Dáil Éireann debate -
Tuesday, 14 Feb 2012

Vol. 755 No. 2

Private Members Business

Stroke Services

Deputy Maureen O’Sullivan

I move:

That Dáil Éireann, in recognising the findings of the Irish Heart Foundation's report entitled ‘Cost of Stroke in Ireland: Estimating the annual economic cost of stroke and transient ischaemic attack (TIA) in Ireland':

— acknowledges that in Ireland approximately 10,000 people per year will suffer a stroke which, at a cost of over 2,000 lives annually, makes stroke Ireland's third largest killer;

— accepts that in the region of 50,000 people throughout Ireland are living with a disability attained through stroke and that stroke is the biggest cause of acquired disability in Ireland;

— finds it to be of grave concern that the lack of prioritisation of rehabilitation services for stroke survivors to date has created, and continues to create, an unnecessary barrier to the achievement of better outcomes for as many of those affected by stroke as possible, thereby limiting the life opportunities of many of those affected; and

— is strongly committed to front-loading investment in stroke prevention and rehabilitation services to improve the quality of life of those affected by stroke and, as a significant by-product, address a situation whereby €414 million of the total €557 million in annual Exchequer spending on stroke goes towards nursing home care for the 1 in 6 nursing home patients who are survivors of stroke; and

calls on the Government to:

— develop forthwith an implementation plan based on the recommendations of the National Policy and Strategy for the Provision of Neuro-Rehabilitation Services;

— actively develop a multidisciplinary rehabilitation network to include teams throughout the country who would provide specialist supports to stroke survivors and persons with neurological conditions;

— place community rehabilitation and an aspiration towards independent living at the very heart of its stroke-related policies to ensure connectedness and quality of life for stroke survivors and their families; and

— proactively, creatively and realistically address the causes and implications of this silent killer.

I am sharing time.

I acknowledge the work of the Irish Heart Foundation on prevention, public awareness and input into the way forward. The way forward is being covered in this motion, which has been tabled by the members of the Technical Group.

From having listened to various experts, including medical experts, and those who have had strokes, I note it is vital that there be immediate intervention. Those who have strokes and their carers must be able to gain access to a range of services in and after they leave hospital, including services such as physiotherapy, speech and language therapy, occupational therapy and nutritional services. The key, apart from speedy availability of services, is for the services to be community-based.

I am told there are stroke survivors who do not have access to the rehabilitation services they need. This is not to take from the great work and services offered by various professionals, including medical, nursing and therapeutical professionals, to stroke survivors. They have allowed the victims to recover and resume their lives. In many cases, they live full lives after having a stroke.

There is sadness among those who would not be so incapacitated had more services been available and had more been done. The frustration among those needlessly disabled by stroke over not being able to communicate, move freely or attend to their hygiene needs and the feeling of being a burden on their loved ones are compounded by the realisation that they would not be in such circumstances had they received a certain drug, physiotherapy, occupational therapy or speech therapy more quickly.

The ESRI tells us the direct annual cost of stroke is up to €557 million, of which as much as €414 million is spent on nursing home care. Just €7 million is spent on community rehabilitation services that would keep Ireland's stroke survivors, numbering approximately 50,000, largely at home. I acknowledge the plans to do this but it is a question of direct action.

With regard to immediate intervention when someone suffers a stroke, stroke units and the thrombolytic clot-busting drug ought to be more widely available. This would reduce the number of deaths and the number who suffer from permanent severe disability by at least 750 per year. Economically, the saving through the reduced need for nursing home places would amount to some €230 million. We could imagine an injection of funding for the stroke units and the wider availability of the drug, and the effect on the number with permanent severe disability. It must be heartbreaking for those who were not able to avail of the drug, for whatever reason.

It requires saying "stop" and not investing vast amounts in the one area. Instead, we must invest money where it can do the most to prevent the worsening of circumstances for stroke victims.

We are told stroke is the biggest single cause of severe disability. Multiple sclerosis and motor neurone disease, which do so much damage in impairing one's ability to function, have in common with stroke the fact that they rob the person of his or her dignity and make him or her dependent on others for practically everything. They erode one's quality of life.

Some 10,000 people will suffer from stroke in Ireland this year. It is Ireland's third biggest killer, with some 2,000 lives lost every year.

It is also the biggest case of acquired disability and there are horrific numbers of people living with disability as a result of stroke.

In 2008, the Irish Heart Foundation undertook an audit which showed what people experienced after a stroke. Almost half had a weakness on one side of the body, 22% were unable to walk and one third had a cognitive impairment. More than half needed assistance with activities associated with normal daily life. Those are frightening statistics, particularly as some of that number need not be as disabled as they are had the necessary services been in place. Many people who suffer stroke also suffer from depression because of the frustration that stroke brings and the way in which people can be isolated because of suffering stroke.

There is a need to prioritise what needs to be done, as well as creating a proper rehabilitation network with the necessary multidisciplinary supports in place. I support the Irish Heart Foundation's call for stroke rehabilitation research to be conducted more regularly in order that health gains and economic savings can be made. Rehabilitation services, like services for those with mental health issues, need to be community based. Everyone who suffers stroke should have access as soon as possible to the appropriate service and the necessary specialised short-term and longer-term rehabilitation in hospital or in the community.

Stroke survivors require different levels of therapy and support at various stages of their journey. In the immediate aftermath of the stroke, they need acute rehab in hospital and appropriate rehab in the community later. It is horrifying to learn that some stroke survivors in nursing homes often have no access to therapists. After 11 months in office, the new coalition Government is saying that great strides are being made and that care is being provided for stroke sufferers, but I can guarantee that right now, somewhere there are stroke victims who are not in receipt of those services or did not get the services they needed at the initial stages.

When I spoke on the disability issue last week, I referred to the matter of access. I wanted to acknowledge the progress that has been made in providing better access to those with a disability, including stroke survivors. We know there have been improvements in venues such as cinemas and theatres. Local authorities have been proactive on this matter but there is a need for a speedier resolution when someone suffers a stroke and their mobility is severely impaired, particularly if they live in local authority houses of flats without proper access.

The 2008 national audit makes for grim reading in stating that acute rehab was only available for one in four patients or was delayed to a point at which it was not as effective as it could have been if it had been made available sooner. Continuing care and long-term recovery programmes were haphazardly organised. In addition, so much in terms of care and delivery depended on location, chance and circumstances which meant avoidable and unduly prolonged disability. That was in 2008, but a new audit is needed now because ongoing auditing could identify the scale of the deficit, identify the gaps and set about narrowing them.

Everyone agrees that community rehabilitation would improve the outcomes for survivors and, in purely economic terms, would reduce the financial implications for the State. We know what is needed: supported discharge, community rehab and home care supports, as well as access to required services, including occupational therapy, physio, speech and language. Those elements would increase the survivors' ability to live independently. They would also reduce the number of stroke patients in nursing homes, which can only have a positive effect on their quality of life.

I have examined what is happening in Britain where, up to three years ago, there was a lot of anger at the poor level of services there. Up to then, stroke survivors described it as falling into a black hole between hospital discharge and community-based care. In Britain now, stroke has a higher priority in the health service than ever before. One stroke prevention and action project in Hull provided intensive support to assist people in making the lifestyle changes necessary to reduce the risk of further stroke. That involved one-to-one sessions in people's homes, including looking at risk factors, going into the necessary lifestyle changes such as giving up smoking, and eating more healthily. That personal focus on people's individual lives had a very beneficial effect.

The Hull project also featured a weekly healthy lifestyle course which examined how even small changes can make a difference. Another aspect was prompt treatment for people with minor stroke or TIA, which reduced the risk of a major stroke. Various studies in Britain and elsewhere abroad have recommended specialist assessment within 24 hours for TIA patients at high risk of a major stroke. All such studies say that being seen promptly means patients are more motivated to make the lifestyle changes that could cut the risk of a further stroke.

Another study in Britain completely reorganised stroke services at one London hospital, which saved lives. It improved outcomes within that hospital where strong links were developed between clinical staff and the stroke research team. It showed that when research is undertaken, the units carrying it out have better patient outcomes.

A hospital in Wales created a stroke unit from scratch and the only extra funding required was to create the post of a specialist stroke nurse. Everything else came from reorganising the existing services. There was better teamwork between accident and emergency, hospital management, consultant physicians and the ambulance crew. The unit also included a fast-tracking system within the hospital.

Another hospital developed an information strategy to ensure people with stroke, and their carers, got the information they needed. They produced a handbook entitled Living With Stroke. Communications support groups were set up, particularly for young people. The public perception is that stroke only afflicts older people, while one quarter of all strokes in Britain, for example, happen to younger people.

In Britain, there is a dedicated helpline for those who suspect they are having a stroke or someone they know is having a stroke. The helpline helps them to identify factors such as facial weakness, arm weakness and speech problems.

We should try to imagine an ambulance being called for someone who has collapsed. The ideal scenario is to go straight to a hospital where there is acute care for people with stroke. Within an hour they should have received clot-busting treatment and will go on to make a full recovery with additional services. However, such a person could sit in accident and emergency for hours until it is too late and so they are left with complex disabilities. The moral of the story is to go straight to the treatment that is most appropriate to ensure a speedy recovery.

One cannot discuss stroke without examining smoking and the role tobacco plays in the ill health of the nation. As the Irish Cancer Society tells us, tobacco is the single largest cause of preventable death and disease in Ireland today. It kills one half of all lifetime users, causes one in three cancers and contributes to stroke. In addition, it costs the State €2 billion a year to provide services for smokers.

We have a new experience this evening of debating an agreed motion. I hope it will be a positive step because I do not see why Private Members' business should have to be a them-or-us situation. Real reform should bring about an honest and frank debate whenever Private Members' business arises. I would also like to see such debates being accompanied by a free vote. I do not want to appear cynical but we do wonder what the level of interest in the debate will be tomorrow night when there is the prospect that there might not be a vote at 9 p.m. It is to be hoped this topic, which touches so many people, will generate a high level of interest.

It is important to work on a collaborative basis. Just because one moves to the other side of the House does not mean that all knowledge and expertise is on the Government benches. There is still some expertise on the Opposition benches, as the Minister for Health would have discovered when he was an Opposition Deputy in the previous Dáil.

Deputy Finian McGrath

No better man.

Deputy Maureen O’Sullivan

The motion notes the "increase in the number of stroke units" and "that over 90% of all admitting hospitals will have effective stroke units". In addition, the motion refers to tackling "the risk factors for cardiovascular and chronic conditions", "front-loading investment in stroke prevention and rehabilitation services" and developing "an implementation plan". It also mentions the development of "a multi-disciplinary rehabilitation network", "community rehabilitation and an aspiration towards independent living", as well as committing "the Government to investing significantly in stroke services".

It is said that the proof of the pudding is in the eating. We agree with all of the aforementioned plans but we will have to see what happens. We know what is needed to bring about success, which is co-ordination between hospitals, clinics, professionals, local organisations, patients and their loved ones. Services should be provided at the point of most need and should continue to be provided for people, preferably within their community.

Deputy Luke ‘Ming’ Flanagan

I hope Members on this side of the House are listened to because we have some good ideas, as I am sure Members opposite have great ideas as well. There is not enough concentration on the prevention of strokes. The Minister for Health no doubt has heard the phrase, "Prevention is better than cure". Apart from causing less pain for patients, from an economic perspective, prevention is also infinitely cheaper. Without decisive action stroke numbers could increase by 50% by 2021 with the bill for this as high as €1.5 billion. Annually, 10,000 people are affected by stroke, of whom 2,000 die while 50,000 live with disabilities caused by stroke. What more incentive does one need to prevent this from happening in the first place? I accept prevention cannot work in all cases as some may be unlucky to have a genetic disposition towards stroke. However, the majority of cases can be prevented.

The other day I read that stroke is the leading cause of disability which I initially did not believe because I thought that would have jumped out at us long ago. When I verified it from other sources, it added to the reasons why we need to tackle strokes.

I was accused by Deputy Buttimer of never agreeing with the Government. Last week, however, I did agree with it. It is not often I will cheer anyone joining Fine Gael but it was an excellent move for the Government to bring Senator Eamon Coghlan on board to promote his points for life fitness programme for schools. He knows what he is talking about when it comes to fitness. His points for life initiative aims to make physical fitness for children and young people a core part of their lives and the school curriculum including bringing in exercise programmes for 15 minutes every day. While I believe it is an excellent idea, I would go further and stretch it to half an hour every day even if means taking five minutes off each class in secondary school or less teaching time in national school.

People take in more information in a much shorter time after exercise. Up until last week I was a runner but now I have had to buy a bike because of a bad hip. From personal experience, I know when I do a radio interview after exercise, I would not like to be the person on the other end. It makes total sense from a mental and physical point to ensure such a fitness programme is introduced. Last week Senator Eamon Coghlan pointed out that even though a new physical education curriculum at primary level has been in place since 1999, unfortunately it has only been fully implemented in 65% of schools. That needs to change.

More importantly, what also needs to change is the idea that when one stops playing for, say, Castlerea St. Kevin's football club or playing sport in school, that is the end of exercise in one's life. The German, French and other European health systems do things differently to here. Their people also do more exercise than us which is one major factor that leads to their people having better health. If one does more exercise, one is less likely to get a stroke or other lifestyle diseases and, accordingly, less likely to put pressure on the health system. That is the road we need to take. Instead of it being the Department of Sickness, it should become the Department of Health.

The amount of good exercise can achieve will be limited if one eats a lot of junk food, however. It has been suggested the Government places a calorie counter on all restaurant menus. While I do not agree it should apply to all restaurants as it does not make sense for some, a point which was teased out very well on RTE's "The Frontline" the other evening, such a regime should be applied to all fast food. Last summer, my family and I had the experience of a calorie counter on a menu in a restaurant near Luton. We were entertained, as well as everything else, by the number of calories contained in a dessert. Skinny as I am, we made our decision on which dessert to have based on the number of calories contained in them. To use the Celtic tiger phrase, we will get more bang for our bucks in the health area by encouraging people to do exercise. As someone connected with cannabis and drug culture, I tell those who are looking for a buzz to go out for a run instead as nothing can beat it.

While I am full of opinions on many matters, I am out of them when it comes to smoking. What does it take to convince people to stop smoking? Someone recently told me that the new advertisements against smoking told them they had a 50% chance of surviving. That is not the Minister's fault, it is something that is very hard to get around. For the past six weeks, five of my immediate family have used plastic inhalers to give up cigarettes. These are people who said they could never give them up. I have never seen them get this far in quitting. The Government is going to get a lot less in terms of tobacco duties from the Kelly and Flanagan families in the future.

Alcohol abuse is a massively contributing factor to stroke occurrence. Having lived in Europe and purchased alcohol on every street corner for low prices, raising the price of alcohol will not solve the problem of alcohol abuse. The approach must be through education. Marketing is the education the alcohol companies - the drugs companies - use. No matter what education the State gives young and old on alcohol abuse, there is no way to keep up with the message sent out by slick alcohol marketing companies. Alcohol advertising and marketing must be banned. On Monday night's "The Frontline", we were told that rather than such a ban coming in, which had been promised, the debate would continue on it.

I understand the downsides of such a ban, how it could hit sporting organisations and the pressure that entails. When I was a councillor, I ran a five-a-side league in my town which comprised 16 teams. Pressure was put on me by local publicans to have the teams go to their pubs after the game on Thursdays for some sandwiches in exchange for having a pub's name on the league. We resisted this, the league happened and we put the matches on later so the teams could not get to the pub. We survived and when the word got out we were not taking money off pubs, we got money from other people.

Unfortunately, prevention is not going to work for everyone and inevitably, some people will need care. The acronym FAST is used in a campaign for identifying stroke. "F" stands for face - has the person's face fallen on one side? "A" is for arms - can the victim raise both arms and keep them there? "S" is for speech - is their speech slurred? "T" is for time - time to call 999. I presume the acronym FAST was chosen because speed is of the essence when dealing with stroke victims. I will be accused of turning into a parish pump politician but then again I have been called worse.

Roscommon hospital has a problem not with expertise in treating stroke victims but with speed of access to stroke care. If a patient in Roscommon hospital has a stroke, he or she will be seen to, given a scan and thrombolysed quickly. However, if a stroke victim happens to be standing outside the hospital walls when he or she has a stroke, he or she will have to get into an ambulance to go to Galway or Ballinasloe. If it is at the wrong time traffic-wise, trying to get through Claregalway could mean the journey to Galway hospital could take up to four hours. Dr. O'Keeffe, clinical director of Galway and Roscommon hospitals, said stroke patients have a window of four and a half hours to get correct care. Not everyone agrees with this, however. Dr. Ronan Collins, director of stroke services at Tallaght hospital, said he would not support that view and did not endorse providing such information to people who may suffer from a stroke in future. That is a good idea because they will probably end up dying. He advised that if a distinction is made between heart attack and stroke it is not accurate to suggest that patients in rural areas have up to 4.5 hours to receive appropriate treatment after suffering from strokes. He also stressed the critical importance of transporting stroke patients to hospital as quickly as possible.

Unfortunately, those who suffer strokes in Roscommon or other areas that were dependent on Roscommon hospital will not be helped by the 90% of hospitals that have stroke units. I support the motion and if the Minister has news on our air ambulance service I would be delighted to hear about it.

Deputy Thomas Pringle

I welcome the opportunity to contribute to this debate on stroke services. Every year, 10,000 people will suffer from strokes and 2,000 of these will die. Many more will become disabled and dependent on services for the rest of their lives.

Unfortunately our health services are reactive rather than proactive. It is vital that we develop services to prevent strokes. The Private Members' motion welcomes the increase in the number of stroke units because despite the cutbacks being implemented in the health service we must ensure stroke units continue to be rolled out and made available to patients across the country.

Prevention is definitely better than cure in the case of strokes. Up to 50% of strokes can be prevented and in this regard awareness is crucial. The Irish Heart Foundation's face, arms, speech and time to call 999, FAST, campaign has produced results even at this early stage. A survey by the foundation found that admissions to hospitals relating to stroke symptoms increased by 87% over the lifetime of the campaign. The Royal College of Surgeons in Ireland conducted another study which revealed that the number of patients getting to hospital in time to be treated increased by 59%. As the FAST campaign reminds us, time is of the essence. Disturbingly, it appears that awareness is tailing off as funding for the advertising campaign comes to an end. It is vital that the campaign is supported if we are to get the best outcome for stroke sufferers by getting them to hospital on time.

The foundation spent €250,000 on the campaign, of which €50,000 returned to the State in VAT and other charges. This is something that needs to be seriously examined because that €50,000 would have been better spent on prolonging the campaign. The value of the campaign is there to be seen. By maximising the amount of funding available to it, we can ensure it has a long-lasting impact on stroke sufferers' outcomes.

The Department of Health states that 90% of all admitting hospitals will contain stroke units. That is welcome news because the value of such units cannot be overestimated, especially where units are integrated with care teams and rehabilitation services. The quicker one gets into rehabilitation, the better the outcome and the opportunity to return to society to leave a full life.

In 2009, only 3% of stroke patients received thrombolysis treatment. That is an amazing figure when one considers the life saving impact of the treatment in terms of preventing further implications of stroke. In many hospitals it is only available during office hours. Thrombolysis treatment should be available on a 24-seven basis to anyone who needs it.

Aftercare in the community is hugely important for stroke sufferers. Unfortunately, however, the quality of aftercare depends on where one lives and whether local health management is proactive in providing services such physiotherapy and occupational therapy. These services are suffering from the embargo on HSE recruitment and testimonials from stroke sufferers reveal the repercussions. One sufferer was waiting for physiotherapy for two months because the physiotherapist was out sick without cover. Another sufferer who had contacted a doctor to arrange physiotherapy heard nothing back for a year.

The cutbacks do not make sense because people who can get the services they need to get fit again will be able to return to work and fullly participate in the community, which is more economical in the long term. Too often funding is decided on a year-to-year basis when the longer term payback times should be taken into account. By investing that money now, the State will save money in five years time. Investment in care saves money. The Irish Heart Foundation estimated that rolling out full stroke services across the country would be cost neutral at minimum. That estimate should be sufficient enticement to ensure it happens. We already spend €422 million per year on stroke care and if that can be cost neutral or save money in the future, we would achieve the best outcome for everybody.

It is estimated that 50% of strokes are preventable. That is equivalent to 5,000 strokes and 1,000 deaths. They are totally preventable if we get it right.

Deputy Seamus Healy

I thank the Irish Heart Foundation for the massive amount of work it has done in this area over the years by way of reports, research and proposals. Without its reports, there would have been much less progress in this area. We owe it a debt of gratitude for its work. As previous speakers noted, 10,000 people suffer from strokes every year in this country and as many as 2,000 die as a result. Approximately 50,000 people live with disabilities as a result of strokes.

This is an area in which prevention is better than cure. I welcome the progress that has been made over the past several years in this regard. I understand 16 hospitals now contain stroke units and the Government has announced that 90% of hospitals will contain units before the end of the year.

A report by the Irish Heart Foundation estimated the cost of stroke to be as high as €1 billion per annum. Approximately 40% of this amount is spent on nursing home accommodation. A significant proportion of this expenditure could be saved if acute services were made more widely available. The report also found that providing 95% access to stroke units could save 650 suffers from death or dependency each year. Achieving a 20% rate of thrombolysis could save a further 100 people from death or dependency. These are huge figures and they need to be taken on board by ensuring that a proper stroke service is in place throughout the country. The purpose of improving the Irish stroke service to acceptable international levels is not to save the Exchequer money but is to eliminate the catastrophic human cost of avoidable death and disability arising from stroke. Even today despite the improvement in services and the additional units I mentioned it is still to a certain extent hit and miss for stroke patients. Any Government will receive reports claiming that upgraded services would result in cost reductions at some stage in the future. The difference in this case is that better stroke services will lead to almost instant savings because the increased access to stroke and thrombolysis units will result in immediate improvements in outcomes. There would be immediate savings to the Exchequer and the State if the services are provided.

As other speakers have said, lifestyle, diet and exercise are obviously important. Other speakers have referred to the FAST - face, arms, speech and time - media campaign. I hope that campaign will be extended. I have heard there may be some difficulty with its funding and I hope the Minister will ensure ongoing funding will be made available for such a campaign, which has already been successful.

There is an absolute need for an integrated seamless stroke service, including rapid-access clinics, CT or MRI scanning and specialists for thrombolysis assessment. Ideally we would have dedicated teams in stroke units to provide care for stroke patients. Obviously those units should include medical, nursing and allied health professionals specialising in this area, which would ensure a major improvement in outcomes for patients who are threatened with stroke or who have a stroke event.

We need rehabilitation units as part of the service. These units need to be close to the patients as research has shown that support from families aids rehabilitation substantially. Obviously these units need to be properly resourced, staffed and funded. We need community-based services to ensure stroke patients can be brought back to their own homes and communities to recover and have a long life. I hope that the reductions in the home-help services as part of the HSE national health plan would be reversed because these home care packages must be available if the community-based services are to be effective. The service obviously needs to be fully funded and staffed with professionals with the expertise in the various areas to ensure a complete and holistic service is available from the beginning of the event through to rehabilitation and community care.

Minister for Health (Deputy James Reilly)

I am grateful to have the opportunity to speak in Dáil Éireann on the subject of stroke, rehabilitation services for stroke survivors and persons with neurological conditions, and what can be done to prevent stroke. The Irish Heart Foundation's report, Cost of Stroke in Ireland: Estimating the annual economic cost of stroke and transient ischaemic attack (TIA) in Ireland, set out the burden of stroke. I thank the Technical Group, in particular Deputies Maureen O'Sullivan and Catherine Murphy, for raising the matter.

It is estimated that there are more than 10,000 acute strokes per year. There have been welcome advances in recent years in the investigation, treatment and rehabilitation following an acute stroke and, thankfully, mortality rates from stroke have fallen considerably. While many people are, therefore, spared the worst consequences of stroke, many more patients and their families live with the effects of residual disability from stroke. One in ten people remains heavily dependent on long-term institutional care. With an aging population and longer life expectancy after stroke, this condition will continue to pose challenges for individuals, families, communities and the health service for years to come.

In June 2010, Changing Cardiovascular Health: National Cardiovascular Health Policy 2010-2019 was launched. This policy establishes a framework for the prevention, detection and treatment of cardiovascular diseases, which seeks to ensure an integrated and quality-assured approach in their management in order to reduce the burden of these conditions. It set out a model for stroke care including rehabilitation through an integrated service.

Initial rehabilitation assessment begins within the first 24 hours of admission or as soon as feasible according to the patient's condition. Rehabilitation in stroke is multidisciplinary, involving clinicians, nursing, physiotherapy, occupational therapy, speech and language therapy, psychology, dietetics and medical social work. Many stroke patients have co-morbidities and the purpose of rehabilitation is to adapt to loss of function, to prevent further impairment and to promote a return to independent living and full participation in society.

The inpatient early stroke rehabilitation model involves a multidisciplinary assessment of rehabilitation needs with an appropriate care plan for the patient. The presence of on-site acute stroke rehabilitation units allows the timely transfer from acute care to rehabilitation with subsequent home discharge when appropriate. The aim is to have early supported discharge to home or to the patient's place of residence prior to admission to hospital. Integration between hospital-based and community-based stroke services is an important element of care to allow people living with stroke to function at home or return to work as appropriate. When a patient with stroke has benefited from the initial phase, he or she is transferred into the care of the GP and the primary health-care system.

The national stroke programme was initiated in 2010 to help lead and co-ordinate the development of stroke services in Ireland. It has operated under the auspices of the programmes directorate of the HSE and, more recently, the special delivery unit of my Department. The priority of the programme in the first 12 months was the development of acute stroke services - namely, to manage better in the first few hours, patients who have just suffered strokes in order to reduce mortality and disability.

The overall aim of the national stroke programme is to ensure national rapid access to best-quality stroke services; prevent one stroke every day; and avoid death or dependence in one stroke patient every day. The national model of care clearly sets out the care pathways for the patient with stroke as well as the best evidence for stroke prevention. In recent years, new techniques and strategies for improving the care of people with stroke have emerged. For example, the benefits of organised clinical services for stroke care have been clearly established. Hospital-based stroke units for acute and initial rehabilitation of patients with stroke and TIA are associated with a reduction in death and institutional care of approximately 20%, with one additional patient returned to community living for every 20 patients treated. While those might not sound like large numbers, it is truly great for the individuals concerned. Transient ischaemic attack is a minor stroke where the clot dissolves and the patient makes a full recovery. However, it may herald a more serious stroke to follow if the underlying causes are not treated. I offer an illustration of the progress achieved in the development of stroke units. The Irish national audit of stroke care reported one stroke unit with three under-units under development in 2006. The 2010 hospital emergency stroke service survey in 2010 reported 18 acute hospitals with a stroke unit. In 2011 the programme worked towards achieving stroke unit care for acute stroke patients through the establishment of additional stroke units. Of the nine units planned, seven are open and the remaining two will open early this year. At that stage, almost 94% of stroke patients will have access to stroke unit care. Additional therapy, nursing and consultant posts were provided to support the development of new and existing stroke units. The filling of all outstanding posts will be completed by the early part of this year. Despite budget reductions, we strive to improve these services. Not only will these units save money but, more important, they will save lives and improve the quality of live for people who have had a stroke.

Following emergency admission to hospital with stroke, administration of clot-busting thrombolysis therapy can reverse or substantially reduce disability in one third of patients treated within 90 minutes of stroke onset. However, strict administration guidelines mean that only one in ten or 10% of ischaemic stroke patients are suitable for such treatment. Given the potential for brain haemorrhage associated when thrombolysis is administered inappropriately and the brief time window for treatment, substantial organisation is needed to select patients on arrival in emergency departments and to safely deliver treatment to those most likely to benefit. It is worth recalling the work of Susan O'Reilly, who has shown that improved organisation of our cancer services can improve outcomes for patients by 10%. This is nothing to do with medication but rather better organisation. The same is true of stroke treatment.

The provision of 24 hour, seven day per week access to stroke thrombolysis is a priority for the programme. In 2011 the national clinical leads for stroke worked with hospital consultants and the national ambulance service to agree ambulance access protocols to ensure the safe provision of thrombolysis to eligible patients. The implementation of the telemedicine rapid access for stroke and neurological assessment, TRASNA, project in 2012 will further improve access to a 24 hour, seven day per week consultant assessment for thrombolysis. The delivery of acute stroke services is monitored through the national stroke register. A stroke register was piloted and implemented in partnership with the ESRI in six hospitals in 2011. All remaining hospitals accepting acute stroke patients will implement the register in 2012. There is substantial evidence that early supported discharge programmes for selected stroke patients are associated with reduced hospital costs, fewer bed-days used and greater patient satisfaction.

Planning for the development of stroke services in the community commenced in 2011. A community stroke services survey was completed and consultation has begun with other clinical care programmes to ensure stroke patients have access to rehabilitation and support services in community and primary care. Two early supported discharge programmes were implemented in 2011. Early results are promising and show patients having shorter lengths of stay in hospital without compromising quality of care. The work of the national programme continues in 2012 and includes: the implementation of the TRASNA project; the development of services for the investigation and treatment of patients with suspected transient ischaemic attacks; continued implementation of the stroke register; planning for services to identify patients with high risk factors for stroke, including atrial fibrillation; and working in partnership with other relevant clinical care programmes to ensure access to community-based services for stroke patients.

During the first 18 months of the stroke programme the HSE has been prioritising measures to limit the severity of the initial stroke by making stroke unit care and expert care available to as many people as possible immediately following stroke and by providing national availability of clot-busting thrombolysis therapy to all suitable patients. At the end of this process more than 95% of the population will live in the catchment area of a hospital with acute stroke unit care.

One area of concern is the early discharge of patients from hospital to the community in the absence of well-developed, community-based rehabilitation teams. There is evidence that generic community teams are less effective than specialist teams. Patients should not be discharged early from hospital unless adequate community-based rehabilitation is in place. The need for rehabilitation is recognised and the HSE has approved the appointment of 57 therapy and nursing posts with specific responsibility for stroke. This represents a substantial investment in stroke care and enhances existing stroke service availability throughout the country. The national stroke programme has also completed the largest and most comprehensive survey of therapy services in the country. The findings will be used by the national stroke programme, the rehabilitation medicine programme and the care of the elderly clinical care programme to plan, reorganise and develop rehabilitation services. This will result in more organised community-based rehabilitation services including stroke and neuro-rehabilitation, rheumatology, orthopaedics, geriatrics, primary care and others.

The care and support needs of people in Ireland affected by disabling neurological conditions or significant physically disabling conditions are individualised and varied and present a challenge to the health and personal social services, as well as to the wider public services. However, we know that in spite of the difficulties and the challenges involved people with these conditions, including acquired brain injury, cerebral palsy, multiple sclerosis and others, can get on with life and contribute to and be part of the community when appropriate supports are in place. This is why the publication of the report of the working group for the development of a national policy and strategy for the provision of neuro-rehabilitation services was important. Published by the Department of Health on 16 December 2011, it was jointly commissioned by the Department and the Health Service Executive. The report is entitled National Policy and Strategy for the Provision of Neuro-Rehabilitation Services in Ireland 2011 - 2015. A large number of people, including service providers, service users and their advocates, contributed in various ways to the development of the document. The report sets out a clear policy with a recommended service framework which, when implemented, will ensure that the services are delivered in the most appropriate, effective and efficient way. The report recognises that given the current economic climate the focus in the short to medium term must be on the reconfiguration of services, structures and resources and the enhancement of the skills and competencies required to meet the changing context. The development of joint working or inter-agency protocols is a key requirement and will be central to its implementation. Realising the actions recommended in this policy and strategy will provide real challenges, especially against a landscape of significant economic and resource constraints. However, with the commitment of the HSE and service providers to the implementation process, improved rehabilitation services can be achieved for those persons with a neurological illness or injury or with a significant physical disability.

The focus for service development in the first three years of this policy and strategy will be on network development, the integration of services, the development of protocols, the reconfiguration of existing resources, the achievement of greater cost-effectiveness through the development of greater competencies by those tasked with delivering services, increased teamwork and by more inter-agency collaborative working. The HSE is committed to developing an implementation plan and structure for the provision of neuro-rehabilitation services in close collaboration with the rehabilitation medicine clinical programme.

The aim of rehabilitation is to enable the person to achieve the highest possible level of independence. Desired outcomes range from a return to full independence in social and work activities to a person requiring long-term support and care but with a higher level of independence than in the absence of rehabilitation. As part of its development of clinical care programmes, the quality and clinical care directorate of the HSE has established a rehabilitation medicine programme. This programme will improve and standardise patient care throughout the organisation by bringing together clinical disciplines and enabling them to share innovative solutions to deliver greater benefits to every user of HSE services. The work of the rehabilitation medicine programme will aim to achieve three main objectives - to improve the quality of care, to improve access to services and to improve cost effectiveness. The HSE has appointed a consultant in rehabilitation medicine as clinical lead in respect of the rehabilitation medicine programme and it is committed to this programme.

Several Deputies have referred to prevention. Another important initiative under way in my Department is Your Health is Your Wealth: a Policy Framework for a Healthier Ireland 2012-2020. The aim of this public health policy is to develop a high-level framework for public health and it will address the broad determinants of health and health inequalities throughout our health services.

Smoking has been mentioned. It is a major risk factor for cardiovascular disease, including stroke and heart attacks. The Irish Heart Foundation reports that smoking is the cause of up to 2,500 strokes and 500 stroke-related deaths per year. At a personal level, I know all about this because at the age of 66 my father had a stroke and remained blind for the last 14 years of his life. Indeed, one of my brothers died at the age of 60 with lung cancer as a result of cigarette smoking.

This is a serious problem for our society and a serious risk to our children. It is an issue I am determined to tackle and we have introduced the tobacco policy review which will make further recommendations. We have managed to ensure more graphic images are displayed on cigarette packets to discourage people from taking up this desperately unhealthy and dangerous habit. I am also putting money aside to research a question, the answer to which has eluded me to date, namely, how the tobacco industry continues to attract young people as new recruits to a life that for 50% of them will clearly be destroyed by the habit.

Alcohol and cigarette smoking are connected. Alcohol can be a social lubricant and, used modestly, causes no harm, but every cigarette a person smokes damages the smoker. The Irish Heart Foundation's report on the cost of stroke in Ireland has placed an emphasis on the burden of stroke, the need to prevent it and the provision of rehabilitation services for stroke survivors with neurological conditions. There is broad agreement on the need for an intersectoral approach if the full continuum of care is to be addressed. Prevention is always better than cure. Many studies show that for every €1 spent on prevention, we save from €12 to €20 on treatment. It makes sense to opt for prevention.

I welcome the mention by some speakers of the FAST advertisement. It was instrumental in saving the life of a very good friend of mine last year. That advertisement has worked. Awareness works.

I thank the Deputies on the other side of the House who have raised this issue and thank them for the help it offers to raise awareness of the issue of stroke and the lifestyle issues that increase the risk of stroke, including smoking, abuse of alcohol and obesity. A simple measure for people would be to visit their GP once a year to ensure their blood pressure and cholesterol levels are okay and to check their body mass index. When I was in general practice and took an interest in obesity, half the people I saw in that connection just thought they were a bit overweight. If one does not know one has a problem, one cannot deal with it.

I thank the Members who raised this issue for the opportunity to address it tonight. I thank those Members of the Technical Group who proposed the motion for proposing one on which we can all agree. Let us hope it is the first of many collaborative approaches to health issues in society.

Deputy Patrick O’Donovan

I thank the Members of the Technical Group for raising this issue and, in particular, Deputy Maureen O'Sullivan, for her thoughtful remarks. Two of the issues raised have struck a chord with events in my family in the past 12 months, namely, chronic obstructive pulmonary disorder, COPD, and transient ischaemic attacks, TIAs. Until then, I had not a clue what either of these were. Any family unfortunate enough to be affected by cardiovascular disease knows it is not a nice experience. I am aware the Minister speaks from personal experience on this issue and so do I. I believe that anything that can be done in a cross-party way to try and raise awareness of the issue must be welcome.

The work of the Irish Heart Foundation in this regard is welcome and I am pleased it is now proposed to have a national register. We are aware from dealing with cancer that if we can identify the at-risk categories at an earlier age and get to them then, we can spare them significant problems. Some 10,000 people get a stroke every year, but they are not the only ones affected. There are also 10,000 families affected and a potential 10,000 carers who must care for a stroke victim who, until the day before his or her stroke, was independent and could go about daily life but is now a fully fledged invalid. In many cases, two lives are affected: those who are cared for and those who care for them. Thousands of lives are affected, therefore, and not just the lives of those who suffer from cardiovascular problems, particularly stroke.

Last October I raised an issue with the Minister by way of parliamentary question concerning off-duty doctors visiting patients, particularly in rural areas and areas covered by co-op doctors. As we know, we should watch out for the early signs of stroke or heart problems. We cannot force individual doctors to carry particular instruments, but if all doctors were obliged to carry an oximeter, for example, they would be able to measure the lung capacity and the amount of oxygen in a person's lung. This might be a further yardstick for someone experiencing tiredness and weakness to let them know they are en route to a TIA, stroke or chronic heart attack.

I welcome the Minister's commitment to the community aspect of this and the commitment he has set out on rehabilitation units. We need significant capital investment in this regard. The Minister will be aware that one particular community hospital very close to my heart has taken an initiative in its local community to drive forward on this issue and is providing in excess of 20 beds for rehabilitation for people coming out of acute hospitals, such as the Mid-Western Regional Hospital. It is providing a service for people, especially those who have been discharged from hospital but who have been exposed to hospital acquired infections. These people cannot go into typical rehabilitation units because of the risk of contaminating everyone else and they therefore require single rooms . The earlier these people get their speech, occupational and physical therapy, the better the outcome for them. Therefore, it is important that we have units offering single rooms located in communities, because these are people who have been exposed to hospital acquired infections and who cannot leave the acute hospital until the infection has cleared. They are stuck in a rut waiting for the infection to clear up but are liable all the time to get another infection. They are deprived of the opportunity to avail of the rehabilitation and therapy they need to get their lives back on track. The sooner they get that treatment, the sooner they get back to some level of normality, and the sooner their families are able to pick up the pieces.

The option of pharmacy-led COPD clinics is being considered in the United Kingdom. Many people would not be aware of COPD, which is a long-term lung disease which means a person's lungs begin to wind down, thanks mainly to smoking. If people want to see what smoking does to a person, they should visit any one of the rehabilitation units throughout the country where they will see older people who smoked all their lives. During the war, they may have smoked turf dust rolled up in newspaper because they were so badly addicted to smoking. One will see in those units at first hand what smoking does to a person's life.

I am glad the Minister mentioned the issue of obesity, which is an issue I have raised with him. The sooner we have a national obesity advocate who will drive forward change in this area, in the same way Gay Byrne was able to drive forward change in the mindset and culture of the people from the road safety point of view, the better. That advocate can instil the knowledge that what people ingest will have a long-term impact on their lives. There is no doubt about that. Currently, some 25% of all three year olds in the country are overweight and this will manifest itself as a massive problem in the future. The Minister can put aside all the billions he wants, but type 2 diabetes and obesity related illnesses, whether cancer, stroke, heart attack or whatever, cost €6 billion currently. This is easy to quantify in terms of the impact of this on the HSE budget. However, we cannot quantify the social damage being caused by these illnesses.

We need to arrive at a position where people realise the effect of these illnesses and of what they ingest or inhale, whether alcohol, food or cigarette smoke. We need to get to a position where we have national advocates who can describe in basic language for people the effects of the culture of bad habits in this regard. We need a cohort of people who are respected, such as a sports person like Eamonn Coghlan, and who are regarded as experts in their field who can speak on these issues. This is essential. Otherwise, we will wind up in a situation where we will continue to have these discussions.

Obesity is not just an issue that will affect the Minister and the Department of Health. It is a multidepartmental issue. It will affect education, agriculture, transport, the environment, the arts, finance and a clatter of local authorities and State agencies. These groups must be brought together under one umbrella with the sole motive to reduce the overall weight of the people. If we do not do that now, the problem will become so big that we will not be able to take control of it. Type 2 diabetes is a killer. It is a life-changing illness, along with stroke. The damage it does, not only to the individual who becomes an invalid, but to his or her family and the wider community, cannot be quantified nor can it be estimated in billions of euro.

I implore the Minister to do whatever he can in his tenure to take these issues on head-first, and he will be doing future generations a significant service by doing so.

Deputy Mary Mitchell O’Connor

This subject is dear to my heart as my personal assistant had a stroke this weekend and he spent the weekend fighting for his life in one of the major Dublin hospitals. I draw the Minister's attention to the awareness created by the Irish Heart Foundation's FAST campaign, which refers to face, arms, speech and time. It is an appropriate stroke treatment strategy and, unfortunately, economic difficulties are threatening the continuation of the scheme.

Stroke awareness has improved drastically since the FAST campaign was launched. A study has indicated that less than 50% of Irish adults would ring 999 if they thought they were having a stroke, which is a frightening statistic given the average stroke destroys 2 million brain cells every minute. Getting emergency treatment for a stroke can mean the difference between walking from hospital - sometimes within hours - death or spending the rest of one's life being dependent on others.

Thanks to the success of the FAST campaign, there has been a 124% increase in awareness of stroke warning signs. The Royal College of Surgeons in Ireland has completed studies showing that following the launch of the FAST campaign, there was an 87.5% increase in hospital admissions among patients with facial droop, as well as a 68% increase in hospital admissions for those with weakness on one side and a 66% increase in hospital case admissions for slurred speech. This has resulted in hundreds of people being saved from death and disability due to a three-fold increase in the numbers getting to hospital in time to receive clot-busting thrombolysis treatment.

The Irish Heart Foundation spent over €500,000 on the FAST campaign, a significant commitment for a charity that is 90% funded by public donation. Astoundingly, approximately €115,000 of this went in VAT payments to the State; in other words, the foundation was charged by the State to save lives and public money. That is an embarrassing anomaly and I ask the Minister to consider providing a VAT exemption for voluntary health-related charities.

Further improvements are being made in the area of stroke care by the HSE's national stroke programme. The HSE will soon achieve thrombolysis treatment 24 hours a day, seven days a week in all hospitals treating stroke. This is against a position just a couple of years ago when a handful of hospitals provided an adequate service. I congratulate the Minister for improving a service by moving it from Loughlinstown to St. Vincent's Hospital. I call on him not only to investigate the possibility of providing a VAT exemption to the charity but also to part-fund the continuation of the FAST campaign in recognition of the advancements in stroke awareness and quality of life standards for those who suffer a stroke, who thanks to the work of the Irish Heart Foundation and FAST campaign are treated on time.

Deputy Billy Kelleher

I welcome the opportunity to speak and congratulate the Technical Group on tabling a welcome motion, which highlights the issues in the House. The Minister referred to a collaborative approach in dealing with public health and everybody would concur with that in this context of promoting stroke awareness, particularly with regard to the Irish Heart Foundation campaign. It has been a strong advocate for many years in encouraging people into healthier lifestyles and promoting awareness in the general public of the issues surrounding stroke, the need for quick emergency interventions and awareness in the broader community, diagnosis and early treatment. The Irish Heart Foundation should be congratulated for promoting awareness through the FAST advertising campaign, which highlights face, arm, speech and time. Deputy Mary Mitchell O'Connor has indicated that this has brought a new awareness to the population and helps to ensure people gain quick access to medical procedures, meaning stroke can be prevented or damage can be limited.

There is a broader issue. In the Department of Health, like in other Departments, current financial constraints mean immediate issues are prioritised. There is a long-term issue that must nonetheless be addressed in society, namely the overall health of the nation. We can speak about short-term issues, such as the need for rehabilitative programmes for people who have had strokes and need continuing care or community based interventions for rehabilitation, including speech and occupational therapists. We can also discuss the supports required for the short term that will provide proper rehabilitative care and support for people who have had strokes that have left a detrimental effect on their ability to live completely independently. These are urgent and pressing issues.

Equally, there is another obligation. The Minister outlined his personal involvement in this issue, which encourages me and others, who for a long time have been trying to promote the idea of a healthy nation that is conscious of the need to be interested in promoting all facets of health. We can see alarming statistics on the obesity epidemic in the United States. In that nation statistics showed in the 1950s and 1960s there was a creeping movement in the waistline of the American people. This was initially broken into various socioeconomic and ethnic groupings but the problem has broadened across the entire United States. The problem is now evident in the United Kingdom, which also has an issue with obesity. In the last ten or 15 years the problem has arisen on our shores, with a creeping increase in obesity rates that will kill our population if we do not stop it now and proceed with major interventions to promote healthy living.

The national cardiovascular health policy made a recommendation that the Department of Health should prioritise actions to promote the behaviour and profiles underpinning cardiovascular health, with specific targets to pursue actively and achieve within ten years. It indicated the prioritised areas as maintaining a healthy body weight, healthy eating and physical activity, reducing salt intake, refraining from or quitting smoking and consuming alcohol responsibly. The actions would include fostering intersectoral support for initiation of activities promoting health and prohibition of activities that will maintain or foster unhealthy behaviours. Details of how to achieve the targets are contained in a range of Government policies and reducing inequalities in cardiovascular health across society must be an underlying principle in achieving improvements in health behaviour.

The lead organisation in that policy is the Department of Health, and it is critical that the Department encourages all other Departments in their efforts. When the recommendations were made it was the Department of Health and Children but we now have two separate Departments, with one for health and one for children and youth affairs. It is important that there be cross-departmental support and activity to ensure there is a conscious idea that to have a healthy nation we must deal with the underlying problem of obesity. That issue is growing continuously and if we do not take it seriously in the years ahead, there will be problems down the road. The Minister and I are aware of it but we need society to build on this.

I spoke in the debate on a Bill that would have allowed for publication on products of images of the horrific impact that smoking can have on one's health. I am amazed that there is a large cohort of people, particularly young girls, taking up smoking. It is a worrying trend and we must be aggressive in campaigning against and highlighting the problem at every level. We can consider the statistics. Each year, 5,200 people die prematurely from disease caused by tobacco use. When we talk about road fatalities and the carnage on our roads, we reflect on the efforts we have made, such as the establishment of the Road Safety Authority and the improvements in policing and implementation. The cultural shift in our views on drink driving has saved thousands of lives. Such changes have been universally supported in this House and embraced by the community outside.

The nagging view that smoking is cool continues to hang around in our society, particularly among younger people. It is something we have to target. Surveys have shown clearly that younger girls are most likely to take up smoking. This is happening for many reasons. Tobacco companies are engaging in subliminal advertising. Various methods and means are being used to subliminally transmit the message that if one smokes, one will suppress one's food intake and, by extension, one will be slimmer and one will look more like Kate Moss. It is a simplistic approach, but it resonates with young girls. It is having a detrimental effect on their health and, potentially, on the health of the nation in years to come. We owe it to the generations that will come after us to counteract this. We now have the knowledge. It was different when we were young. I started smoking when I was young. We did not have such an awareness of the impact of smoking and its dangers for people. We know it all now. The complete cohort of statistics, research and medical evidence demonstrates that individuals have nothing to gain from taking up smoking and everything to gain from giving up smoking. I implore the Minister to make a strong effort in this area. His Department is the lead Department. As a general practitioner, the Minister has practical experience of this issue. He spoke about his personal experience earlier in the debate.

The issue of encouraging people to be active is another key area. As a nation, we like sport, but unfortunately many of us like sport from the armchair. We have to start getting out there, not necessarily by participating in competitive sport but by engaging in various activities such as walking and general exercise. As a nation, we have to become more conscious of the need to be proactive in promoting our own health. The idea of healthy living being part and parcel of everyday life has been embraced in Australia, for example. When most Australian people get up in the morning, they go for a walk or a jog or do some other form of exercise. The idea is to live a reasonably clean and healthy life, to enjoy oneself and to treat oneself to excess occasionally. In general, the people of Australia have embraced the whole idea of healthy living. I appreciate that the Australian climate means they enjoy more sun. When one goes to Australia, one can sense that Australians have embraced the idea of challenging the problems of obesity, alcohol intake and the use of tobacco. The statistics show that Australia is beginning to climb up the league tables for longevity, life expectancy, body mass index and the general health of the nation. That is happening because certain policies are being pursued and the public is embracing the need to ensure health promotion is part and parcel of every aspect of life.

A Government Deputy suggested that an advocacy group or czar should be appointed to address obesity. I agree that something of that nature will have to be considered. Perhaps we should establish an agency - we do not like quangos in here - that can transcend Departments and bring them together. As I have said, the Department of Education and Skills is involved in ensuring these matters are covered on the school curriculum. The Department of Transport, Tourism and Sport is involved in another area. The Department of Health is the lead Department in this context. Each of those Departments has a critically important role to play. Equally, the local authorities have to provide amenities and facilities, for example by ensuring paths are safe and properly lit. That allows people to organise community walks in their own areas. Simple things can help to ensure we diminish the impact that stroke can have on the individual and, collectively, on the community. As has been pointed out, stroke has an enormous cost to individuals, families and communities. Much of the damage that is done by a stroke is hard to reverse. A large amount of intervention is needed from occupational therapists, speech therapists, language therapists and people with many other skill sets. We must make every effort to ensure those who suffer strokes get the best rehabilitative treatment and assistance possible. Equally, we must look over the horizon at the longer term to ensure fewer people enter the "at risk" category every year.

As a general practitioner, the Minister will be aware that technology is evolving. We should give greater consideration to developing our approach to risk assessment by profiling and testing people. We are familiar with the advertising campaigns that are always being promoted by individual organisations. The Irish Cancer Society's prostate cancer campaign, for example, encourages men to get themselves checked out. We all come in here and encourage each other to get ourselves checked out. Although all of these individual campaigns are worthwhile, I suggest there should be an emphasis on getting people to take an individual MOT test. I think it could lead to substantial cost savings in the short to medium term, but it is particularly worth encouraging because of its longer-term impact on life, on individuals and on society collectively.

I do not know where the need for a proper occasional evaluation and assessment of an individual's health will fit into the plans for universal health insurance and free primary care from general practitioners. I do not want to get into a confrontational political debate on these matters. Such an assessment could be funded or encouraged by the State. If it is not provided for free, some inducement could be offered to people to pay to get themselves checked out. As I have said, the technology that is now available to analyse potential risk is phenomenal. Advances in software technology mean that people who are in the high-risk category can use various types of equipment to analyse their blood on a regular basis to show how near they are to developing various illnesses. The technology that is now available should be embraced.

I will support the Minister when he has a good idea and I will oppose him when he has a bad idea. I applaud his passion and his commitment to promoting a healthy lifestyle, taking on the vested interests of those who encourage young people to kill themselves by taking up smoking, tackling the issue of alcohol abuse and promoting healthy living. I know there is very little to be gained in the short term from promoting something that does not bring an immediate return. Deputy Martin will tell the Minister that. The benefits of health promotion are incremental and come in stages. Perhaps, in years to come, someone will stand up in this Chamber and say "In fairness to the former Minister, James Reilly, when he was in the Department of Health, he stood up to vested interests and promoted healthy living, and for that we are grateful". That might take years to happen, but I will do it sooner if I continue to sense that the Minister has a genuine and positive commitment to promoting health and lifestyle changes, standing up to the vested interests that encourage people to take up smoking and abuse alcohol and inspiring people to change their diets and participate in healthy lifestyles. If the Minister acts on that commitment over the next few years, I am quite confident that the incidence of stroke, heart attack and other cardiovascular diseases and diabetes, etc., will diminish significantly. In such circumstances, future generations will say the Minister did a good job by starting the national cardiovascular health policy and promoting one's health as one's wealth.

Deputy Caoimhghín Ó Caoláin

I welcome the focus of this motion on stroke and stroke services. I commend Deputy Maureen O'Sullivan and her co-signatories for placing it on the clár of the Dáil. The motion describes very well the reality of stroke and how large it looms in the lives of the Irish people. It causes some 2,000 deaths each year, which is approximately ten times more than the number of people killed on our roads each year. It is the third largest killer of Irish people and the biggest cause of acquired disability. Those are startling and thought-provoking statistics.

Much credit is due to the Irish Heart Foundation for the work it has done on this issue. It reported last year that stroke-related hospital admissions had increased by 87% following the launch of its "Act FAST - face, arms, speech, time" campaign. Many people have been educated by the foundation's very effective television advertisements. That is very welcome indeed. According to research carried out by the Irish College of Surgeons, some 59% more stroke victims got to hospital in time to receive potentially life-saving thrombolysis treatment during the first phase of the advertising campaign in 2010. This increased level of awareness needs to be sustained and enhanced further because it is certainly saving lives. It is a disappointment to find, as the motion states, that of the €557 million in annual Exchequer expenditure on stroke, €414 million goes towards nursing home care for the one in six nursing home patients who are stroke survivors. This points to the great need for enhanced commitment to invest in stroke prevention and rehabilitation services. All the main parties committed before the general election to prioritise the elimination of avoidable death and disability in the shortest possible timeframe. Sinn Féin, the Fine Gael Party, the Labour Party and the Fianna Fáil Party signed up to this commitment and must work together in this Dáil with our Independent colleagues to fulfil it. Obviously, a special responsibility resides with the Government parties. Will they continue the legacy of their predecessors and neglect the need to support and develop rehabilitation for stroke survivors and others who require it?

Last year, when we asked the Minister for Health, Deputy Reilly, what action he proposed to take to improve the provision of neurological care he stated the office of clinical strategy and programmes in the Health Service Executive had established three key national programmes in neurological care. This, he added, showed the HSE's commitment to improving access to neurological services and gave these services a major focus in the HSE. He also noted that the third national programme "deals with stroke services and aims to establish robust clinical governance systems for stroke care, including local stroke teams and regional stroke networks."

I am aware, in speaking to the House this evening, of the proposed stroke unit at Cavan General Hospital and, regrettably, the key specialties yet to be secured at the hospital. Will the Minister advise the House of the current and projected status of this important and welcome development at the hospital? I hope progress has been made in the development of the third programme and wonder how effective such a programme can be in the context of the current unacceptable and seriously damaging cuts in the public health services.

Many Deputies will be familiar from representations they have received regarding the position at the neurological department of Beaumont Hospital, with its long waiting lists and shortage of clinicians. The position is that access to rehabilitation in this State is lamentable. In July last year, the National Rehabilitation Hospital, NRH, in Dún Laoghaire was reported to have 150 patients on waiting lists, some of whom had been waiting for up to a year. Lack of specialists and inpatient beds means that those with the most complex needs are often forced to wait longest. That said, once access is secured, patients receive the highest standard of care and support in the hospital. I am proud to note that the same can deservedly be said of the rehabilitation services at Monaghan General Hospital and congratulate all involved.

This State has the lowest number of physical and rehabilitation specialists in Europe. While the European average is approximately 3.3 consultants per 100,000 of the population, this State has 0.17 consultants per 100,000 citizens. The serious shortfalls to which I have alluded must be addressed. Education and awareness raising are vital in stroke prevention and coping with strokes when they occur. Equally, services need to be in place for survivors of stroke and all those who require rehabilitation. I commend the motion again and urge all Deputies to support it.

Debate adjourned.

The Dáil adjourned at 9.25 p.m. until 10.30 a.m. on Wednesday, 15 February 2012.