Joint Committee on Health debate -
Wednesday, 16 Jun 2021

Cardiovascular Health Policy: Discussion

Vice Chairman

The purpose of this meeting is a discussion on cardiovascular health policy in Ireland with Mr. Tim Collins, chief executive officer, CEO; Ms Kathryn Walsh, policy manager; and Mr. Chris Macey, head of advocacy, Irish Heart Foundation, IHF; and Mr. Neil Johnson, CEO, and Ms Irene Gibson, director of programmes and innovation, Croí, which incorporates the West of Ireland Cardiac Foundation and the National Institute for Prevention and Cardiovascular Health, NIPC.

Before I ask our guests to deliver their opening statements, I need to point out to them that there is uncertainty as to whether parliamentary privilege will apply to evidence that is given from a location outside the parliamentary precincts of Leinster House. Therefore, if they are directed by me to cease giving evidence on a particular matter, they must respect that direction.

I now invite Mr. Collins to make his opening statement.

Mr. Tim Collins

I thank the committee for the invitation to meet with it this morning. I accompanied by Mr. Chris Macey and Ms Kathryn Walsh, whom all members know.

Almost 9,000 people die here annually from heart disease and stroke. Given that 80% of cardiovascular disease is preventable, all but approximately 1,800 of these lives could be saved if the right evidence-based policies were put in place. The financial cost of doing so would be far from prohibitive. Much larger amounts of another currency are required to tackle this grim toll of death and misery, that is, political will. We need more political will to address the factors fuelling preventable cardiovascular disease, including overweight and obesity, uncontrolled blood pressure, smoking, physical inactivity, excess alcohol intake and air pollution. Strong action on these issues, along with cost-effective measures to remove chronic deficits in heart and stroke services, will impact innumerable lives in every corner of the country.

Today, we ask the committee to work with us on what we can do right now within the realms of budgetary constraints to save lives that should not be lost and to create a healthier Ireland. In addition to unnecessary deaths, approximately 2 million people are at risk, or living with, the long-term effects of heart disease and stroke. No family is left untouched and we are not doing enough to help them. Better treatments, public health measures and awareness campaigns drove down the burden of heart disease and stroke in the previous generation, but the curve is turning due to a combination of an ageing population and the impact of lifestyle factors.

What can we do now to make a difference? It may sound extraordinary that for the world's biggest killer disease, the first thing we need is a plan. The previous national cardiovascular strategy expired two years ago. Not only has it not been replaced, it was never evaluated. This is even more galling given how neatly a good cardiovascular policy would dovetail with the objectives of Sláintecare. A national cardiac services review has been mothballed by Covid and a stroke strategy focusing on acute services, but we have no overarching framework and no intention currently to create one. This, we believe, is a recipe for failure, with services reliant on piecemeal strategies and HSE firefighting, no long-term planning and, therefore, much-reduced prospects of funding, regardless of patient need, all against a background where services decimated by the pandemic and subsequent cyberattack desperately need to recover.

Cardiac services face many severe challenges due to Covid, on top of significant historical service deficits. Chronic heart disease patients comprise 44% of Covid deaths and 49% of related ICU admissions in Ireland, while the future impact of reductions in heart attack admissions, which peaked at 80%, remains unknown. In the absence of a national cardiac register, real-time data is hard to establish. We know from cardiologists that outpatient waiting times for new cases were as high as 14 months and have deteriorated further. Echocardiogram waiting times that were seven months are now 12 months in some hospitals and waiting lists for angiograms can be more than a year depending where a person is treated. Cardiologists also report that their patients are generally sicker due to cancelled clinics and reduced GP access. In this information twilight, it is not possible to estimate the impact of Covid-related service deficits on death and disability.

We have accurate information on the impact on cardiac rehabilitation from our own national survey and the picture is grim. Evidence shows this service can reduce cardiac mortality by 31%, but 77% of centres closed during the pandemic and 69% had services fully suspended for 12 weeks, the longest for 35 weeks. Even before Covid, services were in crisis with a national waiting list of 2,818, seven centres having a four- to six-month waiting list; seven, more than six months, and three, more than a year.

Stroke services also face a bleak outlook. It is estimated that stroke incidence will increase by 60% in a decade, from approximately 7,500 to 12,000 per annum. Almost four years after the commitment was made to our first national stroke strategy, it remains unpublished. Meanwhile, the window of opportunity to future-proof stroke services, preventing a devastating spillover of cases affecting all emergency services gets ever smaller. The stroke strategy addresses acute service deficits, but it contains no measures to aid the recovery of stroke survivors living in the community. Nothing typifies the neglect of post-discharge services more starkly than the failure to establish how many stroke survivors we have. The estimate used by the HSE and Department of Health of 30,000 is based on an estimate that is almost a quarter of a century old. Institute of Public Health research and extrapolations from UK statistics suggest the real figure is approximately 90,000.

Other aspects of cardiovascular health have also been grievously harmed by Covid. There is evidence of significant weight gain and lower physical activity levels among children and adults and already shocking rates of high blood pressure are getting worse. Surveys suggest people are smoking and drinking more and that the most damaging forms of air pollution to people's health have increased.

What steps can we take now? Given time restrictions, I refer members to our accompanying submission for a fuller explanation, but I particularly highlight the need for a new cardiovascular health policy underpinned by a national cardiac register to provide an evidence-based framework for service recovery and development and urgent implementation of the stroke strategy, with additional measures to support recovery in the community. We also must address the causes of cardiovascular disease rather than just its aftermath. Being overweight and obesity is the biggest threat to the health of our children. Similar to tobacco with the previous generation, we cannot tackle this scourge without first loosening the grip of advertising and require an outright ban on junk food marketing, at the very least to under 18s, in the promised public health obesity Bill. Almost 6,000 people die here annually from smoking. We need increased momentum in the tobacco-free Ireland policy. Teen smoking rates are increasing for the first time in decades amid an explosion in vaping that we know is a gateway to smoking.

This should be addressed in new legislation, including a full ban on e-cigarette advertising and child-friendly flavours. High blood pressure is the biggest cause of cardiovascular disease but we have among the lowest rates of awareness and treatment of it in the developed world. About two thirds of over-50s are affected. A comprehensive plan is required, starting with a rolling national awareness campaign, which would have huge impact at minimal cost. Air pollution costs 1,500 lives here every year, mainly due to heart disease and stroke, yet clean air continues to be addressed from a largely environmental standpoint. We urge the committee to take a lead on addressing this issue through a health lens and a thorough investigation of the actions that may save many lives.

It was always assumed that Covid would end and the world would return to normal, but we are now realising we have to learn to live with this virus. We therefore have to tackle the drivers of Covid-related deaths and hospitalisations, including obesity, smoking, high blood pressure and air pollution, in addition to health service recovery, particularly treatment of chronic heart disease responsible for half of the most serious Covid cases. We therefore ask the committee to support strong action combining a package of preventive measures with improved service planning and development. Doing this would also have a huge impact on preventable death and chronic disease rates generally and, ultimately, help to secure the future of our health services.

Vice Chairman

Thank you very much, Mr. Collins, for your comprehensive opening statement. Mr. Johnson, you have an opening statement as well. We will take it now.

Mr. Neil Johnson

I thank the committee for the invitation to address it. I represent Croí, the west of Ireland heart and stroke foundation, and the NIPC. Croí is a charity which was established in 1984 to lead the fight against heart disease and stroke in the west. The NIPC was established in 2014 and is an independent medical research and education institute committed to driving the cardiovascular disease prevention agenda in Ireland. In the context of a cardiovascular health policy, we wish to highlight some key challenges for Ireland, to outline some unmet needs and to make some specific asks of members as guardians of our health service.

Despite the enormity of the Covid pandemic, we must not be distracted from the fact that cardiovascular disease remains the biggest cause of death globally and in Ireland. The burden of this disease is enormous and growing, driven in particular by the increase in diabetes and obesity. Covid-19 has added an additional burden. Thousands of our patients have had their heart procedures and hospital appointments cancelled or postponed. Consider those who could not get to see their doctor, those who delayed or avoided seeking help and who are now living with the consequences, those with long Covid cardiac complications and together we have a tsunami of post-Covid cardiovascular disease burden coming down the tracks. From a policy perspective, this burden requires urgent attention if our health system is to cope.

Against this background, we live in the absence of a formal national cardiovascular health strategy. As already mentioned, the last strategy expired in 2019. We urgently need a comprehensive strategy to tackle classical cardiovascular disease, that is, cardiovascular disease caused by atherosclerotic disease, or ASCVD, whereby lifestyle and behaviour factors such as high cholesterol, smoking, diet, lack of exercise, etc., are largely preventable risk factors.

We also need to tackle age-related heart conditions, which are primarily a function of vascular ageing. The development of a strategy needs to embrace the views and needs of all stakeholders across the continuum of care, and the patient perspective is central to that. Chronic diseases, of which heart disease is a major contributor, place the greatest demands on our health system, largely presented in the third age, that phase of life from 60 years onwards. Global and national age demographics predict a growing aged population in the coming years. We are living longer, but we are not adequately focused on reducing the consequential health burden. We need a specific third age strategy for early detection, early diagnosis and early treatment of age-related heart conditions such as hypertension, atrial fibrillation, heart failure and heart valve disease. All these age-related conditions, which can be life-threatening and cause chronic disability, could be detected by annual low-cost diagnostic tests, for example: taking a simple blood pressure measure for hypertension, a major cause of heart attack and stroke; checking a pulse for atrial fibrillation, the major cause of devastating stroke; a blood test, proBNP, as a marker for heart failure; or a simple stethoscope examination, which can detect a heart murmur indicative of heart valve disease. Croí recently launched a pilot third age programme in County Mayo supported by HSE West and Mayo County Council and we look forward to publishing the outcomes of this shortly.

What has been and remains significantly absent from our national approach to cardiovascular disease is a serious commitment to prevention. We urgently need a dedicated national cardiovascular disease prevention strategy. In parallel but equally important to the development of acute care and interventional cardiology, we need to advance preventive healthcare and the science of behaviour change. The NIPC has commenced the development of a national White Paper in this regard and, when it is completed, we would welcome the opportunity to present it to the committee. In Ireland what little focus there is currently on prevention from a strategy perspective is on secondary prevention, primarily cardiac rehabilitation for those who have had an event. However, despite the overwhelming evidence of the benefits and importance of cardiac rehabilitation, we have neither agreed nor adopted a national standardised model of care. Equally, a crucially important area of need is primary prevention, where the focus should be on those at highest risk. These are typically individuals without any symptoms but whose cardiovascular disease risk profile puts them at a high risk of a heart attack or stroke. At the Croí Heart and Stroke Centre in Galway we have just completed a very successful demonstration of an effective community-based intervention programme called MySláinte. The development of this evidence-based programme was supported by innovation funding through Sláintecare and it has delivered compelling evidence on the effectiveness and benefits of a multidisciplinary, nurse prescriber-led prevention and rehabilitation programme for high-risk individuals. It was set up during the Covid pandemic as a completely virtual programme and was the only one of its kind in Ireland. In the context of challenges, we wish to impress on the committee the growing burden of disease our citizens face, exacerbated by Covid. Ireland now needs unprecedented policy action to reduce premature death and disability, with its associated enormous economic costs.

As for our calls to the committee, we seek its support as follows. We urgently need a radical national cardiovascular health strategy which can tackle the human and economic burden of the disease. Unlike the previous strategies, we need equal focus on prevention and acute care, and the development of a strategy must involve patients as key stakeholders. We need a strategy which will respond to the burden of atherosclerotic disease. ASCVD is the umbrella term for heart conditions caused by fatty build-up in the lining of the artery wall, the major cause of heart attack and stroke. High cholesterol plays a big part in ASCVD. One cause of high cholesterol has its origins in a genetic condition known as familial hypercholesterolemia, FH. Approximately one in 500 Irish people has this condition and they regrettably remain undiagnosed until they experience a cardiac event, usually before the age of 40, which is very often fatal. If someone has FH, there is a 50-50 chance that a parent or sibling has it. In Ireland this lethal condition remains underdiagnosed and undertreated because we do not have a strategy on screening, detection, referral, specialist care or treatment. The absence of a national strategy on FH is allowing our citizens to die prematurely from an easily detectable and easily treated lethal condition.

We need a strategy which responds equally to the degenerative heart conditions linked to vascular ageing. In particular, we need to address forgotten conditions such as heart valve disease, which is common, serious and treatable. One in eight people over the age of 85 has moderate to severe heart valve disease. The prognosis for untreated severe aortic stenosis is worse than most cancers, yet heart valve disease has not even been mentioned in our previous cardiovascular health strategies. We ask the committee to ensure that, going forward, this treatable condition comes into focus to ensure early and timely diagnosis and treatment. The cost-effectiveness of annual mini cardiac screens, for example, for everyone over the age of 60 might be worth evaluating. We need a strategy which adopts and implements a national model of care for cardiac rehabilitation, supported by the necessary resources to provide comprehensive programmes that are accessible to all. We need a strategy which embeds primary prevention as a central activity in the proposed community hubs, and we strongly recommend the adoption of the Sláintecare-funded Croí MyAction programme as a suitable and scalable model.

In light of recent media attention on the importance of first responder CPR and defibrillation, we call for greater emphasis on bystander CPR training and suggest it be an obligatory part of the senior cycle curriculum in second level schools. The more people trained the greater the likelihood of effective, life-saving CPR in cases of out-of-hospital cardiac arrest.

We also need national policies and guidelines for sports and community organisations with regard to first responder training, defibrillator access and equipment maintenance, etc. Most importantly, we need support for a critical incident and trauma debriefing service. At Croí, we have noticed an increasing demand for this service, as more public access defibrillators have become available.

I thank the committee for this opportunity to address it.

Vice Chairman

I call Senator Kyne and he will be followed by Deputy Lahart.

Senator Seán Kyne

I welcome Mr. Collins and Mr. Johnson to the committee and thank them for their evidence. There is commonality in the statements they have given on the need for an updated cardiovascular disease and stroke strategies. I am sure it is something the committee will take up.

In general, people know what they are supposed to be doing in terms of getting check-ups, eating healthily, taking exercise, not smoking and limiting drinking. Most people are aware of that but putting that into action is a different matter. When we consider the success of the vaccine roll-out for Covid-19 and the fact people volunteered and registered, perhaps we are missing a trick in terms of taking people's blood pressure at the same time, although that would delay appointments. However, there is opportunity through measures such as that to encourage people to lead healthy lives.

Generally, people understand heart attack and stroke but heart failure is a concept many people are not as aware of and maybe it goes under the radar to a degree, but it is a hugely important issue in terms of loss of life and debilitating impact. Perhaps the witnesses would like to comment on the difference in how they would promote that. With regard to the stroke and cardiovascular disease strategies, what practical issues do they envisage in those strategies to encourage people, especially those aged over 60, to get check-ups to monitor their blood pressure, cholesterol and so on?

Mr. Tim Collins

We need to a lot to raise awareness among people about the impact their health behaviours can have on their cardiovascular health and to alert them to the various risks in their health. We concur with Mr. Johnson that we need a comprehensive national prevention strategy. It needs to start with what we call the commercial and social determinants of health. We tend to place significant emphasis in this country on individual responsibility for people's health, whereas we need to start much further back.

There are quite a number of structural issues to do with health inequality and people living in poverty and disadvantage, as well as people being assailed by from all quarters by inappropriate marketing, especially children, in terms of junk food marketing. Until we begin to seriously address many of these commercial determinants of health, we will not make great inputs in terms of impacting on cardiovascular health, just by increasing awareness.

More needs to be done in that area. We need to resource Healthy Ireland more effectively. Its budget this year is €20 million. That is up from approximately €5 million, out of a total health budget of €20 billion, which is, quite plainly, a ridiculous amount to suspend on primary prevention. A hypertension campaign needs to be prioritised. We are in discussions with the Department of Health and Sláintecare about a full-scale national hypertension awareness campaign to encourage people to get their blood pressure checked.

With regard to heart failure, the Senator Kyne is correct. Approximately 90,000 in this country are living with heart failure. They are largely unrecognised and there are few facilities for people living in the community with heart failure, in terms of helping them with self-management. We have a new programme, which we began less than a year ago, supported by the HSE, to help people and to give them the information and support they require to help them to manage their condition. However, it is a significantly under-recognised condition and we need to do much more, both at acute service level and in terms of community support, for people living with the condition.

Mr. Neil Johnson

I will add to what Mr. Collins said and endorse everything he said. With regard to the last comment on heart failure, this is a huge issue and burden, which presents many challenges. One of the big challenges is the diagnosis of heart failure and access to a basic echocardiogram. Reference was made earlier to the waiting time. GPs, who tend to be the first presentation, have a dilemma in that they cannot diagnose the condition if they do not have access to these tests. Access to echocardiograms is an important issue in heart failure.

I will ask my colleague, Ms Gibson, to address behavioural change because she is a specialist in that area. In the context of the overall burden of disease we are describing, there is a bottleneck in that third age when a large proportion of these conditions present. Reference was made to a blood pressure awareness campaign, which is needed, but, equally, there is also a need for a national mini-cardiac screen using some sort of free mechanism through which people can be detected before these conditions become exacerbated. These conditions are easily detected. It is not high science to take a blood pressure, to listen to somebody's heart with a stethoscope or to check a pulse. These simple tests can detect conditions that have an enormous impact on the individual and a significant economic burden on society.

Deputy Seán Kyne

I hear of situations where HSE staff go to marts in rural Ireland to monitor the health of farmers by doing blood tests and so on. Does Mr. Johnson think there could be scope for the HSE to set up a stand at mass gatherings such as football, soccer or rugby matches to do quick blood pressure tests? It may not be as accurate after the match as it would be before it.

HE also mentioned echocardiograms. Would primary care centres be in a position to do them, subject to having the equipment, or is it a specialist requirement in hospitals?

Mr. Neil Johnson

I will let Ms Gibson respond to the Senator on the question of behavioural change and screening. In the context of echocardiograms, one of the biggest challenges right now is the availability of cardiac physiologists, those who conduct these tests. We do not have enough of these in the country.

Ms Irene Gibson

The Senator raised an important point regarding accessibility and supporting people to self-manage their conditions. One of the biggest challenges we have when it comes to prevention of cardiovascular disease is many of the risk factors are silent. Our health system is a reactive system and there are no incentives for people to attend general practice. For the past 20 years or so, much of the Croí's work has been about trying to bring preventative services into the community and reaching hard-to-reach communities, in particular.

There is significant inequality when it comes to accessing services. The highest prevalence of cardiovascular disease is among under-served communities. It is important we look at how we can bring screening services into the community. We know screening in the community works. We have done many projects with the farming community and Traveller and migrant communities, and, without a doubt, early detection makes a huge difference.

It is important we look at universal access to screening services. For many people, unless they have a medical card, they have to pay to go to their GP and have their blood pressure and cholesterol checked. That is a significant problem. I appreciate and acknowledge the great efforts being made in the new GP contract and the management of chronic diseases, such as cardiovascular disease, whereby people over the age of 70 are entitled to two checks per year. However, we need to look at shifting and widening that to the group aged over 40, in particular, when risk significantly increases.

Senator Seán Kyne

May I just ask one more question? I am running out of time.

Vice Chairman

We are just coming up to time.

Senator Seán Kyne

This debate is timely in light of what happened to the Danish footballer, Christian Eriksen, last weekend. We are thankful that he is recovering. Speed, the availability of defibrillators and the fact that this sporting event was being monitored were factors. What more can be done with regard to our front-line paramedics, the old system, particularly in rural communities, involving the Order of Malta and the Red Cross, and the availability of defibrillators? There are State supports but what more can be done? Perhaps Mr. Collins could take that question.

Mr. Tim Collins

There are a couple of simple things we can do. With regard to the availability of defibrillators, we need to give more support to community first responder groups. One very simple thing that could be done would be to allow such groups to claim VAT back on equipment they buy. That would decrease the cost of the equipment to the groups significantly. Approximately 1,800 automated external defibrillators, AEDs, are available to first responder groups around the country. We could probably do with more. We need to fund a cardiopulmonary resuscitation, CPR, programme for schools. In the past four years, we have trained approximately 300,000 children in approximately 70% of schools around the country. We have run out of funding for that. We would like to increase that figure to 100%. We agree with Mr. Johnson that this should be brought in as part of the curriculum.

The final practical thing that could be done would be to ensure that there is enough funding for the National Ambulance Service, NAS, to put in place a registry of defibrillators and an app. The most important thing is that, when a person attends a cardiac arrest and is on the phone to NAS, the service needs to be able to tell the person that there is a defibrillator 100 yd away and that the person should ask someone to get it. We need to know that the defibrillator is properly serviced, that the battery is charged and that the pads have been replaced. Simple things like that will save lives and bring us from a survival rate of 7% or 8% for cardiac arrests in the community to where we should be, which is at least 10% or 12%. That would save 100 or 150 lives.

Vice Chairman

We will move on. I believe I mentioned Deputy Lahart next but I should have said Deputy Cullinane. I apologise.

Deputy David Cullinane

I welcome all of our witnesses. I will put my questions to specific witnesses. I will get to everybody. I am not looking for every witness to answer every question. I will start with Mr. Collins. In his opening statement, he made reference to the previous national plan. It is my understanding that the previous national plan for cardiovascular care ran from 2010 to 2019. Is that correct?

Mr. Tim Collins

Yes, that is correct.

Deputy David Cullinane

There is no new plan. Mr. Collins also said that no evaluation of the previous plan had been carried out by the HSE or the Department.

Mr. Tim Collins

Yes.

Deputy David Cullinane

In his opening statement, Mr. Collins said that this is a recipe for failure. There is an old adage: fail to plan, plan to fail. It is extraordinary that a strategy for a period of almost ten years has not been evaluated. We do not know what has worked from the HSE's perspective or what it might be looking for in a new plan. From what Mr. Collins said, there does not even seem to be an indication as to when we might see the bones of a new strategy or plan. What has the IHF's engagement with the HSE on this matter been like? Has the foundation been given any indication as to when movement on the framing of a new strategy is likely? I assume it has regular contact with the HSE. Has any indication been given as to when discussions on a new strategy might even begin?

Mr. Tim Collins

I might pass over to Ms Walsh, who has been looking into the detail of this issue.

Deputy David Cullinane

Okay, that is perfect.

Ms Kathryn Walsh

I welcome the presentation here today. To go back a bit, any information we have on the previous plan, which ran from 2010 to 2019, we largely got through parliamentary questions. We undertook an exercise in 2017 and 2018 to try to understand the status of the recommendations, particularly as the plan was coming to an end in 2019, but no formal evaluation was planned at that stage. We were told that it would take place in 2019 and that, in deliberations on the national cardiac services review, the status of these recommendations would be revealed. Again, nothing came out of that. In the end, we submitted freedom of information requests to the Department of Health. What we found was that there was no designated responsibility for cardiovascular policy within the Department. We could not find someone to take these freedom of information requests. Eventually, they went to the national patient safety office, NPSO, which had responsibility for the cardiac services review. No evaluation of the recommendations was ever done. As yet, there is no plan to review them, to carry out an evaluation or to put together a new plan. I reiterate that there was nobody with responsibility for cardiovascular policy.

The only thing that is happening in respect of cardiac services is a cardiac services review. This was put on hold as a result of the Covid-19 pandemic and because Professor Philip Nolan is playing an active and important role on the national public health emergency team, NPHET. However, when he took his place there, the process stopped and only recently the post of project manager for the review was advertised. That position was advertised as a 12-month secondment. Outside of the completion of the national cardiac services review, there is no responsibility for cardiovascular policy. I will highlight that the scope and parameters of that review do not cover that full and holistic approach to health that would involve prevention, treatment, care in the community and rehabilitation. It is just looking specifically at the reconfiguration of cardiac services.

Deputy David Cullinane

I might come back in. It is obvious that we need a new strategy. There is a role for the committee in ensuring that is developed. Following this session, we need to write to the HSE to find out what is happening and to put pressure on for a new strategy to be put in place. It is extraordinary that an advocate organisation has to go to the lengths of seeking parliamentary questions and submitting freedom of information requests to evaluate the effect of a strategy that was in place for nearly ten years. It is outrageous that there has been no evaluation of that strategy. That has to be made very clear to the HSE.

It is also extraordinary that there seems to be no lead unit in the HSE or Department when one considers that cardiovascular disease is one of the biggest killers of people in this State. It is just unbelievable that is the case. There is a need for the committee to shine a spotlight on this issue.

I will move to the issue of stroke survivors. I will go back to Mr. Collins in this regard first. He said that the best estimate the HSE has of the number of stroke survivors is 30,000 but that there has not been a comprehensive survey so the figure could be treble that. Is that the reality?

Mr. Tim Collins

Yes.

Deputy David Cullinane

The IHF is calling for the HSE to carry out an audit to establish the true figure.

Mr. Tim Collins

Yes.

Deputy David Cullinane

Here we go again. Again, I find this extraordinary. How, in God's name, are we meant to plan for the needs of stroke survivors if we do not even know how many of them there are? If the HSE has not even conducted an audit and does not have a registry of the number of stroke survivors, how are we going to put in place a plan that provides for their needs? Again, this is something the committee has to take up. It is just outrageous that this is the case.

I will move on to Mr. Johnson on the issue of prevention. He quite rightly outlined that prevention is important. He talked about screening and testing. I myself have been tested, mainly at party Ard-Fheiseanna. The IHF sets up a stall at party Ard-Fheiseanna and similar events and does blood pressure testing. What level of screening and testing is carried out by the HSE in the general population? What more needs to be done?

Mr. Neil Johnson

My understanding is that very little is carried out. There is not a formal strategy for testing. In fact, one can question what tests would be done if, for example, a person was presenting to their GP and what is covered under the GP contract. There is a clear lack of opportunity for some holistic cardiovascular assessment.

It might be a bit of a cliché to say that we refer to the health system or health service, but, actually, it is a sick system. I do not mean that disparagingly. The focus is on treating the sick. What is missing is a preventative healthcare system. That needs to permeate across primary and secondary care. I referred to the idea, which could perhaps be evaluated from a cost-effectiveness point of view, that there would be significant value in carrying out annual mini-cardiac checks on those aged 60 or older, although that might to be too late. I am not talking about comprehensive, heavy diagnostic equipment. Matters such as atrial fibrillation, heart valve disease, heart failure and hypertension can be detected through low-cost intervention. One will not be able to prevent the condition if it has been detected, but if it is caught at the right time, one can halt or slow its progression and thereby reduce the health impact on the individual and the economic impact on society and, potentially, a more active and healthy ageing population with people living longer.

Deputy David Cullinane

I wish to make a final comment. My time is almost up. When there is a review of the existing strategy and consideration is given to framing a new strategy, screening and testing have to be front and centre. It is unacceptable that screening and testing are so minimal. As Mr. Johnson pointed out, it can be low cost and rolled out through general practice. It can also be done in a serial way at mass gatherings, as was stated. There are obvious opportunities there and that has to be part of the national strategy.

The national review of cardiac services is a matter close to my heart, if colleagues will pardon the pun, because it arose from a very high-profile campaign in the south east, where we do not have 24-7 primary percutaneous coronary intervention, PPCI, services, as those present will be aware. It is important that we have regional balance and that all areas have access to critical cardiac care. It is unacceptable that the review still has not been completed. I accept that Professor Nolan was taken away to do other work, which is fair enough, but the review is at least a year and a half in the making. It will have profound implications for cardiovascular policy in the State. In light of its importance, I again ask that the committee write to the HSE to ask about timeframes for the review and its completion.

I will leave it at that. I thank the witnesses for their presence and for raising the important issues they have brought to our attention.

Deputy Cathal Crowe

I confirm that I am in Leinster House. It was great to see Deputy John Paul Phelan on the Leinster House campus yesterday. It has been well reported that he had cardiac health problems. It is great to see him back looking in full health. I wish him plenty of good health in the months ahead.

Events in the past week highlighted the need for greater screening in cardiac care. It was shocking to see Christian Eriksen collapse on the pitch while playing for his country and everything that followed. It is good that he is making a recovery in hospital. One of the statistics in the opening statements is that up to 60% of Irish people are now considered to be obese or overweight. What happened to Christian Eriksen needs to be closely considered because it could be of relevance to several people in my network of friends and acquaintances alone. When persons who are overweight they visit their doctor, more often than not, they are told to stand on the scales and their blood pressure is checked. There are kind of warning signs there already. The very fact that they are carrying excess weight puts them at a high risk. However, many people who jog the roads every day, do triathlons or play team sports and look the picture of health could have blockages in their arteries or their heart may not be firing properly and they may need a pacemaker. Such issues are not always detected. When such people go to a doctor or other health professional, it is often the case that they are looked over but not considered to be particularly high risk. Is there a way to get more of those people into the net? Running has become more than a fad in recent years. Every evening, a significant number of people go running and put their bodies under pressure. Are we focusing very much on those who are obviously in poor health and morbidly obese or very overweight to the detriment of those who appear to be in good health?

Mr. Tim Collins

It is a good point. We need to focus on the low-hanging fruit. The biggest modifiable risk for cardiovascular disease is probably high blood pressure or hypertension. Ireland is a complete outlier in this regard in Europe. The Irish LongituDinal Study on Ageing, TILDA, data for the over-50s indicates that approximately 64% of those aged over 50 have hypertension and approximately half of those have undiagnosed hypertension, so there are many people with high blood pressure, which can cause stroke, heart disease, kidney disease and, ultimately, dementia. They will remain undiagnosed until they have a blood pressure check. The other difficulty in Ireland is that among those who know they have high blood pressure, fewer than half have their condition properly controlled. That is one of the reasons we have promoted the idea of a national hypertension awareness campaign to let people know this is a relatively symptomless condition that can have a major bearing on their health in terms of chronic disease and acute incidents such as stroke. Until we start putting resources into screening for such conditions, we will continue to have the same level of death and disability, with approximately 9,000 lives lost each year from cardiovascular disease. It is an important issue.

Deputy Cathal Crowe

There seem to be defibrillators in every community. All members are politically attuned to their communities. It is our bread and butter to know the people around us and the communities we serve. However, it is difficult to identify where defibrillators are located in neighbouring villages. Mr. Collins might be able to enlighten the committee on this issue. I am aware of two ways in which one can identify the locations of AEDs. One is the Helping Hearts website, which provides a map on which one can zoom in to see where the AEDs are located. The other is to call 999 or 112 and the dispatcher can relate where there is an AED nearby. It concerns me that this is expensive kit, with some of the devices costing up to €2,000 or €2,500. The school in which I formerly taught has an AED mounted on its side gable. There is a code to open the secure box to remove the defibrillator and use it. There was a time when I knew that code off by heart but I have forgotten it. My worry is that when defibrillators are needed, people do not now where they are or the code to open the box. That is happening around Ireland. Are we lacking a database in that regard? Ms Walsh or one of her colleagues may wish to reply to that question.

Mr. Tim Collins

I am happy to respond. The most important thing on coming upon a person who is having cardiac arrest, 70% of which happen in the home, is to immediately call 999 to quickly make contact with the NAS, which can give directions to a nearby defibrillator and all the information about the defibrillator. However, the ambulance service needs a proper national register and to know that the defibrillators on the register are being properly maintained so that it can give things like access codes and so on.

In advance of such a register being put in place, it is important to note that defibrillators are important, but only approximately 20% of people who suffer a cardiac arrest have a shockable rhythm. The most important thing is to have more people in the community who understand how to do high-quality CPR. The main focus for the Irish Heart Foundation in recent years has been to train people in how to do CPR. There is a really high rate, at approximately 85%, of what we call bystander CPR, that is, people who will have a go. Irish people are very good in that regard but many people do not know how to do CPR properly. More resources need to be put into awareness and training of people in CPR at a national level, to begin with schools, as was mentioned, but to also include training the adult population. While they are being trained, they can be told how to use an AED or a defibrillator.

Deputy Cathal Crowe

I have a final, two-pronged question. Inadequacies for stroke survivors were mentioned.

I ask the witnesses to detail those inadequacies and to outline what buttons we, as Oireachtas Members, need to push in that regard.

It was mentioned that air pollution is the cause of 1,500 deaths per annum. That shocked me. In Ireland, much of the resources in this area are focused on litter pollution, with little heed or credence to noise or air pollution. That air pollution accounts for the loss of 1,500 lives per annum is alarming. Are there particular types of air pollution about which the organisations are concerned? Is the figure of 1,500 referenced under a general pollution heading or are there specific things of which we should be more fearful as a society?

Mr. Tim Collins

I will ask my colleague, Mr. Macey, to address the stroke question. Before doing so, I will try to answer the question on air pollution. We did a pubic opinion-awareness survey recently. Most people in Ireland think that air pollution, or at least the air pollution that is impacting on health, comes from transport emissions. The bulk of the particulates we breathe in that cause heart disease and stroke come from burning solid fuels. We have been strong in saying to Government that it needs to do a number of things in this area. It needs to bring in WHO air quality standards, move forward with a clean air Act and ban the burning of the worst smoky solid fuels, that is, smoky coal, wet wood and peat sod turf. We also need to phase out the burning of fuels. We are an outlier in Europe in our reliance on solid fuel to heat our homes. We need to ensure that people have the resources to retrofit their homes and to deal with the issue of fuel poverty. I will hand over to Mr. Macey.

Mr. Chris Macey

Over the past decade our acute stroke services have improved significantly from a low base. We have become good at saving lives from stroke. We are putting a lot of expertise and resources into that area, but we are squandering people's recovery because they are being abandoned at the hospital gates without any access, unless they can afford to pay for it themselves, to the basic rehabilitation programmes they need such as physiotherapy, speech and language therapy, occupational therapy and psychology. This is about a brain injury. There are three whole-time equivalents in the country to help people recover from that injury. They are some of the issues.

The issue is gross underfunding and the sense people have of abandonment in the community. We need to establish the number of stroke survivors in Ireland. That will require a proper needs survey and a plan to roll it out. We have a plan for everything in Ireland these days, but people are being discharged after stroke without a right to a discharge plan. That is crazy and it needs to be addressed.

Deputy Cathal Crowe

I thank the witnesses.

Vice Chairman

The next speaker is Deputy Shortall. We had a bit of a crisis earlier in that my screen went blank on a number of occasions, but not for too long. To ensure there are no further issues in terms of chairing the meeting, Deputy Colm Burke, who is in the committee room in Leinster House, will take over the chair. Is that agreed? Agreed.

Deputy Colm Burke took the Chair.

Deputy Róisín Shortall

I welcome the witnesses and thank them for their presentations, but they are not good for the blood pressure. What the witnesses are talking about is, in many ways, the blindingly obvious but we have to ask questions as to why this is not happening. What they are talking about is also the essence of Sláintecare. One would imagine that at this stage we would have learned lessons. They identified the main causes of cardiovascular disease, most of which are outside of the health services. Why are we not tackling those issues?

Is a chronic illness programme in place in the cardiovascular area? What is the leadership in all of this? The IHF and Croí, as community-based patient organisations, play a critical role. Where is the leadership on this at the Department or HSE level? Why do we have such an overly medical model? The witnesses mentioned the personal burden. This also imposes an economic burden on the country and on the health service. The solutions are obvious. Why are we not doing the obvious? Why are we not concentrating on prevention and doing those things that would make people of the risks involved? Why do we not have primary prevention, community-based healthcare, nurse-led programmes? I would like to know where the blockage is. Why are we not doing what we should?

Mr. Tim Collins

I would call it the tragedy of the horizon in that we tend to address what is in front of us and not what is further out. We have seen inaction on climate change and on a range of social issues that are immediately impacting on us. That is the problem. It is the reason prevention is the poor cousin of acute medicine. I am optimistic. There are things happening. The chronic disease management programme in general practice, which mandates GPs to do annual checks among people of a certain age group, is a good start. There has been a sea change in the attitude and enthusiasm of GPs around the country in regard to prevention, particularly because of that programme, but it is not enough because it is confined to medical card holders.

There are straws in the wind in that the excellent plan which the Deputy shepherded through a number of years ago, that is, Sláintecare, has commenced implementation. Laura Magahy and her team are making inroads and it looks like they are getting some budget. We are in contact with them about hypertension awareness. The response has been slow but positive. I am not pessimistic. We are beginning to make inroads, but we are so far behind in terms of the resources that we put into prevention. One of the things we are asking of the committee today is that it reaches outside of its traditional remit of health and look at the wider determinants of health. Unless this committee takes a lead, there will be no consideration of the health impacts of air pollution and junk food marketing to children. There is no sense in addressing weight management in children unless we shop junk food marketing. That is the first step. Everything else, in terms of the services they need at a health level, must come after that. I am optimist and I think we are beginning to make progress.

Mr. Neil Johnson

What was said by the Deputy and Mr. Collins is correct. We need to call it as it is. The reality is that preventive healthcare has never been a priority. We are at a point now where our health system is crumbling under the burden of cardiovascular disease. It is not sustainable. Clearly, the penny is beginning to drop through programmes such as Sláintecare, but this requires a significant and unprecedented approach, perhaps with a Minister of State with responsibility for prevention at Department of Health level. It may sound an extreme suggestion, but we need somebody to take ownership. So much of cardiovascular disease is preventable. Simple things can be done, but much of it is more challenging, particularly when we get into the behavioural science side of things. We are missing strong, central government leadership. We need a stand-alone strategy on cardiovascular disease prevention. Such a strategy would have knock-on benefits for many other diseases such as cancer, kidney disease, diabetes, and obesity, all of which share the same risk factors, but nobody in Ireland is taking singular responsibility for the prevention agenda.

Deputy Róisín Shortall

I thank the witnesses. We are all familiar with the idea of social determinants of health. Mr. Collins used the phrase "commercial determinants of health". That is quite a telling phrase. Is this at the root of the inaction in terms of the obvious things that we should be doing?

Is it the overbearing commercial influence on a number of activities Mr. Collins identified, such as alcohol misuse, smoking, air pollution, diabetes and, to a large extent, obesity? Are overbearing commercial interests at the heart of this?

Mr. Tim Collins

I will ask Mr. Macey to answer because he has a particular perspective on the influence of IBEC, which is a big issue.

Acting Chairman (Deputy Colm Burke)

There is just a minute left. Can we have the answers quickly?

Mr. Chris Macey

This is not something that can be answered quickly. Clearly, with obesity, there are prerequisites to change. It is a complex issue but if there are vested interests in the Department helping to work out policy, how will you get anywhere with it? It is just not going to happen.

Deputy Róisín Shortall

Are there vested interests in the Department?

Mr. Chris Macey

No. There are vested interests such as organisations like IBEC representing the food industry and helping to develop the policy around, for example, junk food marketing to children and the working out of voluntary codes and things like that. The commercial determinants we are talking about, which are the real drivers of obesity, are intense marketing and the high volume and availability of energy-dense foods. There is now a worldwide snack food industry worth $374 billion that did not exist in the 1960s. It did not exist before obesity became a problem. These are the issues that are driving the problem. All governments tend to do is come up with voluntary codes, which puts the personal responsibility back onto individuals and families when the environment just overwhelms them. You might walk past a shop nine times and not go in for a chocolate bar, but the tenth time you do. The other nine times do not count. We all do it. These are issues that are driving the problem.

Deputy Róisín Shortall

Where is the leadership on this at departmental level or in the HSE? It is much broader than-----

Acting Chairman (Deputy Colm Burke)

We have gone over time at this stage.

Deputy Róisín Shortall

-----hospitals and doctors. How can those wider issues be taken into consideration?

Mr. Chris Macey

There is no one looking at cardiovascular issues in the Department. There is no focus on the issue at all. There is a policy unit for cancer, and rightly so, but for cardiovascular there is nothing. It lacks focus. As Mr. Collins said in his opening statement, we are just lacking a plan. We are at square one and we need to start moving.

Deputy Neasa Hourigan

I thank everybody for being here this morning. I reiterate Mr. Johnson's idea for a junior Ministry in preventative health. It is a very good idea. As one doctor said to me, we need to start living better not just longer.

I will turn to the issue of a cardiac register, which was raised in the opening statements. Can we unpack that a little? The need for greater data has come up during committee meetings on other areas of health. Registers for people who experience chronic illness allow faster access to care or more immediate access to screening and testing. Can the witnesses unpack how that would work for cardiovascular issues in particular? There is a wide spectrum, from people who have fully managed but identified heart murmurs right up to people who experience complex health events.

Mr. Tim Collins

I will ask Mr. Macey to come in on that.

Mr. Chris Macey

What we are lacking, in the absence of a proper national cardiac register, is real-time data. People representing cancer services were before the committee last week. There is a national cancer registry, which provides real-time data that just does not exist for us. As has been said, waiting times for outpatients for echocardiograms and angiograms are months long and getting longer. We get a snapshot of that. We hear about what is happening in an individual hospital, but we never get a full clear and consistent picture of what is going on.

There is a heart attack audit and registers are being done by individual cardiologists for some specific conditions, but there is a dearth of regular real-time data to inform health planning. Service delivery impact and cost-effectiveness cannot be maximised clearly when we do not know what is happening, or what is and is not working, and if there is no fast alert system when problems arise, as they do regularly in individual hospitals and collectively on things like waiting lists. As far as we are concerned, this is something that has to be front and centre of a new national cardiovascular strategy.

Deputy Neasa Hourigan

Is it accurate to say that it is not just an issue of data collection and public health data, but outcomes? We heard from groups speaking about diabetes that a well-working register allows people to access care immediately as soon as they arrive at a hospital. Is it accurate to say data collection also impacts outcomes, not just data?

Mr. Neil Johnson

I will respond to that. Registries are clearly an issue, but it is more about the registry. It is a central health record. In cardiovascular disease, comorbidities are quite significant and what is happening, unfortunately, are silos of care. This is why we have a messy situation. The Deputy mentioned diabetes, for example, which is a major risk factor for cardiovascular disease. The number of individuals being treated for diabetes whose cardio risk factors are not being managed at all is quite disturbing. If there was some central health record that tracked these comorbidities, clinicians would be alerted and prompted to look at a more integrated care approach. The registries are needed first of all to understand the numbers and who has what and how many have it. However, more importantly, we need some central health record, which we do not have, that allows tracking of comorbidities to prompt integrated care. That is not happening, unfortunately, in cardiovascular disease.

Mr. Chris Macey

This is an individual health identifier that has been talked about for 15 or 20 years and just has not happened. Mr. Johnson is completely correct.

Mr. Neil Johnson

This might sound like a frivolous comment, but my dog has a microchip in its ear. When it goes to the vet, with an instant scan, every single visit, medication and transaction that dog has had is there for the vet to see. I am not suggesting we put chips in people's ears-----

Deputy Neasa Hourigan

I was going to-----

Mr. Neil Johnson

-----but the reality is the technology is there so why are we not using it? It is a serious issue.

Deputy Neasa Hourigan

I acknowledge Mr. Johnson is not suggesting microchips for everybody but I take that point. It is important that we begin with a register and then go to the next generation of ensuring that we do not silo information.

On that data issue, one of the points made in Mr. Collins's opening statement was about the incredibly high numbers of women with heart disease. In the past few years, international studies have implied that heart disease in women, or negative outcomes, is increasing. What are the answers in tackling that issue for women, in particular, including the data issue but also, perhaps, public information?

Mr. Tim Collins

The first thing is awareness. Heart disease has almost been considered a male disease. Most women are not aware of the idea that women have heart disease. However, post-menopause, women are as at risk from heart disease as men, if not more so. It is a serious cause of death and disability in women post-menopause. We need to make people aware so that women are more aware and ensure they get themselves checked and that their blood pressure is normal. We also need to get the wider health system to take it seriously as an issue. The chronic disease management programme in general practice will help us there, but we need to put a much greater emphasis on awareness at all levels both within the health services and with women generally.

Deputy Neasa Hourigan

Just to be clear then-----

Acting Chairman (Deputy Colm Burke)

There is less than one minute left.

Deputy Neasa Hourigan

I will finish. We have heard a great deal in the past few months about the lack of menopause care in the Irish system. Is it accurate to say that at menopause there should be a standardised introduction to heart health? Can we get menopause care to a certain standard that would include heart health and a standardised test?

Mr. Tim Collins

It is a difficult question. I am not sure if a gendered approach to heart health is the right way to go. We need a greater level of awareness generally, but we also need to ensure that women are aware that they are as at risk as men, particularly after a certain age.

Acting Chairman (Deputy Colm Burke)

The next contributor is Deputy Gino Kenny.

Deputy Gino Kenny

I thank the witnesses for their opening statements. They have been most informative. In some ways, they have been relevant in respect of what happened on a football pitch a few weeks ago in the match between Denmark and Finland. Everybody was shocked to see what happened to Christian Eriksen on the pitch. One of the best places that someone could suffer a heart attack is on a pitch in a football stadium because there is access to immediate care. Christian Eriksen seems to have made a speedy recovery. Other footballers and athletes have not been so lucky in such situations. The incident threw up many questions in respect of our own heart health. The fact that a professional footballer at the peak of his career can have a heart attack like that has sent shudders down the spines of most people who are healthy and going about their lives. Advancements in health, particularly in cardiac care and CPR, have saved lives. That is good.

I wish to address a number of points in the submission from the IHF. The first point concerns what the foundation describes as the scourge of junk food marketing. It is insidious in society. These companies are involved in extreme marketing that targets young people. They get into the heads of not only young people, but everyone. They tell them that they deserve the food they are marketing. Junk food is marketed as no being longer a treat, but as something to be consumed daily as part of a balanced diet. I ask one of the IHF representatives to comment on how we can address the scourge of advertisements. There are so many vested interests in fast food advertising. It is insidious.

Mr. Tim Collins

I might ask Ms Walsh to respond to that question.

Ms Kathryn Walsh

This is a most topical issue. I am not sure if the Deputy is aware, but we presented to the Joint Oireachtas Committee Tourism, Culture, Arts, Sport and Media a number of weeks ago in a discussion of the online safety and media regulation Bill 2020. We need a ban on junk food marketing to children. We need statutory regulation of that. Voluntary codes do not work and they have not worked. Evidence produced over decades illustrates that it does not, and will not, work. Broadcast regulations have been produced by the Broadcasting Authority of Ireland. There is a broadcast watershed that we believe needs to be extended.

Online junk food marketing has become a particular problem, as young people, particularly during the Covid-19 pandemic, have migrated online for educational purposes in particular. We believe that a statutory ban on junk food marketing to children has to happen. In the UK, the Government committed to introducing an online junk food marketing ban and to extend the watershed from 6 p.m. to 9 p.m. in the Queen's speech.

The Irish Heart Foundation commissioned a public health (obesity) Bill. We presented it to the previous Government and it made it into the programme for Government. There is a commitment to pass such a Bill. We believe and hope that the Bill will be brought forward. We have a serious concern that the commitment in respect of the public health (obesity) bill within the recently published Healthy Ireland strategic framework is just to explore with stakeholders the issues relating to the introduction of the Bill. We are concerned that the Bill will not go further than an initial exploration. It goes to the Deputy's point about the vested interests involved and what was discussed earlier about the commercial determinants of health.

In every group that has been established on obesity policy in Ireland, the food and drink industry has been at the table. Through the submission of freedom of information requests in respect of the voluntary code of practice for non-broadcast marketing that was published three years ago, we know that in some instances the food and drink industry asserted that its members would not agree to it and it needed to be changed. At the last minute, the Department of Health had to pander to industry to change that. When industry is represented in these groups, it is hard for change to happen. If we want change to happen and the scourge of junk food marketing to be eliminated, industry must be removed from the equation. Representatives from the industry should not be sitting at the table in policy discussions. That is not just the case in respect of junk food marketing; it applies to all harmful products. The passing of the Public Health (Alcohol) Act 2018 serves as an example. We need statutory regulation. If Government and the Oireachtas do not intervene, these practices will continue because voluntary codes simply do not work.

Deputy Gino Kenny

Ms Walsh mentioned the public health (obesity) bill. What would the Bill do if was passed tomorrow under the programme for Government?

Ms Kathryn Walsh

The original bill that we submitted was modelled very closely on the Public Health (Alcohol) Act, simply as a measure to get the conversation going. We are not drafters of legislation. We are looking at the introduction of no-fry zones and advertising around schools. In the Bill we are also seeking to extend the broadcast watershed. Online marketing to children should also be considered. Currently, we are looking at the online safety and media regulation Bill 2020 because it transposes the audiovisual media services directive and establishes the Future of Media Commission. There are means of banning junk food marketing within that Bill. We encourage members to take an active role in that when the pre-legislative scrutiny process concludes and the Bill eventually gets published.

We are looking at a model that is similar to that used in the Public Health (Alcohol) Act. We are focusing on advertising and no-fry zones around schools and the broadcast elements. We cannot just focus on the broadcast elements; we must deal with the online marketing.

Deputy Gino Kenny

I have one last question if there is time.

Acting Chairman (Deputy Colm Burke)

The Deputy has three seconds, but he can ask the question.

Deputy Gino Kenny

What is the witnesses' view on the addition of first aid training to the secondary school curriculum?

Mr. Neil Johnson

I will respond to that question. At the outset, the Deputy referenced the Christian Eriksen incident. One of the things that we hope will come from the media attention around that incident is the distinction between cardiac arrest and heart attack. They are quite different. I do not have a full report on what happened to Christian Eriksen, but it would seem that he suffered a cardiac arrest, which, in layman's terms, is an electrical malfunction as opposed to underlying cardiovascular disease and a heart attack.

In response to the Deputy's question, in the case of cardiac arrest, as the IHF has indicated, first and foremost, CPR is needed. Good CPR saves lives. That is the bottom line. It is not a great burden on anybody to learn. There is no obligation, moral or legal, on anyone to use it if they happen to witness a cardiac arrest. The simple maths are that the more people know how to administer CPR, the better.

The foundation is doing great work in training secondary school children through its own resources. Why can we not make it obligatory, as part of the second-level curriculum, that everybody, before they leave secondary school, undertakes a basic course in CPR? I would even go one step further and assert that those who continue to vocational training or third-level education should also be required to complete a top-up or refresher course before they complete their training or studies. In some countries, it is obligatory to be CPR certified before getting a driver's licence. I do not suggest that we place a large burden on the population, but the reality is that CPR saves lives. I am not just talking about cardiac arrest, because part of CPR training also teaches participants how to respond in cases of choking. I strongly suggest that perhaps the Minister for Education considers this making it an obligatory part of second-level education. It could be introduced, for instance, under a CSPE programme or another element. It takes no more than two or three hours to learn CPR.

Acting Chairman (Deputy Colm Burke)

The next speaker is Senator Martin Conway. He has seven minutes.

Senator Martin Conway

I thank our guests. It has been quite an informative morning. As others have said, the events over the weekend have crystalised the importance of this issue. Following on from the previous contribution, it would be a very good start if every teacher in the country were trained in CPR. I agree that CPR needs to be an obligatory part of the curriculum and taught in the workplace and that top-ups should continue. Do the witnesses have a view on the Health and Safety Authority having a role in this?

Defibrillators should be commonplace in workplaces. People should be trained in their use. They should be at the centre of any kind of health and safety plan or programme in workplaces. What engagements have the witnesses had with the Health and Safety Authority in this regard? I missed the very start of the meeting because I had another engagement, so maybe this question has been answered. Do the witnesses know how many defibrillators in the country are working? What is the percentage of defibrillators that are broken, have not been updated or have not been serviced? That has to be a very serious situation. A defibrillator might be used only very rarely but it is critical that they are all working. The witnesses might give us an idea of those percentages.

Other members, including Deputy Cullinane, have spoken about the strategy. It is appalling to think the Department of Health has not been monitoring the strategy or has not really taken it seriously. This is a serious issue. I believe that the engagement with the committee this morning will result in our making contact with or engaging with the Department. We will no doubt have the HSE, the Department officials and the Minister before us in due course and we can put this issue to them then.

Those are a couple of my observations. Any of the witnesses may respond to them; I do not mind who.

Mr. Tim Collins

I will jump in here if that is okay. We think the key to ensuring there are sufficient working defibrillators around the country is community first responder groups. They are volunteer-led groups but are highly trained, very effective and linked in with the National Ambulance Service in a very effective way such that when somebody calls 999, they are alerted if there is a cardiac arrest. They currently have about 1,800 defibrillators around the country in community first responder groups. We think that distributing defibrillators through community first responder, CFR, groups is the way to go because they will maintain them and ensure they are charged, ready to go and available for use. Every major workplace should have a defibrillator. This may be an issue for the Health and Safety Authority. There is a national out-of-hospital cardiac arrest strategy and a lot of work has been done on that. It links in with the ambulance service and CFR Ireland. We train many teachers around the country as part of our CPR for schools programme. About 70% of post-primary school teachers have been trained. If CPR were a mandatory part of the curriculum, we could ensure that all teachers are trained. There is a huge level of enthusiasm among teachers for this. We find it is an easy programme because the teachers like it, it is something different, young people really like to get the skill and it can be done very quickly, in less than one hour. I hope that has answered the Senator's questions.

Senator Martin Conway

Perhaps as a committee we could do a short report making some of these recommendations because they make an awful lot of sense.

I have one final question. Recently, by which I mean in the past two or three years, there was a significant media campaign on what to do if you are in the company of somebody who shows symptoms of a stroke. What was the feedback from that media campaign? Is there any evidence from it or was any research done following it to the effect that it was a success? I thought it was quite a powerful campaign and I am curious to know whether the witnesses deem it as having been a success?

Mr. Tim Collins

Is Mr. Macey available?

Mr. Chris Macey

I will come in on that. We ran a major TV campaign in 2011 on FAST, the stroke warning signs. It brought Ireland's level of awareness up to the highest in the world. The call to action part increased a lot as well but probably not as much as we would have wanted. It went up to about 60%. In the most recent campaign we focused on why minutes matter and why you just have to get in and get treated as quickly as possible. There is nothing else to do. The average stroke destroys 2 million brain cells per minute. There was an 11% increase in awareness following that campaign, which was really good because it was only a radio campaign. We only had the funding for a radio campaign. It was a really good trial of something that needs to be a lot bigger. This needs to be a rolling TV-based campaign that ensures that people get to hospital as quickly as possible. The median presentation time for stroke is now just under three hours, which is just not good enough because with literally every minute that is saved more of the brain is saved. We are talking about 2 million brain cells every minute. Therefore, what we are asking the Department of Health and the national stroke programme to do now is to support a rolling FAST campaign that hardwires this awareness into the national consciousness.

Senator Martin Conway

I thank the witnesses. I appreciate that.

Senator Frances Black

I thank all our witnesses for their very informative presentations. I have learned an awful lot. One thing that kept coming into my mind is that my mother used to say prevention is better than cure, and how true that is, listening to all the witnesses. A lot of the questions have been covered. I am interested in a couple of specific areas. Mr. Collins mentioned looking at air pollution through a health lens and that it is a huge public health concern. Could he say a little more about that? He mentioned fuels like coal and peat. Is gas in there as well? Should the committee link in with the climate action committee on this and explore it a little further? I think the awareness of this is very limited. I certainly had not been aware that air pollution was connected with heart health at all. That is my first question for Mr. Collins.

In Mr. Johnson's opening statement he mentioned the Croí MySláinte programme as a community healthcare model. I would love to hear a little more about that and how it works.

I think it was Mr. Collins who mentioned Healthy Ireland - or was it health and well-being - and how little funding they have received. That could be the Department that could look at prevention. If they had more funding, what more do the witnesses think they could do?

Finally, maybe Ms Walsh could speak a little about the relationship between alcohol and heart disease.

Mr. Tim Collins

I thank the Senator. I will endeavour to get through her questions as quickly as I can.

Air pollution is an interesting one. I worked for Mary Harney in the late 1980s. She was responsible for bringing in the first ban on smoky solid fuel in Dublin and, subsequently, in other major cities in 1990. Over that period we saved about 10,000 lives, but our understanding of air pollution has evolved significantly since then. We used to think air pollution was the stuff you could see, the smog, but in fact the air pollution that kills people is fine particulates called PM2.5. They are invisible. They are about 1/30th the width of a human hair. They are emitted from burning solid fuel. More are emitted from sod turf, which is the worst fuel type in this regard, wet wood and smoky coal, but they are also emitted from other solid fuels.

Smokeless coal also emits these fine particulates. They not only go into the atmosphere through the chimney; they go into the home. Between 30% and 40% of the particulates of an open fire will flow into a living room. We know that these are causing health problems, including cardiovascular disease. They move from the lungs into the fine blood vessels and they cause blockages in those blood vessels. They can cause dementia and a range of other illnesses. The only way to tackle this problem is by removing solid fuel burning as a practice in society, first by tackling the worst fuels. The Government has a consultation process in place to examine the phasing out of smoky coal, wet wood and sod turf. We have wholeheartedly endorsed that process, but we believe it needs to be an all-island basis because air pollution is not something particular to the Twenty-six Counties. If these fuels are available across the Border, towns along the Border will still be exposed.

On Healthy Ireland funding, we think the level of funding is ridiculously low. There is so much that can be done in terms of prevention. As stated, it must start with address of the commercial and social determinants of health. We need to get out into the disadvantaged communities where health inequalities are significant and work at that level. Healthy Ireland has a role to play in that regard. I will hand over to Ms Walsh now.

Ms Kathryn Walsh

As the Senator will be aware, the IHF was very involved with the Alcohol Health Alliance in supporting and pushing for the enactment of the Public Health (Alcohol) Act 2018, recognising that alcohol is a risk factor for cardiovascular disease. We know from the evidence that there are strong links between alcohol and cardiovascular disease. For example, two alcoholic drinks per day in midlife increases a person's risk of stroke by more than one third and it leads to people suffering stroke, on average, five years sooner. Every unit of alcohol per week a person drinks increases the risk of artrial fibrillation by approximately 2%. Alcohol can stress the heart muscles and lead to heart weakness, which makes it harder for the heart to pump blood around the body. In terms of heart failure, the heart is not pumping blood around the body as well as it used to. There are many links as well with high blood pressure. We have always been strong on recognising the harms caused by alcohol in terms of cardiovascular disease and health and the need for that to be recognised in legislation was fed into the Public Health (Alcohol) Act 2018. That is important.

We often hear stories that alcohol is good for the heart. With regard to the increased risk of stroke and heart disease we need it to be front and centre that alcohol increases the risk for cardiovascular disease.

Mr. Neil Johnson

On the question regarding Croí MySláinte, I will ask my colleague, Ms Irene Gibson, who has led that programme, to respond.

Ms Irene Gibson

I will start with by giving a little background. The Senator will have heard about the burden of cardiovascular disease. Between 30% and 50% of cardiovascular disease occurs in patients with existing disease. That is why secondary prevention is so important. When the pandemic hit, 70% of cardiac rehabilitation services in Ireland were significantly affected. Staff were redeployed and centres were closed. One of the projects led by Croí under the Sláintecare integration funding was the development of a virtual cardiac prevention and rehabilitation programme. In essence, it provided an online web-based programme of care to individuals living with cardiovascular disease. Many of these patients were waiting in excess of three to 12 months for preventative care. Some of these problems existed prior to the pandemic. In Ireland, capacity for cardiac rehabilitation is around 37%. We need to look at alternative ways of delivering care.

One of the positives of the pandemic is that we can deliver care digitally and it is acceptable to patients. Over a period of 12 weeks, we offered people an intensive lifestyle and medical risk factor management programme led by a nurse prescriber, supported by a multidisciplinary team of dieticians and physiotherapists under the medical governance of a cardiologist and in collaboration with general practice and community pharmacists. Under the programme, patients joined us once per week for an online Zoom session, such as we are engaged in today, where they completed a supervised exercise session and participated in an interactive health promotion session. A key component of that session focused on self-management. We provided patients with blood pressure monitors to track their blood pressure. We also gave them Fitbits to track their physical activity levels. In looking at the lifestyle factors that contribute to cardiovascular disease, we need to also look at engaging with people in a way that goes way beyond education and information giving. We need to work with people on identifying their goals and priorities for change. We have been astounded by the outcomes of this programme. Over a short timeframe, we have seen anxiety and depression levels halve, an 80% improvement in blood pressure control and improvements of 40% to 60% in cholesterol levels. In terms of our care for cardiovascular patients, we are not meeting the recommended targets and guidelines. That is a real priority.

Acting Chairman (Deputy Colm Burke)

I apologise for interrupting Ms Gibson but we are almost out of time and I need to bring in the next speaker. I may be able to allow her back in after the next speaker has posed his questions.

Deputy Bernard J. Durkan

I thank the witnesses for their informative dissertations. I have a couple of questions for them. First, I would welcome their opinions on the cholesterol reducing drinks and foods, such as butter, that are advertised regularly on the market. Are they worthless or do they have an effect?

Mr. Tim Collins

I wish I had one of my dietician colleagues here today. We have a number of dieticians working for the foundation. Our view is that they have a role to play, but we always place the emphasis on a proper, balanced diet. If somebody has a diagnosed problem with cholesterol, he or she needs to be on a low cholesterol diet. The products mentioned have a role to play. We think that it would probably not be a great idea to say that if a person is using these products, he or she can then afford to eat whatever he or she likes. We do not have a negative view of them, but we think the emphasis should be on a proper, balanced diet. Ms Gibson may have a view on this as well.

Ms Irene Gibson

We know that these drinks contain plant sterols and stanols, which are proven to reduce cholesterol but, again, as part of a heart healthy diet. They work for some individuals, but not for everybody. If we are recommending these products to people, we need to do so with sight of their cholesterol levels and recognising that some products are more efficacious than others.

Deputy Bernard J. Durkan

A large number of the people that I meet in the course of my constituency work have respiratory problems such as asthma and bronchitis. Almost everybody suffers from hay fever, as I do, and a number of other similar complaints. What advice would the witnesses offer regarding the multiplicity of so-called cures for these conditions? As they will be aware, many of these conditions impact on a person's ability to breathe.

Mr. Tim Collins

I am sorry, Deputy, I missed the beginning of your question as you were on mute.

Deputy Bernard J. Durkan

A large number of people throughout the country, young and old, suffer from asthma, bronchitis and associated conditions. What would be the advice of the witnesses on how to avoid such conditions? Is there anything we can do, or do we just have to go with the flow? There are appliances readily available on the market that can be installed in a living room or bedroom, which clean the air and eliminate viruses as well. The witnesses' opinion on those would be helpful.

Mr. Tim Collins

New houses are increasingly hermetically sealed, and we are not dealing with the same environment as in older houses. First, we would go back to basics and say that if someone suffers from asthma, it is not a great idea to have an open fire in the house. It is not even a great idea to have a wood-burning stove in the house, because every time a stove is opened to refuel it, it emits particulates and they can impact on the health of someone who has asthma. As we emphasised earlier, it has a much broader health impact as well in terms of cardiovascular disease.

We would say to people to move away from burning fuel in their house indoors. Over and above that, people with asthma need to make sure that they have a good relationship with their GP and that they are regularly monitored, and their asthma is controlled. Asthma is not only an inconvenient disease; it can be a fatal one and it is something that needs to be properly monitored and controlled by a GP.

Deputy Bernard J. Durkan

Mr. Collins did not mention hay fever or any of the other associated issues.

Mr. Tim Collins

I cannot say that I am an expert on hay fever, so I am reluctant to give the Deputy advice on that.

Deputy Bernard J. Durkan

Could any of the witnesses deal with the question? Nobody. I suggest, with no disrespect to the panel, that perhaps somebody might look at that because it is an issue that affects an awful lot of people, especially in the kind of weather conditions we have had in the past three or four weeks.

Could I ask about the air purifiers to which I referred that are available on the market?

Mr. Tim Collins

Again, I do not have an expertise in the matter, and I am not sure whether any of my colleagues have. We always say to people to go back to basics and ensure that they are not doing anything in their house that is impacting on the air quality. There are lots of gadgets on sale that purport to help with health conditions and to make people healthier.

Deputy Bernard J. Durkan

I want to interrupt there. These are not gadgets. We must eliminate the word "gadgets". They are air purifiers with 100% efficacy that has been well and truly proven. The manufacturers stand over that. Not only that, but they have the ability to eliminate viruses such as Covid as well up to 100%. It would be helpful if we had the opinion of the witnesses regarding their efficacy.

Mr. Tim Collins

We will have to come back to the Deputy on that.

Deputy Bernard J. Durkan

I thank Mr. Collins very much.

Acting Chairman (Deputy Colm Burke)

I thank all the witnesses. One of the questions I want to ask relates to priorities. There has been a sea change in funding for healthcare, which has increased substantially in the past two years because of the Covid pandemic. We now need to prioritise. We touched on heart disease and other areas earlier. Could the witnesses set out a list of four or five priority areas where immediate action could be taken to achieve results reasonably fast? We as a health committee could get the Department to respond to it. The witnesses covered an extensive range of issues and each of those areas is iimportant, but what are the four or five areas they feel the Department and the HSE could respond to very quickly that would produce a beneficial result?

Mr. Tim Collins

I will just mention three. We agree with Croí that the first is a cardiovascular health policy with a significant emphasis on prevention. The second is that we would like a public health obesity Bill to be introduced and immediate action on junk food marketing, in particular to under-18s.

The third, in terms of low-hanging fruit and the best buy to give us a good impact, is a hypertension awareness campaign. Hypertension is costing the health service €700 million a year through chronic heart disease, kidney disease and a range of other illnesses. We think that for tuppence, a small portion of that, we could have a hypertension awareness campaign that would be impactful. We need to take about 100,000 blood pressures a year for the next five years to reduce by 50% the number of people in the community who are hypertensive but unaware of it. That is a realistic target and we can do it with a relatively small budget. They are just three things.

Mr. Neil Johnson

I concur. The first point I will make relates to the plan, or the absence of a cardiovascular strategy. The second is a serious commitment to prevention. The third point relates to a reference I made earlier to the third age cohort. It would be cost-effective to initiate early detection and early diagnosis of many conditions that have an enormous impact, hypertension being one of them.

Acting Chairman (Deputy Colm Burke)

On the medical side, where is the deficiency at the moment that could be dealt with immediately if decisive action was taken by the Department of Health and the HSE?

Mr. Tim Collins

I might ask Mr. Macey to come in on that.

Mr. Chris Macey

We need the stroke strategy to be published, funded and implemented. As has been said earlier, we are talking about a 60% increase in strokes in a decade due to lifestyle issues and age. We have got to future-proof these services but we must also ensure that while saving lives and reducing disability, we put emphasis on recovery as well and we do not squander people's recovery when we can deal with these issues cost-effectively.

Acting Chairman (Deputy Colm Burke)

I have a few minutes left if any member of the committee wants to ask a question. I am prepared to allow two minutes for both the question and the answer.

Deputy Bernard J. Durkan

Could I come back in very quickly?

Acting Chairman (Deputy Colm Burke)

Yes, there is one minute for the question and one minute for the answer.

Deputy Bernard J. Durkan

As you know, Acting Chairman, I am always brief in these situations. We are running out of options as far as solid fuel is concerned. I was one of the people who changed over my entire heating system to eliminate coal and turf some years ago. I moved to wood. Am in now in a position where I have to remove wood as well? This will affect a lot of people throughout the country who see dry wood as a means of heating their homes. Many people cannot afford more modern methods.

Mr. Tim Collins

We need to remove the worst fuels first. Dry wood is probably the least polluting fuel, but it still emits particulates and many studies in the UK show that where people have moved away from traditional fuels and are now burning dry wood in stoves. There are significant levels of air pollution, which are causing health issues. Ultimately, our view is that we need to move away from burning anything in our homes. The Deputy is correct to point out that fuel poverty is an issue. There needs to be a transition allowance to retrofit houses. It is simple to put electric storage heaters into homes. It is not that expensive to retrofit houses. Major retrofits cost upwards of €30,000 or €40,000, but we can replace a lot of solid-fuel burning devices with electric central heating and other forms of heating, which will reduce the particulate matter to zero. Unfortunately, the news is that we are all going to have to move away from burning anything. For the moment, let us move away from the worst fuels. There is no immediate threat to burning dry wood in the home, but it is a health issue both for internal air and external air quality.

Deputy Bernard J. Durkan

I thank the witnesses.

Acting Chairman (Deputy Colm Burke)

I also thank all the witnesses for their contributions and for all of the work they are doing to deal with this important issue. As a committee, we must take on board the advices given this morning. I suggest that at a private meeting we might deal with how we should address the issues raised directly with both the HSE and the Department of Health. We will correspond with the Department on the priorities the witnesses have raised and see if we can get some action on them.

I thank the witnesses for the manner in which they have dealt with all of the questions and queries raised. Our next meeting is on Wednesday, 23 June at 9.30 a.m. Is that agreed? Agreed.

The joint committee adjourned at 11.20 a.m. until 9.30 a.m. on Wednesday, 23 June 2021.