Joint Committee on Health debate -
Wednesday, 23 Oct 2024

Issues and Challenges relating to Cardiology: Irish Cardiac Society

An Cathaoirleach

Apologies have been received from Senators Kyne and Conway.

Before we get to the main item on today's agenda, the minutes of the committee meetings of 8, 9, 10 and 15 October have been circulated to members for consideration. Are they agreed? Agreed.

Today the joint committee will first meet the Irish Cardiac Society to discuss issues and challenges relating to cardiology. Later we will separately meet Fórsa to give further consideration to staffing levels in the HSE.

To commence the committee's consideration I am pleased to welcome from the Irish Cardiac Society, Professor Pascal McKeown, president; Professor Brendan McAdam, president elect of Beaumont Hospital; Dr. Yvonne Smyth, University Hospital Galway, who is joining us online; Dr. Niamh Murphy, Our Lady of Lourdes Hospital, Drogheda and Mater Misericordiae University Hospital, Dublin; and Ms Barbra Dalton, executive director.

I will read a note on privilege. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore if their statements are potentially defamatory in relation to an identifiable person or entity, they may be directed to discontinue their remarks and it is imperative they comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way to make him or her identifiable.

I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex to participate in public meetings. I will not permit a member to participate where they are not adhering to the constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any member participating via MS Teams that, prior to making their contribution, they confirm that they are on the grounds of the Leinster House campus.

To commence our consideration of this matter, I invite Professor McKeown to make his opening remarks on behalf of the Irish Cardiac Society.

Professor Pascal McKeown

I thank the Cathaoirleach, Deputies and Senator. We are grateful to the committee for providing us with this opportunity to discuss issues related to cardiovascular disease in Ireland and, where relevant, the European Union and European Society of Cardiology. I am the immediate past president of the Irish Cardiac Society in that we held our annual general meeting last weekend in Belfast and I handed over the president's role to Professor Brendan McAdam, who is currently the president. The Irish Cardiac Society was founded in 1949; we are celebrating our 75th anniversary. It is the professional society on the island of Ireland for those whose primary interest is in the practice of cardiology, cardiovascular surgery and cardiovascular research. We currently have about 400 members and we are one of the constituent members of the European Society of Cardiology. Key strategic priorities for the society include education, advocacy and the development of research and registries. Cognisant that cardiovascular disease remains one of the main contributors to premature death across the European Union, on 4 July 2024 at a high-level EU ministerial conference in Budapest, representatives from all the EU ministries of health discussed the need to improve cardiovascular health in Europe as well as prioritisation of cardiovascular health plans at both a national and European level. The Minister of State, Deputy Colm Burke, attended that meeting and contributed to ministerial discussions. The European Council is currently working on a draft document which it hopes will be approved by all EU member countries by the end of 2024.

What is the burden of cardiovascular disease? It remains the most common cause of death across Europe, accounting for about 1.7 million deaths annually across the EU and is the second most common contribution to mortality in Ireland. Each year, nearly 9,000 people in Ireland lose their lives to cardiovascular disease. The common forms of cardiovascular disease include coronary heart disease, valvular disease, heart failure, cardiac arrhythmias, congenital heart disease, hypertension, stroke and inherited cardiac conditions. In 2021 in Ireland the estimated costs attributed to cardiovascular diseases, including health and social care, as well as losses due to morbidity and mortality, were estimated to about €3.4 billion. There are many modifiable risk factors, including hypertension, elevated cholesterol levels, diabetes mellitus, smoking, alcohol, being overweight or obese and environmental pollution. The European Society of Cardiology recently published the 2023 Atlas of Cardiovascular Disease Statistics. It is helpful to highlight some important data.

Despite Ireland having one of the highest GDP per capita, it has the lowest number of cardiologists per million population across the EU. Age-standardised mortality rates for cardiovascular diseases in Ireland remain higher than in many other countries in western Europe. There is also a significant gender equality issue in Europe; there are more cardiovascular disease deaths in women than for all cancers combined; mortality following a heart attack is higher in women; and women are significantly under-represented in research studies. In 2004, the Tánaiste, Deputy Micheál Martin, then the Minister of Health, introduced ground-breaking legislation to ban smoking in the workplace. Many countries followed Ireland’s lead. Nevertheless, Ireland still has relatively high rates of tobacco consumption. We are cognisant of recent additional investments related to cardiovascular health announced as part of the budget. We also wish to acknowledge that there are several examples of successful cross-Border initiatives such as the All-Island Congenital Heart Disease Network and treatment for emergency heart attacks in Altnagelvin Hospital for people in Donegal.

Current critical issues in Ireland include the lack of a national cardiovascular strategic plan. The last cardiovascular strategy, from 2010 to 2019, expired five years ago. The national review of cardiac services commenced in 2018 but has not yet been published. There is a lack of comprehensive national registries to facilitate benchmarking and longitudinal studies of the clinical and cost-effectiveness of care. Access to cardiac diagnostics is very restricted and waiting times are long. Investment in cardiac imaging including echocardiography, cardiac CT and cardiac MRI has been identified by the national heart programme as a critical and urgent need for cardiovascular healthcare in Ireland. There is also a lack of access to many evidence-based therapies for patients with cardiovascular disease. As a result, the cardiovascular community in Ireland is currently unable to deliver care at a level consistent with international guidelines.

One example in the management of patients with heart failure is the use of the drug combination of Sacubitril and Valsartan, which has been shown to be a cost-effective medication as it reduces the need for hospital admissions. However, patients in Ireland have restricted access to this important medication as clinical staff members have to undertake an onerous approvals process as part of the medicines management programme, which often ends in rejection due to strict local policies not in keeping with the international guidelines. Another is the prescription of injectable cholesterol-lowering treatments which have been available for nearly six years but because of restrictive criteria, Ireland has the lowest use of this treatment in Europe.

There are significant workforce issues, including an embargo on filling vacant positions since October 2023. A recent example is where some novel services to manage patients in the community following an admission to hospital with acute heart failure in order to reduce readmission have been partially suspended. Very long waiting lists for access to cardiology services and imaging are problematic. The lack of equity of access to timely cardiovascular care for an increasingly diverse population is also important to mention.

Main priorities include support for the upcoming European Union cardiovascular health plan and publication of the Department of Health national review of cardiac services. We need support for the funding of national all-Ireland comprehensive registries for cardiovascular disease. We need improved timely and equitable access to imaging, including cardiac CT in all hospitals admitting patients with chest pain and an advanced cardiac imaging centre with dedicated cardiac MRI and cardiac CT in each regional health authority. We need timely access to evidence-based and guideline-directed therapies and support for investment in cardiovascular posts across multi-disciplinary teams; achievement of a timely reduction in waiting lists with additional funding directed to public cardiology services rather than use of the National Treatment Purchase Fund mechanism; and support for prevention and health promotion, including addressing social determinants of health such as smoking, alcohol consumption, hypertension, obesity and air pollution.

The optimal outcomes for the Irish Cardiac Society would be Government support for the EU strategic plan and rapid development of a similar plan for Ireland and securing additional investment in relation to workforce, service delivery and timely access to guideline-directed therapies. We need support for the development of comprehensive cardiovascular disease registries and further funding for research and innovation and to ensure development of advanced cardiac imaging facilities to improve the diagnosis, management and outcomes for cardiac patients. We look forward very much to discussing these issues and providing clarification for any questions members have. We also hope that we will have the opportunity to return to this committee to discuss progress in achieving these outcomes.

I thank the committee for its time.

An Cathaoirleach

Thank you, Professor McKeown. On behalf of the committee, I congratulate Professor McAdam on his elevation to uachtarán. I also welcome Dr. Yvonne Smyth, who is online.

We will go through Professor McKeown and he will farm the questions out to whoever he thinks is best placed to answer them. We normally do this in ten-minute slots, that is, questions and answers within ten minutes. We will try our best to stick to that. We are on a tight schedule this morning; there will be another group coming in later in the morning. I will open up the floor. Deputy Durkan from Fine Gael will lead us off.

Deputy Bernard J. Durkan

I welcome the witnesses and thank them for giving of their time so readily.

How do we compare with the rest of Europe in terms of ability to detect, diagnose and treat? That is my first question. Who is the best in Europe? Who is the worst?

Professor Brendan McAdam

I thank the Deputy for those questions. A recent European national audit or survey of provision of cardiovascular services and care has been published in one of the heart journals in the past year. Sadly, we have very few statistics or data to offer that registry or survey so we cannot compare our data, because we do not have good data, with what is published in Europe. We know, however, based on our experience, that we are not very good. We have the lowest number of cardiologists per capita in Europe, and only 20% of our cardiology team are women. The only audit data we have in registry form is for heart attacks. We know we do not do as well for provision of care, treatment of hypertension, treatment of cholesterol, and provision of adequate cardiac imaging centres and services to our patients. There is a lot of room for improvement. However, as regards one of the biggest obstacles we have, one of our missions is to try to adopt registries that will allow us to measure what we do so we can actually assess what we are doing, benchmark against our colleagues in Europe and then identify areas for improvement. That would then also allow us to be able to resource services adequately to provide the best care we can provide for our patients. In particular, we do not have any data on gender disparities of care in this country but we know such disparities arise based on data from around Europe.

Deputy Bernard J. Durkan

For instance, whose services should we try to match in order to improve our standards? Who is the best out there, even with the limited information we have available? Who-----

Professor Brendan McAdam

At the top of the scale are France, Germany and Sweden, which provide superb cardiovascular care in all its facets. Cardiovascular disease is a spectrum of diseases including heart failure, heart attacks, endocarditis and hypertension. Those countries do very well in terms of benchmarking. How we know how we do is that we adopt practices based on guidelines of best practice that are adopted by the European Society of Cardiology. In fact, two of our members have been chairmen of two specific areas of disease, hypertension and coronary disease, to advance the practice of cardiovascular care. We know from best practices that we are not living up to what we should do. Treatment of hypertension is suboptimal, treatment of high cholesterol is suboptimal and access to services is very poor. For example, the waiting list for an outpatient echo or CT scan is anything from six months to two years. That is really unacceptable. It is very hard for us to provide that kind of care where we do not have access to proper investigations to make the diagnosis to make people better.

Deputy Bernard J. Durkan

How are patients identified? For example, can a patient living in Donegal, Kerry or the midlands rest assured that he or she will be detected on time and with sufficient scope for treatment and recovery?

Professor Brendan McAdam

It is a great question. Again, we know, although we do not have good data, that there is a lot of disparity in access to services for cardiovascular care all over the country regionally. Obviously, we do not fare very well nationally. We know that people have to travel quite a lot to get care. For example, in the west of Ireland, there is no access to CT or cardiac MRI and very limited access to echo. There are opportunities to improve, including to improve access and equitable access to cardiovascular care all over the country. That is espoused in the national cardiovascular review document that looks to try to improve access throughout the regions of Ireland so people can get the best care locally instead of having to travel.

Deputy Bernard J. Durkan

What is the best way to set about providing the data that would be helpful in dealing with this situation?

Professor Brendan McAdam

First of all, we have to measure what we are doing, so we need registries and better data. Overall, however, we need a better overarching national strategy for cardiovascular care so we can be properly funded to look at these issues, to fund registries and then to provide better care for our patients and equitable access, to have full accountability and be properly funded like the cancer strategy.

Deputy Bernard J. Durkan

Is that being set up at present? Can it be set up at present? Is it being encouraged? Is the ICS encouraging it or can it do so through the hospital system, GPs and so on?

Professor Brendan McAdam

Yes. It is a pan-cardiology care thing. It is both the hospitals and GPs. We have to be empowered and resourced to provide the care we know will save lives. A national cardiovascular strategy would be the way to go. There is the report that is being published. It took about three or four years to complete because of the Covid pandemic, but we are very keen to get that published. That will serve as a template for a formal cardiovascular strategy, with proper funding and proper accountability.

Deputy Bernard J. Durkan

Is there a deficit in that area that is identifiable now, and within what timespan is it possible to address the issue?

Professor Brendan McAdam

That is a great question again. We need a strategy published so we know where we are going. We need a roadmap, and if the funding goes with it, then we can plan our services better, measure what we are doing and make things better, but that could take several years. We are all very supportive and enthusiastic to try to make that happen.

Deputy Bernard J. Durkan

We need a strategy somewhat like the national cancer strategy of some years ago.

Professor Brendan McAdam

Absolutely. We have had two iterations of a cardiovascular strategy, the last of which was five years ago, but there has not been a new strategy for a long time. People are living longer and getting more complex diseases. We need to address these issues urgently with better cardiovascular infrastructure and better personnel.

Deputy Bernard J. Durkan

As regards women's health, Professor McKeown mentioned that this apparently applies throughout Europe as well in terms of danger of heart attacks, cardiovascular failure, etc. What is being done in Europe now to address that issue, and what is being done here?

Professor Brendan McAdam

That is another great question. The most important thing to start with is increased awareness. Many people have a bias that heart disease does not affect women. That is not true. Women have higher case fatality rates than men, they have limited access to care, they do not do as well as men with the provision of cardiovascular care and they are less likely to access rehabilitation, which is a very important part of the treatment for cardiovascular diseases. Increased awareness and increased funding would be very important in trying to progress that issue, but we need to measure what we are doing so we know that we can do better.

Deputy Bernard J. Durkan

Professor McKeown mentioned a treatment that is restricted at the moment. Why is it restricted? What is it?

Professor Pascal McKeown

Dr. Smyth, I think, will join us online. This is a question about treatments-----

Dr. Yvonne Smyth

The medicines management programme is part of the National Centre for Pharmacoeconomics. Even though we must acknowledge that we have tremendous freedom in Ireland in terms of prescribing and a very generous system of reimbursement, the medicines management programme dictates how we prescribe certain drugs in cardiology. While we understand that showing cost-effectiveness is tremendously important for drugs such as the one Professor McKeown mentioned, sacubitril-valsartan, that drug is not particularly expensive. It costs approximately €70 a month. It has shown tremendous benefit to patients suffering from heart failure. The European guidelines, which, as Professor McAdam stated, we go by, dictate that our patients suffering from a certain type of heart failure should have that drug used as first-line therapy. However, our local guidelines issued by the medicines management programme dictate that we have to use an older drug first, show that that drug has failed and then make an application. These applications are typically very onerous, involving six, seven or eight pages of paperwork, documents proving the patients have been on the other drug, blood tests and so on. Unfortunately, a lot of the time, even when we go through all these hurdles trying to achieve best practice, ultimately we are met with rejection, and the cardiology community finds that incredibly frustrating.

Deputy Bernard J. Durkan

Could we have a comparison done between the older drug and its effectiveness and the new drug, and could we avail of that for the committee, Chairman? I think it would be useful, and it could be used further. Is that possible?

Dr. Yvonne Smyth

Absolutely. There is an international trial called the paradigm study looking at heart failure patients throughout the world demonstrating the benefits of these agents.

We must remember heart failure is a terrible condition. It has outcomes worse than many cancers. It is a big cause of admissions to our acute hospitals. Typically, patients will stay an average of eight to ten days. Anything we can do to help these patients stay out of hospital has a tremendous impact.

Deputy Bernard J. Durkan

I have a very short time left. Obviously a strategy is required. Within that strategy certain items, such as the availability of particular drugs that are effective, need to identified. The thing that comes to mind also is there are a number of people who are in danger of heart failure but do not know it for some unknown reason, so the degree to which the services are available for detecting the incidence or potential incidence needs to be accelerated in the course of the strategy or plan, or beforehand if that can be done.

Professor Brendan McAdam

We know 80% of cardiovascular disease is preventable if we identify it early and implement treatment to improve care, reduce the burden of disease, decongest our hospitals, improve outcomes for our patients and improve the quality of life for their families.

Deputy David Cullinane

I welcome our witnesses and thank them for the extensive briefing documents they submitted, as well as the opening statement and the asks they have of this committee.

I will start with the national strategy because it is important. The most important point the witnesses made in their presentation is we do not have an overarching national strategy and have not for five years. Just for the record, I was part of a delegation of Oireachtas Members from the south east that met Simon Harris when he was Minister for Health. He signed off on the Nolan review. The genesis of that was there was a discussion at that point about cardiac services in the south east, which the witnesses might recall, and whether or not PPCI services should be available on a 24-7 basis. A previous report had not recommended that and the Minister at the time said the best way forward was to ask Professor Nolan to look at emergency services and their locations across the State. I understand that report has been on the Minister's desk for months. It should be published. The initial terms of reference were to look at emergency services, so I imagine there would be more work needed to turn his work into a national strategy. The Minister says it covers more than emergency services, but a national strategy has to look at treatment of course. I mean the full range of treatments from planned to emergency. It has to look at diagnostics, imaging and all the other issues the witnesses have raised. Prevention is really important, as is management of the disease in the community. We will get to some of those in a few minutes. Through this committee and the Chair’s offices I call on the Minister again to publish that report. It should set out recommendations for regions so people can know what exactly is being proposed. That is especially important to us in the south east, but we need a national strategy. I understand there are staff who are ready to start working on the strategy but cannot until the Nolan report is published. That is the first point.

I ask the witnesses to address quickly how important it is to have that national strategy.

Professor Brendan McAdam

It is really important. I was on the committee that was involved in one of the stakeholders and actually contributing to the committee. It is a comprehensive document. It covers all aspects of cardiovascular care regionally and nationally. It addresses all the different aspects and the spectrum of diseases. It addresses rehab, cardiac imaging, provision of primary PCI centres - heart attack centres - around the country. It is a comprehensive document. Very importantly, Professor Nolan went around all the hospitals, engaged with all the cardiologists around the country and all the CEOs to formulate his plan.

Deputy David Cullinane

I thank Professor McAdam. I see many of the critical issues the witnesses identified are issues common to a lot of areas we are hearing about. One is the lack of comprehensive national registries. That seems to be a problem across a whole range of diseases. Do the witnesses think there would be a step-change in that if we moved to electronic medical records and digitising the health service? We are way behind in that area. We still have a pen-and-paper healthcare service and need to move in this area, but how important is digital transformation in getting us to a place where we have proper registries?

Professor Brendan McAdam

It is critically important. That is a great point. We are all going around with paper records, which is a bit archaic. You cannot integrate data from different hospitals. You have to ring up people and ring services to get data. If we had electronic records it would facilitate better provision of care. That is widely available across Europe. It would allow hospitals to talk to each other and ensure there was no duplication of services. It would allow us to be involved in registries so we could measure what we are doing and then we can benchmark what we are doing against our colleagues' care across Europe and improve care provision. An e-strategy for healthcare and patient records is an essential part of what we need to do.

Deputy David Cullinane

I thank Professor McAdam. I move to diagnostics, because it is one of those areas in healthcare where the National Treatment Purchase Fund does not publish the diagnostic waiting lists or indeed community waiting lists, which it should. Very often we have to keep digging and asking parliamentary questions to get some sense of how bad they are. We know that in some cases they are not great. In his opening statement Professor McKeown said "Access to cardiac diagnostics is very restricted and waiting times are long". Will he expand on that, first of all?

Professor Pascal McKeown

Dr. Murphy is going to talk about that.

Dr. Niamh Murphy

Cardiovascular imaging is an integral part of cardiology. We have very limited access in the public health system to advanced cardiac imaging, mainly cardiac CT and cardiac MRI. There are a limited number of hospitals performing these tests. If we take the 33 hospitals that admit chest pain, only 11 of them have access to cardiac CT and only six have access to cardiac MR. The hospitals that have access have extremely long waiting lists and very limited access. All these tests are time-dependent, so if there are excessive waiting lists we have to use alternative imaging and alternative testing, such as overreliance on invasive cardiology with its risks. Then a lot of hospitals that do not have access to these tests are outsourcing to the private sector, which is a huge cost for the HSE and one that would be much better off being used to invest in cardiac imaging services locally. I have been involved with the national heart programme to develop a business case for development of advanced cardiac imaging nationally. We have put through a proposal to develop advanced imaging centres in each region with dedicated cardiac MR and dedicated cardiac CT scanners, while at the same time upskilling all hospitals admitting chest pain to use their existing facilities to provide cardiac CT to inpatients who need it.

To take a step back, when somebody comes into hospital with chest pain the recommendation, after ensuring they do not have a heart attack, is to do a cardiac CT to diagnose coronary artery disease. Unfortunately, without access to cardiac CT we are still using other tests that are inferior, like stress tests, and then going on and doing invasive coronary angiogram to try to diagnose if these people with chest pain have cardiac chest pain or not. We would be much bettor off doing cardiac CT on these patients and thereby getting people out of hospital quicker, speeding up discharges and being able to discharge people directly from the emergency department.

Deputy David Cullinane

There is a business case that was developed by the national heart programme around cardiac imaging.

Dr. Niamh Murphy

Yes. Cardiac imaging has been identified as a key component.

Deputy David Cullinane

I am taking it from Dr. Murphy's response that would be more insourcing and more public availability in the public service, as opposed to outsourcing. However, the fundamental point is more capacity.

Dr. Niamh Murphy

Yes, more capacity. Per million of population, we have a need for one cardiac MR scanner and one cardiac CT scanner to fund it. At the moment we have very limited access. At a hospital like the Mater, which serves a huge population we do about six cardiac MRs per week. That translates to about 200 per year. An equivalent hospital in the UK is doing about 4,000 MR scans per year.

Deputy David Cullinane

I thank Dr. Murphy. Our time is limited and I have one more question to put.

An issue that is coming up a lot at this committee when we have witnesses before us is the recruitment embargo that was in place and the still very limited recruitment for 2024. The witnesses' opening statement refers to "... significant workforce issues including an embargo on filling vacant positions since October 2023". That is consistent with what we have heard from SIPTU, Fórsa - which we will hear from later - and the Irish Nurses and Midwives Organisation as well. One example given troubles me because it goes against the spirit of Sláintecare, which is that we provide the right care in the right place at the right time and provide care in the community as an alternative to acute care.

Professor McKeown said in his opening statement that there are novel services to manage patients in the community following an admission to hospital with acute decompensated heart failure in order to reduce their risk of readmission, which has been suspended. It strikes me as bizarre that one would suspend a service like that. In the remaining minute and a half, can he explain what that service was and why it was suspended?

Professor Pascal McKeown

It has been partially suspended. I will ask Dr. Smyth to address that.

Dr. Yvonne Smyth

That service was run by my colleague, Dr. Susan Connolly, in Galway. The hiring embargo the Deputy mentioned, which started in October 2023, meant that any post that had not been filled at that time and has since become vacated or where somebody has left on maternity leave could not be filled. Now, any post that was not filled in January 2024 is being suppressed, as it is called. That is having an enormous impact on our ability to deliver services. These community hubs are led by a cardiologist in conjunction with experienced cardiovascular nurses, supported by cardiac physiologists to perform diagnostics. It is an issue where we do not have those key people and key nursing staff. In our locality, the service still exists in part, but not in its entirety and not to its tremendous potential. There has been great investment in the community and great opportunities with our community cardiology hubs but, unfortunately, we will not see the fruition of that because of the hiring embargo.

There are two other main issues with regard to the hiring embargo. One is cardiac rehabilitation. Of all the things we do for our patients, it is one that they appreciate most in terms of their quality of life but it has also been shown to reduce their chance of dying or of being readmitted to hospital. In 2009, we had 216 whole-time equivalents, WTEs, in cardiac rehabilitation. Now, we have 85 in hospitals and 50 in the community. Our workforce in cardiac rehabilitation has dropped by almost two thirds. Even in 2015, we looked at it and, at that time, we could only meet about 39% of the demand. We are falling way behind because of this hiring embargo.

Cardiac physiologists are a key part of our workforce. These are extremely skilled people. The Government has invested in their education, which is tremendous, both at an undergraduate and postgraduate level. Yet, we conducted a brief survey last week. Fourteen acute hospitals replied to us. They all have vacancies. Some of them are missing up to five cardiac physiologists. In the community now, we have beautiful physical infrastructure and we have equipment we cannot use because of these vacancies. Our inpatients will wait days because of them and our outpatients will wait years because of them.

Professor Brendan McAdam

The under-resourcing of rehabilitation has been going on for nearly 15 years. As Dr. Smyth said, there has been a chronic shortage of staff. In 2021, one of the rehab centres did an audit and found that 50% of rehab centres had no administrative support, 50% had no pharmacy and 50% had no dietician. The multidisciplinary aspect of cardiac rehabilitation has been eroded for years and needs to be addressed urgently by a new cardiovascular strategy.

Deputy David Cullinane

Just to let the Chair know, a health motion is being taken in the Dáil and some of us will have to leave to speak on it.

An Cathaoirleach

Looking around when we were discussing publication of the Nolan report, I saw that people were nodding their heads. The committee will ask the clerk to write to the Minister about publishing that report.

Deputy Róisín Shortall

I will have to leave shortly to go to the Chamber as well.

I find it hard to understand how we get to a point where the cardiac strategy is five years out of date and we are only now talking about a new strategy. When was the Nolan report completed?

Professor Brendan McAdam

I believe it was completed at the end of 2022 and submitted early 2023.

Deputy Róisín Shortall

In that case, it was completed nearly two years ago. What kind of engagement has the Irish Cardiac Society had with the Department of Health, the Minister or anybody at a senior level in the HSE on a new strategy?

Professor Brendan McAdam

We have made representations to meet the Minister over the past couple of months. He has been very busy, so we have not had an opportunity to meet. We have also tried to meet the people in the Department of Health. We postponed a meeting recently because of logistical issues. We hope to meet them in the next couple weeks.

Professor Pascal McKeown

The European Union has created a window of opportunity for all EU member countries. The meeting took place in Budapest in July. Momentum is growing. As a constituent member of the European Society of Cardiology, we are aware of an enormous amount of advocacy that is going on in Brussels as well. If this European cardiovascular health plan is published in December, that will set a direction of travel for us, which will be underpinned by a national strategy. Essentially, we are trying to ensure that all patients across Europe have equity of access to good cardiovascular care. That window of opportunity is one we are pushing to try to ensure we get a cardiovascular health strategy for Ireland, which is linked to the European cardiovascular health plan.

Professor Brendan McAdam

I think 4 December is a big date for endorsement of that national European strategy. If our Minister was able to endorse it, that would mean we would have to have a national strategy in place to move along and make it happen.

Deputy Róisín Shortall

Is Professor McAdam saying we would be required to have a national strategy under development at European level?

Professor Pascal McKeown

We have seen draft recommendations coming through the Council. If it sets up the European-wide strategy, this will have to be underpinned by individual countries interpreting how to deliver a cardiovascular plan locally.

Deputy Róisín Shortall

The likelihood is, even if there is cognisance taken of European developments, that we are talking about developing a new strategy, which would likely take some time.

Professor Pascal McKeown

Yes, but the Nolan report provides us with some background to help develop a new strategic plan. Any strategic plan also needs to be monitored. You cannot just deliver a plan without interpreting what the impact of that is because you want to know there has been value for money for additional investments that have been provided. One of our main requests today is to ensure that Ireland signs up to the EU plan and agrees to develop a national cardiovascular strategy with appropriate infrastructure and funding to allow us to move forward.

Professor Brendan McAdam

I think the Nolan report will be a template for that.

Ms Barbra Dalton

Regarding the question on engaging, it is worth noting our colleagues in the Irish Heart Foundation, for example, advocate on nearly a continuous basis to the Minister around publishing the strategy. When we look at what we are doing in Europe and our work through the European Society of Cardiology, we are always looking for common threads across all the countries that bind us together, and the need for an EU cardiovascular plan is one of those. In addition, when we try to contribute data to the various studies within the EU to show the Irish story, we are restricted the whole time by our lack of data and lack of a strategy. It is the cornerstone to us being able to forge ahead.

Deputy Róisín Shortall

That issue will not change quickly, unfortunately. We have been looking for the health strategy to be implemented for a long time.

Regarding the recent session in Budapest, given the importance of cardiovascular disease and the fact it is the second biggest contributor to mortality, it strikes me, and it is disappointing, that the senior Minister was not there. That is just a comment.

I will ask about a few other issues. Lifestyle was talked about, and it was said that 80% of serious heart disease is preventable. What is the split between genetic or inherited conditions and lifestyle or environmental impacts?

Professor Brendan McAdam

Social determinants of the disease, healthy living, exercise, obesity-----

Deputy Róisín Shortall

Yes, but what is the split?

Professor Brendan McAdam

They are the majority. I think genetic determinants of disease account for probably 5% or 10%, whereas lifestyle is really important, that is, obesity, exercise, pollution, smoking, alcohol and so on.

Deputy Róisín Shortall

I would also add in the commercial determinants of health. We have been doing a lot of work on that and issues related to drinking, smoking, fast food and all of that. There are big commercial pressures brought to bear on government related to that. I think the area of commercial determinants should be included in that because there is those big industries have considerable access to decision-makers.

Regarding inherited or genetic factors, what is the position on screening for those?

Professor Brendan McAdam

There are national services in the Mater and Tallaght hospitals for screening for specific heritable cardiac arrhythmic diseases in particular.

Again, they are very underfunded. It is very stretched and there are long waiting lists. That has to be part of a blueprint for a national strategy all across the country. You should not have to travel from Kerry to get access to those services, which are quite specialised in Dublin.

Deputy Róisín Shortall

Okay, but at the end of that Professor McAdam is saying only 5% of people have inherited conditions.

Professor Brendan McAdam

Those where you have potentially fatal consequences.

Deputy Róisín Shortall

What does the screening entail? Is it very costly or why is it so underdeveloped?

Professor Brendan McAdam

Part of it is a lack of people who have expertise in that area but access to cardiac MRI, CT genetic testing is very patchy throughout the country, as the Deputy has already heard, from an imaging point of view. We do not have a national genetics service. We have to outsource our genetic testing quite a lot to other countries around Europe. We have a small laboratory in Crumlin hospital and in the Mater hospital that perform genetic testing but again the waiting list is substantial.

Professor Pascal McKeown

There are also genetic forms of cholesterol problems as well, familial hypercholesterolemia, which probably affects about 1 in 500 of the population. Other European countries have taken the population approach to this whereby all children are screened for hypercholesterolemia and appropriate treatments are started in childhood. This is about moving upstream to try to prevent rather than waiting until the disease has started. There are European countries which have developed additional models and we could learn-----

Deputy Róisín Shortall

For child screening, when or how is that done?

Professor Pascal McKeown

It is done through blood tests and then genetic testing. For example, we have the heel prick test for lots of metabolic disorders.

Deputy Róisín Shortall

Could it be included in that?

Professor Pascal McKeown

We would need to explore what exactly they are doing. I think Slovenia is the European country that has adopted the process. There are models at which we would want to look. Any cardiovascular health strategy would identify specific areas and then look at the best practice to adopt locally.

Deputy Róisín Shortall

Okay. I want to pick up on some of the points made about testing diagnostics generally. Are cardiac diagnostic services not included in the new primary care diagnostics initiative, that is, the direct referrals?

Dr. Niamh Murphy

Echo is included in the community hubs, whereas cardiac CT and cardiac MRI is not. We have to develop advanced cardiac imaging in Ireland and one possibility we have looked at is colocating the advanced imaging centre along with the surgical hubs in the community. This has a lot of advantages because these are centrally located and they could provide patient-centred care to the whole community. That moves the diagnostics out into the community, freeing up space in acute hospitals for inpatient work. One of the proposals that has gone in is where advanced imaging centres are collocated in the community. The site that has been identified would be adjacent to the surgical hubs, which are going to be amazing facilities.

Deputy Róisín Shortall

That makes sense. I completely agree with Dr. Murphy's point that we should be developing our own services within each RHA instead of the outsourcing.

Dr. Niamh Murphy

Yes. It is absolutely mad spending that amount of money that could be invested in imaging centres in the public sector and then encouraging trainees to come back to take up posts and getting the best consultants, cardiologists back into the unit. Whereas if all the money is being invested in the private hospital, it just does not make sense for us-----

Deputy Róisín Shortall

It reaches a tipping point then and the public service is always inadequate.

I want to go back for a minute to that question of the prescribing of injectable cholesterol-lowering treatments. What is the position? Presumably, we know high cholesterol is very prevalent. What happens if a person is being prescribed that treatment? Does that mean they can eat and drink whatever they like? How does that actually work? Is it only in very serious cases where people are at serious risk that this medicine would be prescribed?

Professor Pascal McKeown

I ask Dr. Smyth to address that question.

Dr. Yvonne Smyth

I thank the Deputy. The drugs we are referring to are something called PCSK9 inhibitors. When we talk about cholesterol circulating in the bloodstream, there essentially are two sources. One is our diet but that is only a small part of where the cholesterol comes from. Most of our cholesterol actually comes from what our liver makes and some of that is genetically predetermined. The Deputy will have heard of statins, I am sure. They are around since the mid-eighties and they have revolutionised cardiology in terms of reducing heart-attack risk and dying from a heart attack. However, some people cannot take statins for a variety of reasons and these drugs can be an alternative in that situation. However, here in Ireland, it is incredibly difficult to utilise them for that reason. If you have a patient who has had multiple stents to treat their coronary artery disease and their high cholesterol has been a major contributing factor, and they cannot take statin therapy for one reason or another and we would like them to avail of a PCSK9 inhibitor, when we go to fill in the paperwork for the medicines management programme, we will find that its definition of coronary artery disease is very restricted. It is somebody who has either has a heart attack or a bypass. If you have a 90% blockage in a critical location that has been stented, that does not meet the programme's definition of having coronary artery disease. As my colleagues, Professor McKeown in particular, has explained in terms of hereditary hypercholesterolemia, those drugs again are for that population. They particularly benefit from these drugs. Even though they are injectable agents, the drugs are only given once or twice a month. They are quite easy to take but they are expensive. The reason there is such restriction on them in our jurisdiction is because of the price, because they are so costly and because you will typically be prescribing them for life for these patients. Even though we feel some of our patients should be able to avail of them because they definitely have coronary artery disease and high cholesterol and they may or may not have a genetic condition, by and large we are unable to use them.

Deputy Róisín Shortall

They are only allowed after the event, as it were, and not as a prevention measure.

Dr. Yvonne Smyth

Exactly. If you have had a heart attack or a bypass then you might meet the rest of the criteria. The rest of the criteria involves blood testing within four weeks, which sometimes can be difficult to see somebody have that and be able to upload that data. They have to go on another drug called an ezetimibe which affects cholesterol absorption to the gut. You have to demonstrate that they have taken that. We do not have a joined-up pharmacy system like they have in New Zealand to demonstrate what people have been prescribed and what they have been taking. It is very difficult to prescribe these drugs.

Deputy Róisín Shortall

Okay.

Dr. Yvonne Smyth

Can you eat and drink everything you want if you are on a statin or on a PCSK9 inhibitor? We would seriously hope to get across the message that the diet is important too but the bulk of your cholesterol is coming from your liver.

An Cathaoirleach

We do not really have the time to go into it but maybe the witnesses could provide the committee with a note on the difficulties related to the injectables, using the older drugs and the process that is there. It might be something we could follow up on.

Deputy Róisín Shortall

Are there any generic medicines coming on stream any time soon on that?

Professor Brendan McAdam

There will be in about three years' time.

Dr. Yvonne Smyth

There is another drug called bempedoic acid which is in tablet form. It only costs €50 a month. It might be suitable for some of these patients but again it has to go through the medicine management programme. To prescribe a drug that only costs €50 a month is going to take an awful lot of paperwork and an awful lot of time that would be better spent serving our patients in different ways.

Deputy Róisín Shortall

That is an important issue we may pursue as a committee.

Professor Brendan McAdam

We know from ESC guidelines that we are told to get people with heart disease and bad cholesterol down to less than 1.4 mmol/L. Between 30% and 40% of patients actually achieve that target, which means there is a huge residual risk of patients not being treated properly. As was mentioned in the report, we are the lowest prescribers of these injectable cholesterol medications in Europe, which is very disappointing and very bad for our patients.

An Cathaoirleach

I thank the witnesses. I will move to Deputy Hourigan next.

Deputy Neasa Hourigan

I will comment on some of the issues around the medicines management programme. For my own clarity, are these injections on cholesterol that we are talking about injections that would be undertaken by a clinician or is it something someone does at home?

Professor Brendan McAdam

The patients are trained to self-prescribe.

Deputy Neasa Hourigan

Okay. That seems to be more prevalent across a number of treatments in healthcare at the moment.

Regarding the medicine management programme, I can only imagine there is a huge amount of innovation in this area. If doctors want to move a treatment off the management programme and make it more freely available, how long is that process?

Professor Brendan McAdam

The criteria have to change. What we are struggling with is the restrictive criteria that is not adopted by the European Society of Cardiology or in fact anybody else around the world. It is very restrictive and there is also the amount of precise paperwork we have to do. If you make any kind of error, you are kicked out and you cannot prescribe the medication, which is lifesaving for many patients. There is a new medicine coming on that is based on small interfering RNA therapy that you inject twice a year that really has a profound effect on your bad cholesterol, which has been shown to have a beneficial effect on cardiovascular outcomes in patients with established heart disease.

Deputy Neasa Hourigan

My question is on changing the criteria. What is the process and how long does it take?

Professor Brendan McAdam

We have been engaging with the national programme for medicines for a long time to try to persuade people there that perhaps the criteria are not in line with what the European Society of Cardiology, ESC, or other lipid societies adopt. We need to just-----

Deputy Neasa Hourigan

Has the engagement been going on for months or years?

Professor Brendan McAdam

Years.

Deputy Neasa Hourigan

That is not great, given that drug innovation happens. We would like there to be a fairly dynamic response from organisations. I want to go back to the registry's issue. This has come up a number of times in other sectors to do with healthcare and anything that is a long-term condition. In a practical sense, what is the hold-up? What is the problem? Is it that there are different systems across different hospital groups? Is it that, as has been aired a lot this morning, not enough data is being gathered? What are the hold-ups on the ground to those being rolled out?

Professor Brendan McAdam

Obviously, if there was an electronic medical record, which will take time to bed down, that would be very helpful, because when the data is collected, registry data can be automatically populated in a parallel system. There is a survey by the ESC called the Euro Heart survey on valvular heart disease, which we believe might be funded initially this year as part of the budget. That would allow us to start the project and roll it out in the south-south west area to see if this is a method we can use in our system to collect data, but we do need an actual strategy.

Deputy Neasa Hourigan

Investment in IT-----

Professor Brendan McAdam

Yes, investment in IT and funding to make sure that happens.

Deputy Neasa Hourigan

There is no structural issue within hospital groups; everyone is perfectly happy to work with that. Is that correct?

Professor Brendan McAdam

We will use Euro Heart, which is a digital registry programme, to try to see but this means that everyone at the source of the patient treatment will have to take five or ten minutes to input all the data into the database to populate it. We can then compare and benchmark what we are doing against our European neighbours.

Deputy Neasa Hourigan

I am sure this will be incredibly useful. Will staff have to undertake training to engage with the system?

Professor Brendan McAdam

Yes, that is all in place.

Deputy Neasa Hourigan

That is all in place already.

Professor Brendan McAdam

It is in place in the south-south west area to go live this year. There will be challenges in adopting it but that will be out pilot programme and test project to make sure it is adaptable. Hopefully, that will be adopted nationwide.

Deputy Neasa Hourigan

Great, I will keep my fingers crossed. Will Professor McAdam reiterate what region that covers?

Professor Brendan McAdam

It covers Cork and the south-south west. Dr. Peter Kearney has been leading the programme. He has linked, with the Irish Cardiac Society, ISC, to the Euro Heart survey, a digital programme that has been adopted by Sweden and other countries in Europe.

Deputy Neasa Hourigan

Does the catchment area cover approximately 400,000 people?

Professor Brendan McAdam

I am not sure of the numbers.

Professor Pascal McKeown

The platform is provided by the ESC, through its Euro Heart registry. If we were able to access gathering all of the data on the Euro Heart registry, we would be in a position to compare ourselves to other European countries in respect of the various conditions. It is going to start with acute coronary syndromes, which would be admissions to hospital with chest pain. This can then be used for other disease entities, which would then allow us to make accurate returns to the ESC atlas. We could then monitor progress against any investments that are provided.

Professor Brendan McAdam

I will add that the National Office of Clinical Audit, NOCA, has had the heart attack audit programme going for the past five years. This has been very successful in collecting data. However, that is only a small fraction of the patients we want to look at.

Deputy Neasa Hourigan

Am I correct that the fact we do not collect enough data is not just a problem for health policy and development but also means that we are not first on the list when it comes to research and development?

Professor Pascal McKeown

Yes, the ideal healthcare system would be one where every patient entering would contribute in some way to information about the system. Registries are one way of monitoring how many patients are presenting with condition X or Y. If we have research and innovation, it allows us to look at novel therapies for heart disease but it is also sometimes around the systems in which we operate and how networks operate to optimise access to care. That might be around care pathways, for example. Dr. Murphy mentioned access to imaging. If we build a culture of innovation around healthcare, we will end up with much better health outcomes. It would also allow us to keep patients in the community and have access to relevant care upstream so that they do not end up actually having to come in to hospital when they have already declared that they have a disease. There is a lot of information that would be aided if we had access to registries and better research and innovation within the healthcare system.

Deputy Neasa Hourigan

Ireland has a fairly significant pharmaceutical sector so it seems like an obvious one. I imagine that at the EU meeting a lot of it would have been about research and innovation and how we can push forward together across the EU.

Professor Pascal McKeown

Yes, it is also about how we look at best practice across the EU. Rather than reinventing the wheel, we need to see if there are models that have worked very well in other European countries that we can adopt. For example, Spain is now spearheading the development of its cardiovascular health strategy. We could look at this model to see how it works and how it would be of help to any future strategy here.

Professor Brendan McAdam

The ISC is a national organisation for cardiologists. We would love to see that being processed as North-South collaboration being involved in registries. Then we could have collaborations for research, innovation and lead clinical trials. For example, the SCOT-HEART trial was a CT scan study conducted in Scotland six or seven years ago. It helped inform best practice about the use of CT technology in patients presenting chest pain, with very favourable outcomes.

Deputy Neasa Hourigan

I think we would all like to see more North-South co-operation. I will move now to the issue of waiting lists. We are dealing with significantly different cohorts across multiple waiting lists. Some people have been referred by a GP, for example, and then we have some people who are experiencing a very specific health crisis. We have talked about it being a matter of days in some cases but years in others. I acknowledge Professor McAdam's point that gender-specific information is not available. If a woman goes to a GP because she feels unwell and the GP has a concern about her cardiac care and refers her for diagnostic testing, what is the average waiting time?

Dr. Niamh Murphy

I do not know if we know those data. It changes between different hospitals. The waiting list for an echocardiogram can be up to a year and the waiting list for an MRI is more than two years. There are excessively long waiting lists for all of these imaging tests. The GP would just have direct access to echocardiogram but that is not being fully developed in the community, because as we have mentioned, we have difficulty recruiting cardiac physiologists due to the embargo. Many community hubs GPs should be able to access for echocardiograms do not have staff in place, even though they may have the equipment, to perform them. Yes, the waiting lists for all of these imaging tests are excessively long.

Deputy Neasa Hourigan

Are there waiting lists for cardiac rehabilitation?

Professor Brendan McAdam

Yes, there are very long waiting lists.

Deputy Neasa Hourigan

How is that possible? I acknowledge Professor McAdam has said that staff levels have dropped by two thirds, which seems extraordinary.

Professor Brendan McAdam

The uptake rate of cardiac rehabilitation for people who would benefit from it is approximately 60%. In fact, women are underrepresented in attendance at cardiac rehabilitation for a variety of psycho-social reasons; because they are older, more frail or they have other comorbidities. With cardiac rehabilitation, we know that people will improve, stay out of hospital and stay well, with a reduced risk of cardiovascular death and myocardial infarction or heart attack, as Dr. Smyth said. However, the waiting list can be from three months to a year, depending on whether a patient is post stent, post bypass or post valve surgery. There are regional variations in the provision of those services around the country. For example, one cardiac rehabilitation unit has no physiologist or medical director. It is very hard to provide the multidisciplinary approach we know works to all patients around the country. Disparity of access is a huge issue.

Deputy Neasa Hourigan

With resulting negative impacts on outcomes, I am sure. Regarding the review of cardiac services, in December 2023, the Minister said it was being published in the new year so we are well over time to put a bit of pressure on there.

An Cathaoirleach

Senator John Cummins is not a member of the committee but he has kindly stepped in for Senator Seán Kyne.

Senator John Cummins

Senator Kyne sends his apologies. I want to take up the point about data. Data is being collected. What is the data that is not being collected compared to our European peers? I am from Waterford and I have seen data on primary percutaneous coronary intervention, PPCI, numbers for University Hospital Waterford, UHW; Cork University Hospital, CUH; Beaumont Hospital and St. Vincents University Hospital and, therefore, data is being collected.

The impression being given is there is no data. There is data. What is the data that is not being collected?

Professor Brendan McAdam

To clarify, we have the national heart attack programme which collects data for people having heart attacks. That goes to the regional centres for procedures to relieve open arteries and prevent further damage to the heart. That is the data we have and it is quite good. It has been collected for the past five years under NOCA. However, that is only one third of the types of heart attack that people suffer. There is another type of heart attack called non-ST-elevation, a different type of heart attack that is much more common and occurs in all the hospitals of the country. We have no data at all on that. We talk about heart failure and there is very limited and fragmented data on that. We have data from St. Vincent’s University Hospital and other units but it is very fragmented. We have no national data on what is going on in Sligo, Kerry or Tipperary for example.

Senator John Cummins

It is-----

Professor Brendan McAdam

No data on endocarditis, no data on atrial fibrillation, hypertension and its treatment, etc.

Senator John Cummins

It is because it is not presenting at regional centres and it is more common that a person presents with those kinds of incidents at a general hospital, as opposed to a model 4 hospital.

Professor Brendan McAdam

Correct. We have not got the infrastructure or the platform to be able to collect the data. That requires personnel and a digital solution which is the EuroHeart platform. That is one of the things we want to roll out all around the country if there is funding for it.

Senator John Cummins

When Professor McAdam mentioned that eurodata hub in the context of the South/South West Hospital Group, is that across all of the hospitals-----

Professor Brendan McAdam

Yes-----

Senator John Cummins

-----within the group?

Professor Brendan McAdam

We are going to start off with non-ST - a different type of heart attack - and roll it out over time to all of the other disease modules in heart disease.

Senator John Cummins

To Professor McAdam what is the most important one, outside of PPCI or STEMI?

Professor Brendan McAdam

The non-ST-elevation myocardial infarction, NSTEMI, is a significant cause for morbidity and mortality in patients. Usually they are in hospital with other comorbidities. On the provision of service for that type of heart attack, the European Society of Cardiology has recommended that those people get formal assessment and, if necessary, have an angiogram within 24 hours. The data in Ireland that we know about - for example in my own hospital - it could be a week before a person has an angiogram. A person could be sitting around waiting for an angiogram for a week.

Senator John Cummins

Professor McAdam mentioned a body; it is not NOAC, as that is local authorities. What is the agency that is collecting-----

Professor Brendan McAdam

It is the National Office of Clinical Audit, NOCA.

Senator John Cummins

The last report I can find is for 2021. Is there data for 2022 or 2023 that I could not find?

Professor Brendan McAdam

Professor Ronan Margey published that data for 2023.

Senator John Cummins

Can Professor McAdam say that again, sorry?

Professor Brendan McAdam

Professor Margey, who is the director, has that data and I have seen it. It has been presented.

Senator John Cummins

Can the committee see it? It is not available online.

Professor Brendan McAdam

I can ask NOCA to share that with the committee.

Dr. Yvonne Smyth

If I may-----

Senator John Cummins

Please.

Dr. Yvonne Smyth

-----the unique health identifier is also very important. We know an ehealth system is a tremendous undertaking and massive investment but a unique health identifier is key to all of this data collection. We can at least know that if a person presents to a hospital, he or she is the same person that presents to another if we are trying to clean our data set. I know from IT colleagues locally that it is sitting there in the background. It is not turned on. We need a unique health identifier, we need one number per person.

Senator John Cummins

Is there a reason why the last report I can see – and I appreciate the witnesses are not representing NOCA – is from 2021? Why is it I cannot see the reports from 2022 and 2023?

Professor Brendan McAdam

I can certainly ask.

Dr. Yvonne Smyth

It has been presented, as Professor McAdam said. Professor Margey has-----

Senator John Cummins

Presented where?

Professor Brendan McAdam

At cardiology meetings.

Senator John Cummins

Right. Is has not been presented anywhere else?

Dr. Yvonne Smyth

NOCA sits within RCSI if I am not mistaken. Invitations have been issued each year for us to attend and look at that data. I am sure it is freely available. I can get it to the Senator.

Senator John Cummins

That would be helpful. This is quite a contentious issue in my own area of the southeast and Waterford in the context of UHW. The 2021 report states that the data that is there regarding STEMI is only related to the time from 8 a.m. to 5 p.m., five days per week, and it states that UHW moved to 8 a.m. to 8 p.m. five days a week. The second session we are having relates to recruitment. There are sanctioned posts at UHW and many of those have been filled. The backfilling of those posts is the challenge and that speaks to what Dr. Smyth has mentioned here in respect of getting that service operating from 8 a.m. to 8 p.m. seven days a week, which is obviously a significant step forward in terms of provision. To be able to see the difference in the numbers is important for me as a politician who is interrogating that. I agree that data is key. It is key in every walk of life. If we do not have data we are not able to compare. What I expect to see in the 2022 and 2023 data is increased numbers at UHW. It has achieved that with less of a staff complement than what is in comparable hospitals. Does Professor McAdam agree with that?

Professor Brendan McAdam

I know from speaking to colleagues that they have worked very hard in that south-west service, in Waterford. It now has two cath labs, I believe.

Senator John Cummins

It does. I see from what happens in the cardiology department and other areas in UHW that the staff team and management are able to achieve numbers that are not being achieved in other hospitals. They have achieved that with fewer staff and less of a budget. That begs the question; if the numbers and presentations are as high and are increasing and the staff complement is considerably lower, how is it achieving that when other hospitals are not? We are talking about money and budgets and making economies of scale regarding efficiencies in ehealth and the rest of it. How do we maximise outcomes based on the staff complement we have? That is the question I am posing.

Professor Brendan McAdam

I obviously cannot speak to Waterford but I know the staff have done a great job there. My own institution of Beaumont Hospital has had two cath labs for ten years. The second cath lab has been closed about 20% of the time because of staff shortages. Somebody asked me why the waiting list for an angiogram after a heart attack takes a week to organise. It is because we have only one lab running with the staff to run one procedure room, while we have another expensive room sitting idle.

Ms Barbra Dalton

There is some data being collected and Professor McAdam has outlined the structured ones. The data that is being collected is generally done in quite an ad hoc way. From the Irish Cardiac Society’s perspective, when we try to submit data to the wider EU surveys, it can end up looking like we are not participating or active in areas where we actually are, which is a real shame as there are fantastic things happening in cardiology and our trainees are the best in the world. We are not even getting a chance to show our figures in that regard. I can say from a cardiac side of things it is a scramble to find the information for that. There is the device side of things also; how many pacemakers or ICDs? We struggle to collect that data. The Senator is correct in that there are some structured systems in place to collect data but as Professor McAdam said, that is only for a certain amount and what we really need is to take that wide open. If we have the data and can put it in, then the comparisons with us across Europe and even across the Border become much clearer. That supports the arguments we are trying to make much better.

Senator John Cummins

Ms Dalton mentioned the position across the Border. The next session relates to recruitment and I am interested in the opinions of our witnesses as clinicians on this. If we ignore the embargo and the challenges it has had for a moment, if there was no restriction and no budget, would we be able to fill all the positions that are there in the field of our witnesses? Is there availability of highly skilled professionals? Are the highly skilled, competent people available? It is a competitive market for staff from right across the world.

Professor Brendan McAdam

Recruitment is a challenge, even with the embargo being lifted. For example, there was a large roll-out of cardiac rehab in the community through community hubs with rehab-dedicated persons, but recruitment has been a challenge because it is difficult to get people who are qualified for that position. We embrace private hospitals as a Band-Aid, in that they help us with investigations that are outsourced, and we must remember that there are very good people working in the private sector, but this makes it difficult for public hospitals to recruit them in order to develop services in CT, rehab, MRI, echocardiogram, etc. It is a competitive environment to work in and private hospitals can sometimes provide better conditions, making it difficult for public hospitals to compete.

Professor Pascal McKeown

It can be difficult. It takes time to bring individuals through the relevant training. From completing undergraduate studies to being eligible for appointment as a cardiologist, it is at least eight years, if not nine or ten.

Ms Barbra Dalton

Add on another six years in specialty training. The training programme is constantly expanding and we now typically take in 13 to 15 trainees per year. Previously, some years only saw four or maybe six. We are planning the workforce and there are more trainees. The programme is second to none and trainees get an opportunity to go away and get their specialty training. All things being equal, we would have the bodies to fill the cardiologist and specialist posts in time.

Senator John Cummins

I mean no disrespect, but none of us wants to see the witnesses. However, it is good to know that, if we do need to see them, there are more people coming through the pipeline.

Deputy Gino Kenny

I thank the witnesses for attending. My first question is on social determinants. This is an important matter in public health, including cardio health. How concerned is Professor McAdam about the proliferation of highly processed foods, particularly among children?

Professor Brendan McAdam

A reflection of that is the fact that obesity is on the increase. People have bad and unhealthy diets and a lack of exercise. They are on their devices all the time. These are important social determinants of disease. If someone becomes obese at a young age, it will be a lifelong problem with a myriad of cardiovascular health, hypertension and diabetic problems, so it has to be tackled at policy level.

Deputy Gino Kenny

If a child consumes that amount of processed food, what are the health effects on the child’s heart?

Professor Brendan McAdam

The child’s lifetime risk of cardiovascular disease, diabetes and hypertension is massive.

Deputy Gino Kenny

Starting at a young age.

Professor Brendan McAdam

Yes. It is very difficult to lose that weight. We have new weight loss injectable medications, but there is limited access to them at the moment for people with diabetes and obesity. There is a future in that regard, but we want to get back to basics and make sure people have a healthy and balanced lifestyle with good eating habits and are educated at a young age about diet and exercise. This is essential.

Deputy Gino Kenny

What factor does drug use play? Regarding the prevalence of cocaine, for example, regular use will obviously have a detrimental effect on someone’s health, including the heart. Does Professor McAdam see that in his work?

Professor Brendan McAdam

Yes. At Beaumont Hospital, my colleagues and I will once or twice per week see people coming in with cocaine-related chest pains, heart attacks and significant-----

Deputy Gino Kenny

How prevalent is that?

Professor Brendan McAdam

It is difficult to give a number. I would say that approximately 10% of our chest pain admissions may be directly or indirectly related to drug use.

Deputy Gino Kenny

That figure is quite high.

Professor Brendan McAdam

There is always a risk of sudden cardiac death. In fact, I have a few patients who have significant heart damage and are on life-saving treatments. One has a defibrillator and is only 29 years of age. That patient may end up getting a transplant. It is a serious health problem and growing.

Deputy Gino Kenny

What about alcohol?

Professor Brendan McAdam

Alcohol has a large impact on adverse cardiovascular outcomes and cancer outcomes. Obesity and poor diet lead to hypertension and significant health problems, including heart and liver problems.

Deputy Gino Kenny

Most of us would not view air pollution as a factor in heart health, but it is. If people are breathing in these fumes-----

Professor Brendan McAdam

It is well described as being an adverse risk factor for cardiovascular disease. Obviously, smoking and e-cigarettes are also harmful.

Professor Pascal McKeown

Within the UN sustainable development goals, carbon-neutral policies and so on, we recognise that levels of PM2.5, that is, particulate matter, remain high and there is a direct correlation between the levels of pollution and the incidence of coronary heart disease. It causes some sort of inflammatory reaction within the walls of one’s arteries, accelerating the risk of atherosclerosis. Part of the European Union’s strategic plan is to consider air pollution and air quality and how they relate to the additional problems associated with smoking, vaping and so on.

The Deputy referred to social determinants of health. At our congress last week, we heard that there was something like a 14-year gap if someone was born into an area – the equivalent of an eircode – of high social deprivation compared with someone who was born into an area with limited social deprivation. It is a large societal issue for us and we need to address the social determinants of health. Someone’s life expectancy should not be determined by where he or she is born.

Deputy Gino Kenny

I thank the witnesses.

An Cathaoirleach

I will ask a couple of questions. Figures of 9,000 deaths and 25,000 hospital admissions per year were mentioned. Cardiovascular disease is the second-most common cause of death in Ireland and cost €3.4 billion in health and social care in 2021. It seems extraordinary that there is no plan. When we met people concerning sight loss, we were told there was no plan in that regard. There is no plan for audiology. It seems that us not having a plan is a common feature across the spectrum. This does not make sense, given the amount of money involved.

It was stated that more women than men were affected by cardiovascular disease in Ireland and that the impression that mostly men were affected was not supported by the research. If the witnesses had the opportunity, what types of research would they pursue? Would they look into why more women than men were affected, for example? What types of research should be done?

Professor Pascal McKeown

I would suggest two main themes, the first of which is research of individual diseases. Women are often under-recruited to clinical trials, so when interpreting the trials’ findings, they are much more difficult to relate. If we do not have women included in the studies, how do we translate those findings to women? There is also the question of the organisation of health services and understanding how to deliver care in a way that provides the best return on our investment. There is clear evidence that it is better to have a community-based approach in order to ensure that services are delivered locally where it is feasible to do so, but also to address the social determinants of health and to move the lens towards prevention to see what we can do. Many of these conditions do not just affect the heart, but also the risk of cancer, the risk of developing obesity and the risk of liver disease. They are all common pathways. If we manage to invest much more in upstream prevention, it will have an impact, not just on heart disease, but on many other diseases as well.

There is an issue around research and innovation. There is also the issue of recruitment and retention of staff. If people work in a culture of inquiry, they are much likelier to remain in that environment because they feel they are contributing to the development of new knowledge. Many of the treatments we are providing at the moment may not be as effective as others. We must ensure that we get value for money for the investment provided to the health service.

An Cathaoirleach

As part of the health initiative, we met Professor McKeown in Queen’s University Belfast.

In the context of our trip to Altnagelvin hospital, there is a link with Donegal. On linkages, I presume our guests would like to see such initiatives rolled out across the island. If patients are living in Cavan they do not want to travel for two hours to get to the nearest hospital. Are there other initiatives like that? Drogheda was mentioned earlier. Would people from the North travel to Drogheda or vice versa? Daisy Hill hospital in Newry would have been one of the centres at one time. Do our guests see that happening more in the Border region, particularly in the context of time-critical care? We have heard talk about the so-called golden hour in respect of many of these matters. How important is that cross-Border element, particularly for those in rural areas?

The plan refers to standardised services that are provided as close to home as possible, but that is not happening in some areas because of geography. Do our guests have any views on that? What is the worst area to live in? Is it Kerry or Donegal? As stated, the latter has a link with Derry. Is it the west of Ireland more generally? Where are the black spots for healthcare and for cardiac care in particular?

Professor Pascal McKeown

The European Union is very focused on border areas. Special funds are available for the development of services but it is very competitive and it is difficult to get that kind of funding through special EU projects. There are areas where patients end up travelling five hours to get to Dublin for treatment, whereas if they were able to go to a local hospital in Northern Ireland, there would be an opportunity to provide services there. The heart attack centre at Altnagelvin hospital provides for patients in Donegal. There are other ways in which we could treat patients using the shared island approach. A lot of funding has gone into the shared island initiative. We would advocate for more money to be made available through that fund. That would be something we could use.

Professor Brendan McAdam

Part of our vision is to try to have registries and structures or networks set up so that we can provide better care, measure what we are doing, collaborate much more and get funding for better innovations. The Cathaoirleach asked about black spots, but it is very hard to know. Most hospitals look at their own data, but it is very fragmented. We would have to get an overall picture to know exactly what we are doing. Thereafter, we can plan and if there are black spots, we can address them with proper resources and personnel.

An Cathaoirleach

We are over time but I want to quickly give a little of my own background. My mother died of a massive heart attack. I was a teenager at the time, so it may have gone over my head but I do not remember the family being told to get tested. This was in the mid-1970s. Things have changed since then. We discovered years later that I am a carrier for haemochromatosis. That might have been the cause of my mother's death but, as a family, we do not know. Certainly, testing was not part of the package then. Is it part of it now? If a family member has a heart attack, a mother or father, for example, would it be normal to contact members of the family, particularly if it is hereditary?

Professor Brendan McAdam

That is what we encourage. It is very fragmented but that is what we encourage. People who have had premature heart disease in their families should get checked out for blood pressure, diabetes and cholesterol, adopt healthy lifestyles and, if necessary, get tested further to see if they are at risk. It is very fragmented at the moment, but that is the kind of service we want to see going forward. We talk about the statistics and 9,000 people dead but they are mothers, fathers, sons or brothers who have been lost and that has a huge psychological impact on families. In that context, rehabilitation and counselling needs to be addressed as well.

An Cathaoirleach

A point was made earlier about women not following up with rehabilitation for various reasons, including, I presume, their caring role. Will our guests to outline the importance of rehabilitation after a cardiac event? Reference was made to peer support. For those in that situation who have not followed up on rehabilitation, I ask our guests to explain its importance.

Professor Brendan McAdam

A sound bite that has been around in rehabilitation circles for a long time is that cardiology teams save lives but rehabilitation teams give patients their lives back.

Professor Pascal McKeown

Rehabilitation is also important from a psychological perspective. It is a very frightening situation to have suffered a heart attack or to have had cardiac surgery. We also look at the mental health and well-being of patients and it is much better if they attend rehabilitation.

Professor Brendan McAdam

Psychologists are part of the rehabilitation teams. However, it is important to point out that for the past ten years 50% of rehabilitation teams have not had a psychologist as an intrinsic member of their programme because of staffing difficulties.

An Cathaoirleach

There are many issues we could discuss if we had the time. Maybe we can do so at some stage in the future. There will be a new committee and there may be a new Cathaoirleach. Who knows? We really appreciate our guests' input today. I thank the Irish Cardiac Society for its engagement with the committee on the important issues and challenges in relation to cardiology.

Sitting suspended at 11.06 a.m. and resumed at 11.12 a.m.