Stroke Services: Statements (Resumed)

The following motion was moved by Deputy Catherine Murphy on Tuesday, 14 February 2012:
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 welcome the opportunity to speak on this important motion and I commend Deputy O'Sullivan and her colleagues in the Technical Group for putting it before the House.

High levels of avoidable death and dependency from stroke in Ireland provide a compelling case for major improvements to acute rehabilitation and support services. The word "avoidable" is key to this discussion. It is generally accepted that the mortality rate from stroke would be cut by a massive 25% if stroke unit care was available to everyone struck by the disease here. 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 those who require rehabilitation.

The economic realities make it more important than ever that health policy makers are fully informed about the cost of existing services and the cost implications of service improvements when making decisions on resource allocation. Recent research has provided the most comprehensive data ever assembled on the baseline economic burden of stroke in Ireland, as well as assessing the potential costs and potential economic benefits of key interventions such as stroke unit care and the clot-busting treatment, thrombolysis. There is potential for improvements in acute stroke services that could save hundreds of people each year from death and institutionalisation at an actual cost saving to the State. The research illustrates the dire future consequences of failing to overhaul these services in terms of a significant increase in stroke incidence in the years ahead driven by factors such as our aging population. It is clear that by providing 95% access to stroke unit care, 650 stroke victims could be saved each year from death or dependency at a potential annual saving of up to €10 million. Achieving a 20% rate of thrombolysis could also save up to 100 people from death or dependency annually at a saving of up to €3 million per year. Better acute stroke services would lead to almost instant savings because increased access to stroke units and thrombolysis would result in immediate improvements in outcome. This would, for example, mean that fewer patients would require nursing home care, which is the single biggest factor in stroke service provision. The motion points out that €414 million out of a total of €557 million spent annually on stroke goes towards nursing home care for the one in six patients who are survivors of stroke.

However, the objective of improving Irish stroke services to acceptable international standards at the very least is not to save money for the Exchequer but to eliminate the catastrophic human cost of avoidable death and disability from stroke in Ireland. The vast majority of people who have a stroke today will face bleak prospects, including limited access to specialised stroke care, problems getting lifesaving thrombolysis at weekends and at night, a chronic shortage of therapists and long waiting lists for the rehabilitation which should be provided from the first day in hospital. Many people will face months, years or even the rest of their lives in a nursing home because their potential for independence diminished while waiting for proper care. These prospects would be transformed by the removal of the constraints on service improvements created by concerns over the cost implications.

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 population, we have 0.17 consultants per 100,000 citizens. These serious shortfalls must be addressed.

The national cardiovascular health policy recommended 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 suggested that prioritised areas could include maintaining a healthy body weight, healthy eating and physical activity, reducing salt intake, refraining from or quitting smoking and consuming alcohol responsibly. Actions would include fostering intersectoral support for activities promoting health and prohibiting activities that maintain or foster unhealthy behaviours.

Details on 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 developing this policy is the Department of Health. It is critical that the Department encourages other Departments in their efforts. Since the recommendations were made the then Department of Health and Children has been divided into two separate Departments with responsibility for health and for children and youth affairs, respectively. It is important that cross-departmental support and activity underpins awareness of the need to build a healthy nation by dealing with the underlying problems of obesity and the so-called metabolic syndrome. This issue is growing continuously and if we do not take it seriously there will be problems down the road.

When the Minister for Health, Deputy Reilly, was asked last year 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. This policy needs to be enhanced, improved and implemented.

I commend the Irish Heart Foundation on its efforts to inform the public on this subject. 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. A considerable number of people have been educated by the foundation's effective television advertisements. According to research carried out by the college of surgeons, some 59% more stroke victims reached 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 goes without saying that the role of emergency and pre-emergency care will be vital in the management and treatment of victims of stroke. Communities are rightly horrified when ambulance and emergency services are cut. I have ample experience of this issue in my constituency of Cork East and my hometown of Youghal. The reconfigurations proposed by the HSE will leave many isolated areas without ambulance services and even further away from the nearest emergency department. Where life saving alternatives exist we must do all we can to ensure they are delivered. Unfortunately, however, the HSE's regional service plans, which are currently being launched across the State, offer little ground for hope.

The Government needs to re-evaluate its priorities. Politics is about choices and this Fine Gael-Labour Party Government is favouring Europe and market confidence over the quality of life of its citizens. This policy approach must be reversed. I commend the motion and urge all Deputies to support it.

I understand the Minister of State at the Department of the Taoiseach, Deputy Kehoe, is sharing time with Deputies Harrington, Griffin, Ann Phelan, McNamara and Hannigan.

I thank Deputy O'Sullivan and the Technical Group for using Private Members' business to give us the opportunity to discuss the report on stroke and stroke victims, which is the most important health issue facing Ireland both now and in the years to come. I especially thank Deputy Maureen O'Sullivan for the way she introduced the motion agreed on both sides of the House in order to allow the debate to focus on the issue. All too often in this Chamber it becomes a case of the Government versus the Opposition rather than debating a real issue. I have no doubt that contributors tonight will continue in the same vein as the speakers last night and talk about what can be done to bring stroke victims back to full health. I am delighted the motion is being discussed in the format we see tonight.

I congratulate the Irish Heart Foundation on its work on prevention and public awareness, as well as its report on the cost of stroke in Ireland. The report estimated that the economic burden of a stroke in Ireland in 2007 was between €472 million and more than €1 billion. It is estimated that up to 10,000 people a year will suffer from strokes, 2,000 of which will be fatal. I have personal experience from my family and I have no doubt that Members on all sides will understand the effect of stroke suffered by a grandparent, aunt, uncle or parent. The number of young victims of stroke is of concern. I recently heard of a man in his early 30s who had suffered a stroke with all the associated consequences he must endure for the rest of his life.

Much can be done from having this debate in a very amicable and parliamentary way. While I know it is the Opposition's job to criticise the Government, the Government can only use the resources available to it. All aspects of the health service cost money. The previous Deputy spoke about reconfiguration. I have no doubt that whenever reconfiguration is happening in any county the primary responsibility is the care of the patient. I understand how difficult it is for Deputies when hospital services are being relocated away from their constituencies. Angry constituents approach Deputies who need to bring their anger to the Chamber and to the attention of the Minister. My county is very lucky to have a facility such as St. John's Hospital in Enniscorthy. I would love to see it double its bed capacity and have a multidisciplinary approach with more staff - occupational therapists, physiotherapists and speech and language therapists - to be able to help stroke victims. However, we need to stick within the resources available to the Minister, Deputy Reilly, for the health service.

We all have a role to play in looking after our own health. Deputies will have seen the television programme "Operation Transformation". The Minister, Deputy Reilly, spoke about calories in food etc., all of which have a very important part to play in people's healthy living. People engaged in healthy living and taking exercise in their 20s and 30s will not fall victim to stroke later in life.

Family members giving care to stroke victims are the unsung heroes. While there are care assistants who receive remuneration, many people receive no monetary benefit from looking after a patient in the family home. It could be the wife, son or daughter. It would cost the State considerably more money without the care they give in their own homes.

I thank Deputy Maureen O'Sullivan for bringing this important motion to the House.

I welcome the opportunity to speak on this debate and I thank Deputy Maureen O'Sullivan and the Technical Group for introducing the motion. The incidence of stroke is likely to increase as the years go on if lifestyle and diet issues leading to obesity continue. Unfortunately stroke is one of the most debilitating and crippling conditions to affect the population with an immense cost to the State.

Perhaps I might be allowed to get somewhat parochial and reflect on the timely nature of the debate with respect to Bantry General Hospital where the Minister for Health officially opened the acute stroke unit last week. As an example of how progress can be made, the unit, which is the first of its kind in Cork and Kerry, admits more than 100 patients with acute stroke annually. It is a key part of the clinical programme in stroke for west Cork and south Kerry. It is a modest four-bed unit set up at the end of 2009 without any extra staff by reorganising existing resources.

Dr. Brian Carey, consultant geriatrician at Bantry General Hospital, has said that the unit has led to substantially improved patient outcomes and enhanced patient access to multidisciplinary team members and CT scanning. The acute stroke unit is located beside the rehabilitation unit to allow for a seamless transition between acute care and rehabilitation. In addition, there has been a significant impact on patient length of stay. Despite a 13% increase in acute stroke admissions since the unit was set up, the total number of bed days used by patients with acute stroke has declined by 35%. Approximately 1,400 bed days have been saved annually in one small county general hospital. Of an annual budget of €15.5 million, the hospital has managed to save €1.2 million, a not insignificant amount relative to the overall budget.

Staff working in the unit use the most up-to-date evidence-based protocols to deliver a high quality service to a rural, isolated population. Since its inception, the unit has facilitated the safe and efficient provision of thrombolysis, the potentially life saving clot-busting treatment. This treatment is so time-sensitive that if patients from the region where I live had to travel to Cork, they would arrive too late to receive it. Some 10% of patients received this clot-busting treatment at Bantry General Hospital in 2011, an outstanding achievement in one of the most peripheral hospitals in the country. That 10% treatment rate is twice the average seen in the UK.

The acute stroke unit provides high quality specialist care for people who have had a stroke. Nursing staff are experienced in the assessment, treatment, monitoring and management of patients. More patients will survive their stroke and more will return home rather than transferring to institutional care as a result of being admitted to the unit. In addition, patients will have less disability when they return home and spend less time in hospital. The care of patients in the stroke unit involves a multidisciplinary team of health professionals including nursing, speech and language therapy, medical, physiotherapy, occupational therapy and counselling. The success of the acute stroke unit at Bantry General Hospital has already been recognised by the award of a special commendation at the Astellas Changing Tomorrow Awards this time last year.

On behalf of all the patients I thank all the staff in the dedicated unit for their contribution to creating a better society in serving west Cork and south Kerry. Small hospitals such as Bantry General Hospital can contribute in a significant way to this treatment, possibly proportionately more significantly than bigger hospitals can. Paramedics and advance paramedics should be trained and tasked with administering thrombolysis to patients in areas where they may not be able to get it in clinical care. That is very important. It is not long ago since people did not know what cholesterol was. Now, it is a part of casual conversation and people can stand in the shop or at the water unit and say they have a level of 7.2, 3.4 or 6.5 and people know exactly what they are talking about. People know exactly what Lipitor is and what statins are and all about the care for stroke prevention. Unfortunately, despite all the care, dedication and advice about diet, exercise and lifestyle we will continue to see increasing numbers of stroke victims in the country. This is regrettable and this why we need dedicated units. I commend the work of this unit at this time of increasing pressure on budgets. They have sought no extra resources, money or finance. There have been no great protests or rallies. The care clinicians on this team went ahead and got together. They put together the protocols and achieved something that could be achieved in every hospital in the country if those involved were minded to consider it.

I welcome the motion from Deputy Maureen O'Sullivan and the Technical Group. It is important that we are in the national Parliament discussing this matter. As previous speakers have remarked, stroke affects 10,000 people nationally on an annual basis. It also affects their families and the health care professionals who care for them. A vast number of people are affected by stroke every year in Ireland.

It is fitting that we are discussing this important health issue in a constructive and collective manner. I hope we will see more of this in the House in future. It is important to have a positive, collective attitude on this issue. Since 10,000 people suffer from stroke annually many people in our community, including myself, have had personal experience of the issue. Some years ago at the age of 61 my father, who was fit and active, suffered a near-fatal stroke. The effects are devastating on the individuals and on the associated family and friends. It is a terrible thing to happen to anyone.

What takes place in the immediate aftermath of the onset of stroke is crucial. This is why I agree entirely with what my colleague, Deputy Harrington, said in respect of the importance of access to emergency care. Thrombolysis and clot-busting medicine are important and prevent damage from becoming permanent. We must ensure that everyone in the State who suffers from a stroke has the opportunity to avail of thrombolysis where it is deemed to be suitable for a patient within the window in which it would be effective.

I refer to the work of Dr. Richard Liston and his colleagues at Kerry General Hospital in my constituency. They have worked to develop a dedicated stroke unit at the facility. I understand work is well under way and I hope significant progress will be made in 2012. Deputy Tom Fleming in the benches opposite has raised this matter over the years at council level and in the Dáil. Many other public representatives have raised this matter and that should be acknowledged. This is an important issue. I wish Dr. Liston and his staff and Michael Fitzgerald of the HSE in Kerry the best in bringing the facility to the fore and ensuring the facility is available for all stroke victims.

We must do what we can to focus on prevention. Other speakers have referred to preventative methods as well. There would be a considerable financial saving to the State if we reduced the levels of stroke. The savings in human terms would be considerable as well. We need to promote healthier lifestyle and living. We need better public information about the risks associated with stroke. We must try to develop a method of identifying high-risk patients in the primary care area and dealing with them before they suffer a stroke. This should be done in every general practitioner's office throughout the country. This would have many positive benefits.

I welcome the public awareness campaigns aimed at helping people to identify the signs of stroke. Once a stroke is coming on a person it is important that the people around that person know what is happening and know what to do. Education is important.

We must be mindful of victims of stroke who may have difficulties with mobility or speech and other difficulties. There should be education and an understanding among the public. One person who suffered a stroke some years ago spoke to me about his speech difficulties. He finds making telephone calls a nightmare. Once, he was accused of being drunk on the telephone when he was making an everyday telephone call, the type we all take for granted. There should be public information efforts on this front to inform people that stroke is a part of everyday life for thousands of people throughout Ireland and we must remain conscious of that.

I complement the Independent Technical Group on bringing this topical issue to the House. It is too important a subject with which to play party politics. I fully endorse their concern about this life and death issue which calls at the doorstep of almost 10,000 people each year in our small country. This is a frightening statistic because as a result of its day-to-day extension to family members it impacts directly on multiples of 10,000 souls. As the motion indicates, when added to those sufferers at various stages of recovery in the community or in care facilities, the number affected possibly amounts to 50,000. Perhaps the greatest concern for those in this position is how they can access support to restore their lives to independent living.

I can talk about stroke with qualified experience. On a mild Friday evening in 2007 I knew someone very well who had such an experience. The CAT scan equipment and other diagnostic services were closed for the weekend in Waterford Regional Hospital. It was a time of abundance in the country. At the time, a five day week service was available from 9 a.m. to 5 p.m. Therefore, the diagnostic process to determine whether it was a stroke had to be deferred until after that weekend. Thankfully, despite these circumstances, that person, who happens to be myself, recovered. I am grateful to the many dedicated people in care and medicine who made it possible for me to be here tonight. I take this opportunity to say that in my ignorance and before I had this episode, I thought that medicine was only about nurses and doctors but now I realise it extends to occupational therapists, speech therapy and all the rehabilitation people who look after a person when something like this occurs.

This experience has had a lasting imprint on my mind and I am more interested in gaining as much information as possible to pass on to others. It is a source of comfort to me that there is now a genuine national attempt being made to front-load investment in stroke prevention.

We must give hope to people in distress. I am often depressed by the scale of negativity I hear sometimes in our national Parliament. People, including the thousands of stroke sufferers, are keen to be assured that the vast amount of resources we put into health services will address their disability.

Stroke units are a key element in the provision of acute care and early rehabilitation. I am also delighted to learn that by the end of June 2012, almost 94% of stroke patients will have access to stroke unit care. In addition, we now have the comfort of knowing that ambulances are now operated by fully trained staff in the safe provision of thrombolyosis.

As with many aspects of health generally, prevention is the key to reducing the incidence of stroke. Although getting the prevention message is often criticised as a waste of money that should be spent on curing, I firmly believe that promoting awareness is money well spent. Like the proposers of the motion, I too would encourage the Department of Health's policy framework for a healthier Ireland as a commendable vehicle to inform the public on stroke prevention. The framework policy aims to address the broad determinants of health and health inequalities through our health services, community and education settings. The review will address a number of key lifestyle issues, including smoking, alcohol and obesity and suggest whether further action is required.

Despite significant tobacco control measures and the widespread knowledge of the harm caused by tobacco, smoking prevalence remains high. There is scope for further progress if we are to achieve modest reductions in smoking initiation. I am aware that one of the reasons for drawing up this motion was also to focus attention on the economic cost of stroke. The proposers are rightly concerned that resources saved sensibly in one part of the health services can be used elsewhere in the care system. I thank the Independent group for taking the trouble to place this motion before us and offer it my full support.

I commend the Independent group on proposing this motion. As a Government backbencher, I also commend the Chief Whip for not opposing it. This may be a small sign of the much needed reform of this Parliament. We have for too long seen a Punch and Judy show here and have not seen the extensive reform we would have liked. Nevertheless, there has been some reform and we should welcome any positive developments in these hard times.

I do not wish to repeat what my colleague, Deputy Phelan has said, but everybody in the House is agreed on the increasing threat posed by stroke in Ireland, because of our increasing older population in particular. We are also agreed on the importance of speedy treatment for stroke. As the House is aware, the chances of surviving stroke are increased by 25% if treated in a multidisciplinary stroke unit. For that reason, last year I asked the Minister for Health whether nursing and therapist posts funded under the national stroke programme, which are essential to the development of an acute stroke unit in the Mid-Western Regional Hospital in Limerick that will save lives and reduce cases of permanent severe disability, would be filled by the end of 2011. I was disappointed to learn from the Minister that he wished to advise that the 45 nursing and therapist posts identified under the national stroke programme were at various stages of the recruitment process but that it was unlikely they would be filled by the end of the year. However, in preparing to debate the motion I researched the matter further with the Department and was gratified to learn that people have now been hired for all of those posts, although they have not all taken up their positions yet. This marks progress.

I would like to draw the attention of Members to the fact that in the early days of this Government, in March 2011, a major tender was launched by the HSE for the construction of a multi-million euro extension at the Mid-Western Regional Hospital. In a summary tender advertised in one of the first weeks of the Government, the HSE said the proposed seven-storey extension and alterations would include a neurological centre, an acute stroke inpatient unit and a cystic fibrosis inpatient and outpatient unit. I am pleased to say that when I visited the hospital recently on a sad occasion unrelated to my public duties, I noticed the extension is proceeding as planned.

I do not pretend there was a miraculous turnabout on the part of the Government and that this extension had not been already planned. Of course, the previous Government had plans in place for it. However, I believe that its progress illustrates that in these times when people are growing increasingly fatalistic and despairing of Government, times are changing and things are improving. Perhaps they are not improving as quickly as we would like, but they are improving. It takes time to turn the ship about but there have been improvements in our health service and I welcome them. I also commend the Technical group on this motion.

I welcome the opportunity to speak on this motion and congratulate Deputy O'Sullivan, her staff and the Members of the Technical group for proposing this motion. Like Deputy McNamara, I was pleased to discover no amendment was tabled by the Government. It is good that we have left behind the back and forth politics this evening that can sometimes dominate Private Members' time and that we can instead focus on the issue being discussed.

As mentioned by previous speakers, strokes affect thousands of people in Ireland every year. Strokes can vary from a mild attack from which people can make a full recovery to debilitating attacks which leave them with a much reduced standard of life. While 10,000 people a year will suffer a stroke and face the consequences, family members and close friends will also have to provide care and support for those who have been affected. In Meath alone, there are three different supports groups, including one in Dunboyne, where people can come together over tea and a biscuit to talk to one another about how they are doing and their recuperation. These types of groups are incredibly important to the well-being of those who attend them.

I congratulate the Irish Heart Foundation for supporting these groups. I also congratulate the foundation for its great work on the Act FAST campaign. As the Minister noted in his speech last night, studies have shown that for every €1 we spend on prevention we can save up to €20 on treatment. The Act FAST campaign has been proven to increase the number of preventative procedures that reduce the more serious effects of a stroke. A study carried out in Sligo General Hospital showed that in the first nine months of the campaign, the percentage of stroke patients who received a potentially life-saving clot-busting treatment almost quadrupled, from 3% to 11%. This is an excellent result for the campaign and for preventative medicine in Ireland.

The Minister made it clear in his speech that the continued roll-out of the national stroke programme is a priority for him and the Department. The purpose of the national stroke programme is to reduce the mortality rate and level of disability after a person suffers a stroke. Towards the middle of this year, 94% of stroke patients will have access to stroke care when the two remaining national acute stroke units open. These stroke units are associated with a reduction in the numbers who die due to stroke and a reduction of approximately 20% in the number of those who need institutional care post stroke. This translates into one additional patient returned to community living for every 20 patients treated. These are positive statistics for people who suffered a stroke.

I note from the HSE Dublin north east service plan for 2012, which I received today, that its plans for stroke care for all patients in its catchment area include many measures, including a register of 80% of stroke victims, and acute stroke units established in five sites across the north east operating to standard. Dedicated stroke units are incredibly important to the recovery of stroke victims, as has been seen across the country by patients and their families. I will press the HSE to ensure that these units operate up to standard for the people of the north east.

I do not need to remind the Minister of the potential role primary programmes for chronic diseases can play and I welcome this opportunity to highlight some of the significant gains and savings on expensive hospital treatments that have been made by addressing some of the deficiencies in stroke services. The inadequate acute services meant the time and place where a person had a stroke largely determined their chance of survival. The HSE and the Minister's Department are to be commended for delivering improvements in acute stroke services across the country.

I will focus on the quality of life of stroke patients once the hospital stay has come to an end. Research carried out for the Irish Heart Foundation by the ESRI shows that the direct costs of stroke in Ireland are up to €557 million per year, with as much as €414 million spent on institutional care and less than €7 million spent on community rehabilitation services that could, in the long term, keep a large number of people out of nursing homes. As has been noted by previous speakers, stroke is the single biggest cause of severe disability, and approximately 50,000 people in communities are now living with disabilities resulting from a stroke.

Gross deficiencies in community rehabilitation face stroke survivors after the completion of hospital treatment. Increased availability of services in the community, especially physiotherapy, speech and language therapy, occupational therapy, nutrition advice and emotional support and psychology, would go a long way in assisting the recovery of somebody who suffers a stroke. As it stands, an average of less than €140 is spent on the rehabilitation of a stroke survivor, which will not go far in assisting a person with a weakness down one side of their body, who is unable to walk, who suffers depression or who needs daily assistance with basic activities such as tying shoe laces. These people may have cognitive impairment and their quality of life could be severely eroded.

In effect, the system waits until after the time in which the stroke survivors can be helped most before any real money is spent. I urge the Minister to put in place supports to allow a more rounded and holistic approach to stroke patients in community settings. It has been proven in many countries around Europe that this increases the chances of people having a better quality of life. For example, patients affected by stroke should have straightforward and immediate access to information and help with entitlements and available services. This could happen immediately upon discharge from hospital.

The lack of follow-up when a stroke patient goes home is of serious concern to many of us. Ideally, patients and carers should have a central person in an area to contact. That is the process in France but in Ireland a person would contact the HSE, if possible. In various areas and cities central contact people could be used to increase the chances of people coming through a stroke without being too psychologically damaged. This would also help carers, who are invariably members of a family.

On a related note, more must be done to support carers for stroke patients. An estimated one in ten carers is at risk of health problems, and the majority of carers are women. My sister is one. The latest statistics show that many carers are over 65 and a failure to support them can often result in the persons being cared for needing long-term residential care, which is at odds with the stated Government policy of supporting elderly people to live independently in their homes. The Government has cut home support hours, which puts in place considerable difficulties for people trying to access carer's allowance, another significant issue.

In the 2012 service plan the HSE has missed an opportunity to put in place long-held plans for the management of such chronic diseases as stroke in primary care. Instead of an uncosted pledge - as it is in the plan - to develop an overall chronic disease watch model of care, with initial focus in 2012 on the diabetes programme, the HSE should move to a new model of primary care. In this respect I draw the attention of the House to the Heartwatch initiative, the first such programme in general practice, which saw 475 GPs involved and 11,000 patients treated. It is reckoned that approximately 81 deaths were prevented or postponed due to treatment in the first two years of the programme.

The Minister should consider the initiative as it was only ever brought to 20% of the population and was never rolled out nationally. It could be an approach that is GP-supervised but delivered by practice nurses, which would be highly effective. A more comprehensive chronic disease management system in primary care may not necessarily bring about decreased demand on hospital services in 2012 but it is important for the overall health of the population, and it could bring about long-term benefits. That has been proved in major cities in other countries around the world.

There is a clear, logical, cost-effective and, more importantly, a humane case for the provision of rehabilitation services for stroke survivors and others with neurological conditions. With the right care and support, thousands of people could be living independently instead of requiring long-term care. I urge the Minister to publish the neuro-rehabilitation policy and include in it clear details of the funding to be provided for its implementation. I ask the Minister to consider the Heartwatch initiative, which proved to be very successful. Many GPs have asked for the programme to be taken up again. It has a low cost and would save money within a year if it could be rolled out nationally.

We need a fully equipped and staffed stroke unit in every county. There is a significant disparity, unfortunately, in the services and facilities between the west and east coast. I compliment the Minister as the new stroke unit for Tralee is imminent; it will be a valuable facility for the future health services in County Kerry. As we are a peripheral county at a significant disadvantage, with many remote communities and far distances to specialised services, many stroke victims are placed at high risk. There is a disadvantage in this respect in accessing appropriate, quick responses and treatment.

Prompt action and immediate intervention is of paramount importance. The "golden hour" factor is crucial in minimising health damage. There is a big variation in response and treatment due to geographical location. In the eastern half of the country the public has an enormous advantage with respect to survival and minimising the effects felt by stroke victims. People are entitled to the highest standards of quality and service, and they should be dealt with in a timely fashion, so we must strive to achieve that throughout this country.

In the remote area of the Ring of Kerry, at the western end of the Dingle Peninsula, the topography is mountainous and access is not easy to many of the valleys and districts. There is now an immediate need for a dedicated air ambulance service to meet demands of fast response not alone for stroke victims but for all types of emergencies, accidents and incidents where people are traumatised and in urgent need of quick transport for specialised service. I am glad the Minister is here and perhaps he might be able to address the following matter. A proposal that has been made by a charitable organisation, Air Ambulance Ireland, which is based in Kerry, is currently on the Minister's desk. The dedicated people who are involved in this worthy group have done a great deal of planning, thought, organisation and fund-raising. The facility they provide has never been more needed across the countryside and along the coastal terrain in Kerry and elsewhere in the south west. I ask the Minister to proceed with haste in approving the vital service that is provided by this charitable organisation, which has funding in place. We should not forget that as a tourism destination, Kerry receives a huge influx of visitors each year. That is all the more reason the proposed air ambulance service should be provided at an early date.

We need to give people an equal chance to access a quality health service. We have to correct the imbalance that exists in this country at the moment. There are statistics to prove that people on the east coast live longer, enjoy better and more immediate services and are closer to centres of specialisation. I ask the Minister, Deputy Reilly, to address this as a matter of urgency.

There is a need to develop proper post-stroke services and to provide for proper rehabilitation in the community. When patients recover, they want to live independent lives. The system makes many people depend on support services. We need to provide those services to people from the outset and thereby relieve the financial burden they often face. That would enable the victims of stroke to enjoy a good quality of life in their own homes.

Deputy Halligan mentioned that the direct annual cost of stroke in this country is €557 million. Of that figure, some €414 million is spent on nursing home care but just €7 million is spent on rehabilitation services in the community, including various essential therapies and the services provided by public health nurses. The €557 million fund should be loaded differently. We should not wait until people go to nursing homes before we spend this money. It should be used in a more meaningful and better fashion to keep the victims of stroke with their own families and communities, where they are happiest.

Reference has been made to clot-busting thrombolytic drugs, which are most effective when administered promptly. A significant statistic is that lives are 25% less likely to be lost, and patients are more likely to make more rapid recoveries, when that happens. Proper staffing levels are needed in the hospital units where this treatment is provided. There is a requirement for one-to-one nursing to be provided throughout the first 24 hours. This treatment should be rolled out in all our acute hospitals and available in strategic locations throughout the country. Now that these drugs are available, it is estimated that 750 patients' lives will be saved every year and €230 million will be saved over the next decade.

The Irish Heart Foundation, which is a small charity, has drawn my attention to the stroke awareness campaign it has been running in recent times. To date, it has spent €500,000 on the campaign, which has saved approximately 100 lives. Unfortunately, a VAT payment of €115,000 is included in the €500,000 figure. I believe that this money should be reimbursed to the charity in question, which is doing valuable work in the health sector. It should be waived as a VAT measure so that it can be reinvested in services that help these people.

I would like to inform the Minister and the Minister of State that, as I understand it, the same problem is being encountered by the cystic fibrosis unit in Cork University Hospital. VAT is being taken from an organisation that has collected a great deal of money through voluntary fund-raising. Perhaps the Minister and the Minister of State can address this matter in the context of the Finance Bill, with the co-operation of the Minister for Finance.

I am delighted to speak on this motion. I compliment and commend Deputy Catherine Murphy and other Deputies from the Technical Group who have proposed it. Ba mhaith liom comhghairdeas a ghabháil leis an Aire agus an Aire Stáit freisin. I thank the Minister, Deputy Reilly, and the Minister of State, Deputy Kathleen Lynch, for selflessly agreeing to this motion. During my five years as a Member of this House, it has been unusual for a motion of this nature to go unchallenged on the floor of the House. I commend the Minister and the Minister of State on that.

I would like to commend Deputy Ann Phelan, who spoke from her heart about her experiences. From the bottom of my heart, I thank her for telling her story in such a humane manner and expressing it so well. No words of mine could follow what she said. One needs to have lived through something like that to understand it.

My attitude to these matters is that prevention of any chronic disease is better than cure. We are talking specifically about stroke in the context of a document that has been produced by the Irish Heart Foundation. Prevention is vital. Our economic disaster should have been prevented because the Financial Regulator and the Central Bank were supposed to be overseeing the financial sector. We are now in this crisis because they failed to do so. That is having a detrimental impact on our health services. I will not make light of this serious issue by speaking further about our economic woes.

The point I am making is that prevention is always 1,000 times easier, safer and healthier than cure. It is better for patients and for the system. When I listened to "The John Murray Show" on RTE radio recently, I heard Professor Niall Moyna speaking about something he is trying to get implemented in schools. I knew Professor Moyna, who is a very experienced intellectual, many years ago. Huge problems like obesity are being caused by a lack of exercise and lifestyle changes. Less than 100 years ago - in some areas, less than 40 years ago - people used to walk or cycle to school. That is no longer possible in many country areas because it is not safe any more.

Lack of exercise is also a problem. Many people spend a great deal of time sitting in front of personal computers and televisions. As times change, dietary problems are becoming more prevalent. I understand the Joint Committee on Communications, Natural Resources and Agriculture is grappling with the question of controlling the sheer amount of advertising, which is another aspect of this problem. We have to deal with this in our schools. The Departments of Education and Skills and Health need to engage in joined-up thinking with families and those of us who are parents.

I would like to compliment South Tipperary General Hospital, which is the only unit in the south east that has the new system, as far as I am aware. It is provided in a four-bed unit that has been in place for the past four years. It has the technology that is needed to provide treatment using the new clot-busting drugs. Deputies will be familiar with the excellent work that is carried out there. I have been impressed by the ability of the hospital authorities to engage with the new treatment, as part of the normal daily running of the hospital, and offer it to serious stroke victims.

I am glad the Minister and the Minister of State are here. I want to remind them that South Tipperary General Hospital is under huge pressure. I am sure they are aware of the state-of-the-art assessment unit in St. Patrick's Hospital in Cashel, which would be nothing without its staff, including the excellent matron. I want to mention everyone from the cleaners to the therapists. The same is true of South Tipperary General Hospital. We get a lot of knocks and hear a lot of bad things. I am keen to mention some of the good things that happen. We have to thank and praise those who are responsible for them.

We are aware that stroke therapy in the community is a dismal failure. The previous speaker said that €557 million has been invested, but just a small percentage of that - €7 million - has been used to provide these services in the community.

I am glad the Minister of State, Deputy Kathleen Lynch, is here. We are having a huge battle with her at the moment about the loss of psychiatric services in Clonmel. The Minister of State and her officials are adamant that it is better to move towards a community-based system. The mental health system receives a minor fraction of the HSE's overall funding. It is given the crumbs. The Minister of State and the Minister, Deputy Reilly, could transfer funds into community services and provide for easier access to those services to ensure that when the unfortunate victims of stroke are released from hospital, they receive after-care, are able to access services and are not frustrated. This should be done hand in hand with the psychiatric services.

One is released from prison and discharged from hospital.

If the Minister wants to be smart, that is fine. However, rather than being smart, I am trying to be humane about this issue. We have accepted the amendment. Just because the Minister of State had to withdraw horrible terminology she used when speaking to people in south Tipperary, she should not try to denigrate me for something I said.

I ask the Deputy to return to the discussion of the motion.

I would like to do so. The Minister of State has shown what interest she has in people.

All she did was ask the Deputy to be careful in the language he uses. This is a serious issue.

Of course it is a serious issue. I did not interrupt the Minister of State. While I may have used the wrong terminology-----

The Deputy should be careful in the language he uses.

I do not need a lecture from Deputy Hannigan or anyone else across the floor. If they want to get into the issue of terminology, we can do so. I am trying to speak to the motion. I admitted I do not have anything like the experience of one of Deputy Hannigan's colleagues who has suffered a stroke and spoke eloquently in the debate. I offered three minutes of my time, as the Leas-Cheann Comhairle will confirm, to allow her to continue her contribution because she knows much more about the issue than I do. I am not being high and mighty; I can make mistakes as well as anyone.

Money is not being invested where it should be invested. Every day, I encounter families who cannot get access to speech therapists and people who turn up for an appointment to find it has been cancelled without warning. This problem with the administration of the system causes serious frustration.

To return to ambulance services and the importance of the golden hour, this issue is relevant in the case of my local hospital. The Minister brought a group of us to see services at Wexford General Hospital. I am informed that ambulances at the hospital are so busy transferring psychotic patients to Waterford Regional Hospital that they are not always available to ferry to hospital people who have had a stroke or have been involved in road traffic accidents and so forth. We cannot put the cart before the horse. While we need careful scrutiny and a shift of emphasis, an appropriate level of services must first be in place.

I commend the Irish Heart Foundation and similar organisations working in the health service from the bottom of my heart. As other speakers noted, it is a disgrace - this applies also to previous Governments - that VAT is charged on vital, life-saving equipment for which many organisations raise funds while working for the good of the community. Imposing VAT on such aids and appliances is anathema and an insult to volunteers.

It needs to be registered that we are discussing thousands of unavoidable deaths and thousands of people who could escape lives of unnecessary disability and dependency if we invested adequately in suitable stroke services. This, of itself, is of major significance. As previous speakers noted, 10,000 people will suffer a stroke this year and the condition is the third biggest killer in society.

While the fact that the House is discussing stroke is significant, I do not agree with Deputies who consider this to be some new departure and believe we are all on the same side. The Government tabled an amendment to water down the motion and secure agreement. We cannot separate health and well-being from overall economic policies and the poverty many people are experiencing and hollow slogans from Government Deputies will not change that fact.

We must not consider this issue in isolation. There is no point having best practice in stroke care if the rest of the health service is falling apart. A stroke victim who recovers and feels great may be subsequently admitted to hospital to have a baby or have a broken leg treated only to find the health service is in bits and underfunded and proper treatment is not available. This discussion is taking place in the context of cuts in the health service budget amounting to €2.5 billion over three years, most of which will be directed at primary and community care.

A policy for dealing with strokes is in place, medical knowledge of strokes is available and we know what needs to be done. While I welcome the increase in the number of stroke units and efforts to promote healthy lifestyles, the question arises as to what happens to stroke victims when they leave hospital or a dedicated stroke unit. We want them either to go home or to move to a nursing home for care. The Government is butchering care provided in both these settings. We cannot ignore the fact that it has slashed home help services and the assistance provided to people in their homes. This year, Government cutbacks will result in the number of people who access home help services falling to 5,000 below the 2008 figure and underfunding will lead to a reduction of 2 million home help hours. How will this help stroke victims recover in their homes? Other Deputies highlighted cuts in the carer's allowance. This issue must be also addressed if we want people to live independently in their own homes. The Government cannot square this circle.

People are enabled to return home by the services provided by a range of health professionals such as physiotherapists, speech therapists, occupational therapists and dieticians. Many stroke victims require modifications to their homes to accommodate and support new needs they may have acquired as a result of a stroke. As Deputies are aware, occupational therapy services are in crisis. In many areas, they are not available meaning the modifications stroke victims and others need in their homes are not carried out and they are unable to return home. If a person who has had a stroke manages to have an occupational therapist write a report, the local authority will inform him or her it has run out of money and cannot grant aid improvements in the house to enable him or her to return home. The Minister will be aware of such cases in his constituency and county. This failure causes people to stay in hospital, with all the effects this has on their quality of life, and creates a major drain on hospital resources.

The other option is to provide nursing home care to allow stroke victims to recuperate before returning home. As the motion points out, one in six nursing home residents is a stroke victim. Against that backdrop, how can the Minister argue that he wants to assist stroke victims while at the same time pursuing a policy of closing community nursing homes? This afternoon, I attended an excellent presentation by residents of St. Joseph's community nursing home in Ardee and their family members. As with residents of Crooksling nursing home in Brittas and other nursing homes, the residents provided graphic examples to demonstrate that supporting community based nursing homes is the most economical and efficient option from the Government's point of view. This type of care enables people to obtain good quality care.

As I have noted previously, one cannot compare the private sector with the public sector because private nursing homes do not have standards and public nursing homes have higher quality health care workers.

That is a scurrilous statement. The Deputy should not insult workers.

There are no standards in place in private nursing homes in respect of minimum staffing levels. Private nursing homes also engage in cherry-picking, as all Deputies are aware. The reality is that Government resources are transferred from the public sector into funding private nursing homes that will not accept high dependence patients. It is a fact that hospitals such as Tallaght Hospital have patients blocking beds at a cost of thousands. These beds could be released if the patients in question were allowed to move to Crooksling nursing home. The Minister has taken a contradictory approach by stating he wants to support stroke victims and enable them to live independently and secure care while standing over cutbacks and waste arising from other policies being pursued by his Department.

It is good that we are discussing this issue and I compliment my colleagues in the Technical Group on having this issue, above all others, highlighted in Private Members' time. This will not be enough unless the Department delivers by stopping the butchery of community services and primary care in which it is engaged. The Government must pursue policies that allow people to return home healthy.

I compliment the Technical Group on the debates it has initiated in recent months. It has used Private Members' time to great effect.

Language is very important. As someone who spent a good deal of my life promoting women, I know how effective, damaging or undermining language can be. That anyone believes there are no standards in private nursing homes is quite astonishing. Private nursing homes are inspected in the same way as public nursing homes so they meet particular standards and the quality of care is the same, despite what the Deputy believes. In some areas, people have higher needs but the standard of care is the same and we should be careful how we say things because people listening will be worried about their loved ones.

I am pleased to have the opportunity to make a concluding statement on the subject of stroke rehabilitation services for stroke survivors and persons with neurological conditions. The debate has centred on what can be done to prevent stroke, rightly so. I thank Members for their helpful contributions on the burden of stroke and the measures to prevent disability from stroke and other neurological conditions. The 2010 cardiovascular health policy established for the first time a framework for the prevention, protection and treatment of cardiovascular diseases, including stroke. The work has been taken forward by the national stroke programme to help lead and co-ordinate the development of stroke services in Ireland. This arose from the Irish Heart Foundation, which should be complimented. I was astonished when a neighbour of mine, a young man, had a stroke a few months ago. The symptoms were recognised very early by his 12 year old son. We asked the son how he knew and he replied that he had seen the Act FAST advertisements on television. Subconsciously, it is sinking in. An early priority was the development of acute stroke services, illustrated by the increase in stroke units from one in 2006 to 26 in 2011. An additional two will open in early 2012. This means that over nine in ten stroke patients will have access to stroke unit care. The HSE has also provided additional therapy and nursing posts with specific responsibility for strokes. This will enhance rehabilitation services and help to reduce the burden of the condition.

A number of specific issues were raised in the debate, which I would like to address. Several Deputies referred to the work of the Irish Heart Foundation. A revenue stream is provided by the HSE to the Irish Heart Foundation and the current provision of services in the National Rehabilitation Hospital will be reviewed with the hospital to identify ways of managing the needs presenting to the hospital in the most efficient way. Recruitment to fill posts for the stroke unit at Cavan hospital is ongoing and the unit is open. Neurological services in Beaumont Hospital are being further developed by the HSE, with the recruitment of a neurologist later this year and additional staff and beds to support the epilepsy service for the region.

Regarding alcohol, last week the report of the national substance misuse strategy steering group was launched. The report contains a range of measures relating to availability, prevention, treatment, rehabilitation and research. The recommendations of the steering group on alcohol will encourage public debate and I envisage an action plan being developed in advance of proposals being drafted for the Government.

I am pleased that smoking has been raised in this debate, as it is a major risk factor for stroke. Ireland has a good reputation on tobacco control legislation. However, we must continue to build on the work done in order to tackle the problem, which results in approximately 5,200 deaths every year. A tobacco policy review is currently under way and will cover areas such as smoking in cars in the presence of children and improving the quality and effectiveness of our smoking cessation services. It is essential that we de-normalise smoking and I anticipate that the report of the tobacco review group will go some way to assisting us in this regard.

During 2012, the Minister for Health established a special action group on obesity. The group is broadly representative and is concentrating on a range of measures, including healthy eating guidelines for the Irish population, calorie posting in restaurants, nutritional labelling, the promotion of physical activity and the detection and treatment of obesity. The group will work with other Departments on a cross-sectoral basis to help halt the rise in overweight people and obesity.

I had the pleasure to publish the national policy and strategy for the provision of neurological rehabilitation services in December. I welcome the publication and I realise the actions recommended will provide real challenges, especially in our current financial landscape of resource constraints. I note the commitment of the HSE and service providers to the implementation process. We can achieve improved rehabilitation services for those with a neurological injury or illness or a significant physical disability. The strategy is focused on the specific needs of those with neurological illness or injury, outside of stroke. Five of the more common neurological conditions were selected for detailed review and analysis. The five conditions were acquired brain injury, cerebral palsy, multiple sclerosis, idiopathic Parkinson's disease and spinal cord injury. The challenge is to ensure provision is appropriate to each individual and the structure supports this provision and an appropriate governance framework is in place. We have the policy strategy, now we need an implementation plan and I look forward to receiving it from the HSE. There is cross-sectoral commitment to continue to improve services for stroke survivors and those with neurological conditions. Such commitments can only help to ensure the burden of stroke and other conditions is minimised for patients and their families. As mentioned by Deputy Halligan, having primary care teams fully fleshed out in the community can only help this area.

I thank the Leas-Cheann Comhairle for this opportunity to speak to this important motion on health and, in particular, the report of the Irish Heart Foundation entitled Cost of Stroke in Ireland. This is an important health issue and I commend my Independent colleagues and Members of the Technical Group for tabling this motion. As well as dealing with the issue in a comprehensive way, it offers solutions and I urge the Government to be brave and responsible and act on this matter. It is in the interests of the Irish people and, if implemented, would lead to a better and healthier Ireland in 2012. In Ireland, approximately 10,000 people per year will suffer a stroke at a cost of over 2,000 lives annually, making stroke Ireland's third largest killer. Some 50,000 people in Ireland are living with a disability acquired through stroke and stroke is the biggest cause of acquired disability in Ireland. The statistics are a wake-up call to us all. The human cost and the financial cost is mind-boggling and reinforces the urgent need for this debate and for action. Action, not talk, is the important factor in this debate. Cutting health services should never be an option.

I commend our health professionals, doctors, nurses, physiotherapists and carers who do an excellent job in the service throughout the State. They are doing a great job with difficult problems and the last thing they want to do is look over their shoulders about the funding issue. I urge the Government to consider this issue. I also commend the work of the National Rehabilitation Hospital. For many years, we have had constituents asking us to make representations to get them a place in it and many of us have had to kick, shout and scream to get people in there. That is unacceptable for families. Some 50,000 people acquire a disability because of stroke and this is an important aspect of the debate.

As I am speaking about disabilities, I condemn, criticise and disagree with the recent remarks of Dr. Tony Humphreys about autism. It was an outrageous attack on families of children and adults with autism and on the disability community. I speak as the parent of a daughter with a disability, although it is Down's syndrome rather than autism. Many other families feel for the parents of autistic kids and I strongly agree with the Minister's remarks in the national media during the week. It is unacceptable for somebody like Dr. Tony Humphreys to call himself a doctor and make outrageous statements. It is unacceptable to us as parents of children and adults with disabilities to insult families in such a way.

On a positive note, I urge the Minister to develop services for motor neurone disease. A lot of good work is going on in Beaumont Hospital but we need to support it in terms of funding. A recent programme on RTE featured the great Colm Murray from Clontarf. He did an excellent job in highlighting the issue and his plight. I had the honour and privilege of meeting him recently. I commend RTE for broadcasting the film. It was an excellent example of public broadcasting which showed the reality of the disease and the people who are brave and dignified in how they deal with it.

Another issue in terms of strokes is linked to mental health. A lot of depression is associated with people who have strokes. This is an issue which is linked to other long-term illnesses. We have to face up to the reality that a lot of people in our society have personal problems. I accept there has been a significant increase in the number of stroke units over the past two years and the Government has committed to ensure over 90% of all admitting hospitals will have effective stroke units in the first half of this year.

I am also aware of the ongoing development of the Department of Health well-being policy to tackle the risk factors for cardiovascular and chronic conditions. I hope the Government is strongly committed to front-loading investment in stroke prevention and rehabilitation services to improve the quality of life of those affected by stroke. A significant by-product would be to address the situation whereby €414 million of the €557 million in annual Exchequer spending on strokes goes toward nursing home care for one in six nursing home patients who are survivors of strokes.

I call on the Government to develop the implementation plan, based on the recommendations of the national policy and strategy for the provision of neuro rehabilitation services in spite of the difficult financial position in which we find ourselves. That is the way forward and Independent Members of the Dáil will strongly support the efforts to support patients and citizens. We have to change the mindset, policy and vision in order to act to deliver a quality health service.

The Taoiseach mentioned Cuba in a derogatory way and I strongly disagree with him. It has an excellent health service and if one goes to hospital in Havana, where I have been, one will not see people on trolleys. There is a lesson to be learned. I urge the Minister to develop the recommendations of the national policy and continue to develop a multidisciplinary rehabilitation network to include teams throughout the country which would provide special support to stroke survivors and persons with neurological conditions.

While this motion considers the health care issues associated with stroke, there are of course wider issues, some of which have been addressed during the debate. Some of these relate to lifestyle choices which generally lead to better health outcomes. Many of these need to be considered in the context of health promotion initiatives. More exercise, a better diet and reduced alcohol consumption will play a part, but the really big change would be a reduction in the number of people who smoke.

In their joint pre-budget submission in 2010, the Irish Cancer Society and the Irish Heart Foundation stated that there are 1 million smokers in Ireland and half of all smokers will die prematurely, which is shocking. In addition to cancer, people who smoke have a threefold risk of heart attack compared to non-smokers and smokers are twice as likely as non-smokers to have a stroke. Tobacco kills more people in Ireland than road accidents, suicides, drugs, farm accidents and AIDS put together.

We have seen the results from the investment in the Road Safety Authority. We need an ongoing and consistent approach to assist smokers to give up. It is in their and all our interests. We cannot wait for better times. That health promotional message needs to go out all the time. My father died of lung cancer. It is a horrible death where patients can be left gasping for even a tiny breath for months on end. It is distressing and one would be convinced never to take up smoking if one saw one person die like that.

In its stroke manifesto the Irish Heart Foundation found up to 50% of strokes are preventable. That means 5,000 strokes and 1,000 deaths could be avoided if people took simple steps to cut down the risk. If we are to get more from less in our health service, the focus on prevention is essential when funds are so limited. Strategic investment in dedicated services such as stroke units makes good medical, economic and social sense.

Limiting the number of deaths and reducing long-term dependence makes sense for more than economic reasons. According to the Irish Heart Foundation, fewer than 3% of stroke patients received the life-saving clot buster treatment, thrombolysis, in the 12 months to April 2010. There has been an improvement since then. In its 2010 document the foundation told us almost half of our acute hospitals cannot provide the treatment and many that do can only provide the drug during office hours or on an intermittent basis. Unfortunately strokes do not confine themselves to office hours. We need to have a comprehensive response.

Is it any wonder that we spend €441 million of the total €557 million spent on nursing home care dealing with strokes? The full cost is much higher, including the loss of independence for so many and a lowering of the quality of life. Changes in family and personal economic circumstances are all components of the true cost. It is scary to read in the stroke manifesto that most people do not know immediate medical treatment after a stroke can make a difference in terms of recovery, death or permanent dependency. It is clear this serious information deficit is dangerous and expensive. We cannot wait for the good times to come back to deal with it. Investment in health promotion has to happen.

One point which jumped out at me was the lopsided and patchy nature of our acute rehabilitation service. It does not surprise me and it is not exclusive to rehabilitation. A good outcome cannot depend on one's address. For many the sense of loss that follows a stroke leads not only to a loss of independence but also spells of depression. That is very understandable.

The Irish Heart Foundation said the average stroke destroys 2 million brain cells every minute. Trained ambulance staff, telemedicine support and properly equipped ambulances and emergency departments are crucial for the prompt treatment of stroke patients. The term "plan" has been absent from how we do things in this country and that needs to change.

We also need to better understand the process of how people become disabled. One of the many excellent reports that have been compiled on behalf of the Joseph Rowntree Foundation deals with this. It is based in the UK but it does some work in Ireland. It found the majority of disabled people who experience the onset of health problems or impairment do so during adulthood.

It should come as no real surprise that income inequality also contributes towards the level of ill health, including stroke. People in the poorest fifth of the income distribution are 2.5 times more likely to become disabled than those in the top fifth. We have to examine the issue not just from a medical point of view but in terms of the totality of policy responses and initiatives taken.

A person becoming disabled also affects other members of the household. In single earner couples, even when the earner does not become disabled one in five leaves employment, in some cases to take up new caring responsibilities. While the focus of this motion is on the health aspects of stroke and the kind of rehabilitation services that should be available we need to think beyond that.

The effect on employment, particularly those of working age, is an issue.

Employment status varies widely depending on the severity of the impairment, according to studies by the Joseph Rowntree Foundation. Of those with the least complex impairments, 84% retained their employment. I do not know how that compares to this country; I feel they may be doing better than us because of better distribution.

I must ask the Deputy to conclude.

I will wrap up, although I have a lot of material that I will have to keep for another debate. We must, however, seek to retain people with disabilities at work.

There is good news about the medicines that are now available but that applies only if people turn up at hospital so they can be properly administered, if the rehabilitation services are available and if we have a good distribution service so the patient can receive what he needs when he needs it.

This agreed motion did not see us competing with each other and will not make the six o'clock news but we in the Technical Group think it was worthwhile that we debated the issue. It is a matter of concern to us both now and in the future.

Motion agreed to.
The Dáil adjourned at 9.05 p.m. until 10.30 a.m. on Thursday, 16 November 2012.