Stroke Care: Discussion with Health Service Executive and Irish Heart Foundation

The committee will now hear a presentation on the report on the cost of stroke in Ireland from representatives from the Health Service Executive, HSE, and the Irish Heart Foundation. I welcome Dr. Barry White, Dr. Joe Harbison and Dr. Peter Kelly from the HSE, and Mr. Michael O'Shea and Mr. Chris Macey, Dr. Francis Horgan and Dr. Samantha Smith, from the Irish Heart Foundation.

I wish to advise that by virtue of section 17(2)(l) of the Defamation Act 2009, 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. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

Dr. Barry White

The HSE has identified specific areas where it believes significant improvements are required in quality of, access to and cost effectiveness of stroke care. Based on national and international evidence, stroke is one area that requires urgent attention in this respect. In June 2010, a programme was established in this area led by two experts in the field, Dr. Joe Harbison, a geriatrician, and Professor Peter Kelly, a stroke neurologist. It involves a general practice lead, specialist nurses, therapy professions and the Irish Heart Foundation as representatives from a patient advocacy perspective.

The programme has been charged with improving quality, access and cost effectiveness of stroke care. The publication of the Irish Heart Foundation report on the cost of stroke care is timely and fits into the programme's work.

Dr. Joe Harbison

Stroke is the third most common cause of death in Ireland and the most common cause of adult physical disability. Approximately 30,000 people live with a stroke-related disability. One in five people will suffer a stroke which means it will affect most families at some point.

There have been amazing advances in stroke care in the past 20 years. In the 1990s, a physician would have said there was nothing that could be done to fix a hole in the brain. We now know, with innovations such as clot-busting drugs, thrombolysis and stroke units, that the outcome for stroke patients can be greatly improved. With improvements in rehabilitation and therapies, we can also reduce the chance of a patient requiring long-term care.

We agree with the Irish Heart Foundation report which is a valuable document in helping to understand the issues around stroke care. The report estimates stroke care costs between €700 million and €1.8 billion. The average cost per patient comes to €22,000 and the spend on nursing home care in Ireland is much higher than in other comparable countries. This is due to the lack of available specialist care and organised rehabilitation services.

Organised stroke care can reduce the need for long-term care by up to one fifth. The average cost of caring for a mini-stroke or TIA, transient ischaemic attack, patient is €5,300. A large proportion of TIA patients could actually manage as outpatients but in Ireland they are frequently admitted often for several days. The average length of stay for a TIA patient is more than six days.

If left unchecked, the number of people suffering strokes in Ireland will increase by more than 50% in the next ten years which will bring the cost to €1.5 billion. The stroke programme was developed as part of the HSE's quality and clinical directorate in June 2010. We are working in association with many specialist groups such as nurses, therapists, managers and doctors. We are currently overseeing the formation of local stroke networks and trying to bring together clinicians from all specialties in a locality to co-ordinate services across sub-regions and regions. We are developing local stroke groups in hospitals to ensure a lead person is available in each of the specialties in medicine, therapies and nursing.

We are working with relevant professional groups to develop emergency care and provide thrombolysis for as many as people as possible. According to our current plans, we aim to have 24 hours a day, seven days a week thrombolysis or clot-busting facilities in all hospitals admitting acute stroke patients in the next year. It currently stands at 50% of hospitals.

We are overseeing the development of specialist stroke units in all hospitals caring for stroke patients. In 2006, the national audit of stroke care reported there was only one stroke unit in Ireland, based in the Mater Hospital, Dublin. There are now 19 units which means 60% of the population is covered. We intend to develop more stroke units in further hospitals to extend coverage to 90% of the population.

We are developing specialist mechanisms to allow people who have suffered TIA to be effectively assessed and treated in an effective manner within 24 hours of their event to prevent further strokes. TIA patients who are not treated immediately have a one in six chance of having full-blown stroke in the following three weeks.

That might do for the time being as an introduction and perhaps we shall now hear from Mr. O'Shea. We can then come back by way of a round of questions.

Mr. Michael O’Shea

I thank the Chairman for inviting us and all the members present for their interest in the cause of stroke patients nationally. We believe that after many years of being ignored, their needs are beginning to receive the attention and action they deserve. I do not propose to go over some of the matters Dr. Harbison has alluded to, but I shall deal with some of the main points we want to make.

It is recognised internationally that in providing a concentration of medical, nursing and therapy services, stroke units can reduce the death and severe disability rate from stroke by 25%. Thrombolytic treatment can mean the difference between a patient walking out of hospital under his or her own steam within days of having a stroke, or spending the rest of his or her life in a nursing home. Therefore it is enormously important, as we have heard from Dr. Harbison.

Unfortunately, the deficits in relation to these services remain particularly bad in our view. According to HSE statistics, just 178 out the 8,000 that suffer acute stroke received thrombolytic treatment in the 12-month period to the end of March 2009, an overall rate of just over 2%. The HSE recognises that 20% could receive this treatment. In other words, just over one in ten people who could have benefited actually received it.

We do not know how many acute stroke beds there are in Ireland at present. The latest study, completed last July, states there are 140 acute and rehabilitation beds, but the Irish Heart Foundation's audit on stroke services, published in 2008, identified the need for 411 acute stroke beds. Although we cannot be sure what percentage of patients are treated in stroke units, it is probably somewhere between one in five and one in six. This compares to a rate of more than 90% in the UK.

Despite these appalling statistics, we believe we are on the brink of a real breakthrough in stroke care. The Government's new cardiovascular help policy sets out a blueprint for the development of truly world-class stroke services in Ireland, and we believe this has 100% support from the relevant stakeholders. Stroke has been prioritised by the HSE, which has put the right leaders in place to deliver change we believe. Nobody in Ireland is more committed to the cause of stroke patients than Professor Kelly and Dr. Harbison, who are here today.

Our strong concern, however, is that although we are informed that stoke is to be included in the HSE's 2011 service plan, the necessary funding will not be there to ensure effective change. To a large extent it boils down to money, and for a long time the sole remaining barrier to the elimination of avoidable death and disability from stroke was a genuine and legitimate uncertainty over the cost implications of the improvements that were needed. Even this has now been swept away we believe by the new report from the heart foundation, compiled by the ESRI and the Royal College of Surgeons in Ireland with the assistance of some of the country's foremost stroke physicians. It shows that the overall cost of stroke in Ireland is up to €1 billion, but by providing stroke unit care and the wider availability of thrombolytic treatment, 750 people could be saved from death or life-long dependency every year, at a cost saving to the Exchequer of €13 million. Over a ten year period the savings from these interventions alone would be up to €225 million.

To understand how lives and money can be saved simultaneously, we must look at how utterly dysfunctional the current system for delivering stroke care has become. It is so dysfunctional that the real money is only spent on patients after a point where they can realistically receive beneficial treatment. For example, the report shows that up to €96 million a year is being spent on acute services for stroke patients, but we are spending as much as €414 million on keeping stroke survivors in nursing homes without any access to rehabilitation. Think of this from a patient's viewpoint. In a frightening number of cases the patient must endure the double whammy of being left with an unduly severe disability because of not receiving the best possible acute services when he or she had the stroke, and then miss the chance of relieving the worst effects of it because he or she cannot access community rehabilitation services.

This is borne out in the report which reveals a national spend on community rehabilitation of less than €7 million annually. Frankly, this is very poor given the often complex needs of stroke survivors in terms of physiotherapy, speech and language therapy, occupational therapy and psychological needs. Indeed, when one considers that there are up to 46,000 stroke survivors in Ireland, this works out at just over €150 per person, enough perhaps to fund a single physiotherapy session in a whole year for people who are battling to put their lives back together. This represents appalling value for the taxpayer. In human terms it is a needless tragedy, but the potential gains in lives saved and disability reduced, not to mention reduced costs, are even bigger.

In addition, the statistics do not take into account that without decisive action now there will be a 50% increase in the incidence of stroke and its overall cost to the economy over the next ten years. Politicians receive many reports claiming that upgraded services will result in cost reductions at some stage in the distant future. In this case better acute stroke services will produce almost instant savings, because increased access to stroke units and thrombolytic treatment will result in immediate improvements in outcomes and therefore lower demand for nursing home places, which is the most expensive end of care. In the midst of economic distress and the short-termism this forces on decision makers, it could be easy for the cause of stroke patients to disappear from the radar. Also, there is a real danger that gains already made in developing stroke services could be swept away. In particular, the expected reductions in the numbers of contract nurses could have a very serious knock-on effect on stroke services. As regards the cost of stroke, the report shows that the better acute services are the more lives and money will be saved. However, the worse they are the more lives and money will be lost.

As a result we have asked the Government for nursing staff working in stroke care to be removed from the HSE recruitment moratorium and for at least €13 million in funding to be made available for stroke service developments in 2011. Any objective analysis of stroke services will show that saving a patient's life costs nothing. We want to ensure that never again will service deficits make patients feel their lives are worth nothing. Therefore, we exhort every member of the committee to support our aims and help us fight for the necessary services to be put in place.

I welcome the representatives from the Irish Heart Foundation and the HSE. This is an enormously important area and Mr. O'Shea's presentation fairly well underscores the fact that the money that might be used to prevent stroke would be very well spent, not just in terms of the ethical issue of saving lives, but also as regards the financial situation in which the country finds itself.

It is very clear that we are paying for long-term care for those who could have avoided the problem in the first place. The old adage that prevention is better than cure certainly rings true here. Just being political for a moment, the national body test, even though some people decry it, could pick up diabetes and ischaemic heart disease, which would alert physicians to the need for their intervention. I know diabetes is not the subject today, but this is an illness that costs the country 10% of its health budget, and one of its complications involves stroke. We know that for every person in the country diagnosed with diabetes, another will remain undiagnosed and will ultimately present with problems such as stroke.

A chronic illness care programme would reduce the incidence of stroke, again looking at conditions such as diabetes, obesity, high blood pressure and ischaemic heart disease, to mention but a few. I agree with Mr. O'Shea in his appeal for the removal of the moratorium on frontline staff as regards the care of stroke, and other areas too. How many acute stroke units are there, and how many should there be? Why are the figures so poor as regards thrombolytic treatment? Is this down to lack of units or lack of experienced radiologists to read CT scans? CT scans are broadly available as well as MRIs, so I should have thought they could be read digitally from a distance.

This is a question for the HSE. Why have we so few rehabilitation facilities in the country?. Why is it not possible to tender for nursing homes with ten to 30 beds, with the additional services as regards physiotherapy, occupational therapy and speech and language therapy? It does not always have to be the National Rehabilitation Board in Dún Laoghaire. For all of us here, and I hope the media pick up on this, these are shocking figures. This is a shocking statement about the state of the health service and how we have allowed an over focus to develop on treating the end result instead of focusing on prevention. Any new Administration with Fine Gael in it will certainly look long and hard at this as part our plan to ensure we keep people well rather than waiting for them to become unwell.

We have a huge job to do in education also. What happened in the old days has to change when people, particularly men, did not visit their doctor until their arms were falling off having been hit by a chainsaw or until they had gone blue in the face with chest pain. We are encouraging people to have themselves checked regularly. We are prepared to send our cars for an NCT every two years; surely people are more important. I would like to hear the delegates' comments on this point, but I must apologise because I will have to leave at 4.10 p.m.

To a great extent, Mr. O'Shea and Dr. Harbison are speaking to the converted. At a time when we have to get value for money, it seems incredible there is not an acute stroke unit in every hospital. This makes no sense, given the numbers involved. Some 500 people die every year as a result of a stroke. While nobody is saying all 500 could be saved, we can assume a significant number could be. On the other hand, the biggest expense is incurred in maintaining people with a disability as a result of a stroke. I have two friends in Cork who had a stroke, one of whom lives with a severe disability, is paralysed on one side and has speech problems. The other was thrombolysed and walked away unscathed.

The argument has been made that we need to do this. We meet groups every week which tell us about certain things. This is not directed at Dr. White, but we need to show a little more urgency in our actions when it comes to stroke patients. How much money is spent on community rehabilitation services? Deputy Reilly has pointed out that the National Rehabilitation Hosptial in Dún Laoghaire is the only rehabilitation institution in the country. If there are 19 units in the country, where are they? As far as I know, there is none in Cork. I would like to know if there is and I am sure Deputy O'Sullivan would like to know if there is one in Limerick. When is this going to happen?

I thank Dr. White, Dr. Harbison and Mr. O'Shea for their presentations. I agree with my colleagues on the need for prevention. Having a healthy lifestyle is a start, followed by visits to the family doctor or nurse to have one's blood pressure and cholesterol levels checked and so on. For as long as I can remember, successive Ministers and health care professionals have been advocating such a course of action to try to get members of the public to take a greater interest in their health. However, we have not seen the level of success we would like to see. I wonder what the views are on how such an approach might be promoted and made more receptive to the public because unless we receive public co-operation, there will not be a successful prevention programme.

There is pressure on beds at the National Rehabilitation Centre and their unavailability has to be of concern. What rehabilitation centres do the delegates believe should be available in the various acute hospitals and step-down facilities in the absence of the major facility we obviously need to supplement the National Rehabilitation Centre?

My main interest is in diagnosis and early intervention. Speedy access to thrombolysis is needed. There are two issues in this regard, the first of which is related to the fact that some people live in more remote areas. The second more critical issue concerns those who turn up at accident and emergency departments. They may or may not be seen by a triage nurse and then have to wait three or four hours. They need to be fast-tracked in order to ensure there is thrombolysis. Would a GP note identifying that a patient has suffered a stroke help in this regard? If the problem has been diagnosed by the GP, the patient should not have to wait any length of time.

I welcome the members of both groups. Having listened to the previous delegation speak about the allocation of funding, if someone was to do what they said and allocate funding on the basis of the outcomes achieved, one would certainly provide for thrombolysis, stroke units and the preventive measures mentioned. The delegations have the full support of the committee in what they are trying to achieve.

I welcome the fact that Dr. White has said the HSE delegates accepts the findings of the report and wants to implement it. What power do they have over the budget? I know they are clinical directors rather than managers of the money. I wish them well with what they have told us in ensuring 90% of the population will have access to stroke units by the end of 2011 and thrombolysis on a 24-hour basis in all hospitals within the next year. Will that actually happen? On what does it depend? That contrasts with what we have been told by the Irish Heart Foundation, that only about 2% access thrombolysis therapy and that only one in five is treated in a stroke unit. If thrombolysis and stroke units are to be available, how is it that so few have access to them? Will the delegates clarify the figures? How would the HSE team define a stroke unit? Does it provide for what is required?

I support Mr. O'Shea's point that the moratorium on recruitment should not hinder the development of stroke units or the provision of such services. What effect is it having in developing the services required?

For the purposes of clarity, will Dr. Harbison explain how the system of thrombolysis works? He made the point that sometimes a transient ischaemic attack leads to a full-blown stroke. Are there indicators people should be aware of?

Dr. Joe Harbison

In essence, strokes are caused by clots, formed in the heart or the great vessels of the neck, which become detached and enter the blood vessels in the brain causing a blockage. Some patients will receive a warning. They will have a small clot that will transiently block an artery and then disperse. It will not leave them with a permanent deficit. That is a precursor to the formation of another larger clot causing a blockage. There are things we can do. Some good studies show that f we act within 24 hours of a patient suffering an episode, we can reduce the chances of a patient having a full blown stroke by about 80%.

We can look at the neck to ascertain whether there is a narrowing of or ulcer in the artery in the neck on which clots can form. If that is present, we would hope to be able to get them to operation within two weeks and stop that happening. I noticed that both Deputies O'Hanlon and Reilly mentioned prevention and we can establish whether they have an irregular heartbeat. If so, that suggests a higher chance of developing clots in the heart and those causing transient ischaemic attack, TIA. That is what a TIA is and so people get a warning. The warnings could be something simple such a weakness in an arm or a leg, loss of sensation, loss of language or the ability to speak, suddenly developing very slurred speech, sudden loss of vision in an eye which comes back or the loss of vision in half a visual field in both eyes. These are common examples.

As for what is thrombolysis, approximately 80% of strokes are caused by a blockage of an artery in the brain and the concept behind thrombolysis is that one gives a very powerful clot-dissolving drug very quickly to disperse the clot before brain damage results, that is, before the loss of oxygen to that part of the brain causes permanent damage. To do this, one must act quickly, which requires a lot of organisation. The person must present to hospital quickly and in saying this, I must compliment the Irish Heart Foundation on its recent FAST campaign on television, which we believe has dramatically increased the number of people getting to hospital in time for this treatment. One must have a medical team that is aware and organised to know what is going on. To be able to make a diagnosis, one must have scanning available to be performed immediately, someone must be able to interpret the scan and someone then must be able to act accordingly.

Reaching a thrombolysis rate of 20% constitutes a real challenge and the places internationally that have reached 20% tend to be large urban areas in which many patients are selected into that group. From a European perspective, we think that a rate of 10% is achievable and some places in Europe, such as Spain, as well as some locations in Australia, have reached 10%. While this would be an eventual goal, in the first instance, our goal is to try to get up as far as a rate of 7.5%, at which point we would have reached levels achieved by many of our European neighbours. While a thrombolysis rate of 7.5% does not sound like many people, members must imagine that there are some people with strokes, such as, for example, those with brain haemorrhages, to whom one will not administer a clot buster. Other people will have strokes that are too severe for a clot buster to be given or will have contraindications to the clot buster. Other people will have strokes that are too mild. The problem with the clot buster is that although it is beneficial, it also is hazardous. If one gives the drug to people with a very mild stroke, one may increase their risk of having a poor outcome. Of those who arrive in time for thrombolysis, approximately one in three will derive genuine benefit from it and between one in eight and one in ten people will get a genuine cure from it. However, approximately one in 35 people will end up with a slightly worsened outcome and approximately 1 in 100 people will end up with a severely worsened outcome. Thrombolysis requires expertise and trained staff because it is a potentially hazardous therapy.

Dr. Barry White

If we go through the questions, starting with that posed by Deputy Reilly as to the reason there are so few stroke units, the answer certainly is that there are not enough stroke units in place. One reason we established the programme is to have a sustained focus on this area. There is certainly a lack of consultant expertise staff in some of those areas but Dr. Peter Kelly may wish to address this further.

Dr. Peter Kelly

First, we acknowledge there undoubtedly are not as many stroke units as there should be. As members are aware, historically in Ireland the manner in which services have developed for stroke has been more on an ad hoc basis than according to a regional or national plan that has evaluated the need for or gaps in a certain service in a particular area and then has ascertained what is needed to fill in that gap and what are the likely benefits that will accrue from it. Consequently, with a good degree of variation, we have seen the appointment of clinical champions at certain sites. I guess that a reason I was chosen by my peers to take up this role may have been that I would have been recognised as someone who championed the development of stroke services at the Mater Hospital and similarly with Dr. Harbison at St. James’s Hospital and many early adopters of such improvements of services nationwide. However, it also is true to state that there are many sites around the country where, unfortunately, such champions may not have been appointed and as a result, we do not have someone speaking up locally at the hospital site on behalf of the patients or the clinical staff with whom he or she works. Consequently, we find ourselves in the present position in which gaps still exist.

At present, we estimate that approximately 60% of all acute hospitals in the country, defined as hospitals with an emergency room, report to us that they have a stroke unit in place. However, there are two caveats that we acknowledge upfront in this regard. First, these stroke units are self-reported and as yet, there has been no independent validation of the accuracy of that. That said, this information is coming from multiple independent clinical leaders on the nursing, medical and therapy sides at each site and therefore we hope there is a good degree of reliability about that. The second caveat is that we also acknowledge that we do not have information on whether the size of these stroke units is sufficient to admit all patients with stroke who are coming to each individual hospital. This is a piece of work that we will prioritise and that certainly must be done but we think a fair start is to get a unit into each hospital that requires it. It also is fair to state that good progress has been made in the four years since the Irish Heart Foundation stroke audit of 2006, when only one hospital had such a unit. As we have moved from having one to 19 such units within four years, the rate of improvement is extremely rapid. That said, there is more to do.

We must define what constitutes a proper stroke unit.

Dr. Peter Kelly


Unfortunately, the HSE has a history of calling things by names that do not really match their capabilities.

Dr. Peter Kelly


Consequently, of the 19 units to which Dr. Peter Kelly alludes, how many have in place the full team of people they should have?

Dr. Peter Kelly

When we surveyed the individual hospitals, we used the internationally recommended definition for a stroke unit, which to my understanding is practically identical with the definition that was used in the 2006 Irish Heart Foundation stroke audit. Consequently, the definition we are using is that recommended by the European Stroke Organisation. It defines a stroke unit as being a ward or part of a ward that is protected for the exclusive or near-exclusive care of patients with stroke and that has a defined core of multidisciplinary staff consisting of a lead physician, lead and specialist nursing and the core therapy disciplines. The latter are defined by the European Stroke Organisation as being physiotherapy, occupational therapy, speech and language therapy and social work. This is the definition to which we have been adhering and we intend to independently validate the self-reporting that we have received. If it is a case that there is a discrepancy between the information we have to hand at present and the application of that definition, we will be clear about it and certainly will make no attempt to obscure or fudge the issue. This perhaps also addresses Deputy O'Sullivan's question.

Does Cork have such a unit?

Dr. Peter Kelly

No, not at present.

Would each unit not also be obliged to have a scanner to identify a bleed or a clot?

Dr. Peter Kelly

Right. On the issue in respect of CT scanning and thrombolysis, again we surveyed all the acute hospitals, defined as having in place an emergency room, over the summer. One of the questions we asked was whether they had 24-seven availability of CT scanning. All but two of those hospitals answered affirmatively. Both exceptions were in the south west. In consultation with their clinicians and regional directors, we will be focusing on putting the service in place if thrombolysis is to be delivered there.

Do Mr. O'Shea, Mr. Macey or Dr. Horgan wish to address the committee?

Mr. Chris Macey

Deputy O'Hanlon asked about prevention, something to which Dr. Harbison alluded. We have conducted a preliminary evaluation of our national FAST campaign, including our television advertisements. The evaluation has shown that the campaign has led to a 30% increase in the number of stroke patients attending the two hospitals - Beaumont and James Connolly - where the survey was done. There was a 60% increase in the number attending hospital in time to be assessed for thrombolysis.

To pick up another point made by Dr. Harbison, research conducted by the HSE in April 2009 indicates it is widely agreed that 20% of all stroke patients are eligible for thrombolysis. This figure would rise to 24% with public education, which is what we are engaging in. The targets need to be kept high and not be allowed to slip.

One is better off risking failure than setting one's sights too low.

Mr. Chris Macey

Exactly. That 60% of acute hospitals have stroke units does not mean that 60% of patients are being treated in stroke units. We need to know the actual numbers being treated. We know that acute and rehab stroke units comprise 140 beds in the country. This figure comes from the HSE's July 2010 study. However, the stroke audit conducted by the Irish Heart Foundation found that 411 acute beds were needed. We will conduct another national audit in 2012 to determine what gains have been made. There is no doubt that significant gains have been made, but we are coming from a low base. We need to keep our momentum. We need money, as a bit of upfront funding could make a significant difference in the year ahead. Dr. Kelly and Dr. Harbison are in place and are the best people to be delivering the programme. However, if they do not have the tools, they will not be able to deliver fully. This is what we hope can be achieved.

In that regard, I do not know whether anyone can answer my question about whether the HSE will give our guests the money.

Dr. Barry White

I will address Deputy O'Sullivan's question on what power we have over the budget involved. Of every area we have considered, stroke and diabetes make the most compelling cases in terms of the cost effectiveness of interventions. In the short term, stroke is the most compelling, given that retinopathy screening and foot care for diabetics have a delayed impact in comparison to stroke treatments. We have been arguing a compelling case not just on the grounds of clinical outcomes, which have been substantial, but also on the grounds of cost effectiveness and our ability to take the health service from poor to good in terms of international figures over a reasonably short period.

As to what money will be provided next year, we are in discussions on the service plan and the budget. I appreciate the cross-party support in this regard, as it will strengthen our hand in our discussions on this compelling case. On 1 January, we will know whether we have been able to make any progress. My feeling is that we will and that we are progressing well with this case. The Irish Heart Foundation and the programme itself have done superb work to make the case that this is the direction in which we must travel.

Someone mentioned the impact of the moratorium. The new stroke units that must be opened and existing stroke units need to be protected and enhanced to ensure that more than just a fraction of people pass through them. While this will require investment, it will generate savings. The simple answer is that I hope we will be able to achieve our clinical targets. These will be subject to discussions, but I will take the committee's support with us into our negotiations.

Rehabilitation beds were discussed. It is important to point out that some rehabilitation needs to be immediate. Most of our concerns in this regard centre around those who are not rehabilitated rapidly and do not recover because the damage has become irreversible. For want of a better phrase, the acute rehabilitation component must be addressed quickly. Different hospitals may be doing different things, but they are all necessary. Certain hospitals have an opportunity to grow in this sector. A patient with acute stroke may get his or her initial thrombolysis assessment in one area but be rehabilitated in another hospital. Such hospitals could become excellent in the rehabilitation phase just as other hospitals become excellent in addressing the first five-day period and the initial thrombolysis.

Patients are in the system, they are being seen and their care is consuming resources. The challenge for us is to improve the situation. This will involve a change in the type of staff with which they are engaging, that is, a move to an aggressive rehabilitation staff model away from the standard model, which was to manage patients as medical admissions.

Dr. Frances Horgan

To pick up on the point about aggressive rehabilitation, there is irrefutable evidence of the benefits of rehabilitation in the acute phase in the stroke unit, starting on the first day with physiotherapy and swallow assessments. Eight out of ten patients have difficulty walking, six out of ten will become depressed and six out of ten will have swallow and speech difficulties. There is a window of opportunity to maximise recovery.

When we conducted the first stroke audit in 2006, we found that Irish patients were more disabled, fewer were returning home and more were going into nursing homes, yet they had the same medical risk factor profile as their UK counterparts. We set our study against the methodology that is used every two years in the UK. Patients should be getting approximately 45 minutes of therapy every day from all of the therapists they require. Guidelines exist as to what staff a stroke unit should have, but the staff numbers of some physiotherapy departments have decreased by 40% because of the staff moratorium.

Another significant area in which we do not have a clear idea of what is occurring with regard to rehabilitation is the transition from hospital to home. It is fragmented and we do not have specialist teams in the community to take up the torch of the rehab provided in hospitals. There are many models, for example, the UK's early supported discharge, although the economics have not been worked out yet. It is not a case of one size fits all and there are pockets of expertise and models in Ireland. Investments in them could be made to ensure access to ongoing rehabilitation. We can see from Cost of Stroke in Ireland, COSI, that some of these points are adding up, in that 40% of costs are attributable to nursing home costs where patients are more disabled. We must take a few steps back and examine investment in rehabilitation following thrombolysis to maximise patients' independence.

Are there concluding remarks?

Mr. Michael O’Shea

Next year, we will continue the FAST campaign to make the public aware of the need to be alerted as quickly as possible to the symptoms of stroke and to get the victim to hospital. If the figures of 60% and 30%, to which my colleague Mr. Macey alluded earlier, are correct there will be an additional need to have these units in place and the services available. If members of the public are aware of the symptoms we need the service at the other end.

I acknowledge the work being done by the HSE. It is very positive. We have a good working relationship with HSE which we value.

Dr. Barry White

I thank the Irish Heart Foundation for the excellent work being done. I thank the committee for addressing the issue of stroke which is very important. It is worth returning to and whatever the arrangements in the future, this issue needs to be followed. It is an area in our health care system which requires urgent attention.

I thank all of the witnesses for their presentations and for dealing with the questions. It is wonderful to see such a degree of collegiality and mutual respect between the witnesses. I look forward to supporting their case in whatever way we can.

The joint committee adjourned at 4.20 p.m. until 2.15 p.m. on Tuesday, 14 December 2010.