Dáil Éireann díospóireacht -
Tuesday, 11 Apr 2017

Vol. 946 No. 2

Topical Issue Debate (Resumed)

National Stroke Programme Implementation

Deputy Maureen O'Sullivan

I welcome the opportunity to discuss this matter. The Minister for Health, Deputy Harris, explained that he had to leave, but I know he will hear about it. This issue is particularly alarming because I was in the audio-visual, AV, room last week and heard from the Irish Heart Foundation and doctors who are involved in the treatment of strokes that there has been a regression from the positives of some years ago. The advances in acute stroke care, which saved more than 200 lives a year and reduced the rate of severe disability by more than a quarter, are being undermined. They are the facts as presented by Professor Joe Harbison, who was the head of the HSE national stroke programme. For me, right across the board on health matters, whether it is to do with heart, cancer, addiction, strokes or whatever, prevention and immediate intervention are paramount. If we get those right, it is infinitely better for the person involved, his or her family and our health services. In the main, prevention and immediate intervention do not cost as much as long-term care.

The facts are that stroke is Ireland's third-leading cause of death. It is the biggest cause of adult physical disability. Some 20% to 25% of residents in nursing homes are there due to strokes. It is estimated that the rate of stroke will increase by a further 50% in the next five to eight years. There is a crisis and it has been described as an avalanche. Very sadly, this comes after a number of years of improvement. We knew, and the recent census figures have confirmed it, that we have an increasingly ageing population with people living longer. An important indicator of the worsening outcome is the increase in the length of hospital stay and the increase in direct discharges to nursing homes. That is the case for the first time since the national stroke programme was established and it means that the costs are increasing. We know that nursing home care is expensive. There was a figure from 2015 on nursing home care which showed a 2.3% increase, which amounts to €17.3 million. That would pay for 1.6 million hours of home care at current rates. I want to stress very forcibly the fact that death and severe disability from stroke were being dramatically reduced in recent years.

There was a stroke survivor in the AV room who was visible proof of how those procedures were working. He had a stroke a number of years ago and was totally paralysed on one side, unable to speak and unable to move. He got to Beaumont in a reasonably timely way, was subjected to the necessary procedures and normal life resumed. He spoke very graphically of what that has meant to him. If it had not happened, the process would have meant that he would be in a nursing home long term.

In the four years from 2010 on, the national stroke programme was responsible for reducing nursing home costs by €30 million a year. If the HSE had spent €15 million a year on providing the 200 extra therapists required in stroke units, the cost reductions would be restored and the service would be able to deal with the increase in strokes that the hospitals are seeing. It was horrifying to hear that there are more people being employed in a coffee shop in one hospital than there are in the stroke programme in that hospital.

We know what works. Initially, prevention is needed beforehand, as well as awareness and screening programmes for those with high blood pressure and atrial fibrillation. Also required are immediate investigations and assessments of mini-strokes and access to the clot treatment thrombectomy for all stroke patients regardless of location. Timely access is needed to appropriate levels of in-hospital rehabilitation as well as a national roll-out of an early supported discharge programme. That is what works. It is what saves money and lives. I ask the Minister to look at the 2017 manifesto of the Irish Heart Foundation because the measures suggested there are largely deliverable within the funding, with perhaps only a small increase necessary. Many consider as basic the standards of care in other countries that are not available here. This is about preventing death and disability.

Minister of State at the Department of Health (Deputy Finian McGrath)

Before I respond to Deputy Maureen O'Sullivan, I warmly welcome the agreement between Vertex, the HSE and the Government on the drugs for treating cystic fibrosis. I want to commend all those involved, including the Minister, the cystic fibrosis families and Ms Rebecca Hunt from Vertex, who did a lot of work on this issue as well. I just want to wish everybody well because it is a good day for cystic fibrosis families and a good day for the health service.

With regard to this Topical Issue, I am very grateful to Deputy Maureen O'Sullivan for providing me with the welcome opportunity to talk about stroke services in Ireland. Let me start by referring to the good work of the HSE national clinical programme for stroke. The national clinical programme for stroke has been in place since early 2010. The vision of the programme is to design standardised models of integrated care pathways for the delivery of clinical care to ensure sustained quality clinical operational management. Overall, the programme aims to improve the quality, access and cost-effectiveness of stroke services in Ireland. The programme can point to many improvements in stroke care since its inception. The HSE has previously advised my Department that emergency thrombolysis is now provided to patients in all regions through improved hospital and ambulance protocols, health professional training and the appointment of new physicians. There is national 24-7 access to safe stroke thrombolysis, the rate of which has increased from 1% in 2006 to a current rate of 13%. This exceeds the national target of 9%.

Access to stroke unit care has been shown to improve stroke patient outcomes through reduced mortality rates, reduced dependency and shorter lengths of stay in hospital for patients. Since the commencement of the national clinical programme for stroke, nine new stroke units have been opened, bringing the total number of stroke units in acute hospitals to 22. This is a major improvement on the first national stroke care audit in 2006, which reported one stroke unit in the country. The programme has also developed a range of care pathways to assist the streamlining and standardisation of stroke care delivery. The cost objectives of the programme have also been met with more stroke patients experiencing improved clinical outcomes. Examples include: fewer stroke patients are dying in hospital - the rate dropped from 16.2% in 2009 to 14.1% in 2014, an overall percentage reduction of 12.9%; fewer stroke patients are discharged to nursing homes and, therefore, there are improved disability outcomes - this decreased from 17.7% in 2009 to 13.8% in 2014, an overall percentage reduction of 22.1%; more stroke patients are discharged directly to home from acute hospitals - the rate increased from 50.7% in 2009 to 51.6% in 2014; and the median acute hospital length of stay for stroke fell from ten days in 2009 to nine days in 2014, with an estimated 19,000 bed days saved in the 2011 to 2014 period. This is all good news for stroke patients. However, I accept Deputy Maureen O'Sullivan's point that we have to do more and that more has to be done.

Deputy Maureen O'Sullivan

Nobody is denying the progress that has been made. However, there is a real fear that that progress is being undermined. There is somewhat a discrepancy between the facts provided in the Minister of State's answer and what we heard last week in the AV room. There must be action around the rehabilitation services. As the Minister of State said, more people than ever are living and not dying following strokes, but they are living with the aftereffects of strokes. More lives are being saved because of the improvements in the acute services. However, the therapy to ensure quality of life is missing. The physical, psychological and communication services are available to those with private insurance.

The rate of the return home of stroke patients is falling. Returning home is more beneficial personally and costs less, but the services have to be there to ensure that. We need to look at the way the money is spent. Immediate treatment in hospital, rehabilitation in the community and home care mean less reliance on nursing home care. There is research from the Irish Heart Foundation on the cost of stroke. Out of a direct cost to the State of up to €557 million per annum, as much as €414 million is spent on long-term care for stroke patients. Less than €7 million is spent on community rehabilitation programmes that help people remain at home.

I want to quote from an advocate whose family have suffered strokes. He said: "Tonight hundreds of people will sit down to dinner with their families because of service improvements delivered by stroke teams in every corner of the country in the last six years but a great deal more will not be in their own homes but forced to live away from their families in long-term care because we ultimately did not do enough for them." He is just asking that we look again at how the money is being spent to ensure people do not have to go into long-term nursing care but can go home.

Deputy Finian McGrath

I am particularly conscious that the early supported discharge service for stroke patients requires attention. Indeed, it has been recognised internationally that early supported discharge of stroke patients from hospital improves outcomes, reduces the need for long-term care and increases acute hospital capacity by freeing up beds. I accept those arguments. The programme has helped to establish three effective early supported discharge teams in Dublin and Galway. The Galway service has developed a model whereby the service can be effectively provided in the more rural areas of Ireland. This and other issues for stroke services will be considered as part of the annual Estimates process, which frames the HSE's national service plan for 2018.

I take the Deputy's valid points in regard to quality of life and the return home. We need to develop community rehabilitation programmes and other services in the interests of the patient but also in the interests of cost-effectiveness. I will bring the important issues raised by the Deputy to the attention of the Minister, Deputy Harris.

School Accommodation Provision

Deputy Shane Cassells

I thank the Ceann Comhairle for the opportunity to raise in our national Parliament the concerns and issues of St. Fiach's national school in the small parish of Ballinacree in north Meath. I am very appreciative of the fact it is the Minister, Deputy Bruton, who is present and I thank him for that because, as a Meath man, he knows this area of the county well and knows how this little school is so integral to the way of life in north Meath. It is the most northern part of the county. This little village is made up of the school, the church, the community centre and Briody Beds, which is the main employer in the area. The people of Ballinacree are proud and resilient but that little school, which keeps the village alive, is in dire need of help and attention.

The school, which I visited yesterday, was built and opened in 1961, and the facilities which I inspected with the principal, Dr. Ann Bennett, have changed very little since that time. The changing rooms for the boys are adjoining out-of-date toilet facilities and are unhealthy. The lack of any resource facilities for the SNA teacher is a scandal. The classroom floors bear the scars from the turf-burning stoves, which were only recently removed. I do not think students in any other part of the country could envisage such a scenario. To participate in PE, gymnastics, school drama and assemblies, the children have to leave the school premises and walk to the nearby community centre. Until recently, this was a case of taking their lives in their hands because there were no footpaths connecting the two buildings and they were walking along a busy country road where trucks pass by on their way to the industrial units. As Dr. Bennett told me yesterday, the facilities she had when she taught in Botswana were better than those she has to work with in this little school since she arrived in 2011.

The fact it is a little school and located in the most rural part of north Meath should not conspire against it in terms of access and funding. This is quite a famous little school and two years ago, it received international acclaim because All Blacks fly-half, Beauden Barrett, had attended primary school here when his family relocated from New Zealand for a while, and he even played Gaelic football with the school. This World Cup winner returned to Ballinacree recently and even performed the haka on the front lawn of the school. However, the facilities he saw did not meet world standards - they do not even meet basic health and safety standards, as matters stand.

The school applied recently for funding to construct additional rooms - a general purpose room and classroom facilities - and that application was refused on 10 March. This was despite the fact the school inspector and the senior medical officer in the HSE were in unison in terms of the dire need to progress the plans from a health and safety point of view. The school was awarded an additional teacher in 2011 but due to internal issues at the time, applications for the additional space were not progressed and as a result, the issue of the cramped facilities was compounded. The school's board of management has appealed to the Department to look at this retrospectively and work with it to achieve what is needed for the 94 pupils and six teachers.

The Minister will have prepared notes on behalf of his Department, which I appreciate. However, I appeal to him to look at the needs of this little school again, at what it has achieved and what it aspires to achieve. As Dr. Bennett said to me yesterday, the kids in this school want to kick football in their own parish, not in another one. As a fellow Meath man, I know the Minister will know what I mean by that. To do that, however, and for this community to continue to survive, they need the facilities to so do. I ask the Minister to please look again at this file in order that the opportunity for these kids to develop their critical thinking and to fulfil their thirst for knowledge in facilities fit for this age will become a reality.

Minister for Education and Skills (Deputy Richard Bruton)

I thank Deputy Cassells for raising this issue and I can understand his concern. The backdrop to this, which he probably understands, is the pressure I am under to deliver new school places. Each year we have to deliver at least 15,000 new school places and 5,000 absolutely essential replacements, and, therefore, the Department has to become very selective and prioritise very carefully. Obviously the first emphasis has to be where new places are not available and have to be built. As my written reply states, there is pressure at primary level, with about 25,000 pupils having to be provided for over three years, and the position is similar at second level, which gives the overall figure of 15,000-plus per year. That is the backdrop and it takes up about 80% of the budget. It is for this reason that, when this application was made to convert two existing classrooms into a general purpose room and to build two new classrooms and a resource room, the Department turned it down. In doing so, it looked at pupil number trends, which have been pretty stable in the past few years, and this resulted in the turning down of the school, as the Deputy has outlined.

The Deputy asked that this be re-examined. I understand the school, pretty much simultaneously, has resubmitted the application and the school authorities have asked that this be reconsidered. I note the points the Deputy is making, which are obviously part of the reconsideration, including the added teacher. I also note the school has made an application in respect of the toilets under the summer works scheme and that has yet to be decided. It is in category five under the summer works scheme, which is still under consideration and a decision will have to be made on that.

The Deputy also spoke on the issue of support for SNAs and resource teachers. Bearing in mind the points he has made and the submission the authority has made, I will ask the Department to look afresh at this and to reconsider the application. The difficulty I have is that we are against this backdrop of pressure on our capital budget to deliver the new build that is absolutely essential because, otherwise, children will have no place to go. That has forced us to be very strict in regard to which of the extensions that are not meeting demographic need we can cater for. I will convey the concerns of the Deputy in the context of this reconsideration of the submission made by the school.

Deputy Shane Cassells

I thank the Minister for the response and I appreciate he gets many such requests. However, the context for engaging with him on this particular file is the fact the school was awarded an additional teacher in 2011 and the plans to progress the much-needed facilities were never implemented. The school needs positive engagement with the Department. I ask the Minister to re-examine that technical issue of how it lost out, in particular in the context of how that has now compounded the cramped facilities. The school management has requested a reappraisal with Brian O'Connell from the buildings works section and a request for a meeting to discuss the intricate nature of the required works has been sent to Tona Redmond in the school capital appraisal section. In the first instance, I ask that the Minister would ensure this meeting goes ahead, that there is positive engagement in terms of the officials actually looking at the case file from 2011, given there is a need to revisit the events that occurred at that time, and that the pressing need to develop facilities is examined.

They are good kids. As I said, the Minister knows this part of the county very well. They just want simple, basic facilities.

In order for the school to provide whiteboards, the principal had to acquire them from another school that was throwing its boards out because it was getting upgraded equipment. The school is literally living on the clippings of tin. Just because it is out of the main gaze of the media and not in a big town or this city does not mean its pupils do not deserve the same crack at life as anyone living in this city or any big town.

When one walks through the front door of the tiny little school, one is struck by the amazing wall of achievement. It nurtures every little child as one of its own. It is rightly proud of how a current member of the famed All Blacks team is a past pupil. I would desperately love it if on the next occasion Beauden Barrett and his family visit, they will be able to see a school that will encourage the next generation of young scholars and sports stars in this part of County Meath. They visit regularly and I met Beauden's dad in Oldcastle last year.

Dr. Ann Bennett, who is the principal, Fr. Philip O'Connor and all the people of Ballinacree are willing to play their part in working with the Department to see the facilities they require developed. I passionately request that the Minister meet them half way on the road to help them to do so.

Deputy Richard Bruton

There is no doubt but that if Meath footballers started to do the haka before their competitions, we would certainly see a bit of a change. I note that the Dublin team was under pressure at the weekend-----

Deputy Michael Healy-Rae

And rightly so.

Deputy Richard Bruton

-----so perhaps this is the start of the great revival.

I will definitely ask the Department to examine this matter. The position is that the school has 93 pupils enrolled. There are four permanent classrooms, a resource room, a staff room and an office. As the Deputy said, the school is using the local community centre for physical education. That is the factual situation against which the Department will be judging the application and also the application in respect of the summer works scheme regarding toilet facilities.

It is stated that there is a resource room. I do not know whether the Deputy said there is none.

Deputy Shane Cassells

It is not a proper one. It is a room the school has adapted.

Deputy Richard Bruton

I will convey that to the team examining this. My briefing notes do not refer to the added teacher in 2011 and how that issue was dealt with at that stage. I will ask that this be included in the assessment.