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.