This part of the meeting is devoted to presentations by Dr. Orla Hardiman of the Irish Institute of Clinical Neuroscience, Ms Mags Rogers of the Neurological Alliance of Ireland, and Mr. Fearghal Grimes of the Irish Society of Quality and Safety in Health Care.
I ask Dr. Hardiman to commence her presentation and, if possible, to restrict it to between ten and 15 minutes. Members will then be free to ask follow-up questions.
I thank the committee for allowing us to attend again to present a way forward for the people we represent. We are aware the joint committee has heard representations from groups representing chronic neurologic disease, including epilepsy and chronic pain. We realise that committee members must be aware of deficiencies within our health system and that it must be very depressing to hear repeated concerns about the difficulties we have in accessing care for our patients.
We have all heard and read of how our public hospitals are overcrowded, how there are long delays in accident and emergency departments, and how it is almost impossible to get a bed in a public hospital unless there is an emergency. We have not come today to rehearse all these depressing aspects of our health service, nor to complain about how slowly the recommendations of the 2003 Comhairle na nOspidéal report on neurology and neurophysiology have been implemented. We realise that members of this committee must be aware that only 17 neurologists serve a population of almost 4.5 million citizens and that the pace of improvement has been all too slow. We are sure the committee is aware of the terrible frustration and evolving cynicism among idealistic colleagues working hard in the public sector, not to mention the plight of hundreds of thousands of people in Ireland living daily with neurological conditions and trying to access very limited services.
We have come before the committee to make a case for positive improvements that would change the way neurological conditions and all chronic conditions are managed by the health services. We call for two major things to happen within the neurological sector. The first is an adjustment into the way services are currently organised and the second is for general investment in the service.
We will set the scene with an example of what might happen to a neurological patient, given the way the services are currently designed. Then we will describe how they can be improved, with a little thought and some sensible investment in personnel and technology. We ask for members' attention because these proposals make a lot of sense and, in the long term, will help to fix what is now perceived as a crisis in our accident and emergency departments and within the long-term sector, which are symptoms of a much larger problem. We propose a model that can be also applied beyond neurology to other chronic diseases that beset modern society in Ireland.
We will tell members of a hypothetical patient known as "Mary". Mary has a problem. She goes to her general practitioner, who is not sure what to do. The GP carries out some routine tests and prescribes an antibiotic. Mary does not get better and so returns to her GP, who now thinks her problem may be neurological and writes a letter to a neurological centre. However, because there are very few neurologists, Mary receives an appointment for 18 months' time. In the meantime she is getting worse and is worried, as is her GP. This is an unusual problem and the GP does not know much about neurological conditions, as they are not common in general practice compared with sore throats. The GP is sufficiently worried to suggest to Mary that she go to her local accident and emergency department. The local hospital does not have a neurology department and Mary must wait for two or three days in the accident and emergency unit for a bed. She is then seen by an intern, who is not sure what to do. She receives a CAT scan of her brain, as this is available, but it does not help in making a diagnosis. The consultant in the local hospital, who is not a neurologist, refers her to the nearest neurology centre, to which she is ultimately transferred, after a two-week delay owing to a bed shortage.
Mary is subsequently diagnosed by a consultant neurologist and is discharged to her local hospital on treatment and with some advice. The local hospital discharges her back to her GP, with similar advice on treatment. Mary has a return appointment with a neurologist but it is a long time away and she must manage her condition in the meantime. She has developed some problems that require the input of an occupational therapist, a physiotherapist and a speech therapist. Those professions are very stretched in local communities, so she receives only a proportion of the sessions she needs. She has no access to a social worker and, because there is none locally for adults, she develops a complication. Her GP does not really know much about her condition and neither the GP nor Mary has a clear idea as to whom they should call for advice. It is too long to wait for her next neurology appointment, so the safest thing to do is send her to the local accident and emergency unit. She is admitted but it is very overcrowded because she must again wait for two or three days for a bed. There is no neurology service in the local hospital and Mary's doctors are not sure what to do. They contact the neurology centre again and she is again transferred for further management. The transfer takes two weeks, during which time she is occupying a bed in the local hospital.
How should we assess Mary's patient journey? Is it satisfactory? Of course it is not. What needs to change in Mary's case? Obviously we must change the system. It would help, for example, if the GP could access the neurology service in a more efficient way. If the GP had had an efficient means of contacting a neurologist for advice, it might have been possible to avoid the first referral to accident and emergency. This could have been done, for example, by e-mail or by using a triage system manned by a nurse with specialist expertise with back-up from a neurologist. It goes without saying that she should be reviewed by a neurologist as well, and this must happen much more quickly than the 18 months she has to wait. If there were more neurologists, she would not have to wait as long for an appointment, which would also have avoided the first referral to the accident and emergency department.
If there had been well-established channels of communication between the general practitioner and the local and regional hospital, Mary's discharge plan would have been clearer. If a GP had been part of a primary team, Mary would have been able to avail herself of all the therapists and the condition would have been managed in a more proper and holistic way. If there had been a liaison nurse whose specific job was to troubleshoot problems for patients recently discharged, Mary's second admission to the accident and emergency department would have been avoided.
What we are describing is integrated care, the first part of our argument. It is the need to change how services are organised. We are not describing anything terribly novel. Integrated care is where the patient comes first, and it is international best practice. Integrated care works for patients because they are placed at the very centre of the health service, where many groups, including the Irish Society for Quality and Safety in Healthcare, have been saying they should have been for many years. It should not be about doctors, nurses or managers but patients. If we get the patient's needs right, we will get the balance right for all the care-providers.
How would this help to resolve the current crisis in health? Mary is an example of somebody with a chronic neurological disease, but it could be anything else. The many other types of chronic disease include diabetes, arthritis, respiratory disease and heart disease. People with a chronic disease are the most frequent and long-term users of the health service. They account for 80% of all GP consultations, 60% of all hospital bed days and 70% of all accident and emergency department admissions.
If we improve the services for people with chronic disease, which would involve most neurological patients, we would have a massive impact on how we use our hospitals and nursing homes, as we would be able to keep people in their homes. In Ireland, 5% of patients occupy 40% of all inpatient bed days. They are people with complex and chronic needs. We know from our research and that of others that if chronic conditions were properly managed, the number of emergency admissions could be reduced significantly and people would be happier and more content with our service.
On reflection, it becomes very clear that the overcrowding in accident and emergency departments, the so-called crisis, is really a symptom of a much larger problem in the way we deliver care as physicians and other health care providers. If we were more joined up and integrated, many patients attending accident and emergency departments could be treated at home before crisis point was reached.
The Health Service Executive has already embraced the concept of integrated care. There is the provision of primary care teams, for which a specifically allocated budget has been alluded to in yesterday's budget. The HSE is committed to the integration of care between hospitals and communities on this basis. However, it should be noted that the shift towards integrated care will take much effort, and change is always very difficult. It should be recognised that it is not necessarily a cheaper option, but it is certainly less wasteful and one which our patients deserve. We still require more neurologists, specialist nurses and therapists, as well as a much-improved system by which these various teams in either hospital or primary care can effectively communicate.
The second part of our proposal is a substantial programme of investment in neurological services at primary and secondary care level. There will be a return on this investment in terms of better care, patient outcomes and satisfaction for everybody. More importantly, it will reduce appropriate demand and focus on secondary and long-term care. Our capacity will be enhanced to respond better to demand and find the right care at the right time in the right place.
This is not about vested interests but a better way of anticipating and delivering care that will treat patients as people. It is about learning to work together to keep people out of hospital and long-term care rather than going from hospital to long-term care. It is about consistently applying best practice in a fair way and finding the right place and treatment at the right time for those who depend on us. We would expect nothing less for ourselves or our families.
We would like the committee to recognise that the crisis in health does not lie in overcrowded accident and emergency departments, no matter how easy that is to believe. We would like members to recognise that the provision of a high-quality service in neurology will rest on the investment in teams both within hospitals and in communities. It is about service-providers, policy-makers and the patients, represented by us, changing our behaviour together and improving the system. We are all part of the solution, not the cause of the problem. This can and should be a blueprint for managing other chronic health conditions as well.
We need the committee's support in shifting the attention of the current Administration away from quick-fix solutions. It is very unpleasant to sit in an accident and emergency department for two or three days waiting for a bed and it is unacceptable to have an operation cancelled, but we must tackle the real problem. We have ignored the greatest users of the health services and we will never achieve a world-class health service unless we address these issues.
The witnesses are talking about multidisciplinary teams in the community, including neurologists, therapists and nurses. What number of teams would be required, and what are the manpower implications? How many nurses and therapists, for example, would be required if people were to be trained or recruited for those teams? Manpower would be key in bringing such multidisciplinary teams about.
We advocate integrated care or the development of integrated services within the primary sector in the community. That is already rolling out, with the provision of 100 primary care teams funded in the current budget. In addition, we wish to develop the multidisciplinary management of neurological conditions within the secondary care sector in hospitals.
Such a roll-out would be contingent on a needs assessment currently taking place at the behest of the HSE and led by Dr. Marie Laffoy. We are in the process of elucidating the ultimate numbers for the various teams. We know from the Comhairle na nOspidéal report on neurology, published in 2003, that we needed at least 35 neurologists at that time. We have 17 and the population has grown since the report's population, so we may need more.
How the neurologists are dispersed and the teams developed around such personnel will be defined in the needs assessment being chaired by Dr. Laffoy. It should be published in February next year, so we can return to the committee on that matter. It will be at least 35 to 40 neurologists along with the 100 primary care teams.
Dr. Hardiman has stated that 17 neurologists serve a population of 4.5 million. In the areas where a service is available, what is the waiting time? Did Dr. Hardiman state the wait was 18 months where no service is available?
As neurologists are currently located in the main population centres, the waiting list is roughly the same throughout the country at about 18 months.
Where the service is available, is it fairly good in respect of waiting times?
Unfortunately not, as each of the centres serves the population. For example, in Beaumont Hospital we probably serve a population of 1 million people and our waiting times are approximately 18 months. It is about the same for the other hospitals.
If we had a utopian scenario, how many additional consultant neurologists would be required?
We need at least 35, but probably 40, consultant neurologists. The figure of 35 would be in line with the Comhairle na nOspidéal review published in 2003.
Neurologists cannot work in isolation and we are part of teams. We would need a roll-out of a multidisciplinary team for each of the chronic conditions we manage. In addition to neurologists, we would need funding for allied health professionals in the different areas we serve.
Dr. Hardiman has made her point on the leading consultant vis-à-vis neurologists, but what is the availability of staff to make up the other members of a multidisciplinary team?
It is similar and perhaps Ms Rogers would like to address the issue from the perspective of the Neurological Alliance of Ireland.
To what disciplines are we referring?
We are referring to occupational therapy, speech and language therapy and physiotherapy. As Dr. Hardiman mentioned, there are representatives from each of the groups of allied health professionals partaking in the current nationwide review of neurology services and they point out that the funding does not exist to provide specialist posts in occupational therapy, speech and language therapy and physiotherapy to supply the high level of expertise needed by neurological patients.
If the funding were available, would consultants be available?
Is the Senator asking if we have enough people in training?
Yes.
Every time we advertise for neurologists we receive, at least, eight or nine applications from highly qualified individuals and if a job were made available today, I could name eight people who would like to come home to accept the post. Furthermore, we are producing qualified people through our specialist registrar programme, so there are people available, but there are simply no jobs for them.
I apologise for being late. However, I have familiarised myself with the presentation that was given. I compliment the witnesses on setting out a significant approach to care which reflects the manner in which we must develop in future. This is only in its early days and requires significant change from many people.
I will ask my questions together as they come to mind. Are consultants willing to follow the approach outlined in the presentation? Regarding future needs, is this area growing at a faster rate than the rate of general population growth? I appreciate that the report will be published in February, but is there any indication of additional consultant posts for 2007? I recall a similar presentation some time ago from rheumatologists who were concerned at the long waiting lists facing patients. In 2007 there will be no new rheumatology posts.
There seems to be a pattern of things going on hold while reports are prepared — is that the case in this instance? Some 35 neurologists were needed in 2003, yet today we have only 17. This is a significant gap, and considerably more staff would be needed, as each consultant functions as part of a team. Perhaps the witnesses could give a ball-park figure on the total number of staff required by each consultant.
The 100 primary care teams to be created will vary considerably, with some more elaborate, occupying spacious buildings, and others more virtual. Complaints have arisen that people whose family doctor is not part of a primary care team are being isolated. How should we deal with this issue? We must consider all patients, not only those to be used as guinea pigs in such pilot schemes. I think primary care teams are a good idea but we must be careful that they do not create inequity at primary care level. Perhaps the witnesses could comment on this matter.
I am sorry I was not here at the beginning of the presentation and request the witnesses to address the issue of waiting times again because individual cases in my constituency have caused me great concern in this regard.
Given current funding levels, is it realistic to expect the goals that have been discussed to be reached? Health Service Executive funding for the eastern region will only maintain the existing level of service. Today and tomorrow we will see money shifted from the capital programme to current spending to try to make up for the shortfall in hospitals around the country. The question of whether such actions are legal is still unanswered and shifting money in this manner should be decided in the Dáil. Capital money has not been spent by the end of the year, meaning targets have not been met, and money is being shifted to compensate for black holes in hospital budgets. Perhaps the witnesses could comment on this also.
The first question was on the willingness of consultants to change. I represent the Irish Institute of Clinical Neuroscience, the body representing Irish neurologists and other individuals engaged in clinical care, and I can assure the Deputy that my colleagues have signed up to this. We are in agreement that change must happen and will embrace it. We are active members of the steering group on needs assessment, led by Dr. Marie Laffoy of the HSE, and our objective is to deliver quality care for patients.
Current and future needs represent a growth area and chronic neurological disease has been underresourced for many years. Adding a number of neurologists to such an area generates work, rather than solving problems, because a significant need exists that has not been met. Moreover, there is a series of conditions for which treatments now exist, of which multiple sclerosis is a good example. Everyone knows about Elan's drug Tysabri, which has benefited a number of patients but which requires more work. Regardless, it is an example of a drug that was not available previously that is available now.
There are many new treatments for Parkinson's disease and treatment options for neurodegenerative diseases are developing. This is a massive growth area because as the population ages, it becomes more prone to neurodegenerative diseases and we will, therefore, see an increase in the prevalence of such diseases in the coming years. It is necessary to address not only existing needs but expanding projected needs.
Regarding additional consultants for 2007, €3 million was allocated for neurology in 2006 and approximately €500,000 of that was subsequently allocated to neurosurgery, a major area of need. Some €4 million has been budgeted for neuroscience next year, which is a drop in the ocean to be divided between neurology and neurosurgery. Such funding represents a small contribution towards a major problem, but it is better than nothing.
The €3 million allocated this year was broken down in the middle of 2006 showing how it would be divided but, unfortunately, some of those posts have not yet been approved. Funding has been made available for three allied health professionals attached to each consultant post, but the consultant jobs have not yet come on stream in some hospitals. Allocations were made for Waterford, Limerick, Sligo and Beaumont but none of these jobs has yet come about, for a variety of reasons.
I will ask Mr. Grimes and Ms Rogers to address the issues of primary and secondary care.
I represent the Irish Society of Quality and Safety in Healthcare, which is a group consisting of volunteers across the health service. We are glad to be here today supporting Dr. Hardiman and the Neurological Alliance of Ireland because those involved at the coalface of the health service can see that the system needs to change and are involved in bringing about such change. The system, as it stands, is perfectly designed to produce the results that it does and throwing money at it, just to keep it going, is not necessarily the answer. We believe the emphasis should be on community care, specifically care for chronic neurological disease, and we favour the idea of primary care teams.
Regarding inequity, it is possible that it may occur and the challenge is to prevent it. If there is integration, people communicate across primary, secondary and tertiary care, and the patient is at the centre, the patient will have a voice and we can empower him or her. If we do not change the way we think, the current system will not change.
There are two points in response. I agree that general practitioners are an essential part of the primary care team and that it is vital that they be linked. What is vital also is that the allied health professionals working in hospitals have someone in the community to whom they can refer, that they should know who the local occupational therapist and speech therapist is in the primary care team and that they can speak directly to and liaise with him or her. It is not just about involving GPs in the primary care team. While this is essential, there are other links that can be developed.
To be clear, where there is a primary care team in place with physiotherapists, occupational therapists and so on, family doctors outside that team sometimes have difficulty in enabling their patients to avail themselves of physiotherapy or occupational therapy services because they fall within the established primary care team. That is the difficulty as I see it.
When the primary care teams are up and running and there is evidence that they are providing a better level of care, for more integration and patient involvement, the hope is that this will develop throughout the entire system. That is the ideal and what the money is intended for. These are pilot schemes which are working well. The outcome of the analysis will quickly demonstrate that this is the way forward.
One of our concerns is that there is massive inequity in accessing community-based services for the patients I look after and those Ms Rogers represents. Many of the patients I look after cannot access an occupational therapist because there are difficulties at a staffing level and in assessing need. The integration of the community-based service with the general practitioner service would go some way towards addressing this. If we, at least, signed up to the idea that community-based services should be integrated and that integration should feed into secondary and tertiary care services, that would be an improvement.
How many, in numbers or percentages, have neurological problems? Is there a problem in a regional imbalance? Last week my colleague, Senator Ulick Burke, raised the issue of neurological services in Galway being grouped, which was causing a major problem. Are neurological problems genetic or a reflection of the modern lifestyle? The new buzz word in teaching is ADHD, with which many children are being diagnosed. Is the condition being over-diagnosed or under-diagnosed? The major difficulty is that parents who are worried about their child have him or her assessed and he or she is then diagnosed as having ADHD. The parents are almost relieved that they can put a name to their child's condition but, unfortunately, the help comes to a halt because nobody knows what to do next. The reality is that while they have a name for the condition, they cannot do much to have it treated.
ADHD is not a condition we manage.
To answer the question about the prevalence of neurologic disease, we have estimated that if all neurologic diseases are included, including high prevalence conditions such as migraine and neurodegenerative diseases such as Alzheimer's disease and other forms of dementia, there are approximately 400,000 with a neurological disease. These numbers are likely to increase as the population ages. Stroke affects a further number of patients but we have not included them in the figures of 400,000 because we are discussing chronic neurological diseases. The numbers will probably increase, not as a function of some fashion in making diagnoses which the Senator appears to be implying but because, as the number of specialists and the skill level in making diagnosies increase, we are more likely to pick up conditions that might otherwise not have been identified. That is certainly the case with neurodegenerative and other chronic neurological diseases. We are more likely to diagnose if we have specialists making diagnoses.
What is the age profile breakdown in paediatric neurology versus adult——
We are talking primarily about adult neurology, from the age of 18 years upwards.
What is the percentage of patients in the 18 to 35 year old category?
The most common conditions in the 18 to 35 year old category in the non-physically disabling category would probably be migraine and epilepsy. The most common disabling neurological condition would probably be multiple sclerosis. Moving up the age categories, we see conditions such as motor neurone disease, as well as some of the neurodegenerative diseases such as Parkinson's disease or early-onset Alzheimer's disease. As the population ages, one can see a shift towards the progression of these diseases, which are all chronic. We accrue people as the age profile increases; as we reach the older age groups, we begin to see more cases of neuro-degenerative disease.
I realise some of the conditions arise later in life but if there were better screening and diagnosis, could they be picked up earlier?
Yes. The most important point is that where conditions such as MS are diagnosed earlier, we can make a difference. We can improve outcomes and reduce the level of disability if a condition is diagnosed early and treated because we have disease-modifying drugs. That is also true in the case of epilepsy. If it were treated earlier, outcomes could be improved. Therefore, it is important to be able to diagnose conditions, treat patients and get them back into the community. We can improve their quality of life, keep them in their family environment and, in many cases, working.
How would these conditions be picked up earlier? Is it by way of CT scans or blood tests?
It depends on the disease but it is through neurological consultation and expert opinion.
In the case of Alzheimer's disease, people aged over 65 years are generally seen by a geriatrician and have access to care of good quality but there are not enough neurologists in the system to see those under aged under 65 and their condition can go undiagnosed for a long time.
The other issue the Senator raised concerns geographic inequity, an issue I understand Ms Rogers wants to address.
Yes. I believe the Senator is referring to the report on neurosurgical services published last week. Some areas do not have a neurology service; patients in the south east, the mid-west and the entire north west do not have access to consultant neurologist services. There is major inequity in that regard.
Where do patients go? Do people from County Carlow and living in the south east have to go to Beaumont Hospital?
Patients from Cork go to Beaumont Hospital. There are two neurologists in Galway who are trying to serve the entire western seaboard.
I thought the appointment of a consultant neurologist was approved for Sligo General Hospital.
Yes.
What is the current status?
The appointment has not yet been made.
Has the post been advertised?
No. The posts approved this year are at various stages. The money has been allocated by one part of the Health Service Executive but approval is contingent on what happens in another part of the executive. There are difficulties. The posts have all been allocated in terms of funding but none has been advertised as of today.
Will Dr. Hardiman explain the difficulty between one part of the HSE and the other? The post has been approved; the money has been allocated but the position has still not been advertised.
It is not within our remit to explain it. It is deeply frustrating for us, as the Deputy will be aware.
It is deeply frustrating for everybody, particularly patients.
From the point of view of patients, it is very frustrating because they hear that a post has been approved, yet there is a long delay from the time it is dealt with by the Public Appointments Commission to the time it is advertised and the time someone is recruited. That is very frustrating for people living in the north west because they know the post has been approved but there is no sign of anyone being appointed.
I live in the north west and I am well aware of the position. However, I understood the post was to be advertised in the very near future. I did not realise there was a difficulty between two branches of the HSE. That is an issue the committee should investigate.
I support Deputy Devins's suggestion.
Professor Drumm and the Minister will appear before the committee in early January. I would like to establish the two sections of the HSE we are talking about because we cannot even name them.
From what we understand, funding of €3 million was allocated earlier this year specifically for the development of neurological services. That funding was broken down specifically for various posts. The document covering that was circulated in the middle of this year, but to date the posts have not come on stream.
Are there posts proposed for any other areas except Sligo?
Yes, for Beaumont and Waterford.
Also Limerick.
Yes, Sligo, Limerick, Waterford and Beaumont.
That is four areas. There will be four posts.
Is it correct that none of them has been advertised?
Not yet.
We should tease this out because this is rather embarrassing. The funding has been approved. How long ago was the funding agreed?
The document was circulated before the summer.
Is that the service plan agreement?
Yes. The allocation of the €3 million was circulated——
It was circulated at the beginning of last year.
The breakdown of the allocation of the funding was circulated in the summer, in July. Therefore, we have known about it since July.
Given that specific funding was put in place last July, the advertisements should have taken place.
The Minister allocated €3 million for this area in last year's budget and it took approximately six months for the breakdown of that allocation to be generated and then circulated. About €400,000 to €500,000 of that allocation has been granted to neurosurgery. While that is a need area, it is not part of neurology. Some of the funding has come through for the allied health professionals, but the funding for the consultant posts has not yet been sanctioned, despite the fact that the funding is available.
We did not have the money required in the past and now that we have it, we cannot make the appointments, but that is a matter for us.
I propose that the Chairman write on our behalf to Professor Drumm immediately to ask for a full explanation.
I second that proposal. People in Sligo, as I am sure people in Limerick, Waterford and Dublin, are incredibly frustrated at the apparent block to making the appointments even though the posts have been approved and the money allocated.
The funding is available but it is the question of what a post approval means. That seems to be the issue.
I made inquiries in Sligo some weeks ago and I was told that the advertisement was being drawn up.
I apologise for being late. I congratulate Dr. Hardiman on her untiring efforts to try to get something done about services in neurology, which are in a dreadful mess, as are services in rheumatology, and that has been the case for years. We were supposed to overcome situations such as this with money being in place and approval granted for posts, but nothing further has happened with the HSE being set up and changes in the Department of Health and Children. I was a member of Comhairle na nOspidéal on several occasions when we brought forward posts, specifying that they were needed, and then the matter was passed into the maw of the Department of Health and Children and that was the end of it. It is outrageous that this is still happening. Funding of €3 million for this specialty is a drop in the ocean. There should be no congratulations about that. Such funding will not result in getting anything started and, furthermore, some of the allocation has already been given to neurosurgery.
Some €500,000 of the €3 million has been allocated to various aspects of neurosurgery and next year, €4 million will be allocated for neurosciences. Neurosurgery is in dire straits as well. Clearly, neurosurgery will have to receive some of the €4 million that has been allocated for neurosciences. However, for us to develop and roll out our plan based on the Comhairle report and on the HSE needs assessment, which will be a comprehensive, up-to-date and well-developed document with a buy-in from all the providers, its implementation will cost much more than the percentage of €4 million that neurology will be allocated next year.
It is really a drop in the ocean. How can we get across to the public the seriousness of the delay in treatment for people with neurological and neurosurgical conditions? They are deteriorating while they are waiting to get treatment. It is outrageous. How can we get the message across to people, which I suppose we must do, that access to someone such as an occupational therapist based in the community can transform a person's life within his or her home?
There is a more important point we would like the committee to take home. What the Senator said is important. However, if investment is properly made in the way we advocate, the number of people who end up in accident and emergency departments will be reduced.
That is right.
That is an important point. Let us consider a hypothetical case based on patient experience, on people that I, Ms Rogers and Mr. Grimes know, and while the person, Mary, does not exist by that name, that person exists. That person had two accident and emergency department admissions that were unnecessary because of a fragmentation of services. That person could have chronic obstructive airway disease, a rheumatological problem or cardiac disease. If we invest in the services in an integrated way, we can go quite a long way to ameliorating the current crisis being experienced in secondary care. That is important.
The point that Senator Henry made is well taken, namely, that the way neurological diseases are being managed is a scandal, but we need to move one step beyond that. This is why Mr. Grimes is here. How we manage people in general is a scandal and we must move away from the idea that investing in accident and emergency services and in secondary care alone is the way to fix this problem. We must look at how we treat people from the beginning, and we treat them badly. We do a bad job in the respect we pay to people with any type of chronic disease. Clearly, I am mostly interested in neurological disease, but that is true in general. We do a dreadful job in the way we treat people and the manner in which they must access care in an emergency way when we could be doing it much better by streamlining their care such that they would never have to see the inside of an accident and emergency room.
Redesign is key and a change of focus is required. The second example we have identified, plan B, is of a person who does not go to an accident and emergency department, huge savings are made and hospitals are freed to do the job they are designed to do. This applies to all chronic care areas, be it diabetes or other conditions. If primary care teams are in place, they look after neurology and diabetes and are multifunctional. It marks a change in focus.
The primary care team must hook up with the existing team in the hospital.
I wish to make a final comment on which Dr. Hardiman might like to reply. Many people in nursing homes with chronic conditions might not be nearly as bad as they are if they could get a re-assessment. I have found that to be a terrible problem. People are in nursing homes with multiple sclerosis or another condition and are badly in need of a re-assessment and they wait years for it. They are in a very vulnerable position and it is difficult for nursing homes to deal with them.
I completely agree.
Chronic care is sucking up all the money being allocated, and that money is focused on care in hospitals and nursing homes. With the model proposed here, such care would be provided in the community but would be linked very much with hospitals and communication between primary care and secondary care.
Many of our patients end up in situations where there is a breakdown of care. If we had intervened earlier and could predict the breakdown of care, it might be possible in situations such as that, especially with the new care packages coming on stream, to prevent people from ending up in crisis where the family cannot cope any more and the person must go into State-sponsored care. We should be able to avoid that by intervening at an earlier stage.
I agree that we ask the Chairman to write to the executive because the lack of a sense of urgency is dreadful.
I will come to that shortly before I conclude.
I note that Ms Rogers is here today representing the care of people aged 18 years and over. Who is involved or representing the paediatric neurological services?
The paediatric neurologists and the allied health professionals supporting that group would also feed into this nationwide neurology group. We hope to have a much better picture of what is happening in this area by February or March next year. We are involved mostly on the adult side of services. There is an information deficit and we need to know the needs in this area. That has not been examined.
Is Ms Rogers saying that by February or March——
That is when the group hopes to publish its report. That will give a much clearer picture of the needs in that area. There are anecdotal reports of problems in paediatric neurology services, but we will know more when we have the report of the sub-group.
To clarify, the main reason for the needs assessment is a massive deficit in the Comhairle report on neurology and neurophysiology services published in 2003. The remit of Comhairle at the time was merely to examine consultant numbers, not the delivery of care. The report is centred on hospital-based services and purely about consultant numbers. Comhairle recognised that deficit and recommended that a subsequent review relating to rehabilitation take place. The needs assessment is based on examining the needs of patients with neurological disease and examining them within the format of existing health structures, which are different from those in place when the Comhairle report was published. It is a direct follow-through from the Comhairle report but will be a far more extensive document. There is more of a buy-in because there are representatives from all the allied health professions such as consultants, the voluntary sector and the nursing service. It will be a comprehensive document with a strong buy-in from all the care-providers, as well as users. It should be an important document when it is produced.
The delegation has given us a serious presentation and we can see the gaps identified. What is most alarming is the fact that funding has been allocated but it has only given us three or four positions, a drop in the ocean. It is up to us to rectify this. Rather than just pay lip service to the presentation, the Minister and Professor Drumm will attend our meeting in early January and we will take up with them the issues presented. The delegates talked about the poor level of service to patients. What is the ideal?
The ideal is what we are advocating today. We have advocated two strands, one of which is an improvement in resources which everybody——
What is separate from this? The delegation has made the point that just throwing money at the problem will not solve it. Let us presume the resources are available. What change is necessary?
We want to shift the focus from accident and emergency services to resourcing the patient journey as it happens. That means resourcing primary care or buying into the primary care programme, which we support, and resourcing secondary care neurology services at an appropriate level, as well as resourcing the interface between the two. Integrated care is not a cheaper option; it will not lead to a cost saving. It means not throwing money at accident and emergency services. One must look at the root cause, which is within the interface between primary and secondary care. It means investing in primary and secondary care but investing strategically. It involves stepping back and examining the problem, which is fragmentation and under-resourcing. These are massive problems.
It would be helpful if the delegation gave us a shorter presentation on the ideal solution and where it sees difficulties within the service. When we meet the HSE and the Minister, we will bring the issues raised to their attention.
We will put together a single-page summary of what we said today.
That is exactly what we are seeking. A single page would be sufficient. If it contains the main points, we will follow through on them. I thank the delegation for its presentation.
