The issues of health promotion, illness prevention, women's health and the ageing population and disability were highlighted in the health strategy. The Irish Society for Rheumatology set out to examine the service delivery of rheumatological services throughout the country.
I will open this part of the presentation by outlining how rheumatologists perceive the level and quality of service. If one manages to get access to the outpatient departments of hospitals, the quality of rheumatology services is excellent. However, we have the lowest consultant to population ratio in Europe, both within and without the EU. There is an inadequate infrastructure in terms of dedicated outpatient services and day care services. There is difficulty in access to support services, particularly services like radiology and MRI scanning. There are few dedicated rheumatology beds in the country, with only 104 in total of which 46 are in the rheumatology rehabilitation unit in Harold's Cross.
There is insufficient specialist nursing. A number of departments throughout the country do not have a specialist nurse in rheumatology, neither do they have dedicated physiotherapists or occupational therapists. These are the key non-medical health professional personnel who are required to deliver care to these patients. The extent of general medicine commitment was highlighted when last we met. In some units, up to 1,700 patients per annum are admitted to rheumatology services from accident and emergency departments. While these patients have non-rheumatology problems, they have to be cared for in addition to the large number of patients requiring rheumatology input. The heavy administrative load in trying to manage the service is a considerable burden.
The patients' view of the level and quality of service is that it is a good quality service - if it can be accessed. Equity of access is a major problem for patients with rheumatic diseases. There are areas of the country with no rheumatology services. The Mid-Western Health Board last week appointed its first rheumatologist. He or she has not taken up the position as of yet, but at least there is a move. There is no rheumatologist in the Midland Health Board area. The North-Eastern Health Board has just advertised for a rheumatologist-general physician; this will be the first such appointment in the area. Tallaght has no rheumatology service.
There are lengthy outpatient waiting lists and it can take up to four years to see a rheumatologist in Galway. Galway is not alone in this as things are not much better in Cork. The shortest waiting list is in Dublin and may be as low as six months in some units. The average wait is one year to 18 months. There are long waiting times and because of the large numbers of patients at outpatient clinics, some have to wait for up to five years before being seen. There are few if any dedicated beds for in-patient treatment. There is inadequate or an absence of nursing-paramedical support in some units.
These were the key findings in the manpower strategy document from which recommendations derived. We have suggested that certain emergency issues need to be addressed. Health board areas where there is no consultant rheumatologist, or regions where the consultant-population ratio is less than 0.4 per 100,000 of population, should be considered as emergencies. Consultant rheumatology posts are urgently needed in the North-Eastern Health Board, Midland Health Board, Mid-Western Health Board, Western Health Board, the Southern Health Board and the ERHA, south western region.
There is currently no paediatric rheumatology service in the country. We estimate there are approximately 700 children with arthritis in the country and general paediatricians deal with them. International evidence suggests paediatric rheumatologists are required to manage these complex patients. This service needs to be developed as a matter of urgency. We recommend the immediate appointment of two consultant paediatric rheumatologists, linked to both paediatric and rheumatology services.
As regards the allied health professions, we recommend that at least one or other of clinical rheumatology nurse practitioners, dedicated rheumatology occupational therapists and physiotherapists should be present in every rheumatology department. There are a number of posts that should be created as a matter or urgency. We need three rheumatology nurse specialists in Merlin Park Hospital in Galway, South Infirmary in Cork and Cork University Hospital. We need 2.5 whole time equivalent occupational therapists to meet the requirement of one full-time occupational therapist. We need 0.5 physiotherapists for Cork University Hospital. In addition, we suggest that the consultant posts created in the mid western, midland and north eastern health boards, as well as Tallaght, should each have a clinical nurse specialist, a dedicated occupational therapist and a dedicated physiotherapist. Members will have heard the overall recommendations on consultant provision. While we recommended one per 80,000 of population, we also indicated that with the NCHD working hours directive, a figure lower than that was likely. I am glad to hear that the Hanly report has recommended a figure of one per 50,000 of population. If this is implemented, this will be sufficient to deliver care to patients.
We recommend four paediatric rheumatology positions in the country as a whole and that each unit should have two rheumatology nurse specialists posts, three dedicated physiotherapists, two dedicated occupational therapists, a dedicated clinical psychologist, a dedicated podiatrist and a dedicated medical social worker.
As regards infrastructure, work needs to be done to deliver outpatient services, dedicated day centres and day ward facilities. As regards in-patient beds, we recommend that each unit would have dedicated rheumatology beds. The proportion we suggest is two acute beds and eight rehabilitation beds per 80,000 of population.
