JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Thursday, 11 May 2006

Rheumatology Services: Presentation.

Vice Chairman

We are in public session for a presentation by a delegation of consultant rheumatologists and Arthritis Ireland on the needs of the rheumatology services. I welcome Dr. Paul O'Connell, rheumatology department, Beaumont Hospital, Dr. Gaye Cunnane, consultant in rheumatology and internal medicine at St. James's Hospital, Dr. Robert Coughlan, consultant rheumatologist, Merlin Park Hospital in Galway, Dr. Mick Molloy, consultant rheumatologist at Cork University Hospital, Ms Mary Healy, a patient representing Arthritis Ireland and Mr. John Church, CEO of Arthritis Ireland.

Before I ask witnesses to commence their presentation I draw attention to the fact that while members of the committee have absolute privilege, this privilege does not apply to witnesses appearing before the committee. Members are also reminded of long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.

Dr. Gaye Cunnane

I thank the joint committee for inviting us today to talk about Irish rheumatology services. Most of us in this room will develop arthritis, not necessarily when we are old. Many people develop symptoms when they are very young and their only hope of a normal life is to receive early rheumatological assessment and treatment.

The term "rheumatology" means all forms of arthritis, in addition to rare and potentially life-threatening conditions such as vasculitis, lupus and scleroderma. These diseases affect the internal organs and cause damage to the heart, lungs, liver, kidneys and brain. Patients with chronic inflammatory arthritis such as rheumatoid arthritis have a poor prognosis. While most people realise that people with arthritis suffer chronic pain, disability, depression, social isolation and work loss, few realise that arthritis patients actually die younger than they should, from heart disease, cancer and serious infections.

From an economic viewpoint it is cost effective to treat these conditions early and minimise the complications. On the other hand it is extremely expensive to allow these secondary consequences of disease to develop. The Irish taxpayer unwittingly bears the financial burden of poor rheumatology services. The lack of resources means inequality of access to rheumatology services, thus discriminating against patients who live in certain parts of Dublin or certain parts of Ireland. This is unacceptable when we know that early and effective treatment can revolutionise the outcome of these diseases and allow patients to live normal lives.

I particularly emphasise early arthritis, which refers to joint inflammation that has been present for just a few weeks. An example is rheumatoid arthritis and Ms Mary Healy will speak shortly about what it is like to live with the disease. There is now considerable evidence that the only opportunity for sustained disease remission in patients with rheumatoid arthritis occurs in the first few weeks after symptom onset. Once that time period has passed the opportunity has gone and it never returns. The disease then becomes established and eventually resistant to treatment. The patient becomes susceptible to a range of other diseases and longevity is reduced.

Given the overwhelming evidence of the benefits of early intervention in rheumatoid arthritis it is no longer medically or ethically acceptable to be unable to provide access for sufferers to rheumatology services. In the past ten years enormous advances have been made in the world of rheumatology in terms of revolutionary new treatments that can dramatically alter the outcome of these diseases, alongside improvements in technology that allow us to diagnose problems at a much earlier stage. These advances are of no consequence if we cannot provide the basics and get access for these patients to specialised rheumatology services in a timely manner.

Irish rheumatology services compare poorly with international standards of best practice. In the UK, the British Society for Rheumatology and the Royal College of Physicians have made recommendations for the care of rheumatology patients. For example, in a rheumatology clinic they recommend that a maximum of 25 patients, both new and returned, be seen, to take into account the complexity of rheumatic diseases and to facilitate safe and optimal patient care.

In Ireland, however, many rheumatology clinics have up to 60 patients, because of the pressure of waiting lists and the urgent nature of patient symptoms. In addition, it is recommended that patients with early arthritis wait a maximum of six weeks. This, however, is impossible in many services in Ireland because there are no resources for urgent referrals. As members will be aware, many patients on Irish rheumatology waiting lists wait more than a year for an appointment and in some parts of Ireland, particularly in the west, they wait up to four years. This is in contrast to the recommended six weeks.

There are 3.5 rheumatologists per 100,000 population in certain parts of Europe, which contrasts starkly with the Irish ratio of 0.25 per 100,000. The Government-commissioned Hanly report in 2003 recommended that there be 47 rheumatologists in the Republic. Currently there are 20.5 with three posts due to be filled shortly. All of the consultant rheumatologists in Ireland participate in the general medical emergency rota which takes up approximately 50% of our workload. Therefore, in real terms, the actual number of consultant rheumatologists working in the Republic is closer to ten whole-time equivalents. As many consultant rheumatologists in Ireland do not participate in any voluntary private practice, they can devote their time and resources to developing the public services.

Ireland is grossly underresourced in allied health professionals such as nurse specialists, physiotherapists, podiatrists and occupational therapists. The lack of such personnel greatly contributes to the long waiting lists, the overburdened clinics and the poor patient outcomes. The recent Comhairle na nOspidéal report on rheumatology services highlights many of these issues.

Each hospital unit that has a rheumatology service requires adequate infrastructure for patients with disabilities. Surprisingly, this is not the case in every rheumatology centre and this deficiency clearly requires capital investment. Community services in rheumatology are well developed in the UK, the US and many parts of mainland Europe. This makes sense because musculoskeletal problems account for approximately 25% of GP consultations. GPs should have greater access to physiotherapy, occupational therapy and podiatry services. They should also have access to osteoporosis screening and radiological investigation. It is surprising that this is not the case and it adds to the burden of rheumatology waiting lists.

Community services for rheumatology are very underdeveloped in Ireland and we are not making use of an obvious way of reducing the long waiting lists for patients with acute and chronic musculoskeletal conditions, the majority of whom have treatable problems, particularly with early intervention. The geographic gaps in rheumatology services in Ireland need to be filled as a matter of urgency. For example, there are no rheumatology services in Letterkenny, Sligo, Mayo, Tralee or the midlands.

Our priorities for action must, therefore, be to ensure equality of access and resources in all parts of Dublin and the remainder of the country by increasing consultant numbers, with those relating to all other members of multidisciplinary teams. We must achieve parity with other EU countries in respect of service delivery and international standards of patient care. National standards for services and treatment must also be developed, with the setting of appropriate targets and outcomes. Community services must be established by strengthening links between hospitals and GPs. It is important to increase both public and political awareness of arthritis as a treatable and not necessarily inevitable disease.

Historically, rheumatology services in Ireland have been ignored and poorly funded, possibly because it was thought that the diseases to which they relate were chronic and untreatable. Hope has accompanied the recent dramatic changes in treatment, and rheumatology services in Ireland urgently need to reflect this reality. History will judge all of us poorly if we do not fix this problem before thousands more patients with arthritis become unnecessarily disabled, before countless more family lives are unnecessarily ruined, before thousands more good employees are unnecessarily lost from service and before thousands more arthritis patients die at an unnecessarily young age of diseases which, with early intervention, are preventable.

That is all I wish to say as an introduction, but other members of the delegation are keen to contribute.

Dr. Mick Molloy

I thank Dr. Cunnane for an excellent presentation that crystallises the problems as we see them and seeks the help and support that is absolutely necessary for us to provide services. We are encouraged by the recent Comhairle na nOspidéal document that makes strong recommendations with regard to the numbers of consultants and other staff in rheumatology.

We hope that, with the joint committee's support, we can work on this plan because we feel it is quite comprehensive and has prioritised certain posts and offered support for the numbers that would bring us close to the European standards. The community aspect is a major problem in Ireland, although we are trying to develop this. Without community back-up, it is difficult to manage and the further we go from the major centres, the more difficult that will become.

Dr. Paul O’Connell

To emphasise the comments of Dr. Cunnane and Dr. Molloy, there is a way forward in the rheumatology services report from Comhairle na nOspidéal. It provides clear guidelines regarding a number of emergency posts. The Irish Society for Rheumatology, in alliance with Arthritis Ireland, a number of rheumatology health professionals and other organisations is meeting the Health Services Executive to hopefully persuade it to undertake an agenda to implement the Comhairle na nOspidéal report over the next three to four years.

A clear protocol is outlined in the report in respect of how the services should be developed. If we can get the joint committee's support in persuading the Health Service Executive to persuade the Department of Finance to provide funding for this, there would be a clear road ahead. There is agreement, not just in the rheumatology community but also in the wider community concerned with arthritis. Arthritis Ireland is the national charity representing patients and Ms Healy will discuss the patient experience. There is a way forward in terms of developing services in rheumatology, and we have a template.

Ms Mary Healy

I thank the joint committee for inviting us to reappear. I was diagnosed with rheumatoid arthritis in my 20s and it impacted upon my quality of life. I experienced difficulty while performing everyday tasks such as holding a cup or opening a jar. By the time I was seen by a consultant, I had waited 18 months and had permanent damage to my joints. I realised that I could not access physiotherapy services, because of the long waiting list, or occupational therapy services, which help to improve one's quality of life. There are various aids and appliances available.

The biggest problem I had was travelling to the rheumatology centre in Galway. I am lucky because I can drive, although I found it difficult to sit for a number of hours in the car before waiting for what was, in some cases, five to six hours before being seen. I would then travel home. A significant problem in Mayo is that we do not have a rheumatology unit at Mayo General Hospital. Therefore, people who wish to be treated in Galway must use their own transport or travel by public transport. Many patients are unable to use public transport because of their arthritis disability. Up to now, the HSE provided patient transport to the rheumatology unit in Galway. However, we have been informed by the HSE western region that this transport is no longer available. Some patients are, therefore, unable to attend the rheumatology clinic in Galway for treatment. These patients have been waiting a number of years to be seen. The current waiting list in Galway consists of 729 patients waiting for a first appointment.

Some of those patients have been waiting since 1999. It is astonishing to think that a person with an inflammatory condition would be waiting seven years to be seen at a first appointment, given that early intervention is the most important factor in preventing joint damage. I know what it is like to have joint damage. My daily living is severely impaired because of the damage done to my hands joints while I was waiting for an appointment.

There are 81 urgent cases in Galway that need to be seen immediately. Taking into account the seven-year waiting list and the fact that 81 people are waiting to be seen by consultant as a matter of urgency, it is a public scandal. It is immoral that people must be subjected to this treatment. I call on the committee to support our campaign to have more rheumatologists in Ireland, along with more physiotherapy and occupational therapy services and more rheumatology nurse specialists. The full package provides an invaluable service for patients but, unfortunately, patients are unable to access the services in various areas.

Mr. John Church

To reiterate what my colleagues said, we welcome the production of the Comhairle na nOspidéal report. Everybody from patient support, Arthritis Ireland and the health professionals here today are very much agreed on what is needed. The report recommends 16 priority posts, which is four per annum over the next four years. That would go a significant way towards alleviating many of the problems mentioned by Ms Healy. We call on this report to be recommended.

Vice Chairman

Before members ask questions, I wish to seek clarification on two points. It is approximately one year since the delegation's last visit. Will the witnesses compare the position regarding consultant rheumatology posts now to that which obtained at that time? Has there been any change?

Dr. Cunnane

Three posts are about to be filled. One is a paediatric rheumatology post in Crumlin, which existed last year but which was not filled. The person that will fill the post is in Ireland, which is fantastic. A post is advertised for Galway and another is about to be filled in Limerick. Those posts about to be filled were already in existence but there has been no other change in terms of consultant numbers.

Dr. Robert Coughlan

The post in Limerick was filled last year, and is still being filled, by a locum. A second post in Galway was filled by a locum and is still being filled by that person. Since we were last here the post in Manorhamilton has become vacant.

Ms Healy mentioned the figures for the west. There are between 400 and 500 patients waiting in the combined Letterkenny, Manorhamilton and Sligo area, with a waiting time of around four years. In the Limerick, Nenagh and Ennis area the waiting time is also around four years and it is estimated that approximately 400 people are waiting.

We have been coming here for four years asking for help and we have been given some help. As we have been innovative in our work, we can see more people in an efficient manner. We have endeavoured to run clinics in a different way, to shorten waiting lists, introduce nurse specialists and biologics clinics and get to the people who urgently need services more quickly. The Health Service Executive asks us to innovate, but we have demonstrated about as much innovation as possible. We need more personnel in order to deliver services.

Vice Chairman

I would like clarification on the Comhairle na nOspidéal report on rheumatology services. The internationally recommended ratio of rheumatologists to the general population is 1:80,000. Is that correct?

Dr. Coughlan

Yes.

Vice Chairman

At present, in parts of Ireland, particularly the west, it is 1:235,000. Is that correct? In parts of the south it is 1:160,000 and in parts of Dublin it varies between 1:120,000 and 1:190,000. Is that correct?

Dr. Molloy

Yes.

Vice Chairman

They are appalling figures.

Dr. Coughlan

In the midlands, between Galway and Dublin, between Cork and the Border, there are no rheumatologists on the flat plains. They are not there.

Vice Chairman

We must devise a game, find the rheumatologist. We will take the first batch of questions.

Deputy McManus

Dr. Coughlan has painted a stark picture. There are two shocking pieces of information, namely, the seven year waiting time and the fact that no new posts have been created, that nothing has moved on. We are constantly lectured on the additional funding that the health service is receiving. However, the improvements that desperately need to be made are not happening.

It seems that the chief executive officer of the Health Service Executive is effectively the Minister for Health and Children. There is an independent structure running the health service and it is difficult for us to influence it, however I will do what I can with regard to this scandal. How does Comhairle na nOspidéal envisage the response of the Health Service Executive as it is now under its aegis? Do the members of the delegation expect a time-frame for the delivery of this strategy? Without a time-frame it does not have much value.

Do the doctors see new centres being provided to the north west? In other specialties there is an emphasis on people travelling to centres of excellence. Is it better in rheumatology, instead, to have many local centres? If so, and in terms of appointing new consultants, does this require additional staffing and capital costs?

Osteoporosis is a relatively easy condition to prevent, yet screening seems to be increasingly scarce. Can the delegation comment on this?

Deputy Gormley

The presentation by Dr. Cunnane was clear and concise. With regard to arthritis, can a price be placed on the lack of early detection in this country and the fact that we do not have proper infrastructure in place? Does the lay person need to be educated on recognising the symptoms because there are people who display them early on? What causes arthritis? Is it genetic or can it be brought on by certain activities? How does Ireland compare internationally? Are our rates higher because of our climate? What would the proper infrastructure cost?

Senator Henry

I was in Dr. Coughlan's clinic at least 12 years ago as part of a Comhairle na nOspidéal delegation and the situation was exactly the same as the one illustrated by him today. Patients from Mayo echoed Ms Healy's words precisely. We went up to Sligo, Letterkenny and Manorhamilton and the situation is exactly the same over a decade later.

How will we instil a sense of urgency on this issue? Our delegation wrote in strong terms that an increase in posts was needed yet this much time has passed and nothing has happened. The trouble with arthritis is that it is not dramatic enough. I wrote recently that it would be easier to have heart transplants done in Tullamore than to have rheumatologists appointed around the country. Everyone here will do what they can.

Dr. Cunnane

Nobody knows what causes early arthritis. The theory is that it is a virus in conjunction with a genetic predisposition. It is very common and occurs in about 5% of the population. The key is that while the disease is not preventable, the complications are with early intervention. We costed an early arthritis unit recently for St. James's Hospital and, less the capital investment for infrastructure, the cost was approximately €600,000. That included a consultant, registrar, nurse specialist, physiotherapist, occupational therapist and podiatrist, so the costs are very low. Several units are preferable to one large, specialised unit. Rheumatology lends itself to community services closely allied with general practitioners where patients could gain easy access. This is the way to solve this problem.

It is unacceptable that in Ireland, where rates of osteoporosis are exceptionally high, we do not have adequate access to screening facilities. In my catchment area, GPs must refer to a rheumatologist in order to arrange a DEXA scan. That adds to the waiting list, makes no sense and could be easily fixed. Do we need consultants or a multi-disciplinary team? We need the whole team, the whole package. The provision of a rheumatology service is cheap if it is addressed in the right manner, it is very expensive otherwise.

Dr. O’Connell

Osteoporosis is one of those areas that becomes a major health problem as we age. There are other such areas, such as obesity, but there is more arthritis in later life. Many of these approaches can be dealt with by co-ordination between community services and the hospital services. The development of rheumatoid osteoporosis specialists may allow consultant and doctor manpower to be extended and to develop regional programmes. There is a way forward in that respect, although it was not specifically brought up in the Comhairle report, but it is an issue that could be there. I agree, to a point, about the dispersal of services but a core is necessary. In other words, in the long term there should be two rheumatologists in a centre to develop and keep a certain level of expertise. The concept is that there should be a dispersal of services around the country in order that people do not have very long drives to get to a service and services are local. That all makes sense.

Dr. Coughlan

I will respond to the Deputy's question on osteoporosis and give her a happy story. One of the problems with these waiting lists is that osteoporosis is not a high priority. It can be seen and treated largely by primary care if the resources are in place. The block is the DEXA scanner. We have a DEXA scanner in Merlin Park Hospital which is open access, so patients come and have their scans for free, general practitioners get the results and can operate on it. One major problem with osteoporosis is that the people who really need the treatment are those who have a fracture and osteoporosis. Now we have a specialist, with pharmaceutical company funding, who sees all the patients over 50 with fractures, gets their DEXA scan organised and gives them and their general practitioner the results. Most of these patients are never seen by a consultant because they do not need to be. With that innovation, we still have capacity and we need to see more people.

Dr. Molloy

I would certainly support Dr. Coughlan on that matter. We have a scanner in our hospital that is accessed only by GPs and their colleagues in the hospital and we have 30,000 patients in our databank. It is a service for GPs and a community service. GPs manage most of those patients and we help with the diagnosis. As our population of rheumatoid patients is at a higher risk from osteoporosis, we are familiar with the treatments which are improving all the time. Obviously, it is a devastating event if somebody fractures a hip — 25% do not survive — and with fractured spines as well there is a long-term problem afterwards. However, the system is working very well.

Many DEXA scanners are available in Ireland in general practice and in hospitals. They are not necessarily in X-ray departments. They are run separately from them which makes them more accessible and allows for a quicker turnover. The education is increasing all the time. Therefore, when somebody has a fracture, we know there is a 50% chance of another one within a year. All patients recieve treatment, regardless of whether they are scanned.

On Dr. Cunnane's reference to rheumatoid arthritis treatment, setting up the service is important but, as we have heard, it is difficult for patients to travel. Most of us are now expected to provide outreach clinics in small hospitals in each district. That will be part of the provision with these new people coming aboard. The expensive part is the cost of the new biologic drugs which are dramatically effective for the disease and have changed the prognosis for rheumatoid arthritis. They are expensive but it is money well spent because people get back to full-time activity and have good quality of life. They can actually go back to heavy physical work, such as farming and plumbing. We all have many patients who can do that.

They are expensive drugs, however, which need very careful monitoring, and all our patients are dependent on a very good general practice service. We cannot operate the system without general practitioners, because people on drugs for arthritis require regular monthly monitoring. Most of that is done in general practice in conjunction with the hospital clinics. It is very much a community service with the clinics dispersed as far as possible into the community to make easy access for the patients.

Deputy O’Connor

I also welcome Dr. Cunnane and the team. We should remind ourselves of the importance of Oireachtas joint hearings. It is important when groups attend, especially such a high level group as this one, that account is taken of the concerns they express to us and the aspirations they list. It is good, too, when subsequent meetings are held that they are not too depressing and there is some good news. I noticed that in Dr. Cunnane's presentation she talked about the need to raise awareness, not only with the public but with the political process. I hope that we are all co-operating with that.

I do not want just to talk about Tallaght, but I am pleased——

Deputy Gormley

How long would it take the Deputy?

Deputy O’Connor

I am pleased, particularly in a week when there has been a lot of pressure on the name Tallaght, that Dr. David Kane has settled in and is doing a great job. I am hearing very good vibes about the service he is providing, as I have from Dr. Cunnane about St. James's Hospital. It is important we acknowledge that. My more eminent colleagues such as Deputy Twomey will probably remind me that I am not a doctor, and that is good, but even I know that there are headline diseases and illnesses. I am not going to list them all but we agreed the last time the delegation attended that the disease we are discussing is not seen as a headline one. I bring my life experience to my work. My father, who was a patient in St. James's for a while with a quite serious illness, had a problem with arthritis when he was not that old. We heard the point being made in the discussion that it is not only very old people who are affected.

We all have a responsibility to help the process and to try to support the work as much as possible and I shall certainly, in my small way, continue to do that. I wish the delegation well. I have no hard questions to ask, but I welcome what is happening in Tallaght. Senator Henry made the point that development of further services throughout the country is something we should strongly support. It is important that the Department of Health should understand that, while there are headline illnesses, there are many other disciplines for which support is clearly required.

Senator Glynn

I preface my remarks by saying that what obtains at the moment is unacceptable. What Ms Mary Healy was saying makes depressing listening. If we are serious, and I think we all are in this committee, we know that something serious must be done about the situation.

I have a few questions. What is the situation pertaining to the availability of consultant rheumatologists? If we have provision to recruit a certain number of rheumatologists, can we get them? The poor standard of community rheumatology services was mentioned. Are they very underdeveloped? What is the incidence of lupus? On 3 September 2005, I was delighted to attend my niece's wedding in Calgary in Canada. On 17 March this year, her husband came home to find her dead on the Chesterfield. She suffered from lupus. She was just 31 years old. It is a serious condition and I should like to know the statistics on it.

In addition, I should like to know how we are faring with primary care as it obtains in the area of rheumatology. Senator Henry's comment is worth repeating. It is not dramatic enough but it undoubtedly has a dramatic effect on the sufferer. However, in terms of getting to the wider community, it does not appear to have the penetration that it deserves. This situation is totally unacceptable. It is incumbent on the committee to do what it can. Our visitors should not have to return here in 12 months with the situation unchanged.

Deputy Cowley

Twenty eight years ago I worked in the unit in Galway that is now run by Dr. Coughlan and was formerly run by Dr.Donnelly. The situation has not changed since. It is still as Senator Henry outlined. People still have to travel long distances. The distance from here to Galway is almost the same, in terms of mileage, as from Belmullet to Galway. It is the equivalent of people in Dublin having to travel to Galway for their rheumatology services. They would not appreciate that.

As a general practitioner, I recall the case of a young girl who is now in a wheelchair because she missed the window of opportunity. She had to wait for years for something that should be available in a matter of weeks. She had inflammatory arthritis, as outlined by Mary Healy. I commend Mary on her wonderful work as an advocate for patients. I also commend Dr. Coughlan and Dr. Molloy on their wonderful work.

There is a major problem. The delegates made a number of points which I wish to discuss. What chance is there of the Comhairle report being implemented? I started this process in 2002 when I was elected. I asked this committee to invite the consultant rheumatologists and patient advocates to attend a committee meeting. That took place and I received great support from my colleagues on the committee when I insisted that there be a review process. We thought the situation would remain the same and, from what our visitors have said, nothing has changed in four years. What chance is there of something changing? Our visitors see the patients every day. As a general practitioner I saw what was happening and one of the major reasons I got involved in politics was to try and do something about it. This was my contribution and I hope it will bear fruit.

It was pointed out that 50% of consultant rheumatologists' time is taken up with involvement in the medical rosters. If that was taken away, would it follow logically that the input of consultant rheumatologists would be doubled? People are still waiting seven years for an appointment. It must be demoralising for a consultant to deal with that situation, particularly when they know how modern treatments can make such a difference.

I hope our visitors return here in a year. I will ask the Chairman to invite them. What do they think are the chances of some change having occurred in that year?

Deputy Twomey

There will be a different Government.

Deputy Neville

The most telling aspect is the international comparisons. That is the most significant information we have received. We listened carefully to our visitors last year but nothing has changed. Have they met with Professor Drumm and the Health Service Executive? Have they requested a meeting and what type of response have they received? As Deputy McManus said, if they cannot get movement now in that area from the HSE with the encouragement, support and perhaps even direction of the political leadership, in terms of the Tánaiste, nothing will happen. These are the key areas. We can advise and discuss as much as we like but unless the Tánaiste and Professor Drumm actively intervene to move this forward, nothing will happen. What has our visitors' experience been in that regard?

Deputy Cooper-Flynn

I have a question about the provision of services in the west, particularly in County Mayo. When Professor Drumm was before the committee a number of weeks ago he mentioned that the provision of a rheumatologist for Mayo General Hospital is included in the Estimates for next year. As I see one of our visitors throw their eyes upwards, that is probably my answer. Obviously, the geographical consideration is a huge factor. With regard to the cost of the drugs and early intervention, how much is the cost for a patient? Can the doctors quantify the impact that years of delay have on a typical patient's life?

Dr. Cunnane

I will begin with Senator Glynn's questions. With regard to the availability of consultants, there are plenty of people ready and waiting in the wings to take up posts. An average of between two and four consultant rheumatologists qualify each year. There is a training programme in Ireland but there are also people training in the United States. There is no problem with the availability of people to take up these posts.

I agree that we need to strengthen links with primary care. That would help the patient in terms of not travelling long distances. It would also strengthen the links between the community and the general practitioner, allow the general practitioner to monitor the drugs to a greater degree, give the general practitioner greater independence in looking after patients and reduce the hospital waiting lists. It would make a huge difference.

I am sorry that the Senator's niece has lupus. This, unfortunately, can be a consequence of this disease. It is a rare disease but it can be life threatening. There is a huge spectrum. Some people have very mild disease with just joint or skin symptoms but some of them, unfortunately, have life threatening internal organ involvement. That requires specialist rheumatology input, preferably at an early stage to ensure such complications do not develop.

Dr. Molloy

One of the other questions was about general internal medicine. Rheumatology is a multi-system disease even though the thrust of the disease initially is in the joints. It affects every system and that applies to lupus and rheumatoid arthritis. The mortality with rheumatoid arthritis is similar to that for triple coronary artery disease. Therefore, there is a morbidity or mortality related to the multi-system disease. Many studies now show that there is a high incidence of arterial disease generally and cardiac disease in particular in rheumatoid arthritis, as well as lupus. We had a 33 year old patient this year who had a heart attack and also had lupus and was diagnosed for the first time.

With regard to training, it is critical for us in dealing with multi-system disease to be involved with our colleagues in all the other specialties. In most hospitals the rheumatologists are involved in general internal medicine and are communicating on a regular basis with their colleagues in all the other specialties. It is critical to have that part of our work because without it we would become isolated and would not look after our patients as well as we should. I would prefer to look for more people rather than move away from that. Most of our training is in general medicine and rheumatology and that is how we would like to continue in the future.

I have been involved in this for more than 20 years. There have been Comhairle reports in the past but nothing has happened with them. Our biggest worry is that this might happen again.

Dr. Coughlan

The Deputy asked about what happens with regard to general medicine. Most of the arrangements are structured such that, for example in Galway, if there is another rheumatologist there will be the same amount of general medicine divided among two or three people. There is no increase in the load of general medicine once there is more than one consultant in a post. If there are two consultants, therefore, they will do a quarter each instead of one half.

The Deputy asked about costs. The new biologic drugs have revolutionised the outlook for people with rheumatoid arthritis, ankylosing spondylitis, sclerotic arthritis and other diseases. It costs approximately €12,000 per year per patient but the benefit is unquantifiable in terms of quality of health, productivity and outlook. These drugs make a huge difference in the long term in the development of disability. They are available to us and we must credit the HSE with giving us the ability to use these drugs without some of the very tight restrictions that are in place in other jurisdictions. We have relatively free access to using them in patients who require them without much questioning and it has made a significant difference. It is probably one of the main reasons the numbers attending the outpatients department is reducing. More patients with serious diseases are coming back less frequently because they are being well treated.

Deputy Cooper-Flynn

That is fabulous news. Is it ever too late to prescribe these drugs?

Dr. Coughlan

No.

Deputy Cooper-Flynn

But they are more successful the earlier they are prescribed.

Dr. O’Connell

The earlier one treats it, the easier it is to prevent disability. If somebody has joint damage, it cannot be repaired but one can stop the process progressing. Rheumatoid arthritis affects people in middle age such as women rearing families and both men and women in employment. It hits during their working years and if somebody can retain a job where he or she could have become unemployed having had rheumatoid arthritis for three or four years, savings can be made to compensate for the cost of the drugs, joint replacement and long-term care.

A HSE working group meeting is scheduled to push this forward. Arthritis Ireland, the Irish Society for Rheumatology, health care groups and allied health professionals will meet the group. The group is operating a tight schedule and, while our past experience makes us extremely cautious, we are hoping to persuade the group to act on the Comhairle report. We will set a four-year implementation deadline, which would mean at least four new consultant posts a year. We can provide the manpower, if the HSE provides the funding. There will not be an argument about the location of the posts because there is a template. We need agreement from the HSE to commence the funding process in 2007 but this is a tight timeline. I do not know much about budgets but my understanding is the 2007 budget will be finalised in the next few months.

Professor Oliver Fitzgerald is acting on behalf of the Irish Society for Rheumatology on the working group. We ask the committee to use whatever influence it has with the HSE to point out how important this is and to ask the executive to fund the posts. All the care providers are in agreement about what needs to be done and if the HSE provided the funding, we could impact on this process over the next four years.

Mr. Church

A question was asked about the prevalence of arthritis and the dramatic effects of arthritis on the community. The working group stated last year the economic impact of arthritis on the community was €1.6 billion. Given that services have not dramatically increased, that figure probably has not changed.

Arthritis affects one in six people in Ireland or approximately 500,000 people. We recently conducted a survey among a significant sample of patients with rheumatoid arthritis and we found that one in seven could not work as a result of their condition. The cost of the lack of productivity multiplied by the number of patients who cannot work is significant. One can quickly put into perspective the cost of drugs versus the economic impact they could have on the economy if those people returned to work.

Vice Chairman

On behalf of the committee, I thank the consultant rheumatologists and Arthritis Ireland for attending and making this such an informative meeting. I would particularly like to thank Ms Healy for attending. We are fully supportive of what we heard and I would like to take up Deputy Cowley's suggestion to invite the groups back in a year. The Chairman and I will make contact with the Minister and the HSE to press the case further.

Sitting suspended at 10.35 a.m and resumed at 10.45 a.m.