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JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 18 Sep 2003

Vol. 1 No. 14

Rheumatology Service: Presentation.

I apologise, on behalf of the committee, to our guests who were due to give their presentation at 11.30 a.m. but we had a number of issues to discuss following the summer recess.

I welcome Dr. Eoin Casey from St. James's Hospital, Dublin; Dr. Robert Coughlan from Merlin Park Hospital, Galway; Dr. Grainne Kearns from Beaumont Hospital and Dr. Michael Molloy from University College Hospital, Cork. I ask Dr. Casey to begin the presentation on the current and future needs of the rheumatology service. I draw our guests' attention to the fact that while members of the committee have absolute privilege, that same privilege does not apply to witnesses appearing before it. Members are also reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside of the House or an official by name or in such a way as to make him or her identifiable. I apologise for the absence of the Chairman of the committee, Deputy Batt O'Keeffe, who, unfortunately, is unavoidably absent for the day.

Dr. Eoin Casey

I thank the Chairman and members for inviting us to appear before the committee. My colleague, Dr. Kearns, will outline the position in broad detail and she has supplied some material for members. I apologise for the fact that I am not wearing a jacket. I seem to be the only person who does not have a jacket, but I cycled here and did not wear one.

Dr. Casey will freeze to death before he leaves here. The air conditioning appears to be set permanently on cold.

Dr. Casey

If it is acceptable to the committee, I will ask Dr. Grainne Kearns, who was involved in the national strategy, to make her contribution and I will then speak.

Dr. Grainne Kearns

I thank the Chairman and members for inviting us to meet them today.

We have been working on bringing to the Government's and the public's attention the severe constraints in managing patients with rheumatological conditions. I will now provide details of the type of patients we treat and those about whom we are most concerned, who, we believe, are losing out in terms of current health service structures.

The largest group of patients we treat on an ongoing basis is comprised of those with rheumatoid arthritis. Most people have met individuals with rheumatoid arthritis, which is an extremely painful and disabling condition. Patients with this condition suffer severe pain and cannot function. Many of them are afflicted by profound stiffness. Some patients who come into our clinic at 10 a.m. might need to get up at 4.30 a.m. so that their joints are loose enough to allow them to travel to the clinic. Untreated, rheumatoid arthritis leads to ongoing disability. It was traditionally thought that when a patient's condition became quite bad, disease modifying drugs would be prescribed in order to try to help them. We now know there is sound evidence in the relevant medical literature that these patients need to be treated early in order to prevent disability and deformity and to allow them to maintain their functional status in life.

This is a disease that occurs at all ages. Young mothers come into our clinic who are unable to hold their babies, lift them out of their cots or look after their families. A total of 50% of people who are diagnosed with rheumatoid arthritis are out of the workplace in five years. That is a frightening statistic. If we can identify those with the problem at an early stage, we can treat them with disease modifying drugs such as methotrexate, which works well for the vast majority of patients. Newer agents are now available for those patients who are recalcitrant to this treatment.

How can we equate the fact that early diagnosis and treatment are critical in respect of this disease with the fact that there are waiting lists of up to four years in the west? That is an appalling indictment and it is negligent, from a medical and every other point of view, that this position should be allowed to obtain.

The other group, the members of which it is important that we should treat early, is comprised of those with auto-immune disease, of which systemic lupuserythematosus is an example. The latter occurs in women of childbearing years. It can be a mild disease but if it goes unrecognised and untreated, it can be fatal. The disease affects the brain and kidneys and can cause people to go into renal failure. However, it is treatable if it is recognised and monitored. The people it affects are young women with young families. I do not want to appear to be displaying a female bias, but these patients really need to see rheumatologists at an early stage. It is a rare enough condition and those involved in general medicine may not be aware to look for it.

The health strategy placed huge emphasis on ageing. We are an ageing population and osteoarthritis is a condition that affects all of us. If one looks at the cartilage of a person of 40 years of age, one will see the early signs of degeneration. We are all going to get it. However, simple measures such as advice and early intervention can keep people mobile and functional at home and help prevent disability. A badly frozen shoulder can be enough to make an elderly person require long-term care because they cannot look after themselves. If we can get these patients early and treat them, we can prevent this disability. It is not just aches, pains and groans with which we deal.

When the health strategy was published, we were astounded that there was no mention of rheumatology. The Irish Society of Rheumatology, therefore, established a health strategy group, which carried out a survey - it is the rather large document with which members were presented earlier - of rheumatology services in Ireland. I will briefly summarise the main points contained in the survey. We met officials from the Department of Health and Children and the Minister, Deputy Martin, in April and presented the strategy to both.

The number of rheumatologists per 100,000 of population in Ireland is the lowest by far in the European Union. Frighteningly, it is considerably lower than non-EU countries such as Croatia and Russia. There is a graph on pages 8 and 9 of the document if members are interested. We only have 38% of the optimal level of rheumatologists according to a paper by Debbie Symmons who reviewed the status of rheumatology. One of the most frightening statistics is that there are regions of this country that do not have rheumatology services. I refer here to the North-Eastern and Midland health board areas. Since we established the strategy, the Mid-Western Health Board has advertised for its first rheumatologist. There are regions that are particularly under-served which are represented here today, namely, the western seaboard, the Southern Health Board area and also the area of the EHRA that encompasses Tallaght. These limitations lead to very lengthy out-patient waiting lists. In Galway, the waiting list is up to four years.

There are also no paediatric rheumatologists in Ireland. There are paediatricians who have a special interest in trying to fill the gap and who are doing a good job, but they are not fully trained rheumatologists. In Ireland, 94% of rheumatologists also have a general medical take commitment. Only 19% of their counterparts in the UK have such a commitment. This eats considerably into the time available for rheumatology. Beaumont Hospital, for example, has two rheumatologists but if one takes our sessional commitment to rheumatology between both of us, excluding general medicine, there is only 0.8 of a rheumatologist. Rheumatologists do not work alone. We need the backup of physiotherapists and occupational therapists to keep people functional. Early splinting and exercise keep people mobile along with medical help but many areas do not even have such backup support.

I would like to thank the committee for listening to the presentation. We made some recommendations to the Minister, which can be found at the back of the health strategy. Any health board, where there is no consultant rheumatologist, and any region where their ratio is 0.4:100,000 or less, are in an emergency state and they need emergency provision of rheumatologists. At least one paediatric rheumatologist is needed as well as backup, including clinical nurse practitioners, occupational therapists and physiotherapists. We have more short-term recommendations, once the emergency package is filled. They are listed on page 24 of the health strategy. There should be no single-handed rheumatologist. Accountability should be allowed for general medicine to increase the rheumatology commitment. We need to be able to treat patients quickly and arrange for follow ups with their general practitioners.

Dr. Casey

Dr. Kearns has expressed the situation accurately. There are probably two million people with osteoarthritis in Ireland. There are possibly 100,000 with rheumatoid arthritis. These statistics are approximate, as we do not know the exact prevalence or incidence. The Arthritis Foundation is an important organisation and I hope it will conduct a detailed survey of the incidence. The waiting lists in some hospitals in Ireland are almost of third world magnitude.

I refer to statistics at the two institutions in which I have been involved, my rheumatological constituency. Tallaght Hospital is a fantastic new hospital, absolutely superb. We have tremendous facilities, including the best hydrotherapy in the country and that is a dangerous boast. We have had 300 new letters for referrals for arthritis to be seen and they are being filed. Part-time rheumatolgists continue to do a locum there and the administrators are tremendously supportive but there is a need for at least two rheumatologists at the hospital. St. James's Hospital has a possible connection with Naas General Hospital, both of which are in the constituencies of famous politicians, Deputies Harney and McCreevy. We have been seeking support for services in all three hospitals.

Two new rheumatologists have been appointed in St. James's Hospital but the waiting list is still significant and it takes up to eight months for a new appointment. Dr. Gaye Cunnane, my new colleague, who is extremely well trained and experienced, agrees about the urgent need for resources in the hospital. There is a major need for a walk-in, one-stop arthritis day care centre. One has been established in St. James's Hospital and the Minister kindly opened it. He promised us €500,000. He was charming and impressive but we are still waiting for the money. Hospital and community access needs to be improved. The Arthritis Foundation is doing its best to improve the education and long-term benefits of patients. I have brought a few random samples of the booklets given to patients, which are invaluable, because they have a tremendous fear of arthritis and being crippled in wheelchairs and so on. If we get patients early enough, we can help them tremendously. The Arthritis Foundation is doing tremendous work but it needs more support.

I thank the committee for listening to us. I will be more parochial and refer to my health board area and the problems that arise in it. The document I have circulated expresses the difficulties we have. The blue line is through 1994, which is a base year. It was my first full year in Merlin Park Hospital. Subsequently, the number of new and review patients increased every year until 2001 and 2002 when we cut back on the number of new patients because we did not have the physical capacity in terms of rooms and time to see them. Nevertheless, the review patient numbers kept increasing. The orange colouring expresses the increase from the base year as a percentage up to 69% in 2000 compared to 1994. In spite of the increase in the number of patients being seen, which is reflected in other hospitals, the waiting list increased from 113 in 1994 to 1,268 last year and it is longer this year. The waiting time, that is, the time it takes for a patient to be seen following referral, has increased from four months to four years and it is longer this year. We are seeing fewer patients because we do not have the capacity.

To illustrate the problems most rheumatologists have, we are also involved in acute medicine. We also see emergency cases. Our rota varies from one in four to one in eight and that time is represented by the number of admissions in the column, ADM. There was a total of 1,640 in 1994. Using the same number of beds and with a slight reduction in the rota from one in five to one in six, the number of patients put through the unit has increased to 1,361. That is expressed as a percentage in pink. The number of admissions was 30% higher last year compared to 1994. Those are the demands on the service and there is not the capacity to cope with demand. A person who is referred today will not be seen until well after the next election.

This represents difficulties locally. It represents long travelling for patients from the far side of the health board area in north and west Mayo, west Galway, the mid-western area and the Midlands Health Board. These patients travel to clinics operating at twice their capacity and they must wait for two or three hours. They are not healthy and it is not easy for them to sit in an overcrowded waiting room for two hours. A great deal of suffering is expressed within these statistics and is experienced because of the physical condition of the rheumatology service in terms of the type of outpatient clinic we work in, the distance between it and the patient's home and the waiting times.

Dr. Michael Molloy

I thank the committee. Dr. Coughlan's situation in Galway reflects the one I face in Cork. Our service, provided by two full-time rheumatologists, covers Cork and Kerry and a population of 500,000 people. Patient numbers have increased. We see 4,000 to 5,000 patients annually in my hospital and the general medical problem arises there. The number of outpatients requiring to be seen has increased so it is not possible to give an out-patient appointment now unless they are an emergency. They go on to a waiting list and are dealt with on a priority basis, with general practitioners ringing up stating whether the person's condition has worsened. It is far from ideal.

As a consultant rheumatologist for more than 24 years at Cork University Hospital, I find it impossible to find the appropriate word to describe the nature and scale of the crisis affecting this service. Terms such as "disastrous", "appalling" or "catastrophic" could be used without indulging in any degree of hyperbole. To substantiate my assessment, I would like to outline briefly certain aspects of the current situation.

These musculoskeletal conditions are very common, and one in six American citizens is affected by arthritis to some degree. If this is applied to our population, at least 500,000 people are affected by arthritis. A recent World Health Organisation study published extraordinary findings on the burden placed on the health of a developed country's population by musculoskeletal disease. It estimated that this burden was only slightly less than that imposed by either respiratory or digestive diseases, which is not what many think is the case.

Taking the ubiquity of musculoskeletal conditions such as arthritis into account, one cannot sufficiently stress the dreadful level of pain and debility associated with such diseases, especially in the absence of ready access to specialist therapeutic services. Another recent WHO study noted that musculoskeletal disorders are associated with some of the poorest quality of life issues, especially in terms of bodily pain and physical functioning. They rated the severity higher than that associated with gastrointestinal, chronic respiratory or cardiovascular conditions.

From my experience of treating many thousands of patients with such conditions, I can categorically state that such statistics provide only the most minimal of insights into the cruel suffering which can result from belated or inadequate access to appropriate therapeutic services. To observe suffering in its many manifestations is an unwelcome daily reality for anyone working in the medical world. However, to encounter routinely pain and distress that can be removed or at least palliated with adequate modern medical technology and techniques is truly heartbreaking. This is the unfortunate daily reality for those working in the rheumatology services.

I will illustrate some facts about the crisis. A review paper on rheumatology services in Europe estimated that Ireland had by far the lowest rate of official rheumatologists per 100,000 population in the European Union. It was half the figure of the United Kingdom, one-ninth that of France and approximately one-twelfth that of Denmark. We also compare abysmally with a range of non-European Union countries, such as Hungary, Croatia and Russia. This has already been mentioned by other speakers.

It has been estimated that our number of consultant rheumatologists is approximately 38% of the figure recommended as being adequate by international standards. Instead of having one rheumatologist per 80,000 people we have one per 220,000 or so. The Royal College of Physicians suggests an upper limit of 2,000 consultations per year. My personal experience over the past six years or so has been dealing with 5,000 to 6,000 patients per annum.

It is also important to note that the consultant is only one component of a multidisciplinary team dealing with arthritis which includes specialist nurses, physiotherapists, occupational therapists, psychologists, podiatrists and social workers. There is therefore a wider manpower shortage in the service.

The situation is extremely grave. The appalling human suffering associated with untreated patients with conditions such as osteo and rheumatoid arthritis is mirrored by parallel financial costs. The WHO estimates that the annual cost is in the range of 1% to 2.5% of a developed country's gross national product. In the Irish context, this suggests at least €1 billion each year.

I fervently ask the committee to take every option available to it to ensure the enormous human suffering associated with untreated or belatedly treated musculoskeletal disease in our country is systematically and rapidly brought to an end.

A final statistic might highlight the individual trauma characteristic of such conditions. It has been estimated that there is a 42% risk that a person newly diagnosed with rheumatoid arthritis will be assessed as being disabled within three years. All the European and UK figures show that these people rarely come off the disabled list. The technology available in our field is becoming increasingly sophisticated and effective. It is vital that a process of radical development of our rheumatology service be commenced as a matter of extreme urgency to exploit such advances optimally in the best interests of the people. As a profession, we are wholly committed to supporting such a process wholeheartedly.

I do not have the figures for the Southern Health Board region but they are in the public domain and are included in the national manpower document.

I welcome the delegates and thank them for their enlightening if somewhat sad presentation. As they were delivering it, all my joints ached and it occurred to me that we are all unfortunately probably heading to specialists such as the delegates.

What number of specialists or consultants do we need to recruit to address the problem adequately? Do we have a college or institute to which consultant rheumatologists belong; do they act as trainers; how many trainees do they have, and how long does the process take?

The delegates' presentation was very enlightening but it appears we will not solve this sad problem over night. They all referred to the multidisciplinary team and especially occupational therapy, physiotherapy and the clinical nurse practitioner. I know the Commission on Nursing placed major emphasis on clinical nurse practitioners, and that would appear to be the way to go. Is that happening, is it being allowed and has An Bord Altranais allowed for it? Do we have the registration of such specialists? What impact is it having, if any?

On occupational therapists and physio-therapists, we know that new schools are opening and that numbers will be increased. It is to be hoped that, in the next three to four years, we will see more people in these specialties. Willthis make an impact and can it progress the existing situation? Is there a recruitment policy in place?

I apologise to Deputy Olivia Mitchell as I should have called her first as spokesperson for the Fine Gael Party. Before the delegates answer the questions, we will take some more.

I welcome the delegates and thank them for the presentation. I have only one question which, if we had the answer to it, would get to the root of why this area has been so neglected. I speak as someone who knows about pain and suffering. I have suffered from rheumatoid arthritis since I was a teenager and know how disabling it can be in the acute phase. It appears to me that perhaps there is a view that there is something inevitable about us all suffering from it at some stage, that it is not really a disease and that one takes a few Disprin and expects to feel fine. That appears to be the explanation as to why we have so few consultants and the lowest number of them per head of population not just in western Europe but probably in eastern Europe as well. It appears to have been incredibly underresourced over a long time. I know there is a physical capacity problem but I gather that the waiting lists are primarily due to the shortgage of consultants.

Why do the delegates think it is so neglected? Is it that hospitals do not request consultants? Is it because Comhairle na nOspidéal and the Department of Health and Children do not rate it? Why do the delegates think they have not been regarded as essential for such a long time? Is it that there is a view that this is something GPs deal with? I know this is a difficult question.

I thank the delegates for attending. I know they are busy people but theirs is an important presentation which described the stark and terrible situation for patients.

Has the strategy the delegates presented to the Minister been accepted by him and his Department; is it being implemented or do they envisage it will be implemented? We know the cardiovascular strategy has been effective. It is one of the few examples of success. Do the delegates feel confident that the plan has been accepted and that implementation will begin or are they just hoping?

It is staggering that we are providing one third of the consultants we should be providing. We have only half of what is in the UK. Dr. Kearns mentioned one or two appointments being made. Overall, can she see a significant change in the number of consultants and are there unfilled posts anywhere at present? There is obvious geographic inequality. The submission mentioned some places where there are waiting lists of between four and five years and others where the waiting lists are of six to eight months. Is there any region where the system is working? The submission paints a very stark picture.

The capacity problem outlined is, obviously, central to any improvement. The Government keeps telling us it has spent more than 140% more on the health budget than was spent when it came to power in 1997. Have the delegates seen that? Can they say they have seen some improvement in capacity building that relates in any way to that increase in budgeting? We are now at the EU average health spend, yet our rheumatology service seems to be more appropriate to the Third World. Can the delegates say we are even going in the right direction and that there is any correlation between the health budget improvements and improvements the rheumatology service is experiencing?

Dr. Casey

As the oldest rheumatologist here, perhaps I could start. I will be brief. The inevitability of arthritis has been mentioned. When Father Keane, Moss Keane's uncle down in Kerry, used go to the Stations and see people limping he used say it was caused by the bog water. It is not acceptable that everyone will get arthritis.

Deputy McManus asked if improvements are working and what is available. There still seems to be money in the Celtic tiger for new cars, new boats and this and that. However, when one is at the coalface one sees people lying on mattresses and trolleys for three days in the acute services. Arising out of the closure, in my constituency, of the Meath, the Adelaide and other small hospitals patients are pouring into St. James's and Tallaght hospitals. It is horrific to see how primitive things are. The stress level of people at the coalface is tremendous.

The Minister has listened to the strategy but I will let Dr. Kearns talk about that. The service needs more funding. It does not need sophisticated or fantastic tests. Rheumatology nurses and physiotherapists liaising with the community would often provide a fantastic service. We have a training system. There are eight trainees. There would be no shortage of candidates for rheumatology posts if the cheque were signed.

Dr. Kearns

The Minister was very open to our concerns, he agreed there was a major problem and said he would set up a committee. Professor Fitzgerald headed our sub-committee of the ISR and we are awaiting a further response since April. It took us two years to get the meeting with the Minister. We had to go to the health boards' executive and write to all the health boards. We are hopeful that he will respond to us but we also appreciate this opportunity to voice our concerns in another forum.

Some new positions have been created. Mine was a new position. I have been working in Beaumont for two years. There has been a second position established in the Mater and in St. James's Hospital. The Dublin area, apart from Tallaght, is better serviced than areas outside Dublin. It is not ideal and if one accepts our general medicine commitment we are still far below what is required. There is geographic inequity.

We have four rooms for out-patients. Our patients take a while to get in and out of a room so that our clinics go on much longer than they should and we see fewer patients than we should. Rheumatology is a trade. The service should be consultant provided because it is not a question of interpreting a blood result. A clinical examination is required. Most patients need to be assessed by the consultant so one must go from room to room. The system is grossly inefficient. We lack basic essentials such as rooms to see out-patients.

In 1995 Comhairle na n-Ospidéal published a report on the development of rheumatology. The report recommended 11 extra rheumatologists. The recommendations were not different from the recommendations in our manpower study but nothing has happened since. This is really disheartening. We recommend that six consultant posts should be established as a matter of urgency to fill the areas that are underserved. We asked for an emergency package because we felt that was the only way we would get funding. There should be clinical nurse practitioners in every unit. As our patients are on toxic drugs they need to be monitored and there is a huge role for the clinical nurse practitioner. There should be at least one occupational therapist and physiotherapist per rheumatology service. We do not have that. Psychological stress is associated with chronic disease but only one area of the country has psychological support for patients.

We have a long way to go. Our emergency package is a stopgap measure. On page 24 of our submission we make medium and long-term recommendations to improve the service. Our service is relatively cheap. Most of our patients are out-patients. The newer agents are expensive but if applied in a proper fashion over time they will cut down on expenditure because people will be kept in the work place. The health budget must be balanced against social welfare and disability payments. These drugs will pay for themselves at the end of the day.

There has also been a report from the Department and I do not know what has happened to it. I have asked but all I hear is that there are no funds. We have had a nurse specialist for the past year and it has made an enormous difference to the quality of the service. These little things help.

Deputy Mitchell asked why rheumatology has a low priority. It may be our fault. We have been working too hard and not shouting loud enough. We have expected people to see that we need help. In the past 12 months we have realised the need to tell people there is a problem.

Dr. Molloy

I am at the end of the table, appropriately, because we do not even have a nurse specialist although we are talking about a large territory covering the whole of Munster. Our service extends from Cork to Kerry and many of our patients have to travel up to 90 miles to get to the clinic. We do not have a nurse specialist but we do, fortunately, have a research programme that provides a part-time nurse specialist who is paid for out of the research funds. This individual is responsible for the patients and the biological agents that have been mentioned and that are so effective. We have farmers back working who could not dress or feed themselves. These drugs do work. However, they require a huge amount of monitoring. One needs a nurse specialist and a good computer programme. If the distance is great it is even more difficult to deal with patients' problems when they arise, and they arise all the time.

We do not have a high profile in hospitals, although we are internal physicians, because we are playing two roles. We are doing internal medicine so we are getting the benefits of the equipment that comes into internal medicine but our own specialties have lost out. Our colleagues - renal physicians and cardiologists - in the internal medicine division, as we all have in hospitals, are receiving massive funding. One could have four or five oncology nurses and no rheumatology nurse because we have not been prioritised.

We are making this presentation in the hope that this committee can gain some priority for us. We cover a huge territory. It is frustrating to have GPs calling asking us to see particular patients. Our policy has been to see those patients thereby increasing the number of people being treated beyond a manageable level. If we brought risk management into the equation, we would not be allowed to do that. The EU and College of Physicians numbers in this regard are 2,000 patients per consultant per year. That does not include our acute medical remit. We are all over-stretched.

Dr. Coughlan and I are the worst off. Luckily for us an appointment to be made shortly in Limerick will relieve some of that pressure. Waterford has now become self-sufficient because it has received three new appointments but we have faired very badly. To some extent it relates to the health board not pushing these services. They are getting a great deal of money for the other services which we all need to take care of our patients but we as a specialty have been left behind and are really feeling the pinch. Patients are becoming more and more demanding. The average patient attending our clinics wants the new drugs. The drugs are effective but it is a matter of selection. The actuarial figures will show that these drugs not offer immediate and good quality of life but they also have the long-term benefit in that the patients may not have to have surgery or become disabled. They will be able to remain in the workforce and their family members who would otherwise have been affected will not be. A nurse specialist is a critical person when dealing with these drugs. There are many available nurse specialists but there is no funding for them. We are looking for that type of support. The service is so far behind that, as was correctly stated earlier, we need some type of emergency package to assist us in continuing as we are. We are getting bogged down.

I thank the delegates for their presentation. They paint a rather bleak picture but it is good to know what is actually taking place. The presentation was fair. I am very much interested in preventive medicine. Is it the case that rheumatoid arthritis is increasing among younger people and, if so, what is causing it? What can be done to prevent this in terms of diet and exercise? What is involved in early diagnosis? I am speaking very much as a lay person in this regard. It was mentioned that the specialists operating at the coalface are operating well below the EU average. Can that be quantified in monetary terms? What is required to bring us to the EU average?

I am glad to be a member of this committee. It is because of situations like this that I became involved in politics. I laboured at the coalface on the other end for 26 years. The 1,250 people awaiting treatment for the past four years are real people. It is an indictment of the current system that this meeting is taking place today. I requested a meeting to discuss this issue and I am glad we are to have further meetings to examine it. To listen to those specialists, who are not subject to exaggeration, use words such as "extremely grave" is a terrible indictment of the health system. It took them two years to get a meeting with the Minister for Health and Children and there was no mention of their report in the National Health Strategy. They have not heard anything more on the matter. The figure of 0.3 per 100,000 was mentioned. Croatia has four times more rheumatologists than we have. Russia has six times more, yet we call Ireland a developed country. We are at the bottom of the league. It is a disgraceful situation. Penny-wise and pound foolish, an ounce of prevention is worth a ton of cure. This is the biggest cause of disability in the west, yet we are not doing anything about it.

We must look at the cost of employing rheumatologists. People in Mayo get up at 3 a.m. to travel to Galway for treatment. That is almost the same distance as from Dublin to Galway. These people have been awaiting treatment for four or five years.

Time is running out and many more members wish to ask questions.

Would it not make more sense to employ a rheumatologist in Mayo than to have people travel such a distance for treatment? We have been seeking such an appointment for some time. Rheumatologists such as Dr. Coughlan, Dr. Molloy, Dr. Kearns and Dr. Casey spend most of their time with people who are not——

Chairman

I must ask the Deputy to put a question, please.

Would it not be better for such people to work in the treatment of rheumatology only? It would be much better to treat this disability. People view arthritis as a chronic illness; it actually limits life expectancy. Perhaps the delegation will confirm that point. People suffer many other chronic diseases as a result of such illness resulting in their lives being cut short. It was stated earlier that if this illness is not treated early there is a 42% risk that a person newly diagnosed with arthritis will be assessed as being disabled within three years. It would be much better to treat the person at an early stage than to have to treat him or her when totally crippled.

Chairman

I must ask members to be brief.

I have waited a long time for this meeting and I am entitled to my five or ten minutes.

Chairman

We have allocated ten minutes for specific questions. Deputies should try to adhere to that.

I thank the delegation for its presentation which I do not think was bleak enough. The current position is appalling. I am a patron of the Raynaud's Society. Many people around the country who suffer from Raynauds and scleroderma are not receiving treatment. I was a member of Comhairle na n-Oispideál on two occasions and I am worried by the fact that I have no recollection of the health boards pushing for more rheumatologists. We prepared a report on the matter. It is dramatic enough getting musculoskeletal diseases but this militates against it. We have somehow got to get through to the Department of Health and Children the appalling misery not just of the patients but of the huge social and financial cost to the State. One of the most important things highlighted today is the fact that people become disabled so rapidly. Health boards are more rapidly seeking people to perform cardiac transplants than they are seeking rheumatologists.

Dr. Casey

How cultural and progressive is a nation is defined in terms of how it looks after its elderly people. Such patients are not properly cared for in Ireland. We need to get more involved. I agree that Mayo should have its own rheumatologist. There are some very vocal people such as Mary Healy involved in that issue. I wish them well. It is difficult to quantify the cost of a rheumatologist but the resources for such a service must be provided. There are enough people in all the disciplines such as physiotherapy, occupational therapy, nursing and doctoring available to do it if the money is provided.

Dr. Molloy

I would like to mention costs because I was involved recently in an exercise relating to rheumatology costs. Not to mention space or anything else, starting a unit de nouveau and including all the personnel we mentioned would probably cost in the order of €1.5 million to €1.9 million. That is the realistic figure being bandied about because it does not just involve the rheumatologists. Every other department in a hospital affected by a new appointment will look for the maximum support for its department, which adds to the cost.

Has there been an increase in the number of people seeking help?

Dr. Molloy

Certainly, we all see all age groups. We do not have actual figures in Ireland for the increase but one gets the impression it is growing. Dr. Kearns mentioned lupus which in my experience is on the increase in young people, particularly young women in their child-bearingyears.

The Deputy asked about exercise in which I have a special interest because of our faculty of sports medicine. Exercise does help to prevent arthritis. If one wants living proof, my colleague on the right, Dr. Casey, has been running for years and no longer looks his age. He has been keeping himself fit. Instead of believing that arthritis is caused by exercise we know that exercise benefits arthritis, including rheumatoid arthritis.

Dr. Kearns

To address the points made by Deputy Cowley, we met the Minister only in April of this year; therefore he has not been sitting on the report for two years. We should be straight about that. On mortality, in the health strategy there are graphs on pages six and seven which show the decreased mortality and disability associated with the disease. It concurs with what has been said in regard to shortening people's lifespan.

I agree wholeheartedly with the point made by Senator Henry that because we do not have bald children on chemotherapy, or young people dropping dead, this is not a headline catching disease. This is where we have been let down. Although it is not dramatic it is real suffering and it is up to us to get that message across. Early diagnosis is important. When patients complain of pain and stiffness in their joints general practitioners should recognise this in order that we can see the patient quickly to get going with treatment.

Chairman

We will now have the next round of questions.

Thank you Chairman. I thank the rheumatologists for attending the meeting. They have understated their case. In the north west Dr. Raman is grossly overworked and I know that Dr. Coughlan is certainly overworked. They are looking for only six rheumatologists whereas I think they should be looking for eight or ten.

There are six SPRs in training at present. If a genie arrived at the Department of Health and Children and said it had six posts available, could they be filled from those trained? Yes? All right. On the Western Health Board, if a second rheumatologist is appointed, is Castlebar general hospital the ideal location or should he or she be based in Galway Regional Hospital or University College Hospital, Galway? I was a little surprised to hear Dr. Molloy say that there would be three rheumatologists in County Waterford but only one in County Cork.

Dr. Molloy

There are two and the third has been appointed.

Why is that, consideringother areas of the country are so badlyserviced?

Dr. Molloy

I wish I knew.

I also thank the consultants for their presentation. To answer Dr. Devins question, of course Mayo General Hospital is the correct location. This presentation has been quite frightening. Some members of my family suffer with rheumatoid arthritis so I know something about the condition. I have been a member of the Western Health Board and must zone in on Dr. Couglan's presentation. While I know there are problems throughout the country, a waiting list of four and a half years is unacceptable, particularly in view of the statistic, highlighted by Dr. Molloy, that 42% of the patients affected will be disabled within three years. If someone will not be seenfor four and a half years this is somethingthat——

Why did Deputy Cooper-Flynn not do something about it as a member of the health board?

I did not interrupt Dr. Cowley.

I am not on the health board but Deputy Cooper-Flynn is.

Chairman

Deputy Cowley should allow the Deputy to continue.

This is pertinent to my patients.

When Dr. Cowley had the opportunity to ask questions he did not. I would like to ask some questions.

Dr. Coughlan mentioned in his presentation that he also has a general medical function to perform. As an interim measure to see if the situation can be improved, is there any way he can be relieved of that function in order to deal purely with patients with arthritis? Perhaps the question is ridiculous but what is his response to it? While I know arthritis affects all age groups, the figures are bad and I am concerned that we have an ageing population. While arthritis might affect young people it is worse for older people and if we do not put corrective measures in place now it will be a lot worse in five or ten years time. Has Dr. Coughlan factored the ageing population into his recommendations?

I note that one of the overall core objectives mentioned in the Western Health Board report of 2002 has been fulfilled and that a specialist nurse was appointed this year. Have any of the other core objectives been fulfilled since the report was compiled?

I thank the consultants for their interesting but shocking presentation. Is there a gene in the Irish that brings on rheumatoid arthritis? Is there a general awareness campaign to advise people of what they can do in regard to diet or exercise at an early age to offset rheumatoid arthritis? What funding is available to deal with this problem?

I notice that the figures for Northern Ireland per head of population seem to be extraordinarily high. Perhaps the situation is more critical in Ireland and our people are using specialists across the Border. I am only 40 miles from the Border and I know of some people who travel north of it for treatment. The situation is more frightening than displayed in the presentation. I thank the consultants for highlighting the problem because those affected will be left at the bottom of the pack if it is not highlighted.

I thank the consultants for their presentation. I am concerned that there are three consultants in County Waterford but only one in County Cork. Who makes these decisions? We must face the reality of a tight budgetary situation and consider why we should have three positions in one county while people in other parts of the country are not being treated. Are arthritis walk-in day centres seen as centres of excellence? Will they be separate from and independent of hospitals or will they be attached to them?

I welcome these eminent consultants to the committee. Their advice is worthwhile. Dr. Coughlan's schedule did not give a breakdown of the numbers between counties Galway, Mayo and Roscommon where the waiting list is quite staggering in size. I was a member of the health board when its report was prepared and submitted to the Department of Health and Children but I am not sure what results have arisen from it. Prevention and research seem to be lacking in this area. I accept that the pain of rheumatoid arthritis is very great. I was told by a mother of eight children that the pain of arthritis was harder and more difficult to bear than any pain she had experienced in her life. That indicates to me how serious the situation is. Pain is something suffered by individuals and it is hard to convey its impact to other people. The ultimate rheumatology approach to address arthritis would be joint replacement. Obviously, there is a link between the group represented today and the consultant surgeons, who ultimately have to deal with this. Further to what Senator Feighan said, because of the climatic conditions, particularly dampness, are we more prone to this? I find that many people such as builders and farmers who are exposed to the elements in their daily work are more prone to rheumatic illnesses than those who work indoors.

I am delighted the delegation has highlighted this issue, which is not the sexiest at present. It is not getting the coverage it should, but it is affecting many people. The facilities in a small hospital such as Roscommon General Hospital would be ideal for rheumatologists. Rheumatologists do not need significant high-tech backup and do not need to be located in UCHG or Merlin Park. They could be located in Roscommon or Mayo.

Dr. Casey

The sexed-up dossier for arthritis is about who rattles the can or how loudly. One often hears about the children's hospital in Crumlin and oncology. We need a dossier that is pushed up. Could we be invited to appear before the committee in six or 12 months to see what has happened since our visit today? It would be very welcome.

Deputy Fiona O'Malley asked about the walk-in centres. These are situated in the hospital. They are cheap to run. People can go in and out and can communicate on the same day with the nurses, physios and occupational therapists. They do not have to go through all the tests or monitoring. They would be more than welcome in practically every hospital in the country.

Dr. Kearns

I would like to address the comment about only looking for six rheumatologists. Apparently, there is funding for emergency packages. When we discussed strategy with the Department of Health and Children we thought if we could get an emergency package it would not have to sit on a shelf for so long. We first looked for six in the areas of dire need. On page 24 of our submission we show in our short and medium-term recommendations that there should be one whole time equivalent rheumatologist - that is excluding general medicine commitment - per 80,000 of the population and additional resources. I agree that six is not enough, but if we looked for everything at once we would be here in ten years. I do not mean to be cynical about it. We thought we should hit the emergency areas and then fight for a reasonable quality service.

Dr. Molloy

In Cork there are two rheumatologists. In another hospital in Cork, the South Infirmary, there are two for 500,000 people.

Deputy Cooper-Flynn and Senator Leyden asked about the issues relating to Castlebar and Roscommon and general medicine. These are linked. My situation is common to all of us. I am on take one night in six. That takes up about half my week. If there were a second rheumatologist in my hospital in Galway, it would mean that half of my time could be shared between the two of us. There would be the same amount of general medicine, but two rheumatologists doing it would result in more rheumatology time. If a rheumatologist were to be based in Castlebar, that rheumatologist would be doing general medicine maybe one-third or half of his or her time. That is one argument in favour of grouping rheumatologists.

There is another very strong argument and that is the "black sod" argument in favour of spreading rheumatologists and putting them closer to the patients. As Senator Leyden said, it is not particularly high-tech but requires a knowledge base and experience. Those can be put into and close to communities. Those are the issues concerning where they should be located. It does not much matter as long as we get the people there. At present I could be spread all over the place but there is only one rheumatologist in the health board area and covering neighbouring health board areas.

Several members mentioned prevention and education. Deputy Cooper-Flynn will remember that when she was chair of the health board we launched a little osteoporosis service. This was the mother of invention in that we had nowhere to see people with osteoporosis so we put in a service that was delivered to GPs and involved direct access to GPs. That service has grown to about 2,000 examinations a year. It is almost independent but is supported by the rheumatology service with most of it delivered to the community in the community. It is extremely successful, very cost effective and it is a vehicle through which a lot of education and prevention is happening.

Dr. Casey proposed that we should meet them again in six months. We should support the recommendations in their report.

Chairman

The committee wants to be helpful and while we take Dr. Casey's suggestion, we doubt whether six months will be adequate. It might take nine months or longer. Representatives from the Arthritis Foundation will be present on 16 October and a number of groups will be attending.

Further to Dr. Coughlan's point about a pure rheumatologist, is it compulsory to carry out such a level of general medicine?

If I do not do it, the gastroenterologists will have to and they will complain about why they have to do it.

Given the deficit in the rheumatology area, would it not be possible?

Dr. Kearns

There is a deficit in all areas and as most members will be aware patients are admitted to Beaumont Hospital only through casualty. It is an emergency crisis service.

Dr. Molloy

We are engaged in acute rheumatology. In the hospital where I work, there are no routine admissions for rheumatoid arthritis - they must have a complication. So, we are part of the acute group of conditions in the hospital. What Dr. Coughlan said is true, with a second person there is more time for the rheumatology.

I asked the question because in England 19.9% are engaged in both whereas here approximately 98% are doing both. Rheumatologists should do what they are trained for and not general medicine.

Chairman

We thank the consultants for attending today and giving us their valuable time. We will make this a priority for this committee and will make arrangements for a similar meeting in about nine months. We hope to be able to report progress at our next meeting.

The joint committee adjourned at 1.40 p.m. until 9.30 a.m. on Thursday, 2 October 2003.
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