I welcome Dr. Jean Holohan, CEO, Dr. Pat Manning, chairman of the medical advisory council, and Ms Angela Edghill, chairperson, from the Asthma Society of Ireland. Before we begin, I draw attention to the fact that while members of the joint committee have absolute privilege, the same privilege does not apply to witnesses. Members are reminded of the 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. Following the presentation, members will ask questions which we will block. We will come back to the delegates at the end.
Management of Asthma in Primary Care: Discussion with Asthma Society of Ireland.
Ms Angela Edghill
It is a great privilege and pleasure to be here to represent the Asthma Society of Ireland but, more importantly, to speak to members of the joint committee as one of the estimated 470,000 people in this country who have asthma. As to my own story, I was a late starter in many things, including asthma. I was diagnosed as an adult 11 years ago this month. I know at first-hand the profound effect asthma can have on one's personal, professional and social life, as well as on one's self-esteem and self-confidence. My perception had been that asthma was a mild disease that children got and that people like me did not get it. It came as a complete shock to end up in hospital four times through the accident and emergency department and spend almost six months in and out of an acute general hospital with uncontrolled asthma.
The idea that asthma is a mild condition is a myth. That was a very bleak period of my life because it was ruled by uncontrolled asthma. I was five months out of work; I was working here at the time. Five months out of work is a long time. It was only when I contacted the Asthma Society of Ireland and discovered it had information that would help me to manage my condition in partnership with my health care professionals that I realised that for the patient knowledge was power. The more one learns the more one can control one's condition; therefore, that knowledge is key to success. It is very shocking to realise that people die every week in this country from asthma. One of our most committed board members lost her 21 year old son, Alex, to asthma. Her mission and vision always are that no other family should have to suffer the loss they suffered. Unfortunately, people do and continue to do so.
Given that background, it is particularly gratifying — I am very proud and excited — to introduce my two colleagues, Dr. Jean Holohan, our CEO, and Dr. Pat Manning, chairman of our medical advisory council, to outline a strategy which has the potential, if it has the leadership and backing it needs — political leadership is very important — to radically transform the way asthma is treated in Ireland and particularly to stop people dying from this condition.
I thank the Chairman for giving us this opportunity to appear before the joint committee.
Dr. Jean Holohan
Asthma affects almost 500,000 people in Ireland, with patients bearing the main burden in terms of morbidity and mortality. The cost to the health care system is substantial and increasing. Given the magnitude of the problem, it is hard to image how, especially in this very difficult economic climate, it could be possible to deliver better health care outcomes for asthma suffers with a reduction in cost. However, there is such a solution, supported by a rich body of evidence that it is possible to improve asthma control and reduce the number of deaths, the need for hospitalisation and costs per individual patient significantly. Ireland has an opportunity to make asthma a public health priority, take a leading role in Europe and implement an effective asthma programme.
I welcome the opportunity to outline the availability of effective management programmes and the economic impact of successful implementation. Ireland has the fourth highest prevalence of asthma worldwide. Approximately 470,000 people or one in eight of the population have asthma. The prevalence increased fourfold in the 13 to 14 year old age group between 1983 and 2003. Asthma remains the most common chronic disease in children and young adults and the most common respiratory condition in Ireland. At least one person dies from asthma each week. Unfortunately, asthma deaths are under-reported and the true mortality rate remains very difficult to establish; however, any deaths from asthma are unacceptable.
In spite of the availability of international guidelines on achieving and maintaining asthma control, a recent study revealed that for a worrying percentage of Irish patients, levels of asthma control fell well below internationally accepted goals. Of those with persistent asthma, 29% missed school or work, with adults missing an average of 12 days at work and children missing ten days at school every year; 29% had had an emergency visit to their general practitioner or accident and emergency services, while 7% had been hospitalised in the previous year. International guidelines identify the use of rescue medication more than twice a week as an indicator of poor control. A massive 51% of Irish patients use their asthma medication every day and more than 40,000 working days are lost every year to asthma.
In Ireland in 2003 asthma was estimated to have cost the State €463 million in direct health care costs. This is almost four times the European cost per patient. Emergency care and hospitalisation accounted for €227 million. The most recent INHALE report estimated an annual morbidity or indirect cost of €200 million. Uncontrolled asthma places an unacceptable burden on patients and our limited health care resources. This drain on health care resources was highlighted by a five year review of HIPE data from 2000 to 2004. The average number of admissions with the principal diagnosis of asthma was 5,374 each year. This translates into 23,000 hospital bed days for primary diagnosis of asthma every year. It is known that 94% of persons hospitalised with asthma are admitted through accident and emergency departments. Asthma exacerbation contributes significantly to the pressure on our acute hospital services, with an estimated 22,000 accident and emergency department presentations annually or 60 accident and emergency department patient visits per day. This episodic unplanned dependence on emergency care with its consequent excessive and often avoidable demands on our acute hospital services highlights the absence of a structured and integrated plan to manage asthma within the health care system.
The absence of a single data capture for medications prescribed on diagnosis of asthma makes it virtually impossible to put together a picture of medication usage. In 2006 there were 4.2 million items prescribed in Ireland to treat respiratory disease, the majority of which are classified as anti-asthmatics, although the disease range covers everything from cystic fibrosis to pulmonary hypertension and COPD. The total ingredient cost of those 4 million items was just under €100 million and the allocation attributable to asthma medications can only be estimated at €35 million to €40 million, although we consider this to be a conservative figure.
Some figures are accurate and raise real concerns about the management of the condition. For example, prescriptions for rescue medication are twice the prescriptions for inhaled steroid. Inhaled steroid, or what we call preventer medication, should be used daily as the cornerstone of asthma management while rescue treatment should be used twice or less per week. It is clear that we ought to do things the other way around. In 2006, there were more than 50,000 emergency nebuliser treatments for acute asthma attacks in primary care.
This depressing picture could be very different and Ireland has an opportunity to be at the forefront of a very significant international campaign for effective asthma management. The Asthma Society of Ireland is working closely in collaboration with several European and worldwide organisations in our goal to implement an effective asthma management programme. These partner organisations include the Global Initiative for Asthma, GINA. This is a WHO supported organisation which has developed internationally validated evidence based guidelines for effective management of asthma. The Brussels Declaration on Asthma is a ten point plan developed to urge European policy makers to recognise asthma as a public health problem that should be a political priority. We also work in collaboration with, and receive advice from the World Health Organisation through the Global Alliance against Chronic Respiratory Diseases, GARD, programme. We are very closely allied with the European Federation of Asthma and Allergy, the patients' association.
The Asthma Society of Ireland is privileged to have the committed support and participation of an international advisory council that includes: Professor Paul O'Byrne, a leading member of the GINA executive committee and an international expert on asthma from Canada; Professor David Price, from the UK, who is a leading adviser on the Brussels Declaration; and Professor Tari Haahtela, who is director of the Finnish asthma programme. These renowned experts have worked closely with us in analysing the burden of asthma in Ireland. They have advised on the implementation of evidence based guidelines in primary care and, in particular, the group has identified barriers to implementation and proven solutions to these barriers. They have encouraged us with their enthusiasm and conviction that Ireland can take a leading role in asthma management in Europe. Ireland has a proven track record in implementing public policy with far reaching benefits for public health, such as the smoking ban and the ban on smoky coal. These are recognised by our international partners as indicators that further success is possible in tackling the significant public health problems that asthma presents.
International evidence of the effectiveness of implementing an asthma management programme is exemplified by the Finnish experience, which shows that very simple measures, such as early asthma diagnosis, active asthma treatment, guided self-management and patient education, together with reductions in tobacco exposure, can improve asthma outcomes and reduce costs. The impact of this programme on mortality, hospitalisation and disability is breathtaking, especially when coupled with the economic savings seen from the implementation of effective care.
In 1993, the prevalence of asthma in Finland was 3% and the cost to the state at that time was €218 million. The costs were broken down as follows: 16% for doctors' visits; 21% for hospital bed costs; 20% for medications; and 43% for disability payments. Over the next ten years, the prevalence of asthma increased by 50% in Finland and the expected cost in 2003, if there had been no intervention, was €341 million. However, the programme initiated on a phased roll-out basis resulted in a reduction in cost.
It is the breakdown of these costs that is the most interesting. Medication and GP visits increased, partly in keeping with the 50% increase in prevalence and, therefore, patient numbers. I would like to focus on the figures for hospital costs and disability payments. Our Finnish colleagues use this data to show that the fight against asthma can be successful. Hospital bed days were cut by 54% from 110,000 to 51,000 every year. Disability payments fell by 76% and, crucially, the cost per patient fell by 36% from €1,600 to just over €1,000 per patient per year.
In 1993, there were 123 recorded deaths from asthma in Finland. By 2003, this figure had fallen to 80 and by 2006 the number of deaths from asthma in Finland was 13. That is a staggering 90% reduction in asthma mortality.
The key to the success of the asthma management programme is not money. It is political commitment at national level, organisational commitment from health service providers, an effective network of health care professionals, including respiratory physicians, paediatricians, general practitioners, practice nurses and pharmacists. Pivotal to success was the education of patients and their active participation in guided self-management. The programme cost €650,000 in total over ten years. This is less than one third of what we spend in Ireland every year on nebulisations in GP surgeries. Imagine what it would mean if we could implement this kind of programme with similar success in Ireland. We could expect a 54% reduction in the number of hospital bed days, a freeing up 12,000 hospital bed days every year. The number of visits to accident and emergency departments could be reduced by approximately 45%, reducing the strain on emergency services by eliminating 10,000 patient visits. This would benefit those in our acute hospital services who are in greatest need. Above all, the programme has the potential to save more than 50 lives every year.
The development and implementation of a national asthma strategy in partnership with policy makers and health care providers is critical to ensuring optimal control. The strategy should be solutions based, using the Finnish example as evidence of a primary care based cost effective model for implementation, clinically underpinned by the GINA guidelines prioritising written asthma management plans and patient participation. This approach is entirely in keeping with the Department of Health and Children policy on chronic disease which recommends evidence based disease management programmes, a major role for primary health care, implementation of clinical guidelines, agreed management plans for each patient and active patient participation in disease management.
As the patient organisation with the largest single chronic disease population in the country, we see the Asthma Society of Ireland as the driver of change in the face of the escalating burden of asthma. Our vision, goal and purpose reflect that of the Brussels Declaration, to revolutionise asthma management. We at the Asthma Society of Ireland have started a systematic investment programme to reach our objectives. Our patient education programme is based on the GINA model and will provide patients with the tools to actively participate in the management of their asthma. Together with the ICGP Quality in Practice Committee, we have developed GINA based guidelines for primary care. This is a critical step in the process because asthma will be one of the conditions in the chronic disease component of the revised GP contract.
We have created a clinical asthma module for practice nurses, recognising the major role of nurse-led education in the success of the Finnish programme. Together with the Irish Pharmacy Union, we have explored the role of community pharmacy in better asthma control and had one successful nationwide programme involving community pharmacy. The Asthma Society of Ireland has developed co-operative links with respiratory physicians and paediatricians and opened constructive dialogue with the Health Service Executive. We will continue to support this programme with our available resources. However, success is dependent on collaboration between policy makers, health service providers and informed patients. The society can provide patient education and core programmes for health care professionals, but without political acknowledgement that asthma is a major public health problem and a commitment that asthma will be made a political priority, Ireland will never see the outcomes gained in Finland. Achieving this will require Oireachtas support for the implementation of the Finnish programme in Ireland, a firm commitment from the Department of Health and Children and the active engagement of the HSE to fully support and resource implementation in partnership with the Asthma Society of Ireland. Such support would not only improve the health of asthma sufferers and save lives but would also substantially reduce costs for the health service.
With this committee's active support for this initiative, Ireland could be the first country in Europe to formally adopt the Brussels Declaration. A strong political commitment from all parties on this committee to support implementation of this initiative would be the first step in achieving these goals: zero tolerance to asthma deaths, a 50% reduction in the number of patients who require hospitalisation and visits to accident and emergency departments, and a 30% reduction in health care costs per patient. There is no rational reason to say "No" to this programme. The benefit for patients and society is clear. Ireland is a First World country with the capacity to deliver a world class asthma management programme.
Does Dr. Manning wish to add anything?
Dr. Pat Manning
No.
Will Dr. Manning or Dr. Holohan outline the global initiative on asthma, GINA in more detail?
Dr. Pat Manning
The global initiative on asthma is a programme supported by the WHO designed to look at the current state of knowledge on asthma. During the past ten years it has developed evidence based asthma guidelines, using up-to-date information. The information is updated every six months and the guidelines on a yearly basis. The asthma management guidelines for general practitioners and nurse practitioners are regularly updated in order that they can be assured that the data are up-to-date.
I sit on the international committee of the GINA group and we meet twice a year, either in Europe or North America, to look at all the updates. We receive substantial updates every five or six years. The guidelines are updated in respect of the adolescent to adult population. At the end of this year the guidelines relating to children from zero to five years will be updated.
What is required from the international perspective is that the members of the GINA group return to their own countries and look at implementing the guidelines. It is one thing to have very nice guidelines but if they sit on a shelf, they mean nothing. I am very pleased to say the Asthma Society of Ireland, in conjunction with the Irish College of General Practitioners, has taken on the role of looking at the guidelines which will be implemented as the guidelines for Ireland in the next few weeks.
I welcome the delegation from the Asthma Society of Ireland and thank it for its comprehensive presentation. It is very clear that this almost a budget neutral initiative which is a wonder in modern day Ireland, particularly in health care.
I accept the finding of the report that patients are availing of acute rather than preventive treatment. There is only one aspect on which I take issue with the delegation, the 11% of the asthma population who require emergency use of nebulisers. Has the delegation considered the reported use of nebulisers in general practice and taken account of the fact that one patient might be nebulised several times; in other words, has the delegation checked the use of neubilisers against names on the register?
The rest of the report refers to value for money, the saving of lives, the cost to the taxpayer and improved quality of life for asthma suffers. Clearly, the thrust of the presentation is that this is a major public health issue, one which has not received the air time — pardon the pun — it deserves and which needs to be addressed urgently. It is one of the major chronic illnesses for which we need a chronic illness management scheme in primary care which can be carried out more effectively and cheaply than having patients ending up in hospital.
I have no doubt that this issue will be raised during the discussions on primary care. How do we, the members of the joint committee, help the Asthma Society of Ireland to ensure the guidelines will be implemented by general practitioners and general practice nurses? That is the bottom line.
I thank the delegation for its very interesting and informative presentation. I concur with Deputy Reilly. What is the impact of hospitalisation on asthmatics? I know there is a much heftier cost for a three-day rather than a ten-day stay. What standard is used in measuring data? I was particularly struck by the figure of 40,000 working days lost every year. I know this has a huge impact on the economy.
I thank the representatives of the Asthma Society of Ireland for their presentation. Ms Edghill mentioned that without political acknowledgment asthma is a major public health problem and that we will never achieve the outcomes achieved in Finland. I recognise asthma as a major public health problem in Ireland. Chest disease in Ireland is a major problem and asthma is an important part of that. There is no lack of recognition of how major a problem it is. The figures outlined prove that.
The Finnish programme emphasises early diagnosis, patient education and good medical management. Treatment is, obviously, a matter of good medical management. The programme also stresses the reduction of exposure to tobacco and smoke. I suppose we can pat ourselves on the back in those regards. I have no doubt that politicians have a role in promoting guided self-management and patient education.
What does the society see as the priorities where political intervention would help? Much of what is required involves medical management and is outside the direct control of politicians.
I have held the view for many years, including my time as Minister for Health, that the research we carry out in Ireland should be focused on the illnesses that affect Irish people. We, unfortunately, do not have the resources enjoyed, for example, by American universities. We cannot do sophisticated research into dinucleic acid but we can do a great deal in the area of chest disease. It should be one of the focuses of research here. I know the Asthma Society of Ireland collaborates with other organisations in Europe. Does the society hold meetings with the Medical Research Council? What further research could be developed in Ireland into chest disease?
I too welcome the representatives of the Asthma Society of Ireland. I was surprised to learn of the high percentage of people who use rescue medication every day. As Ms Edghill has said, knowledge is power. It is important that people take ownership of their illness and, in that respect, engage in guided self-management. Patient education enables one to deal with a condition on a day to day basis.
Ms Edghill spoke about admissions to hospital. We are currently concerned with inappropriate admissions to hospitals. Senator Prendergast asked about the effect of hospitalisation on people with asthma. To my untrained eye, hospital is not the most appropriate place to treat people with asthma. We need to look at better ways of managing the disease to ensure better patient outcomes. There is a dreadful fear of change in anything connected with health. Sudden talk about taking people out of the hospital setting and treating them in a different way, gives rise to fear of the unknown. Change is not always a bad thing but closing wards and hospitals is never welcomed.
The provision of medical care must always be about what is best for the patient. The hospital is, for want of a better phrase, a comfort zone for patients. If they have an asthmatic attack or a chest infection, they go in for treatment. It may not, however, be the most appropriate place for them because they risk catching something else in hospital. It is a major issue that needs to be examined. The Asthma Society of Ireland might be able to help us in communicating that message to patients.
Deputy O'Hanlon mentioned that we could give ourselves a pat on the back in regard to the reduction in smoking. There has certainly been a change in smoking habits. Unfortunately, however, there are still homes where people with chest diseases and asthma are exposed to smoking. I have had the experience of people coming to my home and taking out a cigarette and lighting up without asking if it was okay to smoke. That is something on which we need to work constantly to ensure people are not exposed to passive smoking.
From working in schools over a long period, I am aware of an increasing number of young people using inhalers who are unable to engage in sports activities because of their asthma. Are there data that show there is an increase in the incidence of childhood asthma? Are there any such statistics?
I welcome the delegation. While I am a non-medical person, I have been around for a while and never seen more people suffering from asthma, particularly in the past five or six years. Perhaps I am not meeting the right people, but there has been a huge increase in the number suffering from asthma. Why is it that so many people who have never had asthma suddenly have a chronic bout in their fifties? At the other end of the scale, recently a mother told me that her child of three months had asthma. It used to be said people who lived in badly insulated houses had colds but never asthma. Houses are trebly insulated now and I wonder whether this has had an effect on the incidence of asthma.
I imagine that implementing the Finnish model which seems extremely sensible would involve a large investment at the beginning and the pay-off would come later. Does the Asthma Society of Ireland have any figures? If the committee is to convince the Department of Health and Children and the HSE, which we will do our best to do, we need to be well armed with the figures and what it would take to kick-start this initiative. I would be grateful to have these figures. We will hang on every word said and do the best we can.
I welcome the delegation. On the points made by Deputy Connaughton, I agree that the statistics are staggering. They indicate that one in eight of the population has asthma and that 40,000 work days are lost each year.
It seems the Finnish asthma programme is highly successful and very much based on outcomes, patient self-management and education. Before attending this meeting I met representatives from the Nutrition and Health Foundation who also talked about the experience of Finland in turning around the statistics for obesity. I would be interested to hear more about the Finnish experience and whether the Finns are more focused on outcomes rather than the way we set rigid health budgets, with not a great amount targeted at public health and health education measures. The Joint Committee on Health and Children has an important role to play in this regard. I wonder whether we should be trying to change spending to focus on holistic outcomes
Dr. Holohan referred to a lack of information. I note that point ten of the ten point plan of action under the Brussels Declaration is that national policies should set targets for health care providers to keep registers and so on. Will Dr. Holohan indicate if there are serious problems with a lack of information to make the case to spend the money in the appropriate areas?
I too join in welcoming the delegation and thank it for its comprehensive submission. Has the Asthma Society of Ireland engaged with the Department of Health and Children and the HSE on the content of this submission? If so, what was their response?
I have heard theories that childhood asthma can clear up around the age of seven years. What are the chances of it recurring in later years? I have an idea that such persons have a higher chance of suffering from asthma in later life.
I join in welcoming Dr. Holohan, Dr. Manning and Ms Edghill.
I want to comment on Finnish health care costs and the comparisons made between the figures in 1993 and 2003. When I look at actual costs in Finland in 2003, I see a marked decrease in the number of hospital bed days and disability payments but a significant increase in the number of visits to the doctor and the use of medication. The position in Ireland is that asthma is not a recognised long-term illness to qualify for the long-term illness card. The two critical elements of the long-term illness card are access to doctor visits and medication, the primary means of avoiding the need for hospitalisation and disability. Without question, the statistics alone add further weight to the long argued case for the extension of entitlement to the medical card or long-term illness card for people with asthma, at least when the condition is judged to be chronic. When the Irish and Finnish figures are compared, it demonstrates the reluctance of Irish people to present immediately to their general practitioner and seek medication. If this is the way to reduce the number of hospital bed days and disability payments, we must recognise that we must give people the wherewithal; all will not exercise the choice, perhaps because they cannot afford to go to their general practitioner. That is the reality in these ever-straitened times. Can the witnesses from the Asthma Society of Ireland comment on that observation?
I do not know the answer as to arguing the case with the HSE and bringing it forward. On the second page of the submission, I read that disability payments in Finland fell by 76%. That is inaccurate and I point this out as a friend who does not want anyone to pick holes in the document. The correct figure is approximately 42%. Holding to the comparison between the actual and ignoring the predicted, one will find the figure of 54% for reduction of hospital beds is correct. The disability payments fell by 42%. Nevertheless, the case stands up and my correction does not dilute the message offered by these figures from the Finnish experience.
In responding to the questions, Dr. Manning, could you say a little about the causes of this disease and the reasons for the rapid increase in the incidence of it?
Dr. Pat Manning
In 1994, I returned to Ireland from Canada, where I worked with Dr. Paul O'Byrne. There was very little information available on the size of the problem in Ireland. We were able to take part in a study called the International Study on Asthma and Allergy in Children, which reported in 1997. We were concerned because the level of asthma was 15% in young children. Between 1984 and 1994 we saw a huge rise in asthma from 4% to 15%. What had happened in that ten year period? Those who have a genetic predisposition to asthma have a tendency to develop the condition. Its primary cause is atopy and the development of twitchy airways, or what we call hyper responsiveness. That is the genetic predisposition to the development of asthma. However, genes do not change that quickly so some problems must have been occurring in that period. The International Study on Asthma and Allergy in Children tried to address those issues. The study was done in approximately 50 countries worldwide, including many countries in Europe. Ireland and the United Kingdom stood out as being in the top four for asthma, worldwide. The changes identified were lifestyle changes. We were becoming an indoor rather than an outdoor people. The development of atopy, the exposure to allergens in the household, was a major component. If one develops an allergy and asthma on top of that, one has the condition for life. We must try to prevent the development of asthma if we can.
Other issues identified were dietary changes such as reduced breast feeding, lower anti-oxidant intake and an increase of salt in the diet. These dietary changes are also associated with other conditions such as diabetes and heart disease. Research is being done at present into the effect of the decline in exposure to childhood illnesses. Vaccination per se does not cause the development of asthma. When our immune response is turned towards fighting infections it turns away from allergies. It can only do one thing at a time. When we remove infections, the body has an opportunity, when exposed to the appropriate allergen, to develop an allergy which we believe develops into asthma. In communities such as the Traveller community there is a lower incidence of asthma. That says a lot about the development of asthma.
I will address the point Deputy Ó Caoláin raised in relation to the figure of 76%, lest I discredit the entire presentation. I should have commented that that figure had recently been given to us by the Finnish asthma group. The published data the committee saw were from 1993 to 2003. The data were recently reviewed up to 2006. That 76% reduction in disability was the reduction between 1993 and 2006. The Deputy is correct in stating the initial reduction and what I have shown in the graphs is lower than it. They are the most recent data which were published only about one month ago.
I will go through the questions individually. Deputy Reilly raised the question of nebuliser treatment. He is right that these are not per individual patient. It is very interesting because nebulisation costs are the only individual costs that we can accurately identify in GMS costings specifically identified by respiratory disease.
The next question was raised by a number of members who referred to what we could do about implementation. The advice from our Finnish colleagues is that while we can do a lot on the ground to improve the quality of asthma care, particularly at primary care level, through initiating a wide variety of education programmes, we will never see significant improvements, unless there is the political will. The key to success in Finland was that from the outset of the programme there was a political drive to say asthma was a significant problem, that it was an enormous burden for patients, that it cost lot of money to manage badly but a lot less to manage well. The added benefit is well patients who are not in hospital, not accessing emergency services and not losing days at work. The importance of a political commitment is pivotal.
Ms Angela Edghill
Deputy O'Hanlon said that as a clinician he would recognise the enormous public health problem that asthma was, but as an asthma patient, as a person with asthma, I do not consider it is recognised as a condition. If one looks at any of the recent policy documents from the Department of Health and Children or the HSE, they mention asthma peripherally, as if it does not matter. They mention adult asthma and COPD or respiratory diseases. Asthma as a condition has a significant and severe impact on individuals and the health system and I do not see that we recognise this. We have strategies for all sorts of things, including diabetes. I am not in any way denigrating any of these other conditions; I am just using them as a comparison. We also have a cardiovascular strategy, as well as a respiratory strategy. I hate to be critical of clinicians but the Irish Thoracic Society launched a major report and never once mentioned asthma, the most prevalent respiratory condition in the country. That shocks me, perhaps because I am a bit of a megalomaniac about being an asthmatic. It is a significant public health problem but is not recognised as such.
Deputy Ó Caoláin raised an interesting point on medical cards and long-term illness schemes and so on. What patients want is to be well. They do not want the condition to affect their lives. That is my experience. They do not want to suffer death, particularly, disability or any disruption to their lives. Therefore, anything that patients can be given to help them would be welcome. We are prescribing lots of drugs but unfortunately people are often not using them well.
This is my plug for the Asthma Society of Ireland. In the audience is our asthma nurse specialist who spends days on helplines giving people information they are not able to obtain anywhere else. We will continue to do this because that is what the society is about. There must be national recognition of this significant health problem which, from the political perspective, is draining significant resources. People are ending up in hospital.
In response to Deputy Connaughton who asked if hospital was the most appropriate place, the answer is no. If one is admitted to hospital following an acute asthma attack, one realises just how serious the condition can be. Nobody wants this. I would do anything to stay out of hospital. People must be assured that they will have access to a comprehensive health service that will respond to their needs and equip them to deal with the condition. We are staggered by the number who have never had a self-management plan, or a written plan. We know that general practitioners are often run off their feet and do not have time to do this. We are asking, therefore, that the treatment of asthma be given political priority and looked at as a significant public health problem. Matters will begin to change because the focus will then begin to shift.
I will ask my colleague to address the question of childhood asthma and whether one is likely to contract it in later life.
Dr. Pat Manning
We were very fortunate to be able to link with the international study of asthma and allergy in children, a study conducted on a worldwide basis in many countries. In order to be involved in that epidemiological study, one had to have a 90% response rate to ensure the results were proper. We were able to do this. We did it in 1994 and repeated it in the late 1990s and again in 2003. More recently, with the support of the Asthma Society of Ireland and the tobacco research institute, we undertook a further study and once again have linked up with our colleagues on an international basis. It is very clear from the research that Ireland remains in the top four for asthma prevalence worldwide. In terms of research, the Asthma Society of Ireland has been investing in seeking that information. As a result, we are now able to appear before a parliamentary committee with our facts and figures. Prior to this, when we approached the Department of Health and Children, the only statistics available were from the United Kingdom. Now we have our own facts and figures.
According to the national quarterly health survey published last week, in 2003 the prevalence of asthma was in the region of 5% in young adults. It has now risen to 6%. In the 18 to 35 year age group it is 8%. It is the most common chronic disease people mention. If people have asthma going into the workplace — we saw the figures for the numbers of days lost from work — this condition leaves workers potentially exposed to chemicals that can actually make their condition worse. As Deputy O'Hanlon knows, asthma can develop in the workplace. Fortunately, however, this has been recognised and we try to prevent it.
Asthma is primarily a childhood illness. At that stage it is primarily a male condition and most of those who develop it develop it by the age of six years. As the young person enters his or her teenage years, their condition improves. However, in the female population it becomes more prevalent as one gets older.
The research shows very clearly that two thirds of asthmatics who have outgrown the disease will have a recurrence in their 30s and 40s. There is a continuum which can be mild, moderate or severe. People with severe asthma present in their general practitioner's clinic or the hospital. They comprise 10% of the asthma population but probably account for 80% of the associated costs as a consequence of hospitalisation. What often happens is that those with asthma that clears up will often develop it as they older when it can become a major issue. They can often have problems associated with asthma in the workplace.
A person who develops asthma in childhood will have the condition for life. We need to focus on ways to prevent it. That is the object of the ongoing research, to try to identify a mechanism to prevent asthma developing. We have looked at lifestyles, for example, the lifestyle of Travellers to see if there are particles in the dust and dirt that could be used in vaccination to try to prevent potential asthmatics developing asthma. Some 470,000 people in Ireland have asthma and the number is rising. We need to look at ways to help them. Deputy O'Hanlon referred to drug management. We have very good guidelines and know how to manage asthma very well. General practitioners see 100% of patients. This is where asthma must and will be managed properly. That will lead to better care for patients and keep them out of hospital, where the cost is enormous.
Dr. Jean Holohan
I will address an issue raised by Senator Prendergast and Deputy O'Sullivan on the quality of data, the standard method for evaluating health care data and costs and how we evaluate the effectiveness of a programme. Dr. Manning referred to this point.
One of the greatest difficulties we have is that the data I have presented are gathered from a multiplicity of sources. It is virtually impossible to collate data from a single unified source. It is a common problem in disease management and the evaluation of disease management programmes in Ireland because Irish health care data are not OECD compliant and in most cases the data we have are not easily or readily comparable with EU data. In the vast majority of cases they do not meet the minimum data set requirements defined by the WHO. This is a particular difficulty for us in trying to evaluate the size of the problem and how one might plan to effect change. If one were to embark on a disease modification or disease management programme similar to the Finnish strategy, how could one evaluate the outcomes in a meaningful way?
It brings me back to the point raised by Deputy O'Hanlon as to whether we had engaged with the Medical Research Council on research projects. One of the areas in which we would like to see investment in research is bringing data collection and evaluation programmes up to date. We have engaged with the Health Research Board and the Health Information and Quality Authority on how best to move forward in investing in research capacity in data gathering and evaluation of programmes. That is an extremely important point.
Deputy Connaughton referred to the Finnish model. The Finns are an extremely practical people. They are very pragmatic and have exact costs for their asthma programme. I can give the joint committee the figure that the Finns invested in the first year of the programme. It cost €125,000 to set up a small office that would begin to produce the educational material for the roll-out programmes through the primary health care system.
It is important to note that in the Finnish programme, 80% of the patient contact with the primary care unit was not with the GP but with the practice nurse. The role of the practice nurse in the success of this programme is absolutely vital as 80% of patient contact for either patient education or first point of contact for a clinical reason was through the practice nurse. Then the patient was referred appropriately to the primary care physician for intervention or evaluation, or he or she stayed with the practice nurse for continuing education. In fact, the investment in education, once the programme was up and running required about 2.3 visits over the initial two-year period.
It is important to remember also that community pharmacists were extremely involved in the programme and were considered very effective. This is a health care resource that is often ignored in Ireland and it is also part of the negotiation for the community pharmacy contract that the pharmacist has greater involvement in patient care. This is a very simple and very cost-effective intervention. The Finnish model is very simple. When a patient picked up his or her prescription for a reliever or preventer medication, he or she was shown the medication and was told that the reliever medication was used only twice a week and if one used it more than that, one called the doctor or practice nurse. In the same way they were shown the preventive medication, which is used every day.
The second element of the programme was keeping an audit on patients' use of rescue medication and any more than one prescription of a rescue inhaler per month would flag a degree of concern in the pharmacy and the patient would be probed about control.
The third element of the Finnish programme, which we have already engaged with the community pharmacy in Ireland, is teaching patients how to use their inhaler. Inhalers look very simple to use and from a patient perspective getting it right is really important. However, 50% of people do not use their inhaler appropriately.
As part of the Finnish programme, on the first dispensing of a prescription for an inhaler, 70% of patients were shown how to use it, not just by the practice nurse, but also by the pharmacist. After that 30% of patient were shown inhaler technique by the pharmacist at repeated visits. The programme is not about new consultants or more hospital beds or additional resources, it is about empowering patients to manage their disease in partnership with the primary care team so that a person knows who to contact in the team when he or she needs help and that the educational process is ongoing.
Asthma is reversible airways obstruction, and being reversible, nobody should die, but people are dying. I am glad Dr. Holohan touched on the considerable percentage of people not using inhalers properly. I did a thesis on asthma years ago as part of my masters degree. I found that 50% of people and 20% of professionals did not know how to use the inhalers. If the professional teaching the patient does not know how to use the inhaler, what hope has the patient? Obviously prevention is better than cure and that is a no-brainer.
Does the Asthma Society of Ireland envisage a model similar to the heart watch programme with the self-help and self-management programme and that people would have a couple of visits a year and thereafter as needed?
Ms Angela Edghill
I thank the Chairman for the opportunity to make a presentation to the joint committee. My professional colleagues are more than confident. The members of the Asthma Society of Ireland are very committed to seeing treatment and care improve for people with asthma. We will be playing our part with all the agencies mentioned by Dr. Holohan. We would like the committee to invite us back on World Asthma Day, usually at the beginning of May, to update it on developments. Otherwise, we would like the opportunity next year to present again to it and give better data on progress. The society will be sending people to Finland to train under its programme. We need this to be a national programme and would be very grateful to have the opportunity to present to committee again next year.
On behalf of the joint committee, I congratulate the Asthma Society of Ireland. Its case is very compelling. The challenge for the committee is to consider what it can do to advance the case so convincingly made by the society. The committee will have an opportunity to engage with the Minister for Health and Children and the chief executive officer of the Health Service Executive at the end of the month. Members can consider among themselves what else can be done to advance the case made. I am sure the committee will be happy to meet the society again next year.
Ms Angela Edghill
Both the Department of Health and Children and the Health Service Executive have been positive in their dealings with us.
Dr. Jean Holohan
In the past six months I have met the primary, continuing and community care, population health and health intelligence sections from the National Hospitals Office. The overwhelming impression is that the Finnish programme is a model to which we should aspire. It has potentially significant benefits to offer patients with asthma in the health care system. However, several issues need to be resolved before the Health Service Executive is in a position to implement the Finnish programme. The programme will not just involve primary care but also accident and emergency care and the National Hospitals Office. The response so far has been very positive. We will meet the Minister for Health and Children in two weeks time. We hope her response will be as positive as the committee's.
I again thank Dr. Manning, Dr. Holohan and Ms Edghill for attending and look forward to meeting them again next year.