Chronic Disease Management: Discussion

We are meeting the HSE's national clinical leads for its national clinical programmes on stroke, heart failure and older people, as well as its national director for clinical programmes and strategy in order to hear the views of the individuals concerned and about the progress made in their individual disciplines. On behalf of the joint committee, I welcome Professor Rónán Collins, clinical lead for the national stroke programme; Professor Ken McDonald, clinical lead for the heart failure programme and Dr. Diarmuid O'Shea, clinical lead for the programme for older people.

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. However, if they are directed by it to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable. I advise that any opening statement made to the committee may be published on its website after the meeting.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable.

I invite Dr. O'Shea to make his opening statement.

Dr. Diarmuid O'Shea

We are very grateful for the invitation and to have the opportunity to attend.

I am the national clinical lead for the clinical programme for older people. I am joined by my colleagues, Professor Ken McDonald, national clinical lead for the heart failure programme, and Professor Rónán Collins, national clinical lead for the stroke programme. We are honoured to be here to represent the clinical care programmes. All of the programme managers and health care professionals are working together to develop different models of care and care pathways to help to improve health care services.

As the population ages, we very much welcome the opportunity to share with the committee the progress made to date and the plans for the future in the older persons programme and chronic disease management under the national clinical and integrated care programmes. In the course of the opening statement we will update the committee on the three national clinical programmes and cover some information from the integrated care programme for the prevention and management of chronic disease, ICPCD.

The objective of the integrated care programmes is to design an integrated model of care to treat patients at the lowest level of complexity that is safe, timely, efficient and as close to home as possible. The ICPCD programme focuses on a number of chronic diseases that impact on a large number of patients. Approximately 1 million people suffer from a variety of chronic illnesses, including dementia, respiratory diseases, cardiovascular diseases and diabetes. The Irish longitudinal study of ageing reports that 65% of the over 65 age cohort live with comorbidities and multiple illnesses. The current and projected impact of chronic disease presents a major challenge not just for the health service but also for Irish society and the economy. We have more people living longer and the numbers with chronic disease and multiple comorbidities will increase. While it is very welcome that the range of investigations, tests and treatments available is increasing and improving, it comes at a cost. We must continue to implement change to meet present and future challenges and the projected demand on services in the next decade.

The ICPCD programme aims to provide better care for people with chronic diseases. This will be achieved by providing for a continuum of preventive, management and support services for patients with these conditions. It is built on an approach which helps people to understand and care for their own condition, with education playing a key role, in collaboration with their general practitioner and the primary care team. It includes easy access to diagnostics and specialist supports in the community and close co-ordination with hospital services in order that people can receive the care they need when they need it and in the most appropriate way to meet their circumstances, be it at home, in the community or hospital. This will require a significant reorientation of service delivery and associated resources and will be challenging, but we believe it is the best and most sustainable approach for the health service.

Through the patient narrative project, patients have clearly articulated their expectations of the health care they wish to receive. They want person-centred, co-ordinated care services that provide them with the services they need. They want care based on a full understanding of their lives and their world, combined with the information and support they need. They want care that respects their choices in building care services around them and those involved in their care. The proposed model of care for people with chronic diseases honours this and will be co-designed in partnership with patients, clinicians and managers who, together, are the stewards of health care.

Having given the committee a brief overview of the ICPCD programme, I will take members through the work of the national clinical programme for older people. The population of those aged 65 years and over is projected to increase by between 58% and 63% between 2015 and 2030. The so-called "older old" population, that is, those aged 80 years and over, is set to rise even more dramatically, as outlined in the recent 2017 ESRI publication entitled, Projections of Demand for Healthcare in Ireland 2015-2030. As older people have complex health care requirements, the health care system needs to adapt to meet the demands associated with this demographic change.

For this to truly happen, we need a culture change to drive the shift in how we think and provide care, especially for the ageing populations. If we get it right for this group of patients, we will get it right for everyone. In line with the recommendations outlined in the national clinical and integrated care programme for older people, NCPOP, the core principles, otherwise known as the ten-step framework, which we have included in our briefing document will support and drive better outcomes for older people at risk or living with frailty and are being implemented throughout the country. Examples of achievements are frailty education programmes, with 22 established, with more than 130 trained facilitators and 550 health care professionals trained in the programmes. Twelve integrated care pilot sites have been developed in the past 18 months and there are numerous other sites throughout the country where local managers, clinicians and health care professional are delivering innovative change, providing evidence that these approaches work.

Growing up and growing old, something we all hope to do, is not easy. Prevention is always a challenge in ageing; therefore, emphasis is placed on wellness. As a result. the NCPOP is collaborating synergistically with other projects to work towards the joint goal of healthy ageing. A few examples include the Irish longitudinal study on ageing, TILDA, and how it will inform policy and give us an evidence base to further improve and target resources and innovation; the Healthy Ireland initiatives to promote wellness and maintain independence that speak to the real importance of the public health message; and collaboration with the acute and emergency medicine programmes and the new dementia clinical lead and national dementia strategy in addressing education needs such as frailty education and managing people with dementia and delirium in the community and hospital.

With regard to future plans, as described in our briefing document, the evolution of the local governance group structure around the theme of "ageing well in the community" will champion the pockets of excellence emerging from the learning in those areas that are redesigning and implementing pathway stages of the specialist geriatric services MOC and the ten-step framework. The delivery of this type of care needs to be built on. Every older person should have access to the right care and support, with personalised, co-ordinated care, integrated between services and putting the older person at the centre of the care pathway. Collaborative working with the integrated care programme for older persons indicates that co-ordinating care for older persons is better, but while some of the costs involved could be met through identifying inefficiencies within the system, there is little doubt that significant investment both in staffing and infrastructure is needed to ensure health and social services will be resourced to effectively manage and respond to the health care needs of the rapidly increasing older population. The ageing population is testament in part to improved health care in Ireland and to be welcomed, but we need to rise to the challenges it presents. Care for the older person is everybody’s business. It is imperative that as these new ways of working are designed and developed under the clinical programmes of the RCPI and the HSE that there be continued ongoing support and investment in implementation as we continue to work with local and regional areas.

I will hand over to my national clinical lead colleague, Professor Ken McDonald, to describe the national clinical programme for heart failure, NCPHF.

Professor Ken McDonald

I am grateful to the joint committee for giving me the opportunity to provide information on the NCPHF. I have circulated my opening statement and associated information, on any of which I am happy to take questions. I will concentrate on the central, important achievements of the NCP and how they relate to other chronic illnesses that we face.

Heart failure, HF, is generally recognised as one of the most challenging chronic diseases. It affects upwards of 90,000 people in the State. A total of 250,000 people are at immediate risk of developing it, with 10,000 new cases every year. The disease significantly curtails longevity, but of equal importance to those with the disease and their family members is that it curtails quality of life, which is probably best exemplified by the fact that 20,000 hospital admissions every year are directly related to it. These hospitalisations usually result in a stay of ten or 11 days. The HF hospital requirement drives the budgetary demand associated with the condition - €700 million annually. The fact that we are focusing on hospitals underlines what the NCPHF is trying to do. It is attempting to transfer what has been historically and still is, to a certain extent, a hospital-centred, reactive care process to one that is community-centred, proactive and preventive, involving at its centre the patient and his or her family and a GP-led, well resourced, HF service with unfettered access to specialist opinion and diagnostics outside the footprint of the standard secondary care service as we know it. That is the umbrella goal of the programme. In many generic ways, it is similar to that of the NCPs in dealing with many chronic illnesses.

I refer to what has been achieved. It may seem to be a contradiction that the first achievement I will outline is hospital developments under the NCPHF. For us to securely provide a community-centred chronic disease management service, we need effective hospital management of heart failure in all our regions. That was the initial goal of the NCP when it commenced. Clinical programmes are available in 12 admitting hospitals. We would like to have them available in all admitting hospitals, but resources are the restraint in that regard. The programmes that are in operation, however, have been effective in reducing the numbers of readmissions with heart failure and length of stay.

I would like to focus on three developments under the NCPHF in respect of community care. I would like to conclude on one on which I want to put a great deal of emphasis because it has pertinence throughout the chronic disease environment. Given that 250,000 people are at immediate risk of developing heart failure, with 10,000 new cases every year, as Dr. O'Shea said, prevention has to be a strong component of a chronic disease programme. In this country we are fortunate to have developed the first internationally proven preventive strategy in one of our units. The HSE NCP has seeded it as a pilot study in one region. The NCPHF not only prevents heart failure but it also prevents other cardiovascular admissions to emergency rooms. If it were rolled out throughout the State tomorrow, it would have a dramatic impact on these admissions, saving up to 100 trolley bays a day, which would be a significant impact.

Moving from prevention to the disease, I mention the demonstrator project which is part of all clinical programmes. As part of it, we place clinical nurse specialists in the community. The purpose is for these well trained nurses to be assistants to GPs in the management of chronic disease, freeing up the GPs to focus on the more medically demanding aspects of chronic illness management, in particular, heart failure, and to have someone specialised at nursing level who can deal with the housekeeping but nonetheless important aspects of chronic disease management. Our experience with the process within the NCPHF has been relatively modest to date. The programme has been in operation for the past 18 months. However, according to the preliminary information we have received, it has improved the overall quality of HF cases and GPs are positive about the development.

I will conclude with a strategy that has been pioneered by the NCPHF. It is an important development, not only in dealing with heart failure but also with cardiovascular disease in general. It will also have an impact on the wider chronic disease framework. I refer to the concept of virtual consultation. It can have an impact on two central problems that we encounter every day in our discussions on health care and the media - waiting lists for outpatient appointments which are increasing and the use of acute medical units and emergency rooms. Virtual consultation is an online, real time, interactive case discussion between the GP and specialist. Multiple GPs can be online at any time; therefore, there is a group learning aspect. The cases usually take five to ten minutes to discuss and six to seven can be dealt with per clinic session.

Returning to the two metrics I mentioned, what was interesting was the impact on waiting times or referral into the outpatient system and on the acute medical unit, AMU. In respect of the approximately 400 cases discussed in the pilot area, GPs have informed us that 80% of this would have been referred into the outpatient system, with a similar percentage referred to the emergency room, ER. This highly innovative way of dealing with heart failure and chronic disease could have a dramatic impact on outpatient waiting times, preserving real outpatient slots as opposed to virtual outpatient slots for people who truly need them. The ancillary benefits of this are self-evident. First, the patient no longer has to travel. The patient must always be at the centre of all we do. Travelling for a patient invariably in heart failure and also having other chronic illness or an elderly individual with multiple diseases is never easy and it often involves taking a family member out of work. The second benefit is group learning.

That is an overview of our achievements to date. As clinical lead, I would like to see us focus into the future on all four of those strategies and to continue their development, namely, development of the hospital programmes, the STOP-HF prevention strategy, the demonstrated project and, in particular, virtual consultation. I am happy to take questions on any issues.

I thank Professor McDonald for his opening statement and I invite Dr. Collins to make his at this point.

Dr. Rónán Collins

I thank the committee for inviting me to talk to it about stroke in particular. It is probably no accident that Professor McDonald, Dr. O'Shea and I are here because there is a common theme running through the topics being discussed this morning and a big challenge ahead of us in terms of our ageing demography and the cardiovascular disease that will be associated with it.

In Ireland, stroke is the third leading cause of death, the leading cause of neurological-acquired disability in adult life and one of the overall causes of adult acquired disability. The Stroke Alliance for Europe, SAFE, has estimated that in light of our demography if we do not change the curve of incidence, we probably will experience a 58% increase in stroke numbers over the next ten to 15 years, which will represent a massive challenge for us. We have come through a very tough period economically but it is important to acknowledge the considerable achievements to date in stroke. I have been working in stroke since I was a young doctor in 1995 and I have seen tremendous changes both here and in the UK. I returned to Ireland from the UK in 2005. In 2008, we had only one stroke unit in this country. Currently, 85% of our acute hospitals have acute stroke units, which is the foundation of all stroke care. In 2008 less than 1% of our patients were receiving emergency clot-busting treatment whereas now almost 12% are receiving it. While this is in line with UK and European norms we could do better. In addition, there has been recent technological advancements in the area of retrieving clots. For example, the majority of strokes are caused by a blockage, similar to a blockage in a pipe. The two analogies to clearing that blocked pipe are clot-busting - pouring Domestos down the sink - and Dyno-Rod. Dyno-Rod in this case is thrombectomy, which is a new technology available to us that is showing massive promise. It is now the single most important treatment for stroke. This service has been developed in Ireland over the past three years with very few extra resources.

All of these changes have had a huge impact in our country. We have reduced mortality from stroke from approximately 19% in 2008 to 12%. This has come without an increase in disability, in that the discharge destination to nursing home for stroke has remained constant at around 15%. More people are surviving stroke, and are doing so in an independent state that allows them to go home. We should acknowledge that tremendous work is being done by the stroke programme and my predecessors but, more important, by a committed multidisciplinary team involved in stroke across the spectrum throughout the country. In regard to mechanical retrieval, our stroke strategy was to develop a two-centre approach initially, one of which is currently working 24-7 at Beaumont Hospital and the other in Cork University Hospital, from 9 a.m. to 5 p.m., Monday to Friday, with plans to operate this centre on a 24-7 basis from the start of the third quarter. This will also cover the southern area.

With regard to rehabilitation services, recovery after stroke takes time, requires skilled multidisciplinary team working and appropriate staffing ratios for critically ill patients with significant physical and psychological difficulties. Rehabilitation is obviously a no-brainer in terms of reducing length of stay in hospital beds but, more important, it is a patient-centred model of rehabilitation and it is often better psychologically for patients to rehabilitate at home. The national stroke programme has introduced three early supported discharge teams, which have been operating for the last two years in the north and south of Dublin city and in Galway. We are happy to announce that this year, we have funded early supported discharge teams in Cork and Limerick, with plans to further extend this service.

In terms of cure and prevention, it is disappointing that the number of people attending emergency departments within an ideal timeframe remains low. At least 60% of patients who have a stroke do not present at our emergency departments in an ideal timeframe. When it comes to acute stroke treatment, time is of the essence. The brain does not survive for very long without its oxygen supply. I am sure the committee is familiar with the FAST campaign. We would like to see it reintroduced. We have strong evidence from this country alone that when the FAST campaign was running, there was a significant increase in the number of people presenting within a much shorter timeframe after onset of symptoms. The numbers now presenting have relapsed to pre-advertisement era, particularly in areas of lower socioeconomic resources. This is a concern for those involved in the stroke programme.

On future plans, the national stroke programme has a number of immediate challenges to meet. We believe that no acute stroke patient should be treated outside of an acute stroke unit. We still have a number of challenges in setting up acute stroke units in one or two hospitals. Stroke unit care reduces death and disability from stroke by 25%. It is the foundation of care that applies to all stroke patients. We must have stroke unit care for our stroke patients or, at least, bypass procedures if it is not possible to have an acute stroke unit in a hospital. As for the time to treatment, it is not all about simply presenting to the hospital. There is an onus on us to improve our assessment and door-to-treatment times. Our median times for door to needle or door to injection of clot-busting treatment have not been historically good but they are improving. While the median time in this regard in 2013 was approximately three hours it is now down to one hour and 40 minutes. Together with the Royal College of Physicians of Ireland, we have introduced a quality improvement initiative for all stroke teams throughout the country to try to improve the processes and to ensure local improvement in door to injection times.

With regard to rehabilitation, in particular for patients under 65 with stroke, services have been historically poor due to under-investment and an age cut-off to protect the over-subscribed services within geriatric medicine. The national stroke programme advocates an all-age approach to the funding of stroke rehabilitation and will be working with colleagues in the national programme for rehabilitation to explore areas of commonality and to ensure that our intersecting Venn diagram also meets the needs of younger people with stroke.

As I said earlier, Professor McDonald, Dr. O'Shea and I are here today because there is a common theme in the topic being discussed today. Approximately 40% of the patients who have stroke also have underlying heart disease and the majority of them are older. The national stroke programme has looked at how funding can be obtained for the stroke programme going forward and we reached the conclusion that we need a more organised strategy. We have decided to produce what will be a realistic five-year model for stroke in terms of treatment. We realise that this needs to be broken down into four areas, namely, acute care and cure, restoration, life after stroke and, most important as we move on in time, to change the demographic prediction from the Stroke Alliance for Europe. We need more investment in prevention and in primary care to prevent stroke.

We also need to have some investment in research and education. The stroke programme has organised four specialty focus groups led by individual chairmen in these areas who have been tasked with producing what is a realistically achievable strategy within five years - not everything we would ideally want - that will have the most impact in the four areas of acute care and cure, restoration to living, prevention, and research and education. We will cost the strategy and we hope to be in a position to deliver it to the health service commissioners and to Members of the Oireachtas later this year.

After the presentations I will be very happy to take any questions on stroke that members may have, but now I shall hand over to our chairman Dr. O'Shea.

Dr. Diarmuid O'Shea

In conclusion, and as stated by my colleagues, a patient-centred approach is being taken in the design and delivery of care of stroke, heart failure and other chronic diseases with specific focus on care for older persons. Emphasis is on prevention of illness where it is possible. Initiatives that focus on total wellness, such as Healthy Ireland and Making Every Contact Count, are being promoted. In the case of an illness - and Professor McDonald and Dr. Collins have alluded to examples in stroke and heart failure - provision of the right care at the right time by the right person at the most appropriate location in our community is our focus and a common aim. Where a patient is chronically ill, self-management education and support is important. Many people with chronic diseases can manage their condition at home, as Professor McDonald has said, with support from their GPs and primary and community care services and the HSE continues to work towards ensuring these supports are available. A common themes for us all is that given the changing landscape of ageing in Ireland over the next decade, it is important that we have an age attuned and age accommodating society and clearly co-ordinated pathway-driven health and social care services for older people.

The clinical and integrated care programmes show how true collaboration happens when patients, carers, health care professionals and managers from across the care spectrum bring to bear their knowledge, skills and experiences to resolve persistent challenges and tackle common problems together. The benefits of reducing the incidence and impact of chronic diseases are nationally significant, societally and economically as well as individually and personally. They extend far beyond the impact on the health of individuals to our children’s future, the well-being of the communities in which we live and the economic prosperity of our society. This increasing focus on people with chronic disease and the health and social care needs of older people can only be achieved if we all work together politically, medically and clinically with the health care professionals and with people in society.

This concludes the opening statement. Dr. Collins, Professor McDonald and I will endeavour to answer any questions members of the committee may have. I thank the committee for its time.

I thank Dr. O'Shea. For the benefit of the committee will the witnesses clarify that as well as their positions as HSE clinical leads in their disciplines, each of them is also a practising physician?

Dr. Diarmuid O'Shea

Absolutely. It is a critical part of this. As practising clinicians we can only make contributions in changes such as this when we are working at the coalface. So the answer is "Yes".

As I will call on members in groups of three, the witnesses may bank the questions and answer after the third member has completed.

I thank the witnesses for their comprehensive presentation and for the work they do. The witnesses have clearly set out the need for change and for further education on a lot of issues and they also referred to trying to get change in the HSE service. A big complaint I hear from practitioners is that when they can clearly see the need to approach a problem in a different way and they try to effect change, there is resistance to getting the change. Practitioners complain to me that when they come up with a comprehensive plan for a change, they encounter resistance. I am referring to both people who work in the community health care sector and those who work in hospital services. The witnesses have given us the figures for the demographics but have targets been set for trying to achieve the change required in each area? Within the HSE's different regional health divisions, is change happening more in some areas than in others and are clear targets set in each area?

I also wish to raise an issue regarding people who working in the community - and I have raised this previously in the health committee - and the numbers of nurses working within the community. Over the past three years the numbers of public health nurses have gone up from 1,460 to 1,540. This is an increase of 80 nurses in real terms. Do the witnesses believe there should be an increase in this area and is there a need for targets to be set around people working out in the community and working with people, rather than patients having to come in to the hospital service? Over the same three-year period there has been a huge increase of 17% in the number of people in administration and management. I raise this issue in the context of priorities within the HSE. On the one hand there is resistance to change and on the other, we do not appear to be recruiting staff in the areas where we really need people - and especially in the types of services the witnesses want to provide.

A GP told me recently that there are only about two consultants in the area in which he works - it is not the Cork area - that he can actually telephone to discuss patient care. He spoke of the disconnect between those who work in the hospital system and those working in the community, especially GPs. The witnesses have given the example of the innovative communication project between GPs and consultants. How could that level of urgently-required communication be fast-tracked in order that more people can be kept out of the hospital services and in order that those who are working in the community can deliver the service that is required? The practitioners in the community also need this support. I believe this is one of the things we need to do but how do we fast-track it to make sure the back-up support is there for those working in the community?

I thank the witnesses again for the work they are doing and for the innovative projects they have taken on in this area.

I welcome the witnesses to the committee this morning and I thank them for giving up their time. I am the Fianna Fáil spokesperson on disability and I deal with a lot of people who are post stroke and some of the patients are left with horrific injuries, as Dr. Collins well knows. Have the witnesses any suggestions on preventative measures? Could there be a public campaign on healthy living? An acquired disability is very hard, not only on the person but also on their families. All of their lives are turned upside down. In some cases, perhaps with better lifestyle choices, the disabilities could have been prevented. The witnesses might share their thoughts on that aspect.

I note the HSE has successfully piloted a home-grown heart failure prevention service on the east coast and that there are plans for the midlands also. I am flying my own parish here but Cork needs more services there. Will Professor McDonald indicate if there are any plans for that area? Cork and Kerry seem to be a little bit left behind in this field. The Irish Heart Foundation advises that diagnosis is often late due to inadequate availability of diagnostic tools. This appears to be the case in Cork. Can this be resolved? How would Professor McDonald suggest it can be resolved?

Senator Dolan was going to contribute at this point but he had to leave. Has Deputy Kelleher his thoughts composed?

I have. I welcome the witnesses and I thank them for their presentations.

The ESRI report indicates that over the next number of years, there will be a dramatic change in the demographics, with the consequences in terms of demands on health services, the need for us to change how we provide health care and with regard to planning. Dr. O'Shea noted we have more people living longer with chronic disease and multiple co-morbidities and while it is good that the range of treatments available is increasing and improving, it also comes at a cost.

Cost is one matter but we are quite adept at identifying problems early on. However, we are not as imaginative in coming up with solutions to meet them. Bearing in mind that it takes a long lead-in time to establish and expand the capacity of training programmes, as well as encouraging people into those various fields due to changing demographics, how advanced are we in assessing the number of professional clinicians we will need in our health services in the years ahead? Where are we in providing people at consultant level and nurse specialists in community care and geriatrics? It was stated that the health care system needs to adapt to meet the demands associated with changing demographics. How do the pathways and integrated care programmes which the witnesses are developing fit in with the recently published Sláintecare report?

Professor McDonald stated, "to fundamentally alter the epidemiology of heart failure, HF, the HSE has piloted a home-grown HF prevention service on the east coast". Is it preventive in the context of changing lifestyles and habits or identifying it and then addressing it in a clinical setting? What type of resources will be required to roll this out across the country?

It was stated that, as a result of the virtual clinic intervention, for every 100 cases discussed, there is a reduction in emergency room-acute medical unit referral by 90% and outpatient referral by 80%. In our deliberations at the Sláintecare committee, it was evident there is significant silo thinking in our health services between hospitals, community care and GP services. GPs told the committee that in some areas, depending on the consultant, the chances of ever being able to talk to that consultant are diminished. Rather than having the goodwill of individual consultants and GPs having a personal relationship, surely we need to have to a defined system in place where there can be continual contact between GPs, who are specialists in the community, and consultants in the hospitals. Is it possible to break down those barriers?

Speaking to nurse practitioners and emergency medicine consultants at the coalface, there seems to be a cohort of elderly people who are transferred from nursing homes to hospitals. If there were a greater number of geriatric community services available, such as specialist nurses able to insert intravenous antibiotics in a nursing home, these older people would not necessarily have to go to hospital. Another issue, which causes great distress to the individual and the family, is the lack of palliative care available to people in nursing home settings. Are we transferring elderly people unnecessarily from a nursing home, which is effectively their home, to a busy hospital setting? Should there be proper community services available in clinical and palliative care.

Professor Collins stated:

The success of acute treatment of stroke is extremely time dependent. Over 60% of our stroke patients currently do not present to our emergency departments within an ideal timeframe.

He referred to the success of the Act FAST television campaign in identifying when someone is having a stroke and getting them to a hospital in a reasonable time. He also stated, "a third to half of all strokes may be prevented through lifestyle change, management of blood pressure and identification of an irregular heart rhythm, and a nationwide approach to cardiovascular disease prevention". There are two types of prevention. The first is a rapid diagnosis whereby the person gets to hospital quickly which prevents a severe outcome. There is also prevention where one identifies early on people who are potentially at risk of a stroke. Will Professor Collins elaborate on this?

Across all the health services, we need to move to a situation where hospitals work beyond the traditional five-day week, eight-to-late model, particularly in the area of diagnostics. Have the witnesses identified ways whereby we could use our assets and infrastructure in a more efficient manner, bearing in mind that an MRI in a private hospital can be done every hour but not in our public systems. We do not have that enhanced capacity in our public system because of demarcation lines and industrial relations issues. Would it make a big difference to the capacity of the health services if we are able to address rostering issues, increase the number of professionals working in the health system and use the assets that are already there effectively in diagnostics and prevention?

Dr. Diarmuid O'Shea

The questions clearly illustrate the depth of understanding this committee has about the challenges we have ahead and how we are going about addressing them.

In general, clear direction in terms of models of care, guidance and pathways are important elements in delivering change. Using the older person programme as an example, people have a good understanding of what needs to be done and the demographic changes occurring. There is a need for support both politically and financially for the implementation of the models of care we have in the older person programme. It is no accident that the first step in the ten-step framework in the programme is establishing local governance groups. I have had the privilege of travelling around the country with Dr. Siobhán Kennelly, our co-lead, looking at all of the integrated care sites, hospital sites, the community sites, the integrated care programme and frailty education programme. I see the enthusiasm, drive and desire of people at the coalface to deliver this integrated care. The governance group gives a unity between the CHO and the hospitals to pull that together.

If we use the knowledge and experience gained from the pilot integrated care sites, of which there are 12, and the frailty education programme sites, this will empower people with knowledge and understanding to effect change from the ground up.

We need leadership and direction from the HSE and the colleges in respect of the clinical programmes and unifying people. From a public health message point of view and from a multidisciplinary and professional perspective, education is one of the key enablers in all of this. It is important, it is not threatening and everybody is willing to sit around a table and talk about those things. It has a wonderful way of breaking down barriers between different groups. Having pilot sites and other sites across the country develops new ways of working within teams and groups. That helps improve flow throughout the system, which is one of the challenges for us all.

We hear regularly about trolley numbers. They always a concern and a worry. When I go down into the emergency department on a post-call round, it is devastating to find that a person has been there for longer than he or she should be. However, it is not actually an emergency department issue. It is an issue around getting good control of community services, good access to community care and good programmes around the country. Deputies have mentioned some such programmes in terms of good input to outreach programmes and co-operation and co-ordination with general practitioners.

Older people are big users of health care. If someone over 80 or 85 attends hospital, he or she has a 50% chance of requiring admission. It is not that they do not need the admission; they do need it. What we need is co-ordinated pathways of care that get older people through their acute illness quickly and get them out of hospital, back home or back to the nursing home quickly. Professor Collins mentioned the success of the stroke unit. We know about the success of the cancer care programme and how well people do in coronary care units. The same is true of older people in specialist wards. They are more likely to go home and to do so more quickly. They are less likely to need to go into a nursing home. We have a lot of initiatives in this regard; there are a couple in Kilkenny and some happening in County Cork, in Deputy Murphy O'Mahony's area, where we are demonstrating that taking a targeted approach to patients leads them to spend less time in hospital. If exposed to interdisciplinary service and the allied health professional team early in the course of an illness, a person is less likely to functionally decline and more likely to go home more quickly.

Senator Colm Burke asked about the need for change and the drivers relating to that. It is a question of having clear plans and models of care from the HSE and from the programme. After that it is the ground-swell of people working together to provide that care. That leads on to the Senator's second point, which is the staffing question. There is a lot of work being done around workforce planning. We talk about the importance of new ways of working. Through both the HSE and the national doctoral training programme in the Royal College of Physicians, in 2014 there was a clear look at workforce planning. However, the workforce has changed and so has that sort of medical workforce planning. Work practice has even changed in the past two or three years for me as a consultant. My clinical job today is different from what it was three or four years ago.

We recently saw the Department of Health create 120 new advanced nurse practitioner roles. They are not new in the sense that we have had advanced nurse practitioners in stroke care for a number of years. While we have had an advanced nurse practitioner dimension, these posts are clinical advanced nurse practitioners. In the first tranche, 43 of them were appointed in older persons care. They are going to become an incredibly important group over the next number of years as they evolve, providing co-ordinated care and crossing the boundaries between hospital and community.

Our challenge in staffing is comparable to capacity. I certainly welcome the Sláintecare report, which we will talk about later in response to some of the other questions. It clearly identified issues around capacity, funding and more integrated work practices. All of the models we are talking about very much fit with that. Going back to the 1980s and 1990s, bed capacity was taken out at that time. According to OECD figures, for 2015 we had 3.3 beds per 1,000 of the population. The figure is approximately 4.5 beds in other countries. We are not just investing for the now but are playing catch-up from underinvestment in the past. When money goes into the services now, we do not see the added value from all of it because it is playing catch-up. That is a problem for us. I welcome much of the Sláintecare report. I welcome the focus on the fact that, while capacity expansion is needed, there is also a consequent need to employ additional health care professionals to provide for those beds. I welcome that it clearly states that there will need to be a €2.8 billion increase in funding by the end of the ten-year programme.

Although there are big challenges for us, I am proud when I look at the group of people who are working together, directed from the HSE's clinical strategy and programmes division, and when I see how the different clinical programmes are evolving. Of most critical importance, however, are those on the front line and how they are providing care. We only need to think back to last week and the efforts that health care workers made to keep things on the road both from a transport point of view, getting people in and out of work, and people being at work and staying there, to understand how committed people are to the work we are doing, in spite of the challenges.

Senator Colm Burke asked a specific question about two consultants, virtual clinics and staffing. Professor McDonald might be better positioned to respond to that.

Professor Ken McDonald

I thank Senator Colm Burke for his questions. Before getting onto the virtual consultation issue, I would like to add a couple of thoughts on the need to change. As the Senator pointed out, is critical that any of these programmes contain measures that we can examine to see whether they are being effective. This is the State's money we are spending so we need to be able to match it up against key performance indicators and all of the programmes provide that data. For example, we know length of stay in cases heart failure has reduced since the development of heart failure care programmes and that saves bed days. Reporting these improvements back to the people involved in these change processes encourages them to continue with the process. Even though we have gone through a very difficult time economically, if we continue to show that the process is bringing improvement, albeit sometimes at quite a slow pace, it still acts as an encouragement.

The Senator's second question was about staffing. He mentioned nurse involvement in chronic disease management. For my area, heart failure, it is a very important development. The national clinical programmes are very conscious of the role that people in allied health care can play in the management of chronic disease. However, we also need to protect the nurse so that he or she is not out on his or her own. I always see the nurse role in the community as being under the guidance of the general practitioner, to try to co-ordinate the overall care of the patient.

When we are talking about allied health care, one group that we have not yet mentioned today that is also an underused resource in the community is that comprising pharmacists. They have a very strong role to play in chronic disease management when one considers an issue such as adherence to medical therapy, such a bugbear for us in the system.

Coming back to virtual consultation, this crosses a couple of the questions from Senator Colm Burke and Deputy Kelleher. On the value of virtual consultation, I think it breaks down this divide that we have between the consultant led specialist services and the general practitioner led community services. That is a real Achilles heel for us at present. Virtual consultation is a very strong way of breaking down this divide because it removes the reliance on the goodwill of a couple of GPs who might know a couple of consultants, as Deputy Kelleher said, for them to interact on a specific case. It formalises the process in the same way as happened with our outpatient clinics in hospital and our formal clinics. Virtual consultation needs to develop and, to use Senator Colm Burke's term, it needs to be fast-tracked to provide an alternative mode of interaction between primary and secondary care. Even if its impact is not as dramatic as the first 400 cases would indicate from the pilot projects to date, and if outpatient referral is reduced by 50% rather than by 80%, that would still be a dramatic impact.

We need to take a strong look at this process, and not only cultivate it in heart failure as much of what we are talking about is generic across chronic disease. We need to look at developing it as a strategy for chronic illness and to learn from the experience.

Dr. Rónán Collins

There is a breadth of interesting and insightful questions. Returning to Senator Burke's question on the culture of change, I very much agree with Dr. O'Shea. My experience, having followed the leader and now being the lead, is that I have not seen barriers or resistance to change in the health service once clinical leadership and direction is given, and there is involvement, particularly among the multidisciplinary team and the stakeholders, and where a cogent argument is made. While there is a pervasive sense of doom and gloom and we have come through a difficult period in Ireland, for a small country with very limited resources, together we have achieved quite a bit. Most of that has come by pulling together and enacting change rather than as a result of receiving huge resources. I replied to Senator Burke about the fractured relationship between general practice and the hospital system. Speaking personally, not on behalf of the HSE, I have never seen such a fractured relationship between the two. There is a real onus on fixing general practice, which will remain broken without investment and a new contract. Fundamentally, that needs to happen because our whole health service is built on what happens in primary care. If that is wrong, the rest of the system will be wrong.

Deputy Kelleher asked specifically about stroke prevention. He is correct. There is an acute aspect. When a patient arrives in hospital there is a question of whether we can prevent disability but neither Deputy Kelleher nor myself wants to be on a table sweating it out, wondering if a treatment will work or not when facing the prospect of being paralysed down one side of the body and being unable to talk. We would by far prefer not to have been in that situation in the first place. Personally, as current lead but also on behalf of the clinical advisory group in the national stroke programme, we are wholly committed to seeking increased investment for prevention. It is the third leading cause of death in this country and our leading cause of acquired adult disability. We reckon we could prevent one third to half of all strokes through lifestyle change as Deputy Margaret Murphy O'Mahony alluded to, in areas such as exercise, weight, not smoking, keeping alcohol consumption levels low and even managing blood pressure.

Getting blood pressure right at 60 or 70 years is important but if we get it right in middle age, such as my own age or that of Deputy Kelleher, we can half a person's risk of stroke. That is a screening target which needs to be tackled. The other big target in prevention relates to irregular heart rhythms. For laymen, irregular heart rhythm, atrial fibrillation, can be completely silent. A person will feel nothing, but it is analogous to having a cement mixer which is not mixing the cement correctly leading to clumps forming in the cement. If that clump falls into the pump chamber of the heart, it fired like a bullet from a gun down the pipe until it gets jammed. It is a very important concept to understand. Most people in Ireland know nothing about the problem, yet it causes one in three of all major strokes in the country. Moreover, if one gets a stroke due to this mechanism, one is more likely to be disabled as a consequence and the acute treatments are less likely to work. That is another screening target for prevention. Through the national stroke programme, in collaboration with the HSE, we have demonstrated that we can introduce an effective, simple screening tool in primary care which has been through a health technology assessment and has been approved. However, to return to my remarks at the start, if the primary care end of things is wrong, we cannot do any of this. It is very much dependent on our getting the situation sorted out in primary care.

Is that screening done by a consultant or can it be done in primary care?

Dr. Rónán Collins

It can be done in primary care. To return to Professor McDonald's point about telemedicine virtual consultation, it is something of which I am a huge fan. I was involved in a telemedicine pilot for strokes back in 2009 and have seen the value in bringing expertise to the table there and in heart failure also. It is very simple. Telemedicine does not have to be high-tech, it can be merely a secure screening showing an ECG in practice, and asking others what they think and then establishing a care pathway based on that. We are currently piloting one in Tallaght.

Returning to the point about nursing homes, there are an increasing number of nursing home admissions in my hospital but the number of nursing homes built in our area has also increased. One problem I have looked at is how the planning and co-ordination of this does not appear to be thought out. If I built a brewery in Tallaght, I would probably have to ask the local council if I could use 20% of its water, yet we can build many nursing homes in one area. It is not unique to Tallaght but we need to refer to how it might impact an acute care area if one introduces a population of people with complex care needs. I am a geriatrician myself as well as specialising in strokes. Of course frail older people should not be bussed around unnecessarily into hospitals but there are several factors at play. First, returning to my opening statement, we need to get primary care resourced again to look after these populations and second, we need effective communications between GPs on the ground, through nurse specialists, geriatricians and the integrated care programmes that Dr. O'Shea spoke about. This can happen through community teams and also through effective telemedicine consultation. Nursing homes are an are in which I am very interested. Often it is not the case that the general practitioner lacks the skill mix to sort this out but they are complex cases that need two sets of eyes, two opinions and reassurance that the treatment and the care pathway are right. Much can be done to improve how we model our care of our most vulnerable people. We always look back on history, but in 20 years we might ask if we did a good job for our frailer persons in nursing homes. Dr. O'Shea referred to this. There is great hope in integrated care. We in geriatric medicine are very committed to looking after what is occasionally referred to as the lost tribe, the people who live their life in residential care, and remember that 15% of stroke patients also end up requiring nursing home care. They need support too.

On the Act FAST campaign, there are numerous health advertisements about everything on television, some from private industry and some from our own public health initiatives. Strokes are our third leading cause of death and our leading cause of acquired adult disability and we have taken off what was probably the most important advertisement explaining what the symptoms of stroke are and most important, what one must do when one sees them, that one does go to hospital as soon as possible. I would encourage all support for initiatives. The Irish Heart Foundation has asked for that advertisement to be put back on televisions.

Dr. Diarmuid O'Shea

Some of the issues have been covered in responses to other members' questions. Before turning to Deputy Murphy O'Mahony's specific questions, I will comment on primary care and general practitioners. There is now a GP primary care lead physician in the national primary care programme in the HSE. In a very welcome move, the Irish College of General Practitioners is now looking for three GPs to be appointed to the chronic disease programme. That type of engagement is actively happening. That is really important.

Dr. Collins referred to nursing homes. If one looks at international figures, one would expect 33 people per 100 nursing home beds to require hospital care annually. Their lengths of stay range between eight and 14 days. Very good work is being done around the country with clinical nurse specialists, but not yet in the case of advanced nurse practitioners.

I mean clinical nurse specialists working in pilot schemes around the country. They specifically look at nursing home patients who have been admitted to hospital and conduct follow-up, virtually, by contact with the nursing home when those patients are discharged back to the nursing home. There are areas around the country that are considering specific nursing home outreach initiatives. At present there is one in north Dublin and one in south Dublin to name but two. The initiatives have clearly demonstrated reduced hospital admissions and that is when there is interaction between nursing homes, the multidisciplinary geriatrician team or clinical nurse specialist and the GP. It is a little like the question around admission avoidance, which is a term that I am uncomfortable with. One really wants the right person looked after in the right place. There is no doubt that there are nursing home residents and frail older people who require acute hospital care, and when they come in they need care in a quick, appropriate and targeted way. Let us consider the huge improvements that have been made in the care administered to a person who has suffered a hip fracture. In such cases we have focused units that have a dedicated bed in the emergency department, ED. The person is admitted straight away for X-ray scanning and is then sent straight to the orthopaedic ward for an operation, with clear pathways and performance indicators outlined thus resulting in good outcomes for the patient. All of the pockets of work have shown that if one has integrated, co-ordinated and focused specialty care - which is what all of the models have shown in terms of specialist wards and specialist multidisciplinary teams who provide focused care with expert nursing care - then patients will be discharged more quickly and are less likely to go into a nursing home. Clearly, if one came from a nursing home then one will return to the same one. Equally, with such teams and care one is less likely to functionally decline in hospital. We must build on these pockets of excellence that are located around the country.

Deputy Murphy O'Mahony asked specific questions about acquired disability after suffering a stroke. I will begin by reiterating what I said about the value of targeted and co-ordinated models of care on a ward and clear follow-up care in the community. If one needs rehabilitation that either happens in the acute hospital or in an appropriately staffed rehabilitation bed. This is where I think language in everything we do is key. If we mis-designate a bed by calling it a convalescence bed or misuse a bed that is a transitional care bed that gives potential licence to not staff in a correct way the rehabilitation needs required by the patient. Quite separately from the neuro-rehabilitation report that will be launched, rehabilitation for an older person, whether it happens in a hospital, in one's home or in a rehabilitation bed at an off-site or on-site facility, is about the appropriate minutes of exposure one receives if one is able for rehabilitation. Dr. Collins will now comment on the stroke perspective before we continue to reply to questions.

I urge Dr. Collins to be brief because other members of the committee wish to comment.

Dr. Rónán Collins

Yes. The national stroke programme gives a commitment to provide rehabilitation for all ages and phases of the stroke. I shall reiterate the point made by Dr. O'Shea. There is some concern about using terminology such as "step-down", "convalescence" and "transitional." Such terms can imply that fewer resources are required when that may not be the case. Instead, a person may require a different type of resource and extra manpower in other areas. Dr. O'Shea was correct to make that point.

In the Cork area, restoration to living is our second pillar of the stroke strategy. It is not just straightforward rehabilitation. We want to bring people back to full vocational life and being able to engage in the things that they did before suffering a stroke such as driving, pastimes and recreational activities. That must be our ambition. It is a challenge but we will work very closely with our colleagues in the national rehabilitation programme to deliver that vision.

I wish to make a comment about the HSE presentation before I bring in Senators Dolan and Conway-Walsh. One of the witnesses said that the present system of care is relatively inefficient, ineffective and is ultimately unsustainable and that integration was a key factor in making the system more efficient and effective. Please concentrate on the barriers to integration and what are the roadblocks to rolling out an integrated programme.

I wish to comment on general practice but first I wish to declare that I am a GP. General practice is now akin to a slow puncture because it is gradually fading due to a lack of infrastructural support, resources and a new contract, as mentioned by Dr. Collins. We hope that the latter will come to fruition this year but the negotiations are painfully slow.

Sláintecare is a very comprehensive document. It is not perfect and not everybody likes everything in it. Key to the success of Sláintecare is a properly functioning primary care service. If one does not have a properly functioning primary care service one cannot build on integration and all of the processes that the witnesses have described.

The witnesses have mentioned that a cultural change is needed, and that we have to adapt, of which integration is a part. Concentrating on the cultural barriers, where do the witnesses feel we are not dealing with demographic changes, an increasing elderly population and an increased general population?

Integrated management has been mentioned. We have talked to representatives of the Carlow-Kilkenny team about the development of the Sláintecare programme. The Carlow-Kilkenny integrated model has been referenced significantly in the report but there are other models of integrated care. I find it very difficult to communicate with my hospital colleagues. We are trying to set up an integrated care committee in our region where we can have a dialogue with our consultant colleagues. I hope that the initiative will come to fruition. That is a key area to develop integration.

I believe every nursing home should have a designated medical officer. I mean one person who looks after the overall management of the medical structures in the hospital and implements certain protocols. Let my explain why. One may have 30 patients in a nursing home. There may be ten GPs who visit in order to deliver care to their patients but they are ten different people with ten different ideas so there is no overall structure. Consequently, when a patient falls ill overnight or at a weekend quite often the default position is to refer him or her to an accident and emergency unit. If one doctor was in charge who had an overall protocol, although not necessarily looking after all of the patients but implementing a management protocol for various acute illnesses, such an initiative could prevent many patients going to accident and emergency departments.

Finally, I wish to state that community intervention teams, that include specialist nurse practitioners, are a halfway house between a person being looked after in the community and being looked after in hospital. Please comment on community intervention teams and barriers to change, in particular.

I call Senator Dolan and he will be followed by Senator Conway-Walsh.

I thank the witnesses for attending and for what they have shared with us this morning. My interest in being in the Seanad, and thankfully I manage to do so, was to represent the interests of people with disabilities and chronic illnesses. This week has been designated Brain Awareness Week, which focuses on the fact that almost 800,000 people suffer from neurological conditions and whatever. Therefore, this debate is timely. I recall, and my recollection dates back nearly 20 years, somebody saying that one third of the people who suffered a stroke died, one third of them escaped and one third of them were left with a legacy. Can the witnesses give me a breakdown of the current statistics? I think fewer people die from strokes at present so more people will be in the category of being left with a legacy.

Some Members of the Oireachtas had an opportunity the week before last to listen to a presentation made by a man called Mr. Martin Quinn. He suffered a stroke when he was in his early 50s and he talked about the frustrations he experienced when dealing with the health system, the economic impact of a stroke, the impact it has on family life, etc.

He mentioned that a stroke nurse had left the local hospital in Clonmel, County Tipperary and not been replaced. Is there an issue with gaps when a practitioner such as a nurse, doctor or allied health professional leaves a post or goes on maternity leave? If so, to what extent and what impact does it have?

On people with disabilities and the question of comorbidity, sadly, many people with Down's syndrome get Alzheimer's disease early. It is welcome that people with disabilities are living longer, as are those in the general population, but it will lead to issues with comorbidity. Are more preventive measures needed? What are the issues in that regard?

As regards the determinants of prevention in terms of early intervention, what assets that are not included in the health Vote could be of assistance in the taking of hard or soft measures that would affect people's lives? I do not wish to ask a leading question, but it is great that certain potential problems are not issues in the lives of some people. They are not clinical issues, but they can be of help or hinder in the outside environment.

When I was young, I thought having a stroke was almost a rite of passage for grandparents. I began working with the Irish Wheelchair Association in 1980 and remember that a woman in her early 20s had a stroke. I could not believe a young person could have a stroke. The level of awareness is changing in that regard, but to what extent is stroke an issue for young people and what are the implications? Such persons have many years of life ahead of them and their normal expectations are more or less dashed.

I thank the delegates for being very strong and clear in their focus on people's lives, that it is not just about patching people up but, rather, their being able to have a life and relationships. I again thank the delegates and apologise that I had to leave the meeting for a time.

I thank the Senator. I call Senator Rose Conway-Walsh who will be followed by Senator Bernard J. Durkan. I am sorry; I should have said Deputy Bernard J. Durkan.

The Chairman does not want to demote the Deputy.

I thank the delegates for their presentations. I disagree with nothing they have said. The models proposed are fantastic and should have been put in place many years ago. They are the way forward. The language used by the delegates would lead people to believe everything will be patient-centred and so on.

On treating patients with heart failure, I very much like the idea of having 12 hospital-based acute units. What is being done in that regard to fill geographical gaps, particularly in counties Cork and Kerry? Is there an estimate of the funding required to make the service available throughout the country?

How many stroke patients have access to a stroke unit? The Irish Hospice Fund and Health Service Executive national stroke audit shows that only 29% of such patients are directly admitted to a stroke unit. The FAST campaign was of great benefit. Have the delegates sought funding for a new campaign of the same ilk?

In my experience, one of the main problems people encounter after a stroke is the lack of availability of physiotherapy in many areas. I am aware of people's experiences in that regard in Mayo, the county from which I come. Patients are discharged from hospital, but thereafter are not provided with physiotherapy and their health deteriorates as a consequence. Is that a big concern for the delegates?

Another issue relates to timing and the centralisation of services. As services become more centralised, it will take longer for some people to get to the units or care services they need. This also applies to patients suffering from heart failure. Problems are being caused in patients being over an hour away from a hospital and by the relevant infrastructure not being in place. It is wonderful to have the models referred to by the delegates, but it will be a huge problem if people cannot get to them or do not have access to them. It could lead to apartheid in access to health services. Have the models been rural-proofed in their development and the decision-making process?

I must ask about the withdrawal of Versatis because chronic disease is directly linked with chronic pain management. Approximately 25,000 patients rely on Versatis to control their pain. Were the delegates consulted about its withdrawal and can they comment on the decision? Are they concerned about the fact that so many people with chronic disease are trying to manage pain without Versatis? Are they concerned that patients' relationships with their GPs and consultants were undermined by the decision? Is it a good use of public money for such senior personnel to review the reviews?

I am very interested in virtual consultations and how they will be rolled out. When the pilot projects under the primary care programme were set up in ten areas across the country in 2000 or 2001, information technology was to play a huge part in providing access and having a better alignment between hospitals and primary care settings, but that never happened. I am concerned that although virtual consultation is a wonderful idea and absolutely the way forward, it will not be delivered, similar to how it was dropped from the development of primary care services almost 20 years ago. I am concerned about the potential impact of the lack of broadband on its delivery, particularly in areas of the west. Will the roll-out of virtual consultation services be population-led?

I have many concerns about post-stroke patients trying to access rehabilitation units. A fantastic job is done in the National Rehabilitation Hospital, Dún Laoghaire, once patients are admitted. However, patients are begging for beds in order to access timely post-stroke rehabilitation services, which are of great importance.

I acknowledge that I have asked the delegates to address many points. I thank them for their attendance as it gives members an opportunity to raise these issues which are of importance in our communities.

I apologise for cutting in ahead of Deputy Bernard J. Durkan. I must leave the meeting in order to be briefed on a Supreme Court decision which has just been announced.

I thank the delegates for their attendance. I am sorry for hopping in and out of the meeting. I was supposed to be in the Dáil Chamber on two occasions, but I missed out on both.

I welcome everything that has been said about addressing the needs of patients who have suffered a stroke, have a heart condition or general health issues. Advertising is hugely important and has been mentioned. Many people are not reached by certain advertisements. Where is an advertiser likely to reach the most people in a single room at one time?

It is the workplace. There are many institutions with huge numbers of employees and some have their own health awareness programmes, as we used to in Leinster House every two or three years, although it has not happened in the past ten years. Every staff member was checked on every aspect of his or her health and quite a number of issues turned up, of which people had not been aware. It brought to our attention the fact that many in the workplace spent their days in schools with large numbers of people who were in a position to spread the word if they had availed of a check-up. There was dietary advice and advice on stroke and heart conditions. Those who attended always say how important and informative they were and how easy they were to follow. Insufficient information is placed in the public arena to warn people of issues, of which they should be aware. There is no point telling somebody he or she has had a serious heart attack or a stroke or that he or she has diabetes. They could be controlled to a huge extent if information and check-ups were made available. The Chairman can organise them for staff of the Houses of the Oireachtas. They took two weeks and proved immensely effective in identifying issues.

Speaking as a resourceful GP, that would not be a problem.

It is ten years since we had them and there was huge sponsorship by our old friends, the pharmaceutical firms.

There could be psychological profiles, too, which might throw up some interesting things.

I could do one of them.

Dr. Diarmuid O'Shea

In response to the Deputy, health prevention and promotion are critically important in everything we do. Growing up and growing old is not easy and habits which start when a person is young are very important. There is a huge public health message in what we are talking about, not just in the workplace but also in schools where the introduction of PE as a subject is welcome. Healthy Ireland is also doing very important things. Health promotion and prevention are very important parts in helping wellness in society as a whole and they are everybody's responsibility.

The Chairman asked about having one medical officer in nursing homes. There are the same challenges in hospitals where multiple teams go around multiple wards, but the level of discharge efficiency is improved if there are single teams on wards. Havomg a single medical officer in nursing homes would be beneficial, rather than having ten or 12 GPs. It would also provide a direct connection with outreach and inreach services. A national transfer letter is being looked at in the context of the older persons programme which would ensure decisions made about advance care plans and treatment levels would be documented and communicated when a person went back to a nursing home. It is a work in progress and there is a lot of work to be done, both from the point of view of contracts and with GPs.

We did not mention ehealth and the single patient record. A patient may be admitted to St. Vincent's Univeristy Hospital, for example, discharged and then admitted to Loughlinstown or some other hospital but with no notes or other communication. The GP often has to be consulted on the patient's background.

Professor Ken McDonald

Senator Rose Conway-Walsh and Deputy Margaret Murphy O'Mahony asked about the hospital service component of the national clinical programme, specifically the deficit in the Cork-Kerry region but also in the midlands. They asked what the cost would be of rolling out further hospital programmes. We estimate the cost for a single unit at somewhere in the region of €400,000 which would be recurring because it would be made up predominantly by staff costs.

In developing hospital frameworks we need to take cognisance of the need for integration of care services across primary and secondary care services. A component is the consultant's cost. We need to look at having a new model of consultant in the health care system, in which they would not just be a silo in the secondary care system but cross the divide and make the boundaries somewhat fuzzy as they worked closely with GP-led primary services. I am talking about an integrative care consultant within different specialties. This is critically important and, as we develop more consultants in the heart failure programme, I would like them to take on that responsibility in order that we can improve communication which has been a common theme of the discussion.

I was asked about the capacity of the health care system to roll out a project as innovative as virtual consultation, VC, given some of the difficulties we might have with information technology. I do not want to be flippant, but if something can be roadtested by me and it works, anyone can do it because I am not the most competent in using information technology. I have been very taken by the ease with which we can run a VC clinic with general practitioners. We do not need to be worried about its complexity, but we do need to be aware of the broadband issue as such consultations are critically dependent on the availability of broadband. I completely agree that we need to focus on fast-tracking its provision. We have the capacity to roll it out once we have the budgetary support to do so.

Senator John Dolan asked what were the ingredients of a prevention strategy and how we could layer them properly. That is critically important as we develop prevention programmes in whatever area, be it heart failure or stroke. It touches on the point raised by Deputy Billy Kelleher, namely, that there is a component of prevention which is the responsibility of the individual. We need to ensure everyone is aware of what he or she needs to do to keep healthy. We should not expect the Health Service Executive to provide everything. However, we also need to drill down into the population and find who is at super risk of developing immediate problems, whether heart failure or a stroke or whatever else. We can do this more effectively now than we could have five or ten years ago. It is the basis of the StopHF project to which I referred. The name suggests it is about stopping heart failure, but it also stops other cardiovascular diseases and prevents more cases of stroke than heart failure. It does this by taking people at risk and defining whether they are at super risk by a simple, straightforward diagnostic blood test. It should be universally available across the country. At a cost of between €15 and €20, it is remarkably powerful.

The prevention of heart failure strategy which is actually a prevention strategy for cardiovascular disease has been roadtested by Dr. Michael Barry and if something can get over the cost-effectiveness hurdle put in front of it, we know that it is robust. He has looked at and signed off on it.

He has stated it is a cost-effective strategy. Again, I encourage all of us to examine this thoroughly, not simply in respect of the national clinical programme for heart failure but also the chronic cardiovascular disease programmes in general.

Dr. Rónán Collins

The committee is hearing many common themes from us. It is not that we sat across the road in Buswells this morning and planned this. We have many views in common on the importance of prevention, working together in primary and secondary care and through the integrated models and using technology to assist us. I agree with Professor Ken McDonald. I am waiting for our own subgroup to report but believe that what we really need is a national preventive strategy on cardiovascular disease that will serve everyone, not just those affected by stroke, heart attacks and heart failure but also those affected by dementia, falls and even incontinence in later life. Much of the latter is due to subtle brain damage over time from vascular disease. There is a significant reason to invest in this area over time.

I had a vision of Deputy Durkan and me doing memory tests like US President Donald Trump did recently in his health check. It would be humorous. The Deputy made a point on where one should advertise. I do not claim to be the expert on this. We certainly live in a time in which there are changes in the media by which we reach people. It is likely that we reach people in different age brackets in different ways, but we also need to make the message effective. There is no point in telling a young man he might get lung cancer because it is so far removed from where he is now and it might not be immediately relevant to him. If he is shown a picture of sexual dysfunction or impotence, he might be much more likely to hone in on it and say it could happen to him if he smoked. It is not just a matter of the message; we must fine-tune it so it is meaningful to people depending on their time of life. A message stating smoking causes premature wrinkling is much more likely to attract the attention of a woman than a message referring to something that might happen in the distant future. There is a mixture of messages involved, and there is probably a mixture of media. There needs to be a panel of experts to consider where we advertise.

Senator Dolan made important points on stroke survival and the impact of clinical nurse specialists' leave. He is right about the rule of thirds. That generally was the rule. I am very happy to say that our stroke mortality rate is now good in this country. It is down to approximately 12%. It has improved dramatically in recent times. It was 19% in 2008 and it is now down to 12%. As far as we can assess, this is not occurring at the expense of excess disability, in that nursing home discharge rates have remained constant. Therefore, not only are more people surviving stroke but more are going back home.

The point made on the impact of clinical nurse specialist leave was absolutely right. There is a danger with isolated positions. Someone will always have to go on leave, and someone will always have to attend to other aspects of life. Therefore, there is always a danger in trying to get a quick backfill. Perhaps we should be considering a model in which people are not working in specialist roles completely on their own. It does have an impact. At times in my hospital when a key member of staff goes, a memory clinic may fall or a falls clinic may fall. It can be challenging in terms of backfill where there are specialised roles.

Reference was made to a subject that is very dear to my heart, namely, soft assets and barriers in the area of disability. It relates to what Dr. O'Shea said about cultural change. In this regard, Professor Bernard Isaacs said that if one designs for older people, one will include everybody. He was the father of modern geriatric medicine and gerontological thinking. The problem with our society is that we are not designing for older people. In fact, we are very much designing, even in the corporate world, around hyper-cognitive people. This is a problem. Anyone who bought a software package could see how difficult and non-intuitive it was for a healthy adult to use. Imagine what that world is like for older people. Technology is forcing them out of our society when it should be including them. If I had my way, I would have a CE mark for technology and ensure it was road-tested for and accessible to older people in addition to younger people. We need to be doing this in society. It goes beyond software and technology. It also applies to building design, signage and all areas of life. These are soft assets, as the Senator said, but they are also barriers that we can easily surmount.

I was very interested in Senator Conway-Walsh's questions. Clearly, she has thought a lot about this. I will throw a grenade in her direction by saying that if one lives up the dales, one lives up the dales. When I worked in Yorkshire, that was the attitude taken to some of the high-technology medicine. It was said it could not be delivered to the deep rural areas. That is not our attitude but it does reflect the fact that there are challenges, as the Senator has identified.

The Senator alluded to a two-centre approach and asked whether it would disenfranchise people in terms of thrombectomy, which is mechanical clot retrieval. Clearly, we cannot do everything straight away. First, we do not have the specialists. Even if we had all the money in the world, we would not have the specialists. Second, there is a need for high-volume centres when carrying out very tricky and dangerous procedures. Our initial approach in the national stroke programme is to get two centres up and running vibrantly. I reassure the Senator that the centre in Dublin is regularly taking patients from the west, including Mayo, Galway and Letterkenny. Therefore, we are trying. It will not be the longer-term model forever. There will probably need to be a centre in the west and there may need to be two in Dublin, depending on how the city grows, but in the shorter term, we need to establish that we can do this well rather than diffusely and badly. Our initial strategy is to try to make sure the majority of the population has access to this really important treatment for stroke. We need to treat only three people with a thrombectomy to achieve one better, independent outcome than would obtain without the facility. This is a game-changer by any stretch of the imagination but it is a huge infrastructural challenge to get people to centres and find the staff who have the skills to do this. It is a challenge to get the radiography staff to work around the clock. The Senator referred to 24-7 care so we can do this. There are challenges but we are meeting them. We grew the thrombectomy service from nothing to one dealing with 120 or 130 cases in 2015. There were approximately 180 cases last year. There have been over 250 already this year. That is a huge increase without a massive investment necessarily. We do need some investment. I reassure the Senator that, as she can probably hear from my accent, I am not originally from an urban area. As with most people, I have family who live in rural areas. We are concerned to make sure people are served.

We have done several modelling exercises. We published a paper recently in the European Stroke Journal on what a drip-and-ship arrangement entails, given various logistical models. I am happy to give the Senator a copy of that paper because it makes interesting reading on the subject of whether one is better off going to the nearby hospital or bypassing it.

With regard to rehabilitation services in rural areas, as mentioned by Deputy O'Mahony, we are very anxious in the stroke programme to ensure everybody has equal access and what he or she needs to return to living. The second pillar of our strategy is restoration to living. There are challenges in this regard. For example, one of our models is to get people home quicker. It is psychologically better to go home. One can imagine the trauma of having had a stroke. One may be in a hospital environment that is frightening and noisy and one might be afraid about what life will be like and what one's relationship with one's family will be like. The sooner people can go back to the home setting, the better. Clearly, however, we have to have a radius around the hospital in which teams can work in order to be efficient. We need a different model for rural areas, perhaps working in conjunction with geriatric medical services and the national rehabilitation service whereby we could have satellite services centred in rural areas through which people with various problems could perhaps gain access to appropriate rehabilitation services. We certainly can do that.

To return to the comment on stroke unit access, we must recognise that although we had difficult times and but one stroke unit in 2008, 85% of our acute hospitals now have one. The national stroke programme is absolutely committed. An acute hospital accepting acute stroke patients should have an acute stroke unit by the end of this year or a bypass arrangement in place. I speak for the programme and personally in saying we cannot condone any longer a system in which patients with an acute stroke cannot get into an acute stroke unit in hospital.

To return to the comment on how many people access an acute stroke unit, it is correct that the rate used to be very poor. I am happy to say we have improved on the rate of many years ago, which was 29%. At present, 65% of our patients get into an acute stroke unit and that is still not good enough.

On our key performance indicators and the questions on whether we have targets, we do have targets. Our target or minimum acceptable standard is 90%. We are a bit away from that. The problem is that it relates to demography also. It is fine to have a stroke unit but the demographic make-up is changing. The Stroke Alliance for Europe is telling us we will have an 58% increase in the absolute number of stroke patients.

Clearly not only must one have a stroke unit, but we need to build in a review system to ensure that the stroke unit one has meets the number of admissions year on year. That is a challenge but in our five-year strategy, we are working to meet that challenge and we will try to model it on a population basis.

Dr. Diarmuid O'Shea

May I respond to Senator Conway-Walsh?

Yes, of course, but then I will bring in some other members.

I really want an answer to my question on Versatis medicated plasters, so will Dr. O'Shea address it please?

Dr. Diarmuid O'Shea

Senator Conway-Walsh commented on rural-proofing. Dr. Collins tells me he is going to throw a grenade and I have worked with him long enough to be able to hold the pin and go over and put it back in. I had not used the term "rural-proof" but one might consider what has been done with the frailty education programme, which is located in 26 sites around the country, one of which is in County Mayo, and the integrated care programme, which is also in County Mayo and is among the sites that has a local governance group established. The establishment of that local governance group, which is the first step in the ten-step framework, speaks to the value of clinical programmes that are clinically-led. We get a significant input from colleagues on the clinical advisory groups in the Royal College of Physicians of Ireland and from the inter-professionals. We will see the benefit in terms of delivering improved care around the country. If one takes stroke as an example, one will want the thrombectomy care done on a particular site but one will want to be back in one's own locality getting rehabilitation services in an appropriately-staffed rehabilitation unit. That is what the model of care is clearly showing.

The models of care, such as the integrated care framework and the local governance group and learning from the frailty education programme sites that are effectively integration ready when they are in place, will make a significant difference.

In response to the question on Versatis, to be fair, I think Professor McDonald gave a very good answer about the importance of cost effectiveness and it is probably not within our remit to give an answer to that.

That is part of the problem. Obviously the management of chronic disease links with chronic pain and chronic pain management. It is quite astounding that medical personnel would not be consulted about that decision that has affected so many people. I refer to how "patient-centred" care means the patient being the centre of all decision making and how person-centred co-ordinated care provides one with the services one needs when and where one needs them. It is based on a full understanding of one's life and world, combined with the information and support one needs. It demonstrates respect for one's preferences, building care around one and those involved in one's care. That is wonderful statement and is what we want to achieve but I cannot reconcile that with the withdrawal of Versatis without giving a clinical plan to the GPs, thereby undermining the GP-consultant-patient relationship and just leaving people in abeyance. When decisions like that are made, it serves to undermine what the witnesses are saying to us about other areas. I ask the witnesses to do anything within their gift to request a review of the decision on Versatis, so that medical personnel listen to the people who are telling them about the impact that the withdrawal of Versatis medicated plasters has had on them.

Dr. Rónán Collins

In addition to my role as clinical lead in the national stroke programme, I am a geriatrician, and Senator Conway-Walsh is absolutely right that pain is an important part of chronic disease. Nobody disputes that. I think there is probably a feeling in the medical community that we need to invest more in our pain services in general. The model for what pain services should look like is probably a multidisciplinary service. The solution to all pain is neither a pill nor a patch but there are other aspects as well. The problem with having limited finance, and I am not speaking on behalf of Professor Michael Barry from the medicines management programme, who is very well able to speak on his own behalf, is that the resource is finite. Looking at the use of this patch as a medic, there is a significant gap in the evidence as to how this patch is working. It has a licence for one treatment but it has been used, and seemingly, I am not doubting the testimonials of patients, it is working in other areas as well. That always poses a problem in medicine in terms of prescribing something, when one does not have a clear licence to use it for that condition. Should it be withdrawn from patients who clearly benefit from it? Definitely not but to be fair, I do not think Professor Barry suggested that either. I think he is suggesting that he needs to have some sort of control over it in terms of how it is prescribed. My personal view is that the issue may have been possibly handled in a hard way but if there was not consultation with general practice, and I am not aware whether there was - that is not an ideal way to conduct business. In general terms, we are a small country with finite resources. I acknowledge the Minister has made an important move to get us involved with other smaller countries in Europe in order that we have better bargaining power for purchasing drugs. That is a very important issue but with resources that are finite, one must conduct some sort of analysis if there is a significant overspend in a particular area.

Yes, of course. The cost-benefit analysis needs to take account of the alternative medication, the hospitalisation and all other services that will be required by the individual. The very first thing that anyone needs to do is to go to the drug company and negotiate a discount based on the increased volume. That was not done. That does not speak to me as a service that is patient-centred.

I acknowledge this is not the area for which the witnesses are responsible but it is connected to their areas. They should please ask that another look be taken at Versatis medicated plasters. The position should be reviewed and in the meantime, the Versatis patches should be reinstated. It should be left to the GPs and the consultants to make that decision.

To come back to my original question, apart from staffing and bed capacity, what are the barriers to implementing the chronic care programmes? Are there structural problems that need to be overcome in how the HSE and the Department of Health are structured and managed or are there other softer barriers apart from the infrastructural and staffing barriers?

Professor Ken McDonald

The Sláintecare report has provided a very good routeway for chronic disease in general. If we can work on implementing its recommendations that certainly would be going in the right direction. The barriers are the need to break down the silos of historical health care, which the Chairman knows about from working in the area. I think we need to go on the route of making sure that we stop the divide between primary and secondary care and that we realise that chronic disease management requires not just the physician, be it the general practitioner or the specialist in the hospital, but also requires a very strong input of allied health care professionals. Moreover, none of these chronic illnesses about which we are speaking will be managed properly unless the patient and his or her family are actively involved in care. That is clearly demonstrated for example in heart failure care where, prior to admission to hospital or to an emergency room, there is a signal available for the patient to act on - if the patient or his or her family is aware of it - that could result in that deterioration being aborted before it got to the stage that it would need emergency care. Breaking down the historical way that we deliver health care is critical, whether we do that through the rolling out of the Sláintecare recommendations or medics trying to reshape the way we deliver care in their own individual areas.

Where does the initial impetus come from to set up local integration groups? Does it come from the hospital sector or from general practice or do the groups come together and decide to do it?

Dr. Diarmuid O'Shea

This is the value of clear leadership and clear models of care from the clinical programmes. We are saying there should be local governance groups in place that are cross-community and hospital and that they can influence and drive change and they should comprise health care professionals, patient representatives and primary care. The answer to the Chairman's question is that is the value of evolving integrated care sites and frailty education programme sites because they have governance groups that are mandated in the programme. When we went to some of the hospitals and community health care organisations about these programmes, they already had version of those groups in place. Where they are not in place, they effectively should be making themselves integration-ready by having these governance groups in place. I would go back to something a Senator of yore said, when Senator William Butler Yeats wrote in a poem:

We thread the needles' eyes, and all we do. All must together do.

If we are not all on the same page clinically, it serves the purpose to have us fighting internally, if we break down these silos. I am a firm believer that education is a real tool to break down barriers and it is important to have that in place.

We see that continually in the context of the growing number of integrated care sites and frailty education programme sites. In this way, we harness the enthusiasm of the health care professionals who are working there.

Before I bring in the next speakers, the witnesses might think about the following question. Is the mixture of private care in public hospitals a barrier to change? Perhaps they might comment on that before we conclude. I call Deputy O'Connell to be followed by Deputy O'Reilly.

I thank the witnesses for attending. I apologise for not being present for part of the meeting. I have looked back at their evidence and have read most of their documents for today. They spoke about a GP-led heart failure service and also about clinical nurse specialists in the community having a role. I am a community pharmacist and I wonder if they would see community pharmacists having a role in the prevention of stroke and the treatment of cardiovascular disease. In Canada, some very interesting work has been done in this area. This committee has heard ad infinitum about he ageing population but also the ageing GP population and about how many of them are due to retire, as well as the huge HR issues we have within the health service. It is all fine and dandy to say that we want a GP-led service but it will not work if we do not have the GPs and cannot get them from somewhere. In the context of Sláintecare, we spoke about ramping up entry level into medicine to try to have more graduates because we need to have the GPs to lead this.

I am of the view that there is a huge role for community pharmacists, especially in light of the new masters in pharmacy courses through the schools of pharmacy. When the Taoiseach, Deputy Varadkar, was Minister for Health, the whole point was to expand the role of community pharmacists. I did the masters in pharmacy course in the UK some years ago and it would always have been considered as more clinically-based in nature. I would like to hear the witnesses' views. Obviously, my view is that there is a huge role for community pharmacists in rationalising medication but also in the management of people when they go home and into the community.

The news on virtual consultation is very positive. Innovation is key to how we move forward in our health service and if we continue doing things the same way, we are not going to get anywhere.

With regard to the FAST campaign for stroke, when was that last rolled out? I felt the campaign was still on the television but the witnesses have suggested people are not acting on the basis of FAST, when we all know that is the key to ensuring less damage and better outcomes.

The witnesses referred to 85% cover in our units and, in particular, to a unit that deals with the Domestos aspect and with the pipe cleaning aspect. Is this a very specialised procedure and can it happen in every hospital? We are talking about trauma centres, orthopaedic centres and maternity centres. However, in a general run-of-the-mill hospital in Tullamore, Mullingar, Carlow or Kilkenny, is it economically viable to have these units in situ? Do the outcomes make it worth the investment? Logically, we cannot just have four centres because travel time will negate the positive side of that.

The time from door to needle has gone down from three hours to one hour and 40 minutes. Have we figures on how this has improved outcomes? Are there figures that apply to the period before reaching the door of the hospital, such as ambulance response times? Have we improved outcomes in these two areas and where can we target to improve them further?

I am conscious we are focusing on the witnesses' areas of speciality. Although I am not sure if diabetes was mentioned, I am sure it is a huge part of this and the obesity epidemic on our doorsteps obviously has a major impact. Healthy Ireland was a positive document. The witnesses might comment on whether it needs to be looked at again and refreshed, or whether it is fine as it is.

I apologise for not being present for part of the meeting. I saw some of the evidence on the monitor and I will have a chance to look back on the rest. If I ask a question the witnesses have already answered, they should feel free to refer me to their earlier statements.

The area of stroke and neurorehabilitation is one I am particularly interested in and one on which we have been doing research in my office for some time. In the context of the link between stroke services and neurorehabilitation strategy, can the witnesses give details on what collaboration has taken place between the HSE national steering group for the national policy and strategy for the provision of neurorehabilitation services and the national stroke programme? How are stroke services going to fit in or feature? I understand, from replies to parliamentary questions, that the neurorehabilitation committee has only spoken to the stroke lead in respect of the mapping of services and not in regard to the clinical care pathway. However, I am also conscious that the deadline is June, which seems a long way away until we realise that it is now March and we see how fast time is moving. The witnesses might comment on the level of collaboration, how it is going to improve and how stroke services are going to feature in the neurorehabilitation strategy? How is it proposed to ensure they are front and centre?

I am also looking at figures in regard to discharges to long-term care. Between 2009 and 2014, there was a 22% reduction, which is obviously a good thing, but the figures suggest this is now starting to creep back up. Will the witnesses comment on the reasons for this? More importantly, given that, as I assume, they know the reasons for this increase, what is being done to ensure that the figures start going in the right direction again? Clearly, they are not going in the right direction. It might be that it has been identified there is a geographic element to this. How is it happening and how does the HSE intend to reverse it?

Dr. Diarmuid O'Shea

We might come back to the private-public question because the answer will not be short, although it is a very important question. Before I pass to Professor McDonald, I want to address Deputy O'Connell's question in regard to polypharmacy and medication from pharmacists on these programmes. There is a pharmacist representative on the clinical programme for older people working group, which is very important from the point of view of all of the programmes. Polypharmacy, medication realisation and de-prescribing as much as prescribing are hugely important parts of this. What the Deputy's question speaks to is the critical importance of getting the constitution of the different clinical advisory and working advisory groups correct. It is about all the breadth of health care professionals working together.

On the question on obesity, diabetes and dementia, a new lead has recently been appointed for the national dementia strategy, Dr. Suzanne Timmons, and there is a specific diabetes lead and a clinical lead for the obesity programme. It might be appropriate for them to attend the committee at some stage to answer questions around those programmes. Professor McDonald had a specific comment to make on diabetes and heart failure.

Professor Ken McDonald

I will try to roll that in with answers to some of the questions Deputy O'Connell asked. In answering, I am simply going to be agreeing strongly with a couple of her sentiments. First, I think the pharmacist is a completely under-used strength of the health care system that we need to start using far more than simply as a drug dispensing outlet. At present it is a leg on the stool of health care delivery that we are simply not using effectively, given the fact that, as the Deputy knows better than I, the pharmacist involved sees the patient probably more frequently than any one other individual involved in health care.

The pharmacist has an opportunity not simply to look at reconciliation of medicines but also to be involved in increasing medicine under appropriate guidelines, linked in very securely with the general practitioner. I am in complete agreement with the Deputy that we need to do something to bring more pharmacists front and central in health care delivery.

On the diabetes issue, the national clinical programme on heart failure has looked at the prevention strategy about which we talked this morning, the Stop HF strategy, as a pilot within the diabetic programme in the midlands. I think the committee has already heard from Dr. Velma Harkins on this. She is the GP who is leading up this effort. The prevention service that I referred to earlier has now been parachuted in on top of the care processes in the midlands to try to accentuate our efforts to prevent cardiovascular disease - heart failure being one aspect of that - within the population most at risk. Obviously, as we all know, diabetics are particularly at risk for cardiovascular disease.

Finally, to come back to the initial point about the pharmacists, as we roll out a prevention strategy for cardiovascular disease, we envisage that an aspect of that strategy can be provided by pharmacists in pharmacies. Some of the initial screening tests should be done there, with patients then triaged based on results.

Dr. Diarmuid O'Shea

To go back on that, before handing over to Dr. Collins, the HSE has an initiative based around making every contact count. It is about the person who has multiple co-morbidities and who is regularly meeting the pharmacist and about making better use of that expertise. However, that has implications for pharmacists.

Dr. Rónán Collins

Very briefly, I agree with Deputy O'Connell. It may interest her to know that the Australians carried out a large atrial fibrillation screening study using pharmacists as the screening interventionists. They came up with a very acceptable result of about $3,400 per stroke saved in terms of using the pharmacist. However, there are national issues about indemnity. Our pharmacists are very integrated into our atrial fibrillation clinic in our hospital. They have done the MSc in cardiovascular prescribing so there are extended roles there. Those roles are changing. As the committee has heard from every witness here, we are into multidisciplinary and interdisciplinary approaches. We see roles for people but obviously there are issues regarding contracts, indemnity and so forth that would need to be teased out.

Specifically with regard to thrombectomy and thrombolysis, we have modelled this recently in Ireland. The important thing is to get the Domestos in as quickly as possible while also trying to carry out thrombectomy, which is the mechanical removal. There will be different models depending on where one lives. We certainly want to get the drug in quickly because most of the thrombectomy trials occurred on top of the fact that patients already had the blood thinner on board, preventing further sludging. It is key to get the drug in quickly but if the door-to-needle time is going to be prolonged in an individual hospital, then maybe one is better bypassing that.

Deputy O'Connell spoke about Mullingar and Tullamore. I do not know if she is from-----

I am from there originally, which is why I mentioned it.

Dr. Rónán Collins

It is interesting that she mentioned that area. When it came to accessing care, for example, that area was in our first tele medicine network, which greatly improved the provision of the clot-busting treatment.

Going back to thrombectomy, it is very specific and a lot of interventionist skill is required. There is a significant risk of bleeding and that can lead to fatal situations. That part of it needs to be done in supra-specialised centres. We are modelling the pathways around that to determine whether patients should stop off in the nearest hospital first to get the clot-busting drug before moving on. We have actually just produced a paper on that for the European Stroke Journal and I would be happy to send that on to the Deputy. That paper illustrates some of the mathematical modelling we have just done in the greater Leinster area.

In terms of the door-to-needle time, things are improving although more work needs to be done. We have started a quality improvement initiative with the Royal College of Physicians for all of our stroke teams and we hope that every hospital stroke team will have completed a quality improvement programme on door-to-needle time by the end of next year.

Going back to Deputy O'Reilly's comments about the neurorehabilitation strategy, that strategy started life as far back as 2010, became more focused in 2012, with the development of the model of care finalised in 2015. It is now at the level of implementation and this is the point where we actually engage. The model of care is generic - it is for everybody with neurological disabilities. Obviously, we need to explore the Venn diagram in terms of where strokes, as well as other neurological disabilities, will fit into the commonality of that. I would reiterate that the national stroke programme wants to ensure - as per the second pillar of our strategy on restoration to living - that everybody, irrespective of age gets the necessary rehabilitation that they require and not just to go home but also to get back to living.

In terms of the figures for discharge to nursing homes-----

I am sorry to interrupt but my question was about the collaboration that had taken place. I referenced the fact that I did not think that the collaboration was at a very deep or advanced stage. Given that June is the date for publication, what level of engagement is planned between now and then on the clinical pathways? This will not happen organically. It has to be driven by both sides but the responses to parliamentary questions that I have submitted would indicate that there is not much of a sense of urgency around this.

Dr. Rónán Collins

I accept that is the Deputy's impression. I have only been in this job for a couple of months. To date, there have been informal discussions but there will be fairly focused meetings between now and June about where we fit into the neurorehabilitation strategy. There are elements of the national care programme for older people that fit into this as well. Indeed, the three programmes need to have a discussion because neurorehabilitation is not just a specific entity on its own. It is a model of care that transcends several different care programmes. A pretty intensive level of work will be done on this over the next couple of months.

Deputy O'Reilly is right to point out the importance of ensuring that more people do not survive stroke at the expense of disability. The mortality figures have dropped from 19% in 2008 to 12% now, which is a huge shift in the stroke survival rates. We have made a lot of progress in that regard. Our nursing home figures have stayed relatively stable over the past three years. They stood at approximately 15.2% in 2015 and are now around 15.9%. They are running a little bit in the wrong direction but people must understand that we are going to have an increase in absolute numbers in the next couple of years. There will be regional variations on which I cannot give answers to the Deputy because I do not have the data here. Some of it can be home-care package dependent, in terms of whether people can get home in certain circumstances. Those admitted to nursing homes tend be people in the moderate to severe disability category but I can assure the Deputy that we are watching it closely. One of our key performance indicators is whether people are being discharged home. Next year we plan to use an indicator of disability as a publishable criteria in our stroke register. We are going to start using the modified rank and scale as an analysis going forward so that the level of disability after stroke will be clearly visible. Up until now, it has been a surrogate in terms of going home or going to a nursing home, as I am sure the Deputy appreciates.

The increase, even though it is small, is costing somewhere in the region of €53 million. There is a cost for discharging people into long term care. I fully appreciate that it is creeping up at a slow rate but it is creeping up nonetheless. It needs to be reversed. Significant money is being spent because it is not going in the right direction; it is actually costing us.

Dr. Rónán Collins

We appreciate that and, as I said, it is one of our key performance indicators. We will be watching it closely going forward. I appreciate everything the Deputy has said. It is a source of considerable cost to the State.

If I may, I wish to pick up on something that Professor Collins said. He spoke about indemnity, which is often mentioned when roles are being expanded. If we cast our minds back to the expansion of the vaccination programme into community pharmacies, the argument was made that people would be having anaphylactic reactions to flu vaccines left, right and centre. People asked what the pharmacists would do when that happened. When I was training, the chance of that happening was one in 1 million and now it is one in 2 million. I had many arguments with medic members of my family as to how we would manage and we all got through it fine. My understanding is that nobody has "croaked it" on a pharmacy floor from having a flu vaccine administered. In that context, the expansion of roles should be governed by the undergraduate course and the issue of indemnity dealt with by the governing and regulatory bodies. I would not like to see the issue of indemnity preventing any expansion of roles.

There has been a call from some quarters for an increase in the availability of defibrillator machines in various settings.

I scanned a study last weekend which said this was not good value for money. A nurse who featured on "The Late Late Show" or "The Ray D'Arcy Show" recently outlined how she gave her husband CPR for half an hour and he survived. In Denmark, children are taught first aid, recognition of the symptoms of stroke and chest compressions. Nobody dies on the street anymore there because most people are able to keep those with heart failure going until the paramedics arrive. It might be popular to suggest defibrillators should be put in every village in the country but they must be used correctly. Perhaps Dr. McDonald could elaborate on what would happen if a defibrillator was used for somebody having a stroke and on the inappropriate use of such devices.

Professor Ken McDonald

Fundamentally, as Dr. O'Shea said, we all need to be educated from school onwards about how to resuscitate and how to recognise symptoms, as happens in Denmark. As the Deputy pointed out, having a defibrillator at every crossroads would not be practical or effective and I wonder whether it would even be safe. There are figures, which I do have with me, for the critical accumulation of people in a zone where a defibrillator would be of practical use to the population. Beyond the defibrillator, we need to make sure that primary resuscitation skills are more readily available and taught to us all.

I would like a response to my question on the mix of private care in public hospitals and the barriers that may cause.

Dr. Diarmuid O'Shea

The questions have been informative and instructive for us but having listened to us for the past two hours, that question on its own could take an entire committee session and more. To be brief but not glib, there is a co-dependency. When I talk about age attuning and being age accommodating and age friendly, there is a need for the private healthcare sector to recognise that it is encountering a larger and increasing cohort of frail older people and its staff needs to be upskilled and geared to deal with that. Generally, from a societal point of view and from a financing point of view, we need to understand that there is co-dependency. If the private sector no longer lowers costs or drives an expectation that people will not sign for private healthcare cover when they are in a public hospital, that will result a huge amount coming out of the public purse. This is probably a question for another meeting but we need to recognise the co-dependency and understand how to work better. This goes back to the benefits of the clinical programmes, clinical advisory groups, working advisory groups and the HSE breaking down the silos and barriers that exist.

One of the great experiences that I have had recently is looking at the provision of education for interdisciplinary staff in nursing homes. When everybody is in the same room, one can experience the informed discussion and the learning from each other that goes on. That is as much about networking and breaking down barriers and we need to do more of that.

I refer to the discussion between Deputy O'Reilly and Dr. Collins and the deadline in June. I have been working as clinical lead since the clinical programme started and something I have learned is that things have to be progressed slowly in certain circumstances. I regard launch dates and other dates for documents as iterative. The fact is that we will be in discussions on that and will influence initially a document; it will not just happen on the basis of one launch in June. It will be an ongoing, iterative process. Once we are sitting in the same room, we are making progress.

My question intended to ascertain whether everyone was in the same room and that all aspects, including the clinical care pathway, would be part of the process.

Dr. Diarmuid O'Shea

Getting it right is important, not exactly when one gets it right.

There has to be a timeline as well but I take Dr. O'Shea's point.

Would Dr. McDonald or Dr. Collins comment on the private mix in our public hospitals?

Professor Ken McDonald

As Dr. O'Shea said, it is a complex area. He has summed it up. I would not be able to do it justice in the time available.

I will give Dr. McDonald five minutes.

Professor Ken McDonald

I will cede my time to Dr. Collins.

Dr. Rónán Collins

The Chairman might be a fly fisherman. He has landed a fly in front of me knowing I might potentially snap at it. It is a difficult area and aspects of it need to be teased out. I will give a vignette to describe what happens. Last week, we experienced a severe weather event and people whose operations had been done in the private sector turned up at our hospital with post-operative issues. They turn up because we are open 24-7 and we deal with all-comers and cases of every complexity. I object to them being told by their insurance companies not to sign in a public hospital. I acknowledge in my area of medicine the fee from insurance companies is small but substantial money accrues to the public, not-for-profit, common good system from these fees. This needs regulation. As Dr. O'Shea alluded to, there is a co-dependency but we want to make sure that, however the model evolves, the public system can stay abreast of technology and that we have sufficient resources to buy the latest PET scanner, for example, in order that everybody can avail of it, otherwise, the public system will be driven into the ground like the veterans health administration system in the US, which became under-resourced and demoralised and nobody would work in it. We want to avoid that. Our public system is vibrant and we want to attract, in an appropriate way, investment and business that is regulated. However, there is a co-dependency and both sectors should not be mutually exclusive in delivering a proper health service.

Dr. Diarmuid O'Shea

We have a vibrant, enthusiastic and incredibly motivated staff and retaining all of them in order that we do not lose nurses, physiotherapists, doctors and other health care professionals is important. That is why it is crucial that enhanced roles are provided for them. Deputy Kelleher asked about workforce planning. It is important that good career pathways and enhanced roles are provided for staff to retain them because that will motivate people to come back into our system and bring back the innovations that we want to develop. I was abroad for some training. One can only be heartened by what happened last week in the middle of the red alert nationally, politically and in health care. The building blocks have been put in place by the clinical strategy and programmes division of the HSE in conjunction with colleges, clinicians, healthcare programme managers and health care professionals and we have a roadmap in the Sláintecare report to move forward but clear support is needed with all of us working together to drive that. That cannot happen with just the clinicians or just the politicians. There are difficult decisions to be made on funding but we are better off making them together rather than fighting about them.

On behalf of the committee, I thank the witnesses for attending to share their expertise.

Sitting suspended at 12 noon and resumed at 12.01 p.m.