When Accidents Happen: North-South Collaborations in Ambulance Services

Sofia Pinheiro graduated in 2023 with a Master’s in Physiology. She was a fellow in the 2022–23 cohort.  

What happens when there are no ambulances available during a medical emergency? Emergency medical services grapple with this question worldwide. Mutual aid agreements attempt to provide a solution. Generally speaking, mutual aid is a tool EMS agencies deploy to fill gaps that arise within their fleets. If an agency’s ambulances are all tied up, it can arrange for ambulances from other towns, cities, or counties to respond to its calls. This ensures that agencies maintain adequate EMS coverage as call volumes rise and fall across jurisdictions. Coordinating these efforts requires cooperation between dispatch centers, ambulance crews, hospitals, and legislative bodies, but how are these arrangements affected when neighboring towns, cities, and counties are separated by an international border?

My research focuses on how Northern Ireland and the Republic have addressed this issue, as the border between them poses a logistical threat to these operations. The mutual aid relationship between the two countries provides a unique window into how EMS personnel must readily adapt to the ever-shifting policies of a politically mercurial region while confronting challenges that await them in the field.

Various treaties and legal documents dictate what can pass through the border. The Good Friday Agreement, Brexit, and most recently, the Windsor Framework, have all reconsidered and reestablished the border’s permeability. The Republic of Ireland and Northern Ireland lie adjacent to one another and are both home to people who identify as Irish. In the world of EMS, this should make them a match made in heaven. However, their mutual aid relationship is complicated by many factors. In the Republic of Ireland, ambulances are part of the National Ambulance Service (NAS), which operates under the Health Service Executive (HSE). Paramedics in the Republic are licensed under the Pre-Hospital Emergency Care Commission (PHECC). In Northern Ireland, as part of the United Kingdom, the Northern Irish Ambulance Service (NIAS) operates under the Health and Social Care Trusts (HSC). No “hard border” in the form of a physical barrier or checkpoint stands between the Republic and the North, so ambulance crews can come and go from one side to the other without any awareness of having crossed into another country. 

Mutual aid agreements are not as spontaneous as the emergencies that necessitate them. Contracts must be written, rewritten, reviewed, and agreed upon by specific agencies that wish to enter into that agreement. Northern Ireland and the Republic have a Memorandum of Understanding between them that delineates the terms of acceptable cross-border ambulance activity. Additional definitions are provided in the Republic’s document titled “A Framework for Major Emergency Management.”

In recent years, headlines in Ireland and the UK have featured mutual aid regularly. Notably, the focus on the deployment of mutual aid has not been limited solely to the COVID-19 pandemic and the strain it placed on healthcare systems. In the fall of 2022, a catastrophic explosion at a gas station in the Irish border town of Creeslough resulted in the deaths of 10 people. A mutual aid response was activated and NIAS ambulance crews and fire personnel responded to the scene. An outpouring of gratitude and appreciation followed from local officials, emergency services personnel, and high-profile politicians. Taoiseach Micheál Martin praised the show of solidarity exhibited by the presence of NIAS crews working alongside their NAS counterparts by stating, “Our colleagues in the Northern Ireland fire service and ambulance came willingly and very quickly to the aid of those impacted by this. That will be long remembered. That solidarity and that sense of strong community between the essential services.”

In addition to providing evidence of ongoing kinship between the two countries, the activation of mutual aid serves as a marker of either side’s capability to provide healthcare to its citizens. As one might expect, prolonged hospital wait times due to the pandemic, and insufficient resources to accommodate these stressors receive significant coverage. When speaking about the strain the NIAS was facing at the height of the pandemic, the service’s Chief Executive, Michael Bloomfield, said that RoI ambulances responding to the North was a “relatively unusual,” occurrence adding that it “reflects the pressure they are under.” While the pandemic certainly stretched EMS thin, this tracker shows data preceding 2019, demonstrating that mutual aid as a resource is not limited to extraordinary circumstances. The pandemic and Creeslough both attracted additional attention, but as a tool, mutual aid can serve people who require medical attention on any given day.

Mutual aid requires contracts, law-makers, and in the case of RoI and NI, treaties. Its utilization, however, would not be possible without the participation of providers. The successful deployment of mutual aid relies upon the work done by paramedics and EMTs employed by the NAS and NIAS. The roles of paramedics on either side of the border differ. What practitioners might share in a title, they do not share in their respective scopes of practice. Paramedics operating under UK-wide standards in Northern Ireland can perform more medical interventions than their colleagues in the Republic. This presents a problem when a paramedic from RoI responds to an emergency in NI, as a patient might expect a certain standard of care that cannot be provided in that instance. Both sides have Advanced Paramedic roles available, but similar inconsistencies exist between their scopes of practice. Additionally, the qualifications of PHECC paramedics in the RoI are technically limited to Ireland alone. Northern Irish Paramedics can practice anywhere in the UK, pursuant to meeting the requirements of the particular region employing them. RoI medics face additional limitations, seeing as their certification is limited to their country alone. Mutual aid agreements allow for a degree of flexibility not provided by these policies alone, but addressing these inconsistencies with updated policies and educational standards in the future could benefit paramedics and other EMS practitioners on either side. Increased cooperation might be possible if roles are standardized across the border. These changes are not only possible but likely imminent, as EMS in RoI has developed rapidly in the last 20 years. Similarly, NI boasts its own advancements, as it recently established a paramedic program through Ulster University in Belfast, elevating EMS education to an academic setting and ensuring its continued growth. These changes are important, especially in the event that a practitioner faces legal action in what is technically a foreign country. Standardizing EMS policies across the whole of the island of Ireland could ensure the peace of mind of both patients and practitioners in an otherwise stressful situation, regardless of which side of the border they are on.