I welcome Dr. Orla Hardiman, consultant neurologist, Beaumont Hospital, Dublin; Dr. Tim Counihan, consultant neurologist, University College Hospital, Galway and Ms Audrey Craven, chairwoman of the Neurological Alliance. I ask Dr. Hardiman to begin the presentation on the present and future needs of the neurology service. I draw attention to the fact that members of this committee have absolute privilege but this same privilege does not apply to witnesses appearing before the committee. Members are also reminded of the longstanding parliamentary practice that members should not comment on, criticise or make charges against a person outside the House, or an official by name, in such a way as to make him or her identifiable.
Neurological Alliance Of Ireland: Presentation.
Dr. Orla Hardiman
I thank the committee for inviting us to make this submission. What we would like to do this morning is first to introduce ourselves, and then give a brief presentation. Initially I would like to call on Audrey Craven, who is the chairwoman of the Neurological Alliance of Ireland, to give a brief presentation on behalf of this umbrella group for patient advocates.
Ms Audrey Craven
As Dr. Hardiman said, the Neurological Alliance of Ireland is the national umbrella group for 23 organisations encompassing the health professionals and other interested parties. This morning I represent among others, the voluntary organisations that cater for people with conditions like epilepsy, motor neurone disease, Alzheimer's disease, multiple sclerosis, and many others, including my own disease area, the Migraine Association of Ireland. Together we seek to represent the needs and to improve care and services for those whose lives are affected by neurological conditions. We want to co-ordinate the approach to achieve our aim.
Our motto, "unity is strength", has served us well to date. We believe we are ahead of the posse. Only last week I heard the farming organisation call for a more united approach to form a national umbrella organisation. Governments all over the world do not want to talk to disparate groups. So it proved when the Minister for Health and Children, Deputy Martin, launched three of our standards of care documents. These were produced by an expert interdisciplinary panel of advisers drawn from neurophysiologists, neurologists and so on right across the board. The Minister has promised us a neurology implementation group. In the pack supplied to the committee we have given key recommendations from the standards of care documents.
Patient needs have to be understood before they can be met. It is important to separate needs and wants. I want a holiday in Bermuda; I do not need a holiday in Bermuda. Among the key recommendations I would like to outline those which are particularly important: early and timely referral for appropriate treatment and services, the promotion of multidisciplinary teams in specialist centres and access to good quality transportation. Any strategy should and must include the voluntary sector. We see this as a dialogue between science and society. The Neurological Society of Ireland is a conduit between the statutory and voluntary sector.
What does all this mean for the 500,000 people who are affected in Ireland? These are quality of life issues, if not as heart-tugging as cancer and heart problems. I know what it is like to have a life-threatening illness as a few years ago I had a brush with breast cancer. Everything swings into actual support mode when a life-threatening illness presents, and that is how it should be. However, I have had very severe migraine all my life, and no support at all. What this experience has taught me is that when one has an illness that threatens quality of life, one also needs support. I want to live until I die, and it has made me re-double my voluntary efforts on behalf of all of those with quality-of-life-threatening illnesses. I say to this committee, charged as it is with the ongoing responsibility for health, that the future belongs to those who give the next generation hope. Thank you.
Thank you very much.
Dr. Hardiman
We would first like to address the nature of our professional discipline. As there are so few of us in Ireland, many people have no concept of what a neurologist does. Even my own children have difficulty understanding the difference between a neurologist and a neurosurgeon. The simple answer is that we do not perform operations, but clearly it is more complicated than that. As Audrey Craven said, there are about 500,000 people in Ireland suffering from a neurological condition, so these conditions are not rare. Common names of conditions that we attend to include multiple sclerosis, Parkinson's disease, epilepsy, motor neurone disease, Alzheimer's disease and stroke. Stroke is one of the leading causes of death in Ireland, yet we have not taken as much care in managing people with stroke as those with other leading causes of death in Ireland, such as heart attack.
Why are we advocating now? What has changed regarding neurology? Why is neurology important nowadays? The main answer is that many neurological conditions are now treatable. When I qualified in 1983, the purpose of the neurologist was primarily to make a diagnosis of a horrible degenerative fatal disease and then to walk away. Things have changed since then. Many of the conditions we deal with are now treatable. Many of the treatments have to be undertaken early in order to improve quality of life and reduce disability. In order for people to obtain treatment early, they have to be able to see a neurologist. If there are not enough neurologists, patients are being disenfranchised.
We know that early treatments of neurological disease produce best results. We know this does not simply mean drugs-related treatments, but also multidisciplinary care involving other paramedical specialities such as physiotherapists, occupational therapists, speech and language therapists and so on.
How are we currently doing in Ireland? At present we are the worst in Europe. In Italy there is one neurologist for 20,000 people. In the UK, our nearest neighbour, there is one neurologist for 150,000 people, and it is considered a scandal there that the ratio is so poor. There is a move in the UK to improve the ratio to one neurologist per 100,000 people, and the UK considers itself very poorly serviced in this regard. In Ireland, the ratio is one neurologist per 280,000 people. We are looking for a target of at least one neurologist per 100,000 people to provide minimum standards of care in Ireland. We also submit that neurology is not just a hospital-based or consultant-based service, though it is consultant-led, because many of the conditions we take care of are chronic and progressive and require ongoing treatment. With very few exceptions, we do not have interdisciplinary clinics here focusing on neurological disease.
I wish to draw the committee's attention to some recent advances that have taken place in the development of neurology. Recently, at the behest of the Minister for Health and Children, a Comhairle na nOspidéal sub-committee was formed to review the status of neurology in Ireland. It recommended a phased increase with development of regional centres in Dublin, Cork and Galway, and associated centres in Limerick, Sligo and Waterford. Beaumont Hospital, where I work, has been identified as the national neuroscience centre. These recommendations provide a genuine core for the development of top-quality service provided by consultants, but if we want to build up a service we need other specialities in addition to neurologists. We need neuropsychiatrists, neuropsychologists, neurorehabilitation doctors and neurophysiologists. We also need to recognise the value that other allied clinical professions provide to the delivery of service. These include specialist nurses, physiotherapists, occupational therapists, speech and language therapists and so on.
Development of a top-quality service will require the development of a top-quality multidisciplinary team-based service too. We know from international evidence and evidence we have produced in Ireland that this provides the best approach and the best standard of care. That is what Irish patients deserve and should demand.
The other recent reports - the Prospectus report and the Brennan report - will obviously have implications as to how we develop our services. The Prospectus report will discuss the rationalisation of health boards and that has implications for services that are not currently represented in all health board regions. Within this report we will need to look at a strategic plan for a speciality like neurology that would provide services for the entire country though not localised in every town in Ireland. The Brennan report calls for more accountability, and my colleagues and I fully subscribe to that. We would like to make sure that the development of our service will take the right form with appropriate facility for clinical audit, the development of a structure in which neurologists can contribute to the planning and development of neurological services and can generate transparent audit-based material that can be shown as evidence for the improvement in services that we provide. The Hanly report discusses medical manpower. The implications for the development of this report with respect to regional and national centres must be addressed - although the report is not published, my understanding is that this issue is not a significant part of it.
My colleague, Dr. Counihan, will discuss the implication for the development of neurology service outside the major centres.
Dr. Tim Counihan
My brief is simple. It is to attempt to guarantee that patients throughout the regions of Ireland outside Dublin have access to the same services that patients in Dublin have. This issue has already been highlighted by Ms Craven and Dr. Hardiman.
Patients must have equity of access. This was made clear in the Comhairle report published in April this year. It stated that patients in Belmullet should have the same access to neurological services as patients from Ballsbridge. That is probably not the case currently, though there are certain aspects of the report which, if implemented, will go a long way towards bringing about that situation.
Once a patient is guaranteed access to the services in a timely fashion, the quality of those services has to be as good as in the capital city. Broadly speaking, we have gone some distance towards ensuring that.
On equity of access, the Comhairle report has recommended an expansion of clinical neurology services at consultant level, including the setting up of sub-regional centres in Sligo, Limerick and Waterford, as part of a hub and spoke mechanism through which to deliver the specialist services. We can discuss that in detail when we come to questions.
The model of neurology services based on the hub and spoke system will require a multidisciplinary approach as outlined by Dr. Hardiman. The goal of this is to achieve the standards of care as outlined by Ms Craven.
We talk about the regions. These should not be seen as secondary referral areas from which patients are necessarily referred to tertiary referral centres in Dublin. According to an edition of The Irish Times this week, if one is unfortunate enough to have a cardiac arrest at Galway Airport, one has a better chance of survival than if, perish the thought, one has a cardiac arrest in Leinster House. One could therefore argue that from a cardiac standpoint, standards in the regions may currently exceed those in the capital city. That is obviously an extreme example in cardiology, but the principle applies also to neurological services.
Even small centres can have a major impact on the delivery of services. In the United States, one of the premier institutes, the Mayo Clinic in Rochester, Minnesota, is in a small, snowy town in the north of the country, yet it delivers a first-class service to its own patients and beyond. We should not lose sight of that point.
Quality of care is the issue. My brief would be to ensure it is a nationwide goal. Thank you.
Dr. Hardiman
The top priority we would like to submit to the committee regarding the development of neurology services in the future would be that mentioned by Audrey Craven, namely that we should appoint an implementation group with a very tight framework and very clearly defined terms of reference which should be centred around the strategic development of multidisciplinary neurological services. What is this strategic development? It should be the development of services at national level in accordance with the recommendations of Comhairle na nOspidéal and with reference to the standards of care to which Audrey Craven alluded, standards which the Neurological Alliance has generated.
Neurology, at present a well-organised discipline, should be used to pilot a new approach that is being advocated by the recent reports on health reform. If we adequately implement these priorities we will transform the nature of the care we provide in Ireland for neurological patients. We will be able to provide a model for all other disciplines in medicine and create momentum for the efficient development and modernisation of the health services. I thank members for their attention.
Thank you very much for your presentation.
I thank the delegation for their presentation which I found very interesting. Deputy Gormley is perhaps entitled to speak first because I think he feels a migraine coming on. The presence of three neuro experts may be very timely.
Despite all the money we are spending on health, we always seem to be at the bottom of every ladder. To find we are the worst in Europe in terms of providing neurologists follows that pattern.
The delegation is talking for the most part about chronic progressive diseases which are extremely expensive to treat from the State's point of view - quite apart from the human cost and suffering. Putting money into the neurology services so that people can be treated early would represent a saving - and the importance of early treatment in reducing disability and slowing the progressing of the illness was stressed by the delegation.
The witnesses talked about the Comhairle report. I presume the delegation has come here to urge the committee to apply pressure to have more neurologists appointed. We will try to do that. The delegation spoke of the multidisciplinary teams and I can understand the need for those. The witnesses also talked of other specialists such as those in neuropsychiatry and neuropsychology. Whose responsibility is it to build that expertise? Is that the responsibility of consultants, or of Comhairle or of the training colleges? How do we kick-start the building of that kind of expertise and as public representatives what can we committee members do to help?
I thank the delegation for its very informative presentation. The issue of rheumatology was considered here recently, as was cancer before that. It is quite startling to find that in these areas we have such low numbers of consultants. To be on the bottom of the European ladder in this regard is a pretty bad place to be when one considers that our funding has now increased significantly and that we are now one of the highest funders in the EU.
On the Comhairle report mentioned, I would like some clarity as to what has happened since its publication. Have there been improvements? Have improvements been too slow in coming, or have they not been of the right nature? The delegation calls for more consultants and also wants the idea of the multidisciplinary team expanded and developed. It is easy enough to work out the number of consultants per head of population. Can one work out the number of support people per head of population and see how we compare with other countries?
The model we have is a cardiovascular strategy which is a national strategy allowing for the speciality to be developed in an appropriate way. In terms of health care reform and the proposal made by the delegation, the problem is that if one is trying to piggy-back on that strategy, there are dangers. First, we have not had publication of the Hanly report. We do not know what is being progressed. There are indications that there will be certain announcements made in mid-October, but the whole nature of this reform has been dogged with delay. Would it not be better for the delegation to simply say that they need what they have called for, and need a strategy applied in the same way it has been applied in the cardiac area?
On the implementation group promised to the delegation by the Minister, has the delegation been given any commitment as to when this might be set up, or within what timeframe? When was the commitment given? Finally, this is not a question but a point for the chairman: we need to follow up points such as these with the Department of Health and Children, and invite the Department to follow up on those points - not just the ones in this presentation but in others too.
We will take one more questioner.
I thank the delegation for its very informative presentation. Has the delegation come up with figures? It wants to achieve a ratio of one neurologist for 100,000 people, an aim we would all agree with, but what would that cost?
My ears pricked up on hearing the word "migraine" as I sometimes suffer from it myself. I am interested to know how a neurologist would treat migraine.
The Deputy will have to pay for that.
I am not trying to get free treatment or anything like that.
The Deputy will do anything for an early referral.
Is the treatment done by way of drugs, or what is it that the neurologists do?
Finally, I agree with Deputy McManus that our function as a committee is to monitor the progress being made. We are hearing many presentations in many areas that show we are bottom of the league in every way. I hope we can take on board Deputy McManus's suggestion in that regard.
Dr. Hardiman
On Deputy Olivia Mitchell's concerns about costs and cost savings, I fully agree - and I think Dr. Counihan and Audrey Craven would also agree - that putting in services would probably be cost-effective. For example, four out of five people with multiple sclerosis will usually go on to develop secondary progression of the disease, but some data has emerged recently showing that if treatment is instituted earlier, that figure falls to two out of five people. There is a significant change in the level of disability after a number of years when treatment is instituted earlier.
There are also some cost implications of keeping people with disabilities alive for longer, and one has to factor that in too.
Audrey Craven has figures on the number of days lost at work due to migraine. If one adequately treats migraine and manages it properly, one can significantly reduce that number. There are therefore many hidden benefits in providing good care. There are also many conditions which can be misdiagnosed if they are not seen by a neurologist, and this creates many extra costs to the health service by overspending on case investigation.
If we provide more neurologists we will create a much more efficient service. My colleagues believe that too. I agree that although it looks like a significant outlay is involved; it is an investment that will prove to be cost-effective.
On the number of neurologists, all of us are overseas-trained, and that is the sad fact of Irish specialists. Most of our specialists are overseas-trained, and we are all trained in sub-specialty areas too. Most of us have probably been trained in the US or the UK, where economy of care is part of the deal too. Health economics are important in the US because of third-party providers and in the UK because of the difficulties with fund management. We are therefore all trained to think about such things but not able to act on it at present because we are overwhelmed by the numbers. There is a cost saving there too.
The Comhairle report addressed the issues raised by Deputy McManus. We were very happy that the review was set up, but we felt that it was only part of the solution to managing neurological problems. We seek implementation of the Comhairle report. My colleagues and I in the Irish Consultant Neurologists' Association, which is chaired by Dr. Tim Lynch, fully accept and agree with the Comhairle recommendations. However, they do not go far enough. We must examine the strategic development of the service. The development of multidisciplinary teams is not part of Comhairle's remit. Rather the task of this statutory body is to recommend on the number and location of consultant posts. It does not look beyond that. It only examines the number of consultants. It does not even deal with the cost implications. Its recommendations are purely on the basis of numbers, and we felt that such an approach was inadequate.
With regard to how we calculate the numbers and cost of multidisciplinary teams, which was Deputy McManus's question, I see that as part of the implementation group's remit. I have written on more than one occasion with Ms Audrey Craven to the Minister and the Department about this: the implementation group should include a health economist, for the only way to calculate those costs is to work with someone qualified to do it. It is very easy to answer what has happened to the Comhairle report. It was published in May, and there has been no implementation. I assume that it was part of the summer, but there appears to have been a consultative period with the health boards, which seemed very difficult for us to understand. It seems to us that Comhairle na nOspidéal is an expert group and statutory body which has made a recommendation that does not seem to be binding. That is our concern; for it seems that we are going back, reinventing the wheel. The Department of Health and Children indicated to us that it may want input from the health boards about Comhairle's recommendations. That did not seem to make much sense, to me at least.
Even if they are allowed to.
Dr. Hardiman
It seemed to me that it was a holding position that the Department of Health and Children was taking to see what the health boards would say. Of course, the health boards will not agree with it, for there are some that would appear to be disenfranchised, and Dr. Counihan will address that issue. We wish to discuss that further, for there are regions in Ireland that do not have neurology. We see one of the roles of the implementation group as being to ensure that those regions are adequately catered for. The Comhairle report is also cognisant of that. In the report, it recommend users' groups to ensure that the areas being serviced by neighbouring regions, for example, in my own case, the North-Eastern Health Board and the Midland Health Board, which would be catered for by Beaumont Hospital, should have a line into the delivery of care. None of the health boards has taken that on board. I met my chief executive yesterday, and it is not something that is being discussed in any shape or form whatsoever. That is what I mean when I say that the Comhairle report does not appear to be in any way binding. There seems to be a bit of a "fudge" on it.
On Deputy Gormley's questions, I think that I addressed the cost issue. We have not calculated the costs, and I am certainly not qualified to do so. I do not think that anyone in the Neurological Alliance of Ireland is qualified to do so. There are health economists whose job it is to work out costs, and we should use their services.
Treating migraines should be done by the general practitioner. We can advise on the standards of care, and our job is to address any difficulties if it is difficult to treat. The first port of call for migraines should be the general practitioner. We should be consultants to the managing of migraines. Some people get migraines that are difficult to manage as attested to by the fact that there is a migraine clinic in Beaumont and one in Cork. One will be set up in Galway if we get the funding. There is clearly a population that needs to be seen by neurologists, and for that reason our migraine clinic is booked out for a year. We come in on the more difficult cases where there may be other diagnoses in addition to migraine or where the management may be suboptimum in the relationship between the patient and the GP.
Dr. Counihan
I entirely agree. It is important that we bear in mind that this should not be purely to do with consultants. As you know, the Comhairle report addressed numbers of consultants, but the delivery of a proper service will require a multidisciplinary team. In figures, a specialist neurology nurse would cost about €50,000. To take the Western Health Board catchment area, for example, one would envisage having three such nurses - one for the Galway region, perhaps one for Roscommon, and one for the Mayo region - who would feed into University Hospital Galway. That would be money well spent and would certainly provide a much better service for patients. We have raised private funding for a second specialist nurse for the region, but the Western Health Board has not allowed us to appoint the nurse because of a cap on the number of employees. We have the funds and have handed over the money, but the individual cannot start work. That is a frustration, and it will presumably be dealt with over time.
Ms Audrey Craven mentioned the incorporation of voluntary groups into the delivery of services. We do not really utilise that as much as we might. I referred to CROI, the West of Ireland Cardiology Foundation. That has been extremely vocal and supportive of the patients, and that has led to a vastly improved service in the provision of ambulances, transport and so on for patients. We could certainly use the funding available in the public sector for neurology services.
Deputy Olivia Mitchell asked who is responsible for developing the service and if the allied health profession made up the service. It is a difficult question to answer. Consultants should be the driving force behind it. The trainees who work in Ireland come from environments where it is a consultant-provided as well as consultant-led service. There is certainly accountability in the United States, and increasingly in the United Kingdom. Consultants are provided with a budget, and if they do not use that for their department appropriately, there are sanctions regarding what happens in subsequent years. That might be a little difficult to implement in Ireland, but providing the standard of care should be the remit of the consultant, and he or she should be accountable.
Under current circumstances, I would take issue with the Brennan report in one respect in that we probably do not have as much clinical autonomy as we might. Perhaps we are not as accountable as we should be for what we do, and if we could increase both of those pari passu, consultants would probably be more accountable and perhaps more productive at the same time. Those are the two points that I wished to make.
There was also mention that most neurological conditions are chronic. It is important that there is an acute medical aspect to neurology. We talked about stroke, which is a larger issue which would require input from other interested parties such as geriatricians. However, there is no question that a neurologist's input shortens hospital stays for patients who have suffered a stroke and improves outcomes for them. Patients can walk away without any deficit from it, so the neurologist's input is not purely as a chronic degenerative carer. Migraine is a chronic condition but is treatable and arguably curable. There are a host of other conditions along the same lines.
Ms Craven
Deputy Gormley said that he had to go. I hope that it is not because of a migraine. In deference to my two medical colleagues, and before Deputy Gormley chases away, perhaps I might say that knowledge is the best medicine. An informed patient is a more responsible one who can more actively participate in his or her health management. I am really making a plea to you all on behalf of the support organisations which I represent this morning. We seek to be a very good one-stop shop. The term "patient empowerment" is much overused. However, if patients are empowered, we can work better.
The Neurological Alliance of Ireland seeks to work in collaboration. What is novel and exciting about that collaboration and its dialogue between science and society is that we work in partnership with our scientific colleagues, the health professionals. In that way we can meet the needs of the client user. We are the clients, and businesses understand the importance of talking to the end user. Look at all the money wasted on non-compliance. It is an absolute disgrace. If one asks the client what he or she requires - going back to needs - neurology can provide some of the answers on the health service.
Dr. Hardiman
Perhaps I might make one point about the responsible person. To some extent one of the problems with the Irish health system hitherto has been the idea, which has given consultants a bad name, of "fiefdom development". Consultants can develop fiefdoms when they come back with a speciality interest, which suddenly becomes an important interest in the relevant geographic area. We feel quite strongly that the development of the service should be national. We concede that the consultant is the main driving force in an individual hospital in generating the service. However, there should be a strategy on top of that which selects the right consultants for the right regions and which supports the need for development in areas of national interest rather than simply the interests of the consultant or the region. While it is true that consultants are currently the primary drivers of service delivery, I argue - and I think that I have Dr. Counihan's agreement - that it should occur in the context of what is in the national interest, and I am afraid that that does not always happen. We would like a national strategy to serve the needs of the Irish population at national level. That should be fed down into the individual centres. That is what we ask of the Department of Health and Children: that it becomes the policy driver in the area.
If we were asked what we would like the committee to do, we would answer, first, to exert pressure for the implementation of the Comhairle report and, second, to take on policy issues and view matters in the context of a national strategy rather than as an individual health board-mediated responsive health service, which is what we have been providing. We need a plan for a service that is national. It should not be in every city and small town in the country, but it should be delivered without disenfranchising centres that do not have neurology. However, that requires a supraregional overview, and that very important thing is not happening at present. Our concern is that going back to the health boards to see what they thought of the Comhairle report smacks once again of regionalised development. It is a huge concern for us.
We will have further questions before the Dáil sitting begins, first from Senator Glynn, followed by Senator Feeney and Deputy Fitzpatrick.
For how many organisations is the NAI an umbrella body?
Ms Craven
Twenty three.
It is interesting that there is reference in the submission to the prospectus report which recommends the rationalisation of several of the health-providing agencies. Does the delegation not consider that the number of agencies representing the neurological problems is too high? Is there a case for rationalising them? Ireland has 14 neurologists, which is one in 280,000, but the figure is one in 20,000 in Italy. There is clearly a case for ensuring that people are encouraged to pursue a neurological career. What is the organisation doing to exhort people to do so? What are they doing right in Italy that we are not doing right here? If they have one neurologist for every 20,000 people, and we have one for every 280,000 people, what are they doing right that we are not doing?
Another matter that we dealt with here on the committee was the problem with orthodontics. In fairness to the health boards, and my own in particular, we certainly got that problem by the scruff of the neck and solved it. If it can be solved in the context of orthodontics, is there a lesson to be learnt in the case of neurology?
The penultimate point that I wish to make concerns the number of treatable diseases. Mention was made of stroke, epilepsy, Parkinson's disease, multiple sclerosis, migraine and Alzheimer's. Am I incorrect in saying that a new wonder drug was displayed on television, though not necessarily on one of our own channels? What are the views of the delegation on that? I wait with bated breath as someone who worked with Alzheimer's sufferers for many years. That has been taken up, and the Cathaoirleach will be aware of that as a member of the Midland Health Board. We advocated the construction of special units.
Dr. Counihan
The Senator should not believe everything that he hears on the television or reads in the newspapers in that regard.
I want to be proven wrong. We are here for information. My last point returns to my second. What can be done to encourage people to pursue a career in neurology that is not being done already?
We will take Deputy Feeney next.
Thank you for the promotion; I am a mere Senator. Perhaps I might pursue the questioning of my colleague, Senator Glynn. I take it that neurology has a college or institute. Is the delegation here representing their peers, or are they here as individuals? Are you representing your college? I will return to Senator Glynn's point. Are you trainers, and, if so, how many trainees do you take on? What are the difficulties in getting people into the speciality of neurology? Dr. Hardiman said something at the close of her main presentation on the subject of the Hanly review. She spoke of regional and national centres but felt that it was not a major part of the report. I thought that the whole purpose of the Hanly report was to manage medical manpower and support centres of excellence. We saw that in other reports. Perhaps Dr. Hardiman knows something that I do not.
It is good to hear the two medical people supporting the reforms now in place. I agree with Deputy Olivia Mitchell that it is sad to come in here every Thursday or other Thursday and hear specialties different such as you telling us that we are bottom of the ladder and the worst in Europe. I feel like screaming across to you that there are billions and billions in taxpayers' money going into our health system, and we all have a role to play. It is good to hear your support for the Minister in what he is trying to do. I will almost "eyeball" you and say that the Hanly report will identify that we now have 1,700 consultants in the system but that we need 4,000. Are you going to play ball with the Department and the Minister regarding change, the common contract and the issue of public versus private? I am sure that you all have private practices. Are we once again going to fail? Will we be bogged down with industrial relations issues? I know that the question is tough, but it would be remiss of me to sit here without asking those kinds of questions.
I have two quick questions which have been asked in different forms before. First, is the comparison with Italy a valid one? Second, how many neurologists do we have in training?
Dr. Hardiman
I would like to ask Ms Craven to deal with the voluntary organisations. Maybe I will deal with the neurologist issues. There appears to be an implication that there are not enough neurologists in training. There are. I run a 'diaspora' meeting every second year where we invite Irish people who are overseas training - or who are already trained and cannot get jobs here, and are now working overseas. It is very well attended, by about 30 or 40 neurologists all of whom would love to come back if there were jobs. It is not a question of there not being enough neurologists. With respect to a college for neurologists, would it that there was one? We would love if there was one. We are part of the Royal College of Physicians in Ireland. There is no separate college of neurologists. We have an Institute of Neurology, which is a group of interested parties who are neurologists and neurosurgeons interested in the development of neurological science. We do not, however, have a formal academy of neurology like the Royal College of Physicians in Ireland. Nonetheless, we are all trainers in neurology through the RCPI.
There are currently nine specialist registrars in training in neurology in Ireland. They are leaving, however, because they cannot get jobs. When they are finished their training - and this is the first year that we had people actually finishing - they go overseas. There is an expanse of neurology in the UK, so they are going there to get jobs. We are losing people in the second and third year of their training for exactly those reasons, because they see no future in staying in Ireland as there are no jobs.
Is Dr. Hardiman here representing all of her 14 colleagues. Is she their spokesperson?
Dr. Hardiman
Yes - I am the medical patron of the neurological alliance and it is in that capacity that we have been lobbying. We have an Irish Consultant Neurologists' Association, as I mentioned. Dr. Tim Lynch is chairman of that group, and Dr.Counihan and I are members. Many of these issues have been discussed at ICNA level. What Dr. Counihan and I are articulating here would be the views of the ICNA. Nothing we are saying is at variance with the views of the ICNA. On the issue of the Hanly report on medical manpower - the report is not published yet, but there are drafts in circulation, as you know——
Chairman, I should have declared an interest. I am a member of the Hanly review group and I should have declared that from the outset. I apologise.
Dr. Hardiman
Yes - obviously, there are drafts circulating. The Hanly report deals with medical manpower in Ireland, but the issue of national or regional centre development from what I understand to be in the public milieu with regard to Hanly - maybe the more recent drafts will deal with this - it appears the problem of how to deal with disciplines that will not be located in every hospital needs to be fleshed out. Perhaps the more recent drafts of the report deal with this. It would be great if they do, because the pilot areas, for example, may not necessarily cater for all the required specialties, in particular those that will be centralised. If we are looking at the development of multidisciplinary teams it is clear that that cannot happen in every town in Ireland, even in all the regional centres that are to be developed. Probably neurology will be located in a number of super-regional centres. How do we cater for that? We should like to work with the Department of Health and Children as the organ of policy development to look at that. That is the context in which the forthcoming Hanly review was brought in.
How many of the health boards have applied to Comhairle na nOspidéal for neurologists?
Dr. Hardiman
I was not a member of the Comhairle sub-committee and neither was Dr. Counihan. We were not privy to all the deliberations, therefore.
Are there no applications with Comhairle, for neurologists?
Dr. Hardiman
We are not privy to what is going on at Comhairle, so——
I find it extremely strange. Did I hear Dr. Hardiman correctly when she said there were nine neurologists in training, but when they are train they go to Britain and other centres because they cannot get jobs here?
Dr. Hardiman
There are nine positions, but there are actually about 30 overseas.
In training?
Dr. Hardiman
Either in training or finished their training - who would come back tomorrow, if there was a job.
The question I asked is how many of the health boards have applied to Comhairle for a neurologist.
Dr. Hardiman
I do not know the answer to that. We are not members of Comhairle.
Dr. Counihan
We would not be privy to that sort of information.
I will not labour the point, Chairman, but it is worth pursuing by someone like yourself, who is currently a member of a health board. If we have all those people in training and there is a dire shortage, as the figures indicate, then surely we should be pursuing it, if people are available. Are the positions there for them to fill?
Dr. Hardiman
No, they are not. That is what the Comhairle review is about. The Comhairle review has made recommendations. That is why we are here. Comhairle na nOspidéal has done a review of neurology and neurophysiology and has made recommendations about increasing the numbers of neurologists in a way that is semi-regionalised - with regional centres feeding into the community at large. Comhairle has already recognised that there is a need to increase the numbers. It has also specified where those neurology posts should be, but none of its recommendations has been implemented. That was published in May of this year and they have not yet been implemented. The costs of putting in neurologists have not been addressed. Neither has the service provision by neurologists been addressed. That is not within the Comhairle remit, but it has not been done in any other form either. The Senator is absolutely correct. All the health boards are in dire need of neurology. We are keen to provide the service, but the two have not met yet, because the Comhairle report has not been implemented.
There is a Comhairle report that services the needs of the health boards which will supercede any submissions that any of the boards have made. All the health boards made submissions, based on their deliberations with expert groups on what should happen. Comhairle has taken all those into account and generated a report - it took two and half years - which is now in the public domain, but nothing has happened with it.
Could a person be considered for a consultant neurologist's post without overseas training?
Dr. Counihan
Yes, they could. There is a specialist registrar training scheme which is run though the auspices of the ICHMT, the Irish committee on higher medical training, through the Royal College of Physicians in Ireland. As Dr. Hardiman mentioned, nine people are in training at present. They would have to compete with trainees who are abroad, however, of which there are about 30.
Perhaps the witnesses may not be able to answer, but are there any consultant neurologists who have not got overseas experience?
Dr. Hardiman
It is something of a 'chicken and egg' situation, because with 14 neurologists it is unfair to expect we can generate a sufficient critical mass to adequately train them to the standard and level they should have in order to service the needs of the Irish population. If we had more neurologists we could home-train people. At the moment many of our trainees do the initial part of their training here. Given our small numbers and lack of critical mass, there is recognition that it is appropriate that many of our brighter people should go overseas - with a view to bringing them back. The ultimate plan would be that we might have an initial training programme here and maybe a fellowship for a year or two - with formal links - with centres of excellence at which many of us trained. I trained in Harvard, as did Dr. Counihan. Many of us have links with centres of excellence overseas - and that would be the plan. That cannot happen at present, however, because we do not have a critical mass to train people.
I would just like to get back to Senator Feeney's point about the common contract, the Hanly report and where we sit on this - private versus public medicine. Most neurologists are so busy doing their public work that the private element is quite limited. Most of us, I believe, are primarily public servants.
I pointedly asked that because I knew neurology was one of the specialties in which there is not private practice - and I am so glad to hear that.
Dr. Hardiman
I do not think it is appropriate for us to speak for other consultants. Consultants by definition are individual practitioners, as the contract is set up. I can give you my personal view which is that I would welcome a reform of the common contract. I would welcome the opportunity to expend my entire professional life in the public sector. I am sure many of my colleagues feel the same. We cannot speak for the general body of consultants, but you can take it that the vast majority of neurologists in Ireland - from my discussions with my colleagues - feel the same as I do. We are committed to service development. That is what we want.
Dr. Counihan
Could I introduce a note of caution, Chairman? Where I come from - University College Hospital, Galway - there are upwards of 20 new consultant appointments, all recent graduate trainees, mostly from abroad, some from Ireland. Without exception they are imbued with enthusiasm towards patient care, public practice. The danger is - where I work in Galway there is a large private hospital currently under construction - in this continuing dissatisfaction with their ability to treat patients within the public system, they may get disillusioned. I do not think that is currently the case, but it is a real danger and I have heard some of my colleagues say that if they can treat even a proportion of their patients properly, albeit in the private sector, at least they are doing something for some of the people in their care. It is a slippery slope, while those consultants are young enough to be able to make a difference.
It was pointed out that week in, week out interest groups come along to promote their own specialty - and how sad it is that we are at the bottom of every pile. I would like to be positive on one thing, things do get done: a farmer last week told me he was washing his boots at the tap in his farmyard. He turned around to look at something and collapsed to the ground. He felt he had been shot in his back. He was brought to the hospital, on a Friday afternoon, at 4 p.m. of a bank holiday weekend - the worst time to become ill in any general hospital. Six hours later he had been operated on and had his disc completely removed. Without question he would have been paralysed if that process had not happened as quickly as it did. That is a standard of care that does happen in an Irish context. I do not believe it is all doom and gloom. We have all come across it, but we have to work very hard to make that happen. The reason we are here is on behalf of our patients to try to improve things.
On a completely different topic, all of the parties have been lobbied by the ME Society. As the Neurological Alliance of Ireland was coming before the committee I promised I would ask: they are a disease looking for a home and they feel neurology is the answer, but it has ignored them. I notice they are not among the groups listed. Does neurology look after ME - and is this the specialty where they would find a happy home? They feel no one looks after them at present and they are trying to get a national strategy for ME. Obviously, they are completely wasting their time. Maybe, as part of the neurology national strategy they might find——
Dr. Hardiman
ME is a very good example of a condition that should be managed by a multidisciplinary team. It actually is one of the best examples because ME is multifaceted. Different people with ME have different reasons why they have the disease. There is clearly a core condition of ME which is genuinely medical - probably muscle-based - but I have seen ME patients at my clinic, and I am sure Dr. Counihan has, as well, and they are very individual. There are many different reasons why they have the myalgia and the fatigue they have. It is a condition that responds very well to multidisciplinary team management, including neurology, physiotherapy, occupational therapy, psychology - maybe psychiatry in some cases - social services etc. It is a good example of where we could provide a very good service if we had the resources. In situations where we have seen people we have tried to plug them into the existing services.
To go back to Senator Feeney's point about public versus private, there are conditions in Ireland that actually do better in the public sector. I have been beating this drum a bit in the media as well. The chronic neurological conditions are probably better serviced in the public sector. We have published evidence on this. If you have a chronic neurological problem you are actually better off in the public sector, because the private sector is primarily geared towards acute management and does not really do very well in terms of ongoing care. One is better off in the public sector if one has got a chronic neurological problem. With all its faults and all its warts and all its difficulties, there is a network that provides a service if you can access it. The voluntary sector has been extremely important in that. We published a paper in the Irish Medical JournaI this summer, looking at access to care for patients with MS and motor neurone disease. We will be talking a little bit about this tonight at a public lecture. The private sector has very little to do in the ongoing management of those patients. What picks up the slack is the voluntary sector. Work in conjunction with the voluntary sector is very important.
I will send them to you, do not worry.
Ms Craven
May I return to the Senator's point and Deputy Olivia Mitchell's? You talked about the plethora of voluntary organisations getting their act together. It is precisely because of unmet needs that we exist. They come from the ground up. Deputy Mitchell talked about the ME organisation. They have come out of an unmet need, people who are so desperate for information who require the multidisciplinary approach as outlined by Dr. Hardiman. I am a very severe migraineur. It started in a shoe box on my table almost ten years ago. All of the organisations - Alzheimer's, multiple sclerosis - I am sure we all have a similar story to tell. In fact we have come together to streamline our thinking and we have looked at the commonalities. I hope you have received a leaflet among your papers - I think you have. What we have actually done is put aside our individual organisation 'hat' for the common good of neurology, working with our colleagues so that we can go forward in a structured strategic way. Have I addressed the Senator's issue?
I am not being critical at all. I asked the question——
Ms Craven
Have I addressed the Senator's issue?
Right. The other question I asked was on Alzheimer's. Dr. Counihan said I should not believe everything I read and see on TV. What is the current situation with regard to Alzheimer's?
Dr. Counihan
The current situation on Alzheimer's disease is there is no cure, as the Senator knows. There are a number of medical treatments currently available that are useful in the early stages of the disease. I am sure if the Senator has dealt with patients who have it he will be familiar with them. One recently launched medication has had a symptomatic effect on patients with more advanced Alzheimer's disease, but there is no treatment currently available - unless you are more ahead than I am in terms of reading the literature——
I looked through the information
Dr. Counihan
——that is known to significantly retard the course of the disease. There are medications under various stages of clinical trial and the hope is they may have a significant modifying effect on the progression of the disease. None of those is currently available and they are still at an early trial stage.
I would like to thank the delegation for their presentation. I will take up what they said to us this morning, as well as Deputy McManus's proposal, to follow through with an invitation to the Department of Health and Children to consider the brief.
The joint committee adjourned at 11. a.m. until 9. 30 a.m. on Thursday, 16 October 2003.