JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Tuesday, 16 Nov 2010

Cardiac Rehabilitation Services: Discussion

Chairman

We shall now have a presentation from the Irish Association of Cardiac Rehabilitation.

By virtue of section 17(2)(l) of the Defamation Act, witnesses are protected by absolute privilege in respect of their evidence to the committee. If witnesses are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence.

The witnesses' paper has been circulated to the committee. I invite a presentation following which I will take questions from members.

Ms Sophie Charles

I thank the Chairman and members for giving us the opportunity to make an opening statement. The document which has been circulated to members contains many of the details but I will just-----

Chairman

Perhaps Ms Charles can give a summary of it.

Ms Sophie Charles

The Irish Association of Cardiac Rehabilitation is a voluntary group set up in 1995. It is a multidisciplinary group under the auspices of the Irish Heart Foundation. It endeavours to promote a greater awareness and understanding of cardiac rehabilitation in Ireland and to facilitate communication and support between multidisciplinary groups involved in the area. It develops guidelines and so on. It also works as an advocate on behalf of cardiac rehabilitation services in Ireland to ensure the service is protected, developed and available to all patients who require it. This is done by collaborating with other organisations, improving the standard of professional education and encouraging support and communication. I will ask Professor John Horgan to speak about what cardiac rehabilitation means.

Professor John Horgan

Rather than give the committee a special lesson I am sure all members know what is meant by primary prevention and secondary prevention. Just in case the committee needs to be reminded, primary prevention means the steps one tries to take in a population to prevent the development of cardiovascular disease. Secondary prevention means the similar steps that must be taken once people have had a heart attack, heart surgery or angioplasty. The concept of cardiac rehabilitation essentially is a system of delivering secondary prevention to those persons who have become manifestly ill. Within the package of cardiac rehabilitation we emphasise the concept of regular exercise, dietary prudence, obviously smoking cessation and medication adherence as many people do not take their tablets according to prescription and forget about them. We are also well aware of many problems within the workplace for people who have cardiovascular disease. The rehabilitative process takes that into consideration and looks at psychological factors where they inflict people who may be particularly stressed by a flirtation with death, which is essentially what many cardiovascular events are.

The system put in place aims to deliver advice and guidance in all these areas, very quickly after an event has occurred. The idea is that within each of the hospitals delivering cardiovascular services within the country, there shall be a system in place, delivered by a multidisciplinary team, that address all of this aspect over a defined period. There is great literature on this. The committee will have seen some of the local Irish contribution to this area.

The concept of the delivery of multidisciplinary care in cardiac rehabilitation has become a path finder for other areas within the medical environment. Those who are delivering care in the areas of stroke and diabetes mellitus, both of which conditions include vascular problems, are very interested in how the rehabilitative process in cardiology is being delivered and are interested in collaborating with the cardiac rehabilitation group in developing similar systems.

Chairman

Do Ms Roisin Duffy or Ms Barbra Dalton wish to contribute?

Ms Sophie Charles

I will continue. Given that our time is limited I will highlight the issues we have come to address. The Building Healthier Hearts strategy was a very successful cardiovascular initiative and did much for cardiac rehabilitation services in Ireland. I acknowledge that money was put into that area in the early 2000s. From a position where 29% of hospitals provided cardiac rehabilitation within four or five years 95% of hospitals were providing such services, the aim is for 100% of hospitals to provide a cardiac rehabilitation service. In the new current strategy there are recommendations which are relevant to cardiac rehabilitation. However, due to cutbacks the services have been affected as has every service. The issues we raise have a particular relevance to cardiac rehabilitation.

We need to protect cardiac rehabilitation from the cutbacks in the health care system. At the current level of services, only 50% of eligible people have access to cardiac rehabilitation. That is not ideal, but we are not unique in Europe in this respect. The incidence of cardiovascular disease will increase as the number of elderly people increases. Cardiology treatments are better and there will be a greater demand for cardiac rehabilitation as the years go on.

We are starting from quite a low baseline and in the past two to three years, 34% of cardiac rehabilitation centres have had staff or service cuts. To provide a cardiac rehabilitation service we need to ensure a multidisciplinary team is in place. The strength of the service is that it is multidisciplinary in nature and a nurse or doctor from one discipline taking on this task is not sufficient to make it work. The cutbacks in different disciplines is affecting the cardiac rehabilitation service for patients. There is a need to streamline the approach and structure cardiac rehabilitation in different centres. Some hospitals were fortunate to get more funding than others and some hospitals face severe staff cutbacks and so on. The standard of rehabilitation is different in different hospitals. Patients deserve the best service to which they are entitled.

Cardiac rehabilitation is a phased service and there is a need to develop phase 3 in the community and introduce phase 4. Phase 3 is what many people consider as cardiac rehabilitation and we are nowhere near maximum capacity. If we continue to cut services, we will decrease the percentage of people who have access to the service. It is a cost-effective service and we have provided documentation on the costing and the evidence that patients who attend cardiac rehabilitation have fewer re-admissions, are more aware of their symptoms and know what to do if they experience chest pains. They are aware of lifestyle factors. This service is cost effective. The new strategy has recommendations on cardiac rehabilitation, such as ensuring adequate and equitable coverage of cardiac rehabilitation for all eligible patients. We are starting from quite a low baseline and we cannot sit back and allow further cuts to our services. It is important that cardiac rehabilitation would be an integral part of the spectrum of cardiac services in public and private health care settings. Cardiac patients should have timely access to cardiac rehabilitation services. There is no point in having a service but offering it to a person in a year's time. This is too late for patients. There must be timely access to the service.

This multidisciplinary approach to cardiac rehabilitation has been replicated in other areas. It is a good service, it works and is cost effective. I have some quotations from people who have benefited from cardiac rehabilitation:

If funds towards this service were cut, I can see it costing the HSE more in the long run as people recovering from heart conditions would more than likely have relapses and nobody wants to see this happening.

Before I attended cardiac rehabilitation I was in a very bleak place and felt totally abandoned. I set off with little enthusiasm and not much hope and I have been amazed at the level of care and the wonderful programme. You have given me my life back.

I thank members for their attention. We are happy to take questions.

Chairman

Thank you.

Deputy Jan O’Sullivan

I thank the witnesses from the Irish Association of Cardiac Rehabilitation for their very succinct presentation and supporting documentation. The strongest point is that it makes absolute sense to continue to fund cardiac rehabilitation appropriately. The association sets out the cost of a two-day admission to hospital at €1,974, whereas the cost of cardiac rehabilitation per patient per year is €1,627. It is cheaper to provide a service for a year than a two-day admission to hospital. It is very important for people's general health and happiness. I know Deputy O'Connor will have much to say on this topic because he can speak from experience.

Heart disease is one of the significant illnesses in the population. Do the witnesses have the statistics on the prevalence of heart disease in Ireland? The provision of cardiac rehabilitation is not available evenly throughout the country and there is more of a threat to the funds in certain areas. By their nature, cutbacks are made from the low hanging fruits. This service might be seen as an easy target for further cutbacks We all agree that it should not be targeted because of the beneficial nature of the service.

The Irish Association of Cardiac Rehabilitation has concerns about cutbacks but what parts of the country are susceptible? Are there big gaps in the services in various parts of the country? As cardiac rehabilitation is multidisciplinary, clearly some health professionals have been seriously affected by the moratorium where people have not been replaced, I would like the witnesses to clarify whether this is a problem.

Deputy Charlie O’Connor

I join in the welcome extended to the delegation. This is an excellent presentation. I note that it was stated in the conclusion that cardiac rehabilitation programmes are a very effective way to help individuals who experience a cardiac event to deal with the consequences of their illness and support and facilitate them on their road to recovery.

I would not normally talk about myself but, as Deputy Jan O'Sullivan gave me a line, it is important to demonstrate my strong support for this service. Mine is a Tallaght story in that I had my heart attack in Tallaght Hospital in August 1999. Strangely enough, it started at a Frances Black concert and, not to be flippant, I often tell the story of meeting Frances Black and she asking me what was she singing at the time. In the excitement I could not really remember but I always say she was singing "The smile on my face". It was a big experience. I had bypass surgery in the Mater Hospital on 20 August. Like most people after a heart attack, I was not sure what I wanted to do because I was the then chairman of the council and I was very busy. People suggested that I should take it easy and retire and do something different.

I can genuinely say that I would not be a Deputy today had I not availed of the cardiac rehabilitation programme in Tallaght Hospital. It was an amazing experience for me and I made many friends, whom I retain. Even though I am a Fianna Fáil Deputy, they still talk to me. It helped me back to recovery in a big way. As was stated in the presentation, it gives a person confidence. When one has a heart attack and is confined to hospital, one suddenly realises that one cannot do the types of things one used to do. I hope no one experiences a heart attack but I thank God that I lived through it and got to the other side. Cardiac rehabilitation taught me about diet and exercise and many of the things I needed to know to make me comfortable and give me the confidence to get back driving and return to politics, which is a stressful occupation. I am here 11 years later.

I genuinely have benefitted from this programme and I would not only support it because of my experience but because of the many people I know in Tallaght and elsewhere who have benefited from the programme in a very positive way. I keep in touch with my friends in the cardiac rehabilitation programme in Tallaght Hospital and one of the things they worry about is that, as Professor Horgan said, the low hanging fruit would be targeted and their highly skilled and qualified staff would find they were reallocated to another area to do an equally good job but lost to the cardiac rehabilitation service. Without doubt it will be under a great deal of pressure and the service will have to be careful in the way it cherry-picks. I have often been amazed by the kinds of people who have heart attacks. Tallaght Hospital used to bring parties in for a little seminar and a glass of wine, which I always drank in moderation. One would discover people from all walks of life - gardaí, teachers, housewives, politicians and people who were not so elderly. It was an amazing experience. When I was elected to the Oireachtas, the former Deputy Séamus Pattison told me that, as he understood it, after his being 45 years in the Dáil, I was the only person he knew who had had a heart attack before becoming a Member. He told me the usual pattern was to have a heart attack when a Member of the House.

I hope I am getting my message across. I am very supportive of this programme and not only for myself because it helped me. I would not be a Deputy today without the Tallaght rehabilitation programme. It is important we understand how many people have benefited since the programme was founded in 1995. It has given people confidence and given them back their lives. I know many people are again playing golf, something I do not do, and engaging in sports. Many have told me that but for the rehabilitation programme, they would not be doing that. It provides that confidence.

I am delighted to support the service which is very important. The Tallaght service is excellent and helped me greatly. I never hesitate to say how important it is and I will not be afraid to speak on its behalf. Everyone will tell me about all the other aspects of the health service that should be highlighted and I will be happy to do that, but cardiac rehabilitation is personally important to me. I am happy to support the delegates.

Deputy Bobby Aylward

I, too, wish to be associated with this sentiment and I welcome the Irish Association of Cardiac Rehabilitation. The old adage of prevention being better than cure comes to mind. That is what the association is about. It supports the patient by preventing heart attacks and sudden cardiac arrest.

The association is under the auspices of the Irish Heart Foundation. From where does its funding come? Does it come directly from the HSE or is the association funded separately? I would like to know a little about that.

Regarding the roll-out of services, the delegates stated that only 50% of eligible patients have access to cardiac rehabilitation. Is the roll-out done on a county or regional basis or through the regional hospital system? Will the delegates tell us more about how they reach the patient and how he or she is treated? Deputy O'Connor made the point well so I need not add to what he said. The service is necessary, and the more patients it sees, the less will be the strain on other services, which is relevant given the current financial situation.

Senator Mary M. White

I cannot follow Deputy O'Connor whose contribution was first class. The association should use him as a role model. The job of politician is very highly pressurised and fair dues to the Deputy for coming to this job after having a heart attack and looking so slim and well.

Deputy Charlie O’Connor

The Senator is embarrassing me.

Senator Mary M. White

It was great to have had that first class presentation. It is a pleasure to read and I say "Well done". I am the opposite to Deputy O' Connor. I have not had a heart attack but I worry that I may have one because I am so unfit and I eat all the wrong foods. I return to Deputy Aylward's point about prevention being better. My belief is there are many thousands of people like me who are not really motivated to prevent themselves getting a heart attack. Logically, I know what to do. More than 20 years ago I gave up smoking because of all the advertising. Eventually I twigged that smoking would kill me if I kept at it and in the end I went cold turkey. There must be someone who could motivate me further. I do not walk and am totally unfit and I know this is very dangerous. The penny dropped with me about smoking because there were so many advertisements showing it was bad for one's health. There was a group or organisation in Ely Place and that was the first attempt made by the Government to try to reduce the number of people who smoked. It worked. That age group tried-----

Deputy Bobby Aylward

Charles J. Haughey was the first man.

Senator Mary M. White

The point I am trying to make is that talk about prevention is not really getting through to the people who should mind themselves. It may be a class thing or whatever, and people are not reading in the newspapers what they should not be doing. I am a perfect example and I need to be motivated. There must be thousands like me who are not minding themselves. I am serious about this, not flippant. The campaign to get people to stop smoking worked for my generation although I cannot speak for the young people now. It worked for many people but many of us put on about three or four stone after giving up cigarettes. There is no doubt about that because I remember during the early 1980s one would meet people who had given up smoking cigarettes and one would not recognise them because they had put on so much weight. It changed them completely and they have not got to grips with the result.

There is a serious issue regarding prevention and getting the message across. The presentation was excellent.

Chairman

The delegates have heard a number of members who are very supportive of the work the association is doing. I am conscious they spoke to the committee after it heard from a number of groups, all saying, in the run-up to the budget, that there are particular areas of activity within the health services which must be protected. I am interested that the delegates included a cost-benefit analysis. Obviously, we appreciate the human benefit delivered but to have the cost-benefit analysis factored in is useful. We are very poor at taking that type of statistic on board. As a committee we must advocate strongly for the association and support it in what it is doing.

I can appreciate how cardiac rehabilitation can be immediately effective for a young person in that such a person can recognise he or she has had a warning and must change his or her lifestyle radically. For an older person with chronic heart disease, must the process of rehabilitation be ongoing? Having seen as much in my own family, I suspect it can be very difficult for some older people to change in a significant way what they describe as the habits of a lifetime. Are there additional costs associated with providing the service?

Members made a key point in asking how we can assist the association. Obviously, we can make a case to the HSE and the Minister for Health and Children and we can discuss ring-fencing and protecting funding in this area. Are there other proposals we might put on the association's behalf to support it in its life-saving work? Who wishes to respond?

Ms Sophie Charles

I will respond to some of the questions and ask Professor Horgan to deal with statistics and the aspect of prevention. In regard to gaps in the service, smaller hospitals are obviously at risk of closure or whatever and therefore there are gaps. Funding is via the HSE and it goes to the acute hospital. For one reason or another funding for cardiac rehabilitation is sometimes diverted to another area. That is the first issue. Cardiac rehabilitation funding must be specifically protected. Second, the moratorium has seriously affected cardiac rehabilitation services because these have a multidisciplinary nature. Nurses, cardiologists, physiotherapists, occupational therapists, social workers, psychologists and so on are involved and nursing and psychology have been hit in a particularly bad way. I cannot say one is more important than the other because the strength of the programme is its multidisciplinary nature. Certain professions have been hit harder than others and continue to be hit and that in itself has caused a cutback of about 34% of rehabilitation services nationally.

Funding is via the HSE. There are no other forums of funding. Access is via local hospitals. Every hospital that deals with acute coronary patients will have a cardiac rehabilitation centre. Capacity depends on their staffing and resources.

Deputy O'Connor mentioned the age profile. In cardiac rehabilitation the profile is predominantly male and perhaps of an older age group. In our rehabilitation centre, for example, the youngest person has been 21 years of age and the oldest has been 91 years of age. Therefore, this affects a huge range of people. It affects everyone, people in every age group and in every walk of life.

Apart from the recommendations we highlighted, we also believe cardiac rehabilitation funding should be ring-fenced and not diverted, which is what happens. Cardiac rehabilitation services are an integral part of cardiovascular care. Sometimes funding it is taken from one aspect of care and given to another. Funding for cardiac rehabilitation must be ring-fenced.

There is no point in reinventing the wheel. The recommendations in health care strategy were comprehensive and set out what provisions should be in place. Unfortunately, services have been eroded over the years and now they are now being cut even more.

I will ask Professor Horgan to talk about the statistics and about the older person.

Professor John Horgan

The simplest statistic is that one third of the population will eventually develop significant vascular disease, one third of the population will have some form of cancer, and other disorders will take care of the rest of population. This emphasises the importance of any intervention that deals with cardiovascular disease without going into complicated numbers.

I support very much what Ms Sophie Charles has said, especially the point about ring-fencing funding. It is important to appreciate that the majority of programmes are in the public hospitals and are utilised by patients who have private health insurance and by those who do not have it. Some private hospitals have only begun to provide programmes in recent times. To the best of my knowledge, none of the insurance companies provides any support for this. I may not be accurate about that in the context of the past six months but, to the best of my knowledge, most people who attend a rehabilitation programme in a private hospital would be self-funding.

We carried out a study some years ago during which we examined the cost of rehabilitation from the cost of the ECG paper through to all the salaries involved. We worked out that for the standard ten-week programme it costs approximately €950 to provide three sessions a week for each individual over a ten-week period. We then examined a four-week programme. One can provide an excellent programme with all the facets for just under €600 over a four-week period and one will get a training response and benefit from the dietary and other advice given. Deputy O'Sullivan mentioned the cost involved. The cost is not excessive given that most of those here will have had some test carried out somewhere. We are talking about a cost of hundreds of euro for the carrying out of tests, irrespective of their nature. Therefore, €900 is a good cost for a ten-week programme for a person where he or she will be treated by well-trained professionals with great experience. The coterie of people delivering this service in Ireland is very good. Members heard the president of the association speak impressively, and she is only one of many who are delivering this service. It was wonderful to hear Deputy O'Connor speak so well about the excellent programme in Tallaght. This programme is not very costly. While these are dreadful times, ring-fencing the amounts is not great, having regard to what is required. Ms Charles spoke about losing staff owing to current policies. That is having a serious impact, of that there is no doubt. I support her on that point.

I wish to make a few general comments. There is no problem about looking after older people. Our population is ageing. Older people are hugely enthused about entering the rehabilitation programmes. One section of the community we have to persuade to participate is ladies. If women enter the programmes, they are fantastic participants but often they are reluctant to do so. There are a number of reasons for that which I will not go into, but there is good literature on this. Women tend to be ten years older than men when they develop significant cardiovascular disease. It involves a little effort to persuade women to enter programmes. There are a variety of reasons for that and this is probably not germane to what we are discussing. The special interest group and people such as Ms Charles and her colleagues work hard to get women to enter the programmes.

Deputy Aylward asked how we get patients. It would be simply by my saying to a person that he or she would have to go into the rehabilitation programme and that was the only course for that person to go. There are not enough programmes. Regrettably, not everyone can be accommodated and sometimes by the time people get an invitation to enter a programme, they have self-rehabilitated and that is a difficulty. We would like far more programmes to be available. That is an important aspect.

A related issue is that it would be nice if more programmes were available for people in rural Ireland. If one lives in Donegal, there is an excellent programme in Letterkenny and it has developed an outreach programme but, unfortunately, one of the outreach programmes had to close owing , I believe, to a lack of funding. It is difficult geographically in a county like Donegal for everyone to be facilitated in Letterkenny. Those problems are replicated in other parts of Ireland, which is perhaps germane to Deputy Aylward's question about where these programmes are in place. Some of the big cities have programmes. For example, Limerick city is not terribly well provided for. There is a programme, which a number of dedicated people have put together, in the Mid-Western Regional Hospital in Dooradoyle, but that is it and it is the service for the whole county. There are blackspots in terms of the provision of programmes.

Chairman

Is it conceivable that this type of rehabilitation programme could be delivered under supervision through a primary care team, or is that out of the question?

Professor John Horgan

I adverted to this earlier and I would like my colleagues to speak on this as well. The rehabilitation team concept was a blueprint for multidisciplinary activity. There is no problem about doing that if the mechanics of it could be addressed. I know the IACR would be only too pleased to discuss this with other colleagues. That would be no problem.

Deputy Bobby Aylward

There are four acute hospitals in the south east - Ardkeen hospital in Waterford and the hospitals in Clonmel, Kilkenny, where I come from, and Wexford. Are there four programmes in those hospitals or are the programmes co-ordinated with one programme being in place for the four hospitals?

Ms Sophie Charles

Every hospital would have one and, even at that, we are not reaching every patient.

Deputy Bobby Aylward

There is a programme in each of those four hospitals.

Ms Sophie Charles

There is still less than 50%-----

Deputy Bobby Aylward

The delegates will note I am not fully aware of the position because, thankfully, I have not had reason to be.

Deputy Jan O’Sullivan

Are there waiting lists for these programmes or is everyone facilitated?

Ms Sophie Charles

Yes.

Deputy Jan O’Sullivan

How long would a person be on a listing list?

Ms Sophie Charles

It depends. It can range from weeks to months. It depends on the capacity of the hospital and the staffing and resources. That is the bottom line. In some hospitals, especially the busier large Dublin hospitals, there would be long waiting lists.

On the point of the programme being delivered through a primary care team in the community, we run an outreach programme in Arklow. We go to Arklow and run that but there is no reason it could not be integrated into primary care, and we have been examining that.

Deputy Charlie O’Connor

Being able to access the service in one's local hospital is important. When I had my heart attack I was sent to Tallaght Hospital but it did not do the surgery I required and I was sent to the Mater hospital. I was happy to go to the north side but it was important for me, bearing in mind the state I was in at the time and the frail nature of my health, that I was then able to do my cardiac programme in a location near my home. That is important as well. Local services are important, as Ms Charles said.

Professor John Horgan

Senator Mary White mentioned in passing the element of primary prevention and referred to exercise and so on. Her point is well taken. There is nothing that concentrates one's mind more than becoming ill, and one will change one's habits. For years, the Irish Heart Foundation has been working with various people in the education field to deal with that. It should be on the school curriculum. It would be wrong to say it is more important than languages but it should be compulsory that one takes a course in self-preservation at school and that one passes that in an examination. That is a must. The Irish Heart Foundation has been advocating that for years. There are people in the education field who are 100% supportive of that but it has not happened. That would be the answer to the primary prevention question. We are secondary prevention people, so to speak, because we only get the patient when they become ill.

Senator Mary M. White

When people have had a heart attack, they become converted.

Deputy Bobby Aylward

The is owing to the awareness they then have.

Professor John Horgan

Absolutely. I wish to mention the importance of regular exercise. Once one stops smoking and is committed to doing the right thing regular exercise is important. A recent report, which was in the newspapers this week, about the economics of sport emphasised this aspect. If there is adequate education for health in schools and people are encouraged to engage in sport their enthusiasm for smoking and other bad habits would be much less and they will almost certainly have very good dietary habits. All of these things hang together and it is very important to have a unitary approach to it.

We look after people who have had heart attacks and are in a little compartment, but there are big general ramifications for what we do. The Irish Heart Foundation has been advocating these types of things for years.

Ms Barbara Dalton

A member asked if the Irish Heart Foundation is involved with the IACR. As Professor Horgan said, the Irish Heart Foundation is largely concerned with prevention and supports the IACR in its work. Essentially the association is made up of individuals who work in cardiac rehab and come together in their own time to work together, to advocate and to try to co-ordinate activities. The IACR is a group of committed people who work in cardiac rehab just working to protect and develop the service which is why it is so important to have a platform like this committee to wave its flag a little.

Ms Roisin Duffy

Heart disease and cardiovascular disease in Ireland are among our biggest killers. Mortality has been declining in recent years but morbidity is increasing, as is the number of people getting older and sicker. Cardiac rehab will be required more in the future. It needs to be protected. We need to secure the service for people who will look for it in the future. We hope we can extend it in the future to other population patient groups.

Deputy Bobby Aylward

What are the worst fears of the delegation in terms of the coming budget? If it had a wish what would it be?

Ms Roisin Duffy

We have many wishes.

Ms Sophie Charles

Our worst fear would be that more staff would be cut. I work in quite a small hospital and the real fear is that hospital services will be cut and the easy targets will be chosen, such as cardiac rehab. There are pros and cons. We have three hospitals that provide cardiac rehab and we might not need them. The three hospitals are available locally for many patients and we do not provide the service to all the patients that require it. To close two out of three, leaving one, will result in the expansion of waiting lists out of all proportion and an effective service will not be given. One of the worst fears would be that somebody would say it was a very clever idea and did we need three rehab centres rather than one. As it is we are starting from a very low baseline and that would defeat the whole point of local access and equity for patients.

Deputy Charlie O’Connor

Professor Horgan made an interesting point, namely, that even within hospitals, not just in Tallaght, there is competition between services. All Deputies are contacted by consultants who are fighting their corner, which is fine. In places like Tallaght and elsewhere services will compete - I will not say fight - with each other to ensure the continuation of the services. I am not being virtuous but I am proof of how important the service is to people of all generations.

Chairman

That is a good note on which to conclude. I thank the delegation for its presentation and the succinct manner in which it dealt with the questions. We will consider the presentation and we have a number of recommendations to make. We look forward to engaging with it in the future because we value the work it does.

Sitting suspended at 4.15 p.m. and resumed at 4.20 p.m.