, Whiteabbey, Carrickfegus +11,264 hours+9,179 hoursEast CityArdoyne & Ballymacarrett 4,614 hoursForster Green, Ballymacarrett, Purdysburn (Ardoyne) +11,264 hours+6,650 hoursEast CountryDownpatrick 2,659 hoursDownpatrick +3,911 hours+1,252 hoursSouthArmagh, Newry, Dungannon and Craigavon 3,128 hoursCraigavon, Newry (Armagh) (Dungannon) +6,884 hours+3,756 hoursWestHours of Extra Cover provided by Relief Staff: 3,076 hours affecting Omagh and AltnagelvinAltnagelvin + West RRVs operating 16 / 18 instead of 12 hours per day +10,324 hours+7,248 hours Total15,562 hours+43, 647 hours+28, 085 hours (Brackets indicate an RRV already operates in that location and is therefore not additional) Table 3 Outline of re-profiled emergency ambulance and RRV cover 8.10 In years 2 and 3, we will extend the criteria applied in year 1 to the consideration of the full 24 hour period of ambulance cover to deliver the best match of resource supply with resource demand for available resources. As previously stated, this will include the review of existing ambulance deployment locations and plans to facilitate optimal deployment of available resources. Having applied the criteria identified within this EQIA in Years 2 and 3 we will monitor the impact of the proposals as they are rolled out. 9 WHAT WILL THIS MEAN FOR PATIENTS? 9.1 It is proposed that in order to apply the required efficiencies during 2008-2011 approximately 70,080 hours of planned ambulance cover will be replaced by approximately 131,400 hours of additional Rapid Response Vehicle (RRV) Paramedic cover on a regional basis. This will result in a total of approximately 61,320 additional hours of paramedic cover throughout Northern Ireland. 9.2 For the general public, and in particular patients, there will be more ambulance vehicles on the road, capable of responding promptly to emergencies compared with previous years. For life-threatening emergency 999 calls, it will become more common for the initial ambulance response, increasingly within 8 minutes, to be a paramedic RRV, closely followed by an emergency ambulance, generally within 21 minutes if transport to hospital is required. The RRV will provide paramedic response to stabilise and prepare the patient for the arrival of the emergency ambulance, which will undertake patient transportation, where necessary. 9.3 Recently introduced technology including predictive tactical deployment plans developed from historical patterns of demand, allied to satellite navigation and automatic vehicle location, will support the deployment of available ambulance resources on the basis of clinical priority. This will target available resources, for both response and patient transportation, at the most clinically urgent patients. Ambulance Control Staff will continue to send the closest available ambulance resource to 999 calls as soon as possible. Where the closest ambulance resource is an RRV, an emergency ambulance will also be sent without delay. As relevant clinical information becomes available during the call, the ambulance response will be reviewed and tailored to deliver the most effective and appropriate clinical response to the patient. The primary objective is to provide the best and fastest response to life-threatening calls. 9.4 Alternatives to transportation to hospital by ambulance will continue to be developed by NIAS to compensate for the reduction in patient transportation capacity, by reducing demand for patient transportation. For example, NIAS is intending to introduce clinical triage into the Regional Emergency Medical Despatch Centre which handles emergency calls. This will enable the triage of calls in order to ensure the most appropriate response and treatment. 10 WHAT WILL THIS MEAN FOR OUR STAFF? 10.1 As previously outlined, NIAS is faced with making 3% efficiencies with a budget that is made up of 82% staff costs. The main impact of these proposals on staff will be a change to rotas. Rota systems within NIAS reflect our need to provide cover twenty four hours a day, seven days a week. Under these proposals, we plan to establish a rota system for Rapid Response Vehicles which enables us to better meet the demand for our services. This will mean extending the operating hours of RRV from a general 8pm finish to a 12 midnight finish during the week and approximately 2am finish at the weekend. RRV paramedics are currently employed on a temporary basis and we also have paramedics who cover RRV on an ad hoc basis. We are using CSR investment to recruit paramedics to work on RRV on a permanent basis. This will result in increased opportunities for promotion to paramedic positions for staff which involves additional training and development. 10.2 Rota systems are already in place for emergency ambulance staff, and subject to existing processes to revise rotas in line with demand and the exigencies of the service. The existing processes will be applied to support the re-profiling of planned emergency ambulance cover to achieve the best match between supply and demand. For emergency ambulance staff this will most likely result in changes to shift start and finish times including shift finishes in the early hours of morning when demand falls. It may also involve introducing specific shifts with a shorter duration than the 12 hours which is currently the norm. For some staff, changes to rotas may also necessitate changes to base location from which they currently operate. 10.3 In order to engage with staff on the proposed efficiency savings, NIAS has established a Comprehensive Spending Review (CSR) Joint Working Group with representatives from both Management and recognised Trade Unions. The purpose of this group is to consult with staff, via their Trade Union Representatives, on issues which impact directly on staff as a result of the proposals. We are committed to continuing to work with staff side colleagues as these proposals are implemented. 11 WHAT INFORMATION DID WE CONSIDER TO CONDUCT OUR EQUALITY IMPACT ASSESSMENT? 11.1 NIAS has examined a range of data in order to assess the potential impacts of these proposals. The Trust has categorised those potentially affected by the proposals into three main groups: Local populations in the areas where the reconfiguration of A&E Services is proposed to take place in Year 1. NIAS A&E Staff who will all be affected by proposals over the three year period. Patients seeking ambulance assistance through 999 calls in Clinical Priority Categories A, B and C. 11.2 In terms of data considered, NIAS has looked at both quantitative and qualitative information. We have examined Northern Ireland Statistics and Research Agency (NISRA) published Section 75 data which relates to the areas affected by the proposals at Local Government District level. For data on political opinion we have referred to 2005 Local Council Election results from ARK NI Social and Political archive which were provided by the DHSSPS Statistics and Analysis Branch. In respect of disability we have looked at The Prevalence of Disability and Activity Limitations amongst adults and children living in private households in Northern Ireland (NISRA 2007) and Disability Allowance - from Department for Social Development, Disability Living Allowance Summary of Statistics, August 2007. In terms of sexual orientation we looked at the research document Shout (published by YouthNet, December 2003). 11.3 In terms of the data held on staff we have looked at available data from internal systems which relates to Accident and Emergency staff. We have examined information relating to gender, age, community background given that monitoring arrangements do not currently explicitly include religious belief and political opinion. NIAS is in the process of working together with other Health and Social Care Trusts to look at monitoring systems in respect of information on access to our services and our staff. 11.4 In terms of the impact of proposals on staff, NIAS has established a Joint Working Group consisting of management and staff side representatives to enable consultation in respect of these proposals. As regards the potential Section 75 impact, the Trust asked staff side representatives to provide detail of the potential impact of the proposals on Section 75 groups also to help inform this EQIA. 11.5 In terms of data relating to patients we have examined available data held on internal databases. This is limited in respect of Section 75 data due to a number of factors including the emergency nature of our service which means the information we record is that information which is clinically relevant. 11.6 Given that there are some gaps in respect of the availability of quantitative information, NIAS invited Section 75 representative groups to a focus group meeting and also had discussions with representative bodies representing the public, patients and staff in order to obtain some qualitative responses to our proposals to aid the development of this EQIA. NIAS is grateful to DHSSPS Statistics and Analysis Branch for some of the data collation work undertaken for the preparation of this document. 11.7 Finally NIAS also considered previous consultations undertaken which relate to the provision of ambulance cover including the DHSSPS EQIA on the Implementation Plan of the Strategic Review of the Ambulance Service in 2001 and the consultation on our Resource Deployment Plan in 2006. 12 WHAT DOES THIS INFORMATION TELL US ABOUT PEOPLE IN SECTION 75 CATEGORIES? 12.1 As previously stated we have categorised those potentially affected by the proposals into three main groups: Local populations in the areas where the reconfiguration of A&E Services is proposed to take place in Year 1. NIAS A&E Operational Staff. Patients seeking ambulance assistance through 999 calls in Clinical Priority Categories A, B and C. Quantitative Data information we have looked at 12.2 Local Populations affected The following information outlines the profile of the local populations potentially affected by the proposals in Year 1 as a group. As previously outlined the areas affected are: Section 75 CategoryStatistical informationReligious Belief54% of the population affected in Year 1 of our proposals is Roman Catholic, 31% is Protestant and 15% is classed as other or none.Political Opinion27% of the population affected is classed as Unionist, 35% as Nationalist and 38% as other or not known.Racial GroupThe population of ethnic minorities in Northern Ireland is approximately 1%.AgeA complete breakdown of the age groups is available at Appendix A. In Summary, 24% of the affected population are under 16, 20% are 16-29, 21% are 30-44, 20% 45-59, 10% 60-74 and 5% are74 and over.Marital Status56% of the populations are married, 32% are single and 12% are identified as other. Gender51% within these affected populations are male and 49% are female.DisabilityThe full detail of this information is set out in Appendix A. In summary, of the populations affected, 23% are living with a limiting long-term illness and 11% are claiming DLA. The proposals affected some part of all the areas examined within the Prevalence of Disability and Activity Limitations amongst adults and children living in private households in Northern Ireland Report.Dependants46 % of the affected populations are identified by NISRA as having dependants and 54% as not having dependants.Sexual OrientationThe Research document Shout (published by YouthNet, December 2003) estimates that up to 10% of the population of Northern Ireland may be Lesbian, Gay or Bi-sexual.Table 4 Section 75 Statistical Information ( population data) 12.3 NIAS STAFF The following information outlines the profile of available data relating to AE staff within NIAS. Community Background We do not currently monitor political opinion and religious belief specifically and so have considered monitoring information relating to community background in this respect. Based on the available data set, approximately 59% of ambulance A&E staff is from the Protestant Community and approximately 39% is from the Roman Catholic Community, 2% is unknown. Gender 78% of ambulance A&E staff are male and 22% female.Age The majority of staff are in the middle age range between 30 and 49 with 76.7 aged between 30 and 49.Table 5 Section 75 Statistical Information (staff data) NIAS has minimal numbers of staff recorded as having a disability or from an ethnic minority. 12.4 Patients affected by modernising proposals The following information outlines the profile of patients seeking ambulance assistance through 999 calls in Clinical Priority Categories A, B and C.   EMBED Excel.Sheet.12  Table 6 Emergency Response by Gender and Call Category A slightly higher proportion of calls are from males than females (roughly 55% for male patients and 45% for female patients). Overall however the profile of calls is broadly similar for both males and females, with over 30% of the calls being classified as Category A, around half of the calls falling into Category B, and around 10 15 % into Category C. Males however have a slightly higher proportion of Category A calls than females (males 38%, females 32%)  EMBED Excel.Sheet.12   EMBED Excel.Sheet.12   EMBED Excel.Sheet.12  Table 7 Emergency Response by Age Range and Call Category Looking at age groups only, the majority of calls come from those over 40 yrs of age, with the highest percentage of calls coming from the 40-49yrs age group. This age group also has a higher percentage of Category A calls (40% as opposed to an average of just over 30%). The second highest number of calls is for patients aged 70 and over. The call profile of this age group is broadly similar to the average call profile. For those aged 70 to 90 around 30% are Cat A calls, between 55% and 60% of the calls are classified as Cat B, and around 10% are classified as Cat C. This pattern shifts slightly for those aged 90 and over, where the percentage of Cat A calls decreases and the number of Cat B calls increases. The lowest number of calls is for patients between 0-2 years of age. This group is significant however insofar as a disproportionately large number of calls fall into Cat A (over 77% as opposed to an average of roughly around 30%). Note: Percentages are approximate Qualitative Information discussions we have already had 12.5 We have had discussions with some Section 75 representative groups, trade unions and other stakeholders which proved very helpful in the development of this document. Section 75 Representative Groups 12.6 We conducted a short informal pre-consultation with some Section 75 groups in relation to these proposals in order to help inform the development of our EQIA. These groups generally welcomed proposals to provide a more efficient service and stressed the importance of proposals for change being focused on the patient. Consultees also welcomed proposals to introduce clinicians into the Control Room to provide medical advice. There was also a welcome for proposals which would mean transportation to hospital only of those who need to go to hospital. Consultees explained that carers prefer to have those they care for at home rather than in an institution, although, they also noted that this means increased medical responsibility for carers. Concern was expressed that the 3% figure for efficiency savings to be made was a blanket figure selected by government, without an audit of efficiency in order to determine which organisations could feasibly make efficiencies and which already operated in an efficient manner. It was suggested that intended changes to staff shift patterns to facilitate these proposals may have an adverse impact on staff who are carers, if they are required to change the geographical location of where they work. In addition NIAS was asked to consider whether the proposals would result in an adverse impact on rural communities and some concern was expressed as to the safety of RRV Paramedics, working as lone workers. Consultees also emphasised the importance of equality training for staff, particularly in respect of Disability Awareness and Good Relations. It was proposed that consideration should be given to a holistic approach to efficiency savings and CSR investment for all Health and Social Care organisations as it was suggested that these organisations may be impacted by one anothers proposals. Trade Union Response 12.7 As previously outlined we have established a CSR Joint Working Group consisting of trade union and management representatives and we are committed to continuing to work with trade union colleagues through this forum, as proposals are implemented. In pre-consultation in advance of this formal consultation process, trade unions have expressed opposition to these proposals. In summary, they object to the majority of savings being released from frontline services. One response contends that NIAS proposals will result in greater delays in patient transportation, reduced clinical care and maintains that there will be an increased risk for loss of life for time critical casualties. This response further claims that the only improvement would be meeting the 8 minute response target for Category A calls and will not result in an improvement of clinical outcomes for patients. It is claimed that the majority of areas affected are rural areas and that insufficient emergency ambulance hours are being maintained which they contend will have an adverse affect on rural areas. Trade union representatives have indicated they believe that RRV paramedics are able only to provide limited treatment and that increasing the hours of cover provided by RRVs to later at night presents health and safety risks for these staff. They further maintain that the proposals will result in less down time between calls which they have indicated could result in increased stress for staff and which they contend could present problems in being able to get vehicles cleaned. Some proposals for further options for efficency savings were presented for consideration and we will give them full consideration however the options presented would not release the level of savings required of the Trust. Trade union representatives have expressed the view that NIAS is a small organisation with a large senior management tier. In addition they have expressed concern in respect of staff who may be unable to avail of potential opportunities for re-skilling due to the nature of the process involved including as a consequence of having caring responsibilities. Objections have also been raised about ongoing recruitment given what they believe to be the potential redundancies. One trade union response also indicated the proposals would have an adverse impact across all Section 75 categories although no further detail or evidence was provided in this regard. NIAS Response to Trade Union Concerns 12.8 This document has outlined that payroll accounted for 82% of total expenditure in 2007/08 and the greatest spend within this is in front-line A&E ambulance personnel (approximately 27.87 million). NIAS operates with a proportion of administrative support staff to operational staff of approximately 3% which is considerably less than other HSC Trusts. As explained previously there is very little scope to deliver further efficiency savings from non-payroll as it is predominately demand-driven and heavily influenced by activity related to patient interaction. NIAS management structures and costs are broadly comparable with other Ambulance Trusts. They include operational and also HQ management costs. The 8 minute response target for Category A calls is a measure of ambulance performance used nationally and reflected in Ministerial priorities for Northern Ireland. The focus on a fast response to potentially life-threatening calls is aimed at providing early clinical intervention in order to improve clinical outcomes for patients. By reducing the number of patients inappropriately transported to hospital, we aim to ensure availability of A&E ambulances for those patients who need transport to definitive care. We are seeking within these proposals to match supply with demand, however we have also taken due account of the need to maintain ambulance response capacity in rural areas with relatively low levels of activity. RRV paramedics are able to provide the full range of skills required to provide this early clinical intervention and administer life saving care. Far from ignoring the potential for delay in transportation, NIAS is responding to this possibility by developing a system that more appropriately deals with patients who simply dont need the traditional model of care. This is not simply about not taking patients to hospital because we can do something else for them the proposals would result in only taking those patients to hospital for whom this is appropriate. Whilst proposals will result in staff spending more time dealing with patients, we will manage this in such a way to ensure staff receive adequate breaks and vehicles are regularly cleaned. We are committed to protecting the health and safety of all our staff. We have undertaken a risk assessment in relation to RRV paramedics operating as lone workers. In this regard we have introduced a number of measures to mitigate against such risk including: Automatic back-up at the scene of calls Provision of digital radio and phone with direct links to ambulance control at all times Vehicle tracking Constant monitoring of activity and staff via 24 hour control room Control system to identify and communicate potential risks to staff Care & Responsibility Training Training in the use of personal dynamic risk assessment which enables staff to withdraw from situations if necessary. In respect of opportunities for re-skilling, we are committed to working with trade union representatives through the CSR Joint Working Group in the management of this process. The Trusts current recruitment plans are based on current and forecast vacancies, which consider the changes in staff levels as a result of the proposed cash releasing efficiency saving proposals, and also the proposed service investments, both at a local level and also as part of the Comprehensive Spending Review. The levels of recruitment and training are essential to maintaining current and future service provision, and are reviewed on a regular basis to ensure that they remain realistic. Previous Consultations 12.9 Previous consultations which relate to the provision of frontline A&E ambulance service reveal particular concerns in respect of the provision of ambulance cover in rural areas. 13 ASSESSMENT OF IMPACTS WHAT THIS INFORMATION TELLS US ABOUT THE IMPACT OF PROPOSALS ON SECTION 75 GROUPS 13.1 NIAS has assessed the impacts of the proposals after having considered all the data outlined in the previous section of this document, and taking into account views expressed in pre-consultation exercises with Section 75 representative groups and trade unions. Section 75 CategoryDifferential/adverse Impact identifiedCommentReligious BeliefDifferential impact.54% of the populations in the areas identified by NIAS to be affected by these proposals in year 1 are Roman Catholic. 59% of A&E ambulance staff are from the Protestant Community, 39% from the Roman Catholic Community. As previously mentioned religious belief is not currently monitored specifically. Political OpinionDifferential impact.27% of the populations affected is classed as Unionist, 35% as Nationalist and 38% as other or not known. Data relating to the Community background of staff indicates that potentially the majority of staff affected may be from a Unionist background.Racial GroupNone identifiedAgeDifferential impact57% of patients who access A&E are over 50 and are therefore more likely to be affected by these proposals. Marital StatusNone identifiedGenderDifferential impact 78% of A&E staff are male.DisabilityNone identifiedDependantsPotential Adverse Impact in respect of A&E staff.Changes to shift patterns which may result in staff being required to move to work from a different station may have an adverse impact on those with caring responsibilities.Sexual OrientationNone identifiedTable 8 Section 75 Impact Assessment 13.2 NIAS is of the opinion that the introduction of proposals to make 3% efficiencies involving the reduction in A&E hours cover alone would have reduced its capacity to respond to emergency calls and would therefore potentially have had an adverse impact across the Section 75 categories. However coupled with the CSR investment, which will be used to provide increased numbers of Rapid Response Vehicles and enable us to modernise and improve our service, we believe the net result of these combined proposals is a positive one. 13.3 For patients and the populations affected, the proposals mean a greater opportunity for a paramedic response in order to provide life-saving care. NIAS will prioritise calls in order to ensure the appropriate allocation of resources and the transportation to hospital of those who need to go to hospital. Transportation of those patients who need to go to hospital will remain a priority and in this regard we are required to despatch an ambulance, capable of transporting patients within 21 minutes of receipt of a Category A call. 13.4 For staff, we have worked to ensure the delivery of the required efficiency savings this year without redundancies in Year 1. We have also established a working group with staff side colleagues to enable consultation on the proposals and we are committed to continue working within this forum as proposals are implemented and monitored. We recognise that the changes proposed over the three years will result in changed shift patterns including potentially shorter shifts and changed start and finish times for A&E staff and the possibility of moving to a different base location. We understand that change of this nature may have the potential to have an adverse impact on those who have caring responsibilities. However changes will be in line with contractual arrangements and we will seek to mitigate any impact identified through the implementation of this process. CSR investment will mean the creation of permanent RRV Paramedic posts and will also provide promotion opportunities for staff. Staff movements in respect of recruitments and transfers will mean that the movement of a very small number of staff to a relief rota in Year 1 will be a temporary measure (such movements will create vacancies on the core rota for which these staff will be first in line). 13.5 These proposals are directed at specific areas as identified within this document for Year 1. Implementation of these proposals will be monitored and evaluated to inform further decision-making about implementation of the proposals over the three year period. However with the use of tactical deployment to ensure vehicles are deployed on the basis of predicted need, NIAS continues to strive for an improvement in response times to life threatening emergency calls in order to save more lives and improve outcomes for patients throughout Northern Ireland. There is no evidence to suggest any adverse impact on any individuals (patients/public generally) as a consequence of being within any of the Section 75 categories, in relation to the proposals. 14 RURALITY AND DEPRIVATION 14.1 NIAS acknowledges that performance in respect of emergency ambulance response is generally lower in rural areas than in urban areas. For 2008-2009 in addition to a target of responding to 70% of Category A calls within 8 minutes for Northern Ireland as a whole, we also have a target of responding to at least 62.5% of Category A calls within 8 minutes in each Board area. 14.2 We have improved performance throughout Northern Ireland, including in rural areas. These proposals are targeted at areas where supporting resources are available which are areas with relatively high population density and ambulance activity. The net increase in paramedic response hours contained in the proposals, allow us to direct paramedic response resources at those areas where we do not currently meet Departmental standards. Through the use of tactical deployment, ambulance resources will be used to provide A&E cover throughout Northern Ireland. 14.3 Emergency ambulance response performance is generally higher in deprived areas than non-deprived areas. Some of the areas affected by the proposals fall within deprived areas. However it is our view that the net impact of the proposals is a positive one. We do not envisage these proposals having a negative impact on either rural areas or on areas of high deprivation. Data in this regard is available at Appendix A. 15 MEASURES TO MITIGATE AGAINST IMPACTS AND CONSIDERATION OF ALTERNATIVE POLICIES - HOW WILL WE MANAGE THE IMPACTS OF THE PROPOSALS? 15.1 It is NIASs view that these proposals represent improved access to paramedic life saving treatment. Although RRVs do not normally transport patients, the transportation of patients who need to go to hospital remains a priority of the Trust and we believe using Intermediate Care Vehicles to support the Accident and Emergency fleet, along with measures outlined to ensure transporting those who really need to go to hospital, will mitigate against any impact which the introduction of efficiency savings alone would have. The proposals are designed to enable the Trust to better meet demand for emergency ambulance response and provide appropriate treatment to our patients. 15.2 In respect of staff, the key impact of the proposals is the proposed change in shift patterns. Shift working is a fact of life within a 24/7 service and changes to shift patterns and movement of base locations are in line with contractual arrangements for operational ambulance staff. However we recognise that changes such as those outlined including staff moving from base locations have the potential to impact adversely for those who have caring responsibilities. In terms of mitigating against this impact, we are in the process of implementing a computerised rota system called PROMIS (Personnel Rostering Overtime Management Information System) to better plan the allocation of duties for all staff which will improve the degree of predictability for staff. In addition we have a number of Work Life Balance Policies. In particular we have a Carers Leave Policy to cover short term leave to respond to the immediate needs of carers arising from unplanned and unforeseen circumstances. Mileage payments will be made to staff who are required to move base locations in accordance with terms and conditions and we will monitor the impact of the proposals as they are implemented. 15.3 In respect of the matter of RRV paramedics operating as lone workers, the health and safety of our staff is of paramount importance to us. We have a number of policies in place in order to protect the health and safety of all our staff and of lone workers specifically. 16 WHAT HAPPENS NEXT? 16.1 NIAS is committed to monitoring the impact of these proposals as they are implemented. It is our intention to monitor the response times in affected areas, including the response times of patient conveying vehicles. We will also monitor any impact on staff as part of our work with staff side representatives within the CSR Joint Working Group. 16.2 In addition, we will monitor the impact of the use of measures designed to reduce the requirement to transport people to hospital who do not require hospital treatment. We consider all this information, including reference to available Section 75 data, information available from our internal information systems and available data relevant to geographical areas affected. We will produce an annual report throughout this three year period which outlines evaluation and monitoring analysis in relation to the proposals outlined in this EQIA. 17 HOW CAN YOU COMMENT? 17.1 This document has been developed to provide a platform for consultation with interested parties and we will meet with key stakeholders in this regard. In addition, the document will be placed on our website ww.niamb.co.uk (under Latest News) and we would welcome views in relation to the proposals outlined by email, post or fax. 17.2 A questionnaire is provided at Appendix C to aid response to the consultation. All consultation responses should be directed to: Miss Christine Stoll Equality Support Officer NIAS Headquarters Knockbracken Healthcare Park Saintfield Road Belfast BT8 8SG  HYPERLINK "mailto:consultation@niamb.co.uk" consultation@niamb.co.uk Fax: 02890 400903 This consultation will last for 12 weeks and will close on 13 February 2009. 18 PUBLICATION OF RESULTS OF EQIA 18.1 NIAS will make the outcome of this equality impact assessment publicly available and will publish a final report on its website. This document will also be made available in alternative formats, on request. APPENDIX A I. AVAILABLE DATA This Appendix provides an outline of data considered in the development of this EQIA. It includes the following: Section 1: Local Populations Section 2: Patient Data Section 3: Staff Data SECTION 1: LOCAL POPULATIONS AFFECTED BY PROPOSALS The following is data in respect of those nine Local Government Districts (LGD) only that are affected by the efficiency proposals for Year. These LGDs are Armagh, Ballymena, Belfast, Craigavon, Derry, Down, Dungannon, Newry and Mourne and Omagh. 1. Section 75 Groups Data presented in the charts in this section looks at the above-mentioned LGDs taken together as a group. Tables show figures for each LGD individually. a) Religious Belief EMBED Excel.Sheet.12 Source: based on NISRA, Census 2001 data Religious Belief EMBED Excel.Sheet.12 Source: based on NISRA, Census 2001 data b) Political Opinion The nine affected LGDs taken together as a group show the following profile: EMBED Excel.Sheet.12 Source: based on data collated from 2005 Local Council Election results from ARK NI Social and Political Archive and provided by DHSSPS Their individual make up is as follows: EMBED Excel.Sheet.12 Source: based on data collated from 2005 Local Council Election results from ARK NI Social and Political Archive and provided by DHSSPS c) Racial Group The 2001 Census reported that the population of ethnic minorities in Northern Ireland stood at 14,279. This was just less than 1% of the entire population. The Department for Social Development publication, National Insurance Number Allocations to Overseas Nationals Entering Northern Ireland (2007) reports the following summarized points: Arrivals 10,433 individuals arrived in the UK in 2004/05 and registered for a National Insurance Number (NINo) with a Northern Ireland address by the end of 2006. This series has risen gradually since total arrivals in 2000/01 of 2,682; Registrations Total NINo registrations have increased by 80% from 5,826 to 10,433 between 2004/05 and 2005/06; Registrations to Accession nationals increased from 1,657 to 10,177 over the same period, with Poland being the largest Accession country represented. Registrations in respect of non-Accession nationals increased by 1,268 (30%) Source: Department for Social Development, National Insurance Number Allocations to Overseas Nationals Entering Northern Ireland (2007) d) Age EMBED Excel.Sheet.12 Source: based on NISRA, Census 2001 data EMBED Excel.Sheet.12 Source: based on NISRA, Census 2001 data e) Marital Status EMBED Excel.Sheet.12 Source: based on NISRA, Census 2001 data EMBED Excel.Sheet.12 Source: based on NISRA, Census 2001 data f) Gender EMBED Excel.Sheet.12 Source: based on NISRA, Census 2001 data  Source: based on NISRA, Census 2001 data g) Persons with a disability and persons without NISRA holds data relating to limiting long-term illness as well as statistics on Disability Prevalence. The Department for Social Development has recently published data relating to people claiming Disability Living Allowance ( DLA). All are given below. i. Limiting long-term illness ( NISRA statistics 2001)  Source: based on NISRA, Census 2001 data EMBED Excel.Sheet.12 Source: based on NISRA, Census 2001 data ii. The Prevalence of Disability and Activity Limitations amongst adults and children living in private households in Northern Ireland ( NISRA 2007) EMBED Excel.Sheet.12 EMBED Excel.Sheet.12 Source: NISRA report The Prevalence of Disability and Activity Limitations amongst adults and children living in private households in Northern Ireland Local Government Districts in the above chart: Belfast - Belfast Outer Belfast -Carrickfergus, Castlereagh, Lisburn, Newtownabbey, North Down East of Northern Ireland - Antrim, Ards, Ballymena, Banbridge, Craigavon, Down, Larne North of Northern Ireland- Ballymoney, Coleraine, Derry, Limavady, Moyle, Strabane West and South of Northern Ireland - Armagh, Cookstown, Dungannon, Fermanagh, Magherafelt, Newry and Mourne, Omagh iii. Disability Living Allowance ( Department for Social Development Statistics 2007)  Source: Department for Social Development EMBED Excel.Sheet.8 Source: Department for Social Development h) Persons with dependants and persons without i. Households with dependent children  Source: based on NISRA, Census 2001 data EMBED Excel.Sheet.8 Source: based on NISRA, Census 2001 data ii. Persons with dependants This category includes people with adult dependants ( for example older people and people with disabilities) Up to date information on people with caring responsibility is provided in the ARK research update report Who cares now? (Eileen Evason, Who cares now? Changes in informal caring 1994 and 2006; ARK Research Update No 5; June 2007) Figures for 2006: 23% provided informal care for someone else, with an increase in the proportion of people providing care for someone living with them. 17% of men and 27% of women said they were carers and almost one half (49%) of them were aged between 35 and 54 years. 31% of carers spent 30 hours a week or more caring, and 62% cared for someone 5-7 days per week. Source: Eileen Evason,  Who cares now? Changes in informal caring 1994 and 2006; ARK Research Update No 5; June 2007 j) Sexual Orientation No data is available for Sexual Orientation, however according to estimates between 2% and 10% of the population could be LGB. Source: Shout, Research into the needs of young people in Northern Ireland who identify as lesbian, gay, bisexual and/or transgender; published by YouthNet, December 2003. 2. Level of Deprivation at Local Government Districts Deprived areas are the 20% most deprived Super Output Areas according to the NI Multiple Deprivation Measure (NISRA 2005). The MDR provides a relative ranking of small areas across Northern Ireland allowing the most deprived areas to be identified. Local Government Districts (LGD) are ranked 1 to 26 with 1 (Strabane) being the most deprived and 26 (North Down) being the least deprived. The graph below shows the deprivation rank of those LGDs affected by the Efficiency Savings in Year 1. North Down has been included here for reference purposes only; it is not directly affected by the proposals. EMBED Excel.Sheet.12 Source: Northern Ireland Neighbourhood Information Service, http://www.ninis.nisra.gov.uk SECTION 2: PATIENT DATA The following data is for the whole of Northern Ireland, i.e. all 26 Local Government Districts 1. Age Data is available for the period 01/04/2008 30/06/2008 EMBED Excel.Sheet.12 Source: Clinical Audit, NIAS internal database The record shows, that the majority of patients (57%) are over 50 years of age:  Source: Clinical Audit, NIAS internal database 2. Gender Data is available for the period 01/04/2008 30/06/2008 EMBED Excel.Sheet.12 Clinical Audit, NIAS internal database 3. Profile of A&E Service Provision a) Percentage of emergency calls per Local Government District Data is available for the period 01/04/2008 30/06/2008 Names of the areas which will be affected are highlighted in bold in the table below. EMBED Excel.Sheet.12 Source: Command and Control System, NIAS internal database EMBED Excel.Sheet.12EMBED Excel.Sheet.12 Source: Command and Control System, NIAS internal database b) Ambulance Response Time The following tables provide an overview of how NIAS emergency response has developed over the past four years. The first table shows the development of response time in deprived and non-deprived areas across Northern Ireland. (for more details on deprivation in Northern Ireland see Section 1, Point 2 above)  EMBED Excel.Sheet.8 Source: Analysis by DHSSPS based on data from Command and Control System, NIAS internal database The following table shows the development of NIAS response time in rural and urban areas across Northern Ireland over the past four years.  EMBED Excel.Sheet.8 Source: Analysis by DHSSPS based on data from Command and Control System, NIAS internal database Note: The distinction between urban and rural is not clear-cut. The Inter-Departmental Urban-Rural Definition Group" identified several criteria as relevant in ascribing urban characteristics to settlements like population size, population density and service provision. It was acknowledged however none of these criteria, in isolation, is sufficient and that a combination of criteria is required to classify settlements. In contrast rural areas are characterized more by a dispersed population, agricultural or other extensive land use and distance from major urban centers. Based on population figures, settlements with a population size of 4500 or more were classified in the report as urban, those with a population size below 4500 were classified as rural. Under this definition, approximately 65 per cent of the Northern Ireland population live in urban areas and 35 per cent in rural areas. Source: "Report of the Inter-Departmental Urban-Rural Definition Group" (NISRA 2005). SECTION 3: STAFF DATA This Section contains data relevant to all A&E operational staff who will be affected by proposals as they are implemented from 2008-2011. 1. Community Background EMBED Excel.Sheet.12 EMBED Excel.Sheet.12 Source: Equal Opportunities Monitoring, NIAS internal database 2. Age EMBED Excel.Sheet.12 Source: Equal Opportunities Monitoring, NIAS internal database EMBED Excel.Sheet.12 Source: Equal Opportunities Monitoring, NIAS internal database 3. Gender  EMBED Excel.Sheet.12 Source: Equal Opportunities Monitoring, NIAS internal database 4. Race As of 31st of December 2007 of all A&E staff one (1) defined themselves as Black and one (1) as Irish Traveller. Source: Equal Opportunities Monitoring, NIAS internal database 5. Disability Disability is monitored at recruitment stage. These figures do not take account of disabilities which may develop whilst in employment. The introduction of mechanisms to capture changes in employee circumstances in this regard is an area for development in 208/2009 in the Trusts Disability Action Plan. As of 31st of December 2007 of all A&E staff one (1) member had considered themselves disabled on the application form. Source: Equal Opportunities Monitoring, NIAS internal database II. INDICATION OF SOURCE SECTION 1: POPULATION DATA 1. Section 75 data All Population Census 2001 except for Political Opinion - collated from 2005 Local Council Election results from ARK NI Social and Political Archive and provided by DHSSPS and Disability Allowance - from Department for Social Development, Disability Living Allowance Summary of Statistics, August 2007 2. Deprivation level of Local Government Districts From the Northern Ireland Neighbourhood Information Service website: http://www.ninis.nisra.gov.uk/mapxtreme/default.asp? SECTION 2: PATIENT DATA 1. Age / Gender Clinical Audit, NIAS internal database 2. Profile of A&E Services Data: Command and Control System, NIAS internal database; Analysis by DHSSPS SECTION 3: STAFF DATA Equal Opportunities Monitoring, NIAS internal database as of 31 December 2007 APPENDIX B LIST OF STAKEHOLDERS CONSULTED The following stakeholders have received copies of this consultation document. If there is an organisation that you feel might be able to contribute to this consultation, please let us know. Contact details are set out on page 69 of the main document. Abbeyfield Society (NI Region) AIDS Helpline Accident Medical Negligence Association Accord Catholic Marriage Counselling Service Action Cancer Action Mental Health Action MS Adopt Advice NI Afro-Asian Residents Group NI Age Concern (NI) Age Sector Reference Group Age Sector Platform (ASP) Al-Anon Family Group Al-Nisa Association Alcohol Awareness for Youth Alliance Party Alzheimers Society An Munia Tober Antrim Borough Council Ards Borough Council Armagh City and District Council Arthritis Research Campaign Arthritis Care (NI) Asthma UK NI Association for Spina Bifida and Hydrocephalus Association of Crossroads Care Attendants Schemes Association of Directors of Social Services Association of Executive Directors of Social Work Association of Independent Advice Centres Association of Local Authorities in Northern Ireland Association of Northern Ireland Colleges Association of Trust Directors of Social Work Banbridge Borough Council Ballymena Borough Council Ballymoney Borough Council Baptist Union of Ireland Baptist Centre Barnardos Beeches Management Centre Belfast Brook Advisory Centre Belfast City Council Belfast Education and Library Board Belfast Health and Social Care Trust Belfast Healthy Cities Belfast Hebrew Congregation Belfast Outreach Centre Belfast Pride Belfast Solicitors Association Blind Centre for Northern Ireland Board of Social Witness, Presbyterian Church in Ireland British Association of Social Workers (NI) British Deaf Association (NI) British Dental Association British Diabetic Association British Dietetic Association British Geriatric Society (NI) British Orthoptic Society British Psychological Society (NI Branch) (for health matters relating to Psychology only) British Red Cross Bryson House British Medical Association (NI) Butterfly Club Cancer Relief Macmillan Fund Carafriend Care for NI Carers National Association (NI) Carers NI Carrickfergus Borough Council Castlereagh Borough Council Catholic Bishops of Northern Ireland Cedar Foundation Central Personal Social Services Advisory Committee Central Services Agency CGAS Chartered Society of Physiotherapy Chief Officers 3rd Sector (CO3) Child Action Prevention Trust Child Care (NI) Centre Children in NI Childrens Day Nursery Association Childrens Law Centre Chinese Welfare Association Church of Ireland Board for Social Responsibility (NI) Clerk of Petty Sessions (Laganside Courts) Coalition on Sexual Orientation (COSO) Coleraine Borough Council College of Occupational Therapists Committee on the Administration of Justice (CAJ) Community Addiction Team Community Development and Health Network Community Evaluation (NI) Community Information Network NI (CINNI) Community Foundation for Northern Ireland Community Relations Council Community Work Education and Training Network Confederation of British Industry (NI Branch) Confederation of Community Groups Conservation Volunteers NI Co-operation Ireland Cookstown District Council Corrymela Community Council for Catholic Maintained Schools Council for the Advancement of Communication with Deaf People Council for the Homeless Council on Social Responsibility Counteract Craigavon Asian Womens Centre Craigavon Borough Council Craigavon Chinese Community Association Craigavon Vietnamese Club Cruse Bereavement Care Department of Agriculture, Arts and Leisure Department of Education Department of Employment and Learning Department of Enterprise, Trade and Investment Department of Finance and Personnel Department of Health, Social Services and Public Safety Departmtent of Regional Development Department of the Environment Derry City Council Derry Travellers Support Group Derry Well Women Diabetes UK Disability Action Down Cardiac Support Group Down District Council Down and Connor Family Ministry Downs Syndrom Association Dungannon and South Tyrone District Council Dunlevey Substance Advice Centre DUP East Belfast Community Development Agency Eastern Health and Social Services Council Economic Research Institute of Northern Ireland Employers Forum on Disability European Infertility Network Equality Coalition Equality Commission for Northern Ireland Equality Forum Equality 2000 Extern Extra Care Falls Community Council Family Care Society Family Planning Association NI Fermanagh District Council Fermanagh Womens Network First Key Food Standard Agency Forum for Action on Substance Abuse Forum for Community Work Education Four Seasons Healthcare Foyle Downs Syndrome Trust Foyle Friend Foyle Womens Aid Gay and Lesbian Youth Northern Ireland General Consumer Council for NI General Medical Council Gingerbread Northern Ireland GMB Union Green Party Guide Dogs for the Blind Association Guild of Healthcare Pharmacists Harmony Community Trust Health Promotion Agency Help the Aged HM Council of County Court Judges Home Start (NI) Include Youth Indian Community Centre Inland Revenue Institute of Directors (Northern Ireland) Institute of Professional Legal Studies Institute of Public Health Irish Congress of Trade Unions NI Committee Issue, the National Fertility Association Japan Society of NI Judicial Appointments Commission Larne Borough Council La Societa Italiana Irlanda Del Norde Lesbian Line Limavady Borough Council Lisburn City Council Law Centre (NI) Law Reform Advisory Committee Law Society of NI Lesbian Line Life (NI) Magherafelt District Council Marie Curie Cancer Care (Belfast) Mediation NI MENCAP Mental Health Commission Ministry of Defence Moderator of the Presbyterian Church in Ireland Moore, Tim (Research & Library Services, Northern Ireland Assembly) Moyle District Council Mulholland After-Care Services Multi-Cultural Group Multi-Cultural Resource Centre Multiple Sclerosis Society (NI) National Deaf Childrens Society National Society for the Prevention of Cruelty to Children (NSPCC) Nevis Healthcare NEWPIN (Foyle NI) Newry and Mourne District Council Newry and Mourne Senior Citizens Consortium Newry and Mourne Women Newtonabbey Borough Council Newtownabbey Senior Citizens Forum Nexus Institute for NI NIPSA North Eastern Education and Library Board North Down Borough Coucnil North West Community Network North West Ethnic Communities Association North West Forum of People with Disabilities Northern Health and Social Care Trust Northern Health and Social Services Council Northern Ireland Affairs Committee, House of Commons Northern Ireland African Cultural Centre Northern Ireland Anti-Poverty Network Northern Ireland Association for Mental Health Northern Ireland Association for the Care and Resettlement of Offenders (NIACRO) Northern Ireland Association of GP Fundholding Practices Northern Ireland Blood Transfusion Agency Northern Ireland Cancer Registry Northern Ireland Chamber of Commerce Northern Ireland Chest, Heart and Stroke Association Northern Ireland Child Minding Association (NICMA) Northern Ireland Citizens Advice Bureau Northern Ireland Commissioner for Children and Young People Northern Ireland Confederation for Health and Social Services Northern Ireland Council for Ethnic Minorities (NICEM) Northern Ireland Council for Voluntary Action (NICVA) Northern Ireland Council on Alcohol Northern Ireland Court Service Northern Ireland Deaf Youth Association Northern Ireland Federation of Housing Associations Northern Ireland Federation of Private Members Non Profit making, Sports, Social & Recreational Clubs Northern Ireland Filipino Association Northern Ireland Fire & Rescue Northern Ireland Foster Care Association (NIFCA) Northern Ireland Gay Rights Association (NIGRA) Northern Ireland Government Departments Permanent Secretaries Northern Ireland Guardian Ad Litem Agency Northern Ireland Home Accident Prevention Council Northern Ireland Hospice Northern Ireland Human Rights Commission Northern Ireland Local Government Association Northern Ireland Regional Medical Physics Agency Northern Ireland Medical & Dental Training Agency (NIMDTA) Northern Ireland Members of the House of Lords Northern Ireland Mother and Baby Action Northern Ireland MPs, MEPs, MLAs Northern Ireland Music Therapy Trust Northern Ireland Office Northern Ireland Ombudsman Northern Ireland Political Party Leaders Northern Ireland Practice and Education Council (NIPEC) Northern Ireland Practice Managers Association Northern Ireland Pre-School Playgroups Association (NIPPA) Northern Ireland Public Service Alliance Northern Ireland Resident Magistrates Association Northern Ireland Social Care Council Northern Ireland Statistics and Research Agency (NISRA) Northern Ireland Student Centre Northern Ireland Volunteer Development Agency Northern Ireland Womens Aid Federation Northern Ireland Womens European Platform (NIWEP) Northern Ireland Youth Forum NUSUI Student Movement Office of Law Reform Office of the Legislative Counsel Omagh District Council Omagh Ethnics Community Support Group Omagh Womens Area Network Pakistani Community Association Parents and Professionals and Autism (PAPA) Parents Advice Centre (PAC) Participation & Practice of Rights Project Pharmaceutical Contractors Committee (NI) Pharmaceutical Society of Northern Ireland Physically Handicapped and Able-Bodied (PHAB) PlayBoard NI POBAL Press for Change PRAXIS Mental Health Public Sector Support Services Forum (PSSSF) PUP Queens University of Belfast, School of Law Queer Space Rape Crisis and Sexual Abuse Centre Registered Nursing Home Association Regulation & Quality Improvement Authority Relate Royal College of Anesthetists Royal College of General Practitioners (NI) Royal College of Midwives Royal College of Nursing (Northern Ireland) Royal College of Ophthalmologists Royal College of Paediatrics & Child Health Royal College of Pathologists Royal College of Physicians Royal College of Physicians in Ireland Royal College of Psychiatry Royal College of Radiologists Royal College of Speech & Language Therapists Royal College of Surgeons Royal College of Surgeons in Ireland Royal Institution of Chartered Surveyors in Northern Ireland Royal National Institute for Deaf People (RNID) Royal National Institute for the Blind (RNIB) Royal Society for the Prevention of Accidents (ROSPA) Rural Community Network Rural Development Council Rural Support Salvation Army District Office Samaritans Save the Children Fund SDLP Sense (National Deaf-Blind and Rubella Association) Shelter Sikh Cultural Centre Simon Community Sinn Fein Society of Local Authority Chief Executives Society of Radiographers Society of St Vincent de Paul South Eastern Education and Library Board Southern Health and Social Care Trust South Eastern Health and Social Care Trust Southern Education and Library Board Southern Health and Social Services Council Sperrin Lakeland Senior Citizens Consortium Staff Commission for Education and Library Boards Strabane District Council The Baptist Centre The Cedar Foundation The Most Reverend Alan Harper, Archbishop of Armagh The Society & College of Radiographers Threshold Traveller Movement (NI) Twins and Multiple Births Association (TAMBA) Ulster Cancer Foundation Ulster Chemists Association Ulster Institute for the Deaf Ulster Quaker Service Committee Unison UNITE University of Ulster, School of Law UUP Voice of Young People in Care (NI) Voluntary Services Belfast (VSB) West Belfast Economic Forum Western Education and Library Board Western Health and Social Care Trust Western Health and Social Services Council Westminster Spokespersons for Northern Ireland Women into Politics Womens Information Group Womens Resource and Development Agency Womens Support Network Young Help Trust Youth Council for Northern Ireland APPENDIX C CONSULTATION QUESTIONNAIRE Information about you and your organisation The questions in this section will enable us to have a better understanding of who has responded to this consultation. The rules about disclosure of consultation responses are outlined on Page 2 of the main document.` Your name ----------------------------------------------------------------------------------- In which of the following capacities are you responding to this consultation? As a representative of a public authority Name of authority: ---------------------------------------------------------------------------------  On behalf of a community or voluntary sector organisation Name of organisation: -----------------------------------------------------------------------------------  On behalf of a trade union organisation Name of trade union organisation: ------------------------------------------------------------------------------------  As a member of the public -------------------------------------------------------------------------------------  As a patient or carer -------------------------------------------------------------------------------------  Other Your response to our consultation document In this section we would like you to comment on the content of the consultation document. The proposals Do you agree with the principle of modernizing the Ambulance Service to deliver efficiency saving and ensure and efficient and patient-centred service?  YES NO Please explain your answer Do you agree with the proposed measures? YES NO Please give reasons for your answer Do you think that NIAS has considered all relevant evidence or information in assessing the equality impacts of these proposals? YES NO If NO, please give reasons Can you identify any other potential adverse impacts with supporting evidence which might occur as a result of these proposals being implemented. Please suggest any other mitigating measures to eliminate or minimise any potential adverse impact in relation to the proposals. Please provide any suggestions as to how NIAS can better promote equality of opportunity in respect of these proposals? Other Comments Please provide any further comments in respect of the proposals outlined. Thank you APPENDIX D ACRONYMS A&E Accident and Emergency AMPDS Advanced Medical Priority Despatch System AVLS Automatic Vehicle Location System CSR Comprehensive Spending Review CGAS Commissioning Group for Ambulance Services DHSSPS Department of Health Social Services and Public Safety DLA Disability Living Allowance DTR Digital Trunked Radio EQIA Equality Impact Assessment ICV Intermediate Care Vehicle ICS Intermediate Care Service LGB Lesbian, Gay and Bisexual LGD Local Government District NI Northern Ireland NIAS Northern Ireland Ambulance Service NISRA Northern Ireland Statistics and Research Agency PCS Patient Care Service PfA Priorities for Action PROMIS Personnel Rostering Overtime Management Information System REMDC Regional Emergency Medical Despatch Centre RNEMDC Non-Emergency Medical Despatch Centre RPA Review of Public Administration RRV Rapid Response Vehicle VCS Voluntary Car Service GLOSSARY OF TERMS Accident and Emergency - treatment for patients who have suffered a serious injury or accident, or who have developed a sudden serious illness or medical condition. Advanced Medical Priority Despatch System - an internationally accredited computer software package that enables control staff to assign clinical priority to emergency calls and dispatch the appropriate response. Ambulance hour - see Emergency Ambulance hour Automatic Vehicle Location System - a remote tracking system, based on the Global Positioning System, which enables the location of a mobile resource, for example an Ambulance vehicle. Baseline budget - The total resources available to provide ambulance services in a year. Capital charges - Used to ensure that the cost of owning a capital asset is recognised in the accounts. Capital charges comprise of depreciation and a rate of return, currently set at 3.5% of the average value of the asset. Category A Call - An emergency call for a patient thought to be in an immediately life-threatening situation or condition e.g. an unconscious patient with abnormal breathing following an episode of severe chest pain. Category B Call - An emergency call for a patient believed to be in a serious but not immediately life-threatening situation or condition e.g. a conscious and alert patient with a history of angina having an episode of chest pain with no other symptoms. Category C Call - An emergency call for a patient believed to be in neither an immediately life-threatening nor serious situation or condition e.g. a conscious and alert patient who has slipped and possible fractured their wrist Collapse Call - a 999 call to the ambulance service that indicates a person has collapsed and is unresponsive. This would always be regarded as a high priority emergency. Commissioning Group for Ambulance Services Group consisting of representatives of four Health Boards which commissions ambulance services for Northern Ireland. Comprehensive Spending Review - a governmental process in the United Kingdom carried out by HM Treasury to set firm and fixed three-year departmental expenditure limits and, through public service agreements, define the key improvements that the public can expect from these resources. Comprehensive Spending Reviews focus upon each government department's spending requirements from a zero base (i.e. without reference to past plans or, initially, current expenditure). Deployment Point - a position where an ambulance stands by, waiting to respond to an emergency call. This might not be at a traditional ambulance station, as some deployments points are located at fire stations or other healthcare facilities. Depreciation - the process of charging the cost of an asset, for example land, buildings and vehicles, over their useful life Digital Trunk Radio - a secure, computer-controlled radio communications system, used by the emergency services. Efficiency Savings - Efficiency savings is money the local devolved government (the Executive) has demanded be saved through re-design and modernisation of the way public services are provided. The Executive expects these savings not to be at the expense of front-line services. In healthcare, efficiency savings are delivered by doing things differently and achieving the same or better results with fewer resources. Emergency Ambulance - a traditional ambulance which contains a variety of essential emergency equipment and supplies as well as a stretcher. It has two ambulance crew members, one of whom should be a paramedic, and can be used to transport one or more patients. Emergency Ambulance Hour - The total cover provided and consequent cost of one hour of traditional two-person ambulance activity. Emergency Medical Technician - an ambulance technician responds to accident and emergency calls, as well as a range of planned and unplanned non-emergency cases. He/she supports a paramedic during the assessment, diagnosis and treatment of patients, and during the journey to hospital. Equality Impact Assessment - an in depth study of a policy or decision to assess the extent of the impact on equality of opportunity for the nine equality categories identified by Section 75 of the Northern Ireland Act. GP Urgent Call - When a GP decides that a patient requires hospital admission, and the patient cannot make their own way to the hospital, the GP arranges for the ambulance service to transport the patient within a specified time scale. Intermediate Care Service - The operations directorate of the ambulance service has two distinct branches Accident and Emergency (A&E) services and Patient Care Services (PCS). PCS crews are deployed to transport patients for routine appointments, inter-hospital transfers and to discharge patients home. Patients transported by PCS tend to have lower dependency than those being cared for by crews from the A&E branch. Intermediate Care Services are provided by PCS crews with some additional skills and knowledge they are provided for patients who have slightly higher dependency than routine but not high enough to require A&E services. Intermediate Care Vehicle - A vehicle equipped to carry a patient on a stretcher for transport, but who does not require any medical treatment during the journey. Paramedic Paramedics are registered with the Health Professions Council. Often one of the first healthcare professionals on the scene they assess the patient's condition and then give essential treatment. Patient Care Service this is the non-emergency tier of NIAS, providing non-emergency patient transport services across Northern Ireland to patients who have a clinical need for ambulance transportation. Pay-Roll / Non-Pay Roll Expenditure - payroll costs represent the cost of employing staff, for example the salaries and wages of ambulance staff. Non payroll costs represent the costs of running the service other than staff costs, for example the cost of fuel and vehicle maintenance. Priorities for Action - Targets set by the Department of Health to improve health and well-being in Northern Ireland. Programme for Government - the Executive's plans and priorities for 2008/09 and beyond. PROMIS - Personnel Rostering Overtime Management Information System. This system is used to plan ambulance cover including staff shifts. Rapid Response Vehicle (RRV) - a vehicle which carries all of the equipment contained within an emergency ambulance except for the stretcher. It is staffed by one experienced paramedic and attends emergency calls only in order to provide a faster response to serious emergencies or to assist crews already present. Regional Emergency Medical Despatch Centre - Control room based at NIAS headquarters in Belfast which coordinates the despatch of resources in response to emergency calls. Review of Public Administration - Transformation of Northern Irelands public services in order to reduce bureaucracy and improve front line services such as health and education. Rota System - This is a pattern of shifts over a number of weeks which provides the levels of ambulance cover required and results in the staff working their contracted hours over the duration of the rota. Tactical Deployment - The ambulance service Command and Control system and related information systems can be utilised to analyse previous call activity or demand and then to use that analysis to predict where the next calls are most likely to come from. The prioritised list of where the next calls are likely to come from forms the basis for tactically deploying ambulance resources to be in the right place at the right time. Thrombolysis - the treatment used to dissolve a blood clot which is blocking one of the arteries supplying a patients heart and giving rise to a heart attack. Voluntary Car Service - The Voluntary Car Service is purely a voluntary scheme which operates under the auspices of NIAS. 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Volunteer drivers are not employed by, or paid by the Ambulance Service, but they do receive a mileage allowance for transporting patients on our behalf.      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