Management of Asthma in Primary Care: Discussion.

I welcome Dr. Jean Holohan, chief executive officer, and Ms Angela Edghill, chairman, of the Asthma Society of Ireland, and Dr. Pat Manning, chairman of the Medical Advisory Council. I draw their attention to the fact that while members of the committee have absolute privilege, the same privilege does not apply to witnesses appearing before the committee. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable.

Ms Angela Edghill

I thank the Chairman for giving us the opportunity to address the committee and update it on progress which Dr. Holohan will do on our behalf.

Dr. Jean Holohan

On 4 November 2008 the Asthma Society of Ireland made a presentation to the joint committee that highlighted the burden of asthma in Ireland, as outlined in our proposal for the introduction of an asthma management plan based on the Finnish model which had resulted in a significant reduction in the number of hospital bed days, emergency visits, health care costs and, most importantly, deaths from asthma. Our delegation was encouraged and motivated by the enthusiastic and positive support we received from members of the committee. Our presentation today is a log of events following that presentation.

On 18 November we met the Minister for Health and Children and presented her with our proposal to develop a national asthma management programme appropriate to the Irish health service. The Minister recognised the merits of the proposal to target the most common chronic disease in Ireland. At that meeting she appointed Dr. John Devlin, deputy chief medical officer, to take responsibility for facilitating meetings between the Asthma Society of Ireland, the Department of Health and Children and the HSE to progress this proposal quickly. She also indicated that she had a visit to Finland scheduled in January 2009 and that, as a result of the society's presentation to her, she would endeavour to meet Professor Tari Haahtela, director of the Finnish national asthma programme.

On 4 December Dr. Devlin chaired the first meeting of the Department of Health and Children, the HSE and the Asthma Society of Ireland. The attendees at the meeting subsequently became the steering committee for the project. The purpose of the steering committee is to recommend to the Minister and the Department a national asthma programme based on international best practice and supported by a strong evidence base to deliver high quality patient care in the primary care setting to the majority of patients with asthma.

As a first step, the steering committee agreed to develop a demonstration project in a limited number of primary care practices. The aim of the project is not to show clinical outcomes but to test the capacity of the processes and systems in the health care system to deliver a co-ordinated chronic disease management programme. The identification of barriers to implementation and the development of solutions will be one of the critical outcomes prior to national roll-out of the programme. The project will recruit 25 general practitioners in primary care teams around the country and we hope it will reach about 5,000 asthma patients. The funding for the project is provided by a research grant from the Asthma Society of Ireland. A draft strategy document was developed by the society and submitted to the steering committee on 16 December, a copy of which has been supplied to the committee as background material.

The Minister and a delegation, including the Secretary General of the Department of Health and Children, travelled to Finland in January. On 16 January they met Professor Haahtela to discuss the Finnish asthma programme and explore how this might be replicated in Ireland. We are extremely grateful to the Minister and her team for the preparations for and engagement in this meeting and for her proactive support for our work. A strong message from Professor Haahtela concerned the importance of integrated health care policy adopted at the highest level in achieving true implementation of evidence-based care programmes.

Shortly after this meeting the Asthma Society of Ireland was invited to speak at a meeting in the European Parliament in Brussels on 28 January. The purpose of the meeting was to discuss the Helping Asthma in Real Patients, HARP, project and Ireland was chosen to host the pilot project for the study to evaluate asthma control measures from a patient's perspective. The meeting was entitled The Irish HARP Project: A Model for Europe. This recognised our contribution to the study but it also recognised the extraordinary momentum generated in Ireland in the last few months since our initial presentation to the committee. The meeting gave us the opportunity to brief MEPs and European opinion leaders in asthma care on the progress we had made in positioning Ireland in the leading role in Europe in developing a co-ordinated approach to asthma management.

The steering committee meets formally on a monthly basis. The partnership between the Asthma Society of Ireland, the Department of Health and Children and the Health Service Executive will have the capacity to develop and deliver a strategic approach to the management of asthma. The programme will be developed in line with the Department of Health and Children policy framework for the management of chronic disease and will be delivered through primary care in line with the objectives of the HSE transformation programme.

To support the development of the core components of the demonstration project, a clinical governance group has also been established. This group is composed of representatives from primary care, practice nurses, community pharmacy and adult and paediatric respiratory physicians. The objectives of this group are: to develop a core asthma education programme for all health care professionals — this will have appropriate accreditation from the ICGP, An Bord Altranais and the Irish Pharmaceutical Society, among others; to develop a "toolkit" for primary care to facilitate the delivery of best practice; to develop a paper and electronic patient record that would serve both as a clinical management tool and for audit and evaluation of the programme. It is our aim that the group will also publish research outcomes where appropriate and that it will have the capacity to influence curricula at undergraduate as well as postgraduate level in the future.

The next steps in the programme will be to recruit the participating primary care teams and the community pharmacies; to develop integrated pathways of care between participating primary and secondary care; to deliver the educational programme to health care professionals; to deliver an IT clinical management programme and, finally, the enrolment of patients and patient education. In summary, in the six months since our first presentation to the committee there has been some extraordinary progress towards delivering a co-ordinated national chronic disease management programme for asthma in Ireland. We believe the unique partnership of all stakeholders in asthma — the patient organisation, the Department of Health and Children, the Health Service Executive and health care professionals at all levels — which has been formed has the capacity to improve health outcomes for patients and, ultimately, to reduce health care costs associated with asthma.

We are aware, however, that the demonstration project is really just a first milestone on this journey. The next steps lie outside the control of the Asthma Society of Ireland. The lessons learned from the demonstration project must be implemented nationally and this will require the continued focus of both the Department and the HSE to ensure that primary care is adequately resourced and supported to manage asthma and other chronic diseases in the community. The ongoing support of the joint committee will be crucial to achieving these aims. The Asthma Society of Ireland is very grateful to the Minister for Health and Children and to the Chairman and members of the Oireachtas Joint Committee on Health and Children for their assistance and encouragement with this project. Without that help and support we would not have advanced to this stage so rapidly.

This is really an update.

Dr. Jean Holohan

That is right.

Dr. Holohan appears to be happy with the progress. Does she have an idea of the cost of rolling this out across the country so people can avail of it nationally? How long will that take? In a chronic illness programme of this nature how many visits of a routine nature per annum does she envisage to monitor the patient's asthma in primary care? What would be a reasonable annual rate of visits, excluding visits caused by exacerbation of illness and so forth?

This was an informative and wide-ranging update. We wish all groups that come before the committee had everything laid out like this so we could read it beforehand and have it further expanded.

Clearly, there are two elements to this. On the one hand is the management of people who have the disease, ranging from mild to moderate to chronic, and on the other is the roll-out of education and information. When the roll-out occurs, is it hoped through education and advice to perhaps prevent people developing asthma? I ask this question because I recently encountered a young boy who did not have asthma for the first five years of his life but due to particular events has now developed either full blown asthma or an asthmatic condition. It is being treated in the same way as asthma is treated. Will that be part of the programme? It could be another area we had not previously considered. It would be very beneficial in the future.

I compliment the society on the work done to date. It is very encouraging. I have always been of the opinion that funding in Ireland that is targeted for research should be geared towards the illnesses that are common in Ireland. Chest disease and asthma contribute greatly to both morbidity and mortality so it is encouraging to see anything in the research area or anything that will help prevention or improve the quality of life for people who suffer from chest disease.

I have two questions. One relates to the stakeholders. It is encouraging to see the society, the Department of Health and Children and the HSE working together. Much good work is being done throughout the country on chest disease and research, for example, the new unit opened recently in Beaumont Hospital. Where do they fit into this or are they involved? Second, at a time of scarce resources, there are always competing priorities. Where does the society envisage the next moves forward taking place to ensure the project, which I support, is progressed?

I welcome the society's representatives and thank them for their detailed chronology of what has happened since their last appearance before the committee. If every group could secure such progress in a short space of time, they would be very happy.

Dr. Holohan spoke about the demonstration project and the next steps. Is there a timeframe for completion? How long does she envisage it taking? When the society's representatives last appeared before the committee, all members were struck by the seriousness of the condition that affects so many people. As Deputy O'Hanlon said, chest conditions are very common in Ireland. What can we do to support the society as it continues with the demonstration project and beyond that?

Does Ms Edghill wish to respond?

Ms Angela Edghill

I will defer to the experts involved in the project on the technical details. I thank the committee for the positive comments. We are delighted. I have been a member of the board of the Asthma Society of Ireland for a long time and this is the most progress we have seen on something that has the potential to be big nationally. However, I must say, as the patient with ever the bitter word, that what we are engaged in at present will have no clinical outcomes for patients. This is looking at the structures that might eventually deliver. My concern, on behalf of people like me with asthma, is that this is put in place as soon as possible.

As Deputy O'Hanlon said, a great deal is happening in the world of medicine. The Irish Thoracic Society fully supports and is involved in this project. However, at a time of scarce resources, there are huge competing priorities. The Asthma Society of Ireland is funding this project and the demonstration model from its own resources. It is a new type of social partnership, which is lovely. This is a real social partnership between patients and the State, Government and health care providers. It is wonderful and we are very pleased about it. From the patient's point of view, it will be a long time before we will be able to say the figures have reduced but we must start somewhere, and this is a big first step. We are delighted with that. I will hand over to my colleagues to deal with the difficult questions. Deputy Reilly asked about the number of visits and how we proposed to deal with them.

Dr. Jean Holohan

I will deal with the costings and the timeline. It took the Finnish programme approximately four years to get all the primary care physicians and community pharmacies involved. The total investment in the Finnish programme in the years 1994 to 2004 was approximately €650,000. This was totally negated by savings in the cost of hospitalisations and reductions in disability, morbidity and mortality costs. In the first year of the Finnish programme the investment was €120,000. Therefore, by inflating these figures to their equivalents for 2009, our contribution to the development of the demonstration project will be approximately €210,000. We will provide a patient information resource for all participants in the programme, every patient with a peak flow meter and all participating practices with barometry devices. The development budget also takes into account training for health care professionals and a nurse educator support role for all participating practices.

As Ms Edghill said, in the long term we do not see the demonstration project as a magic wand. It will not transform practice on a nationwide basis at the flick of a switch. As the transformation programme is rolled out and primary care is adequately resourced to manage all chronic disease we envisage the demonstration project guiding the implementation of an asthma management programme through the primary care strategy. We will learn lessons and gain firm ideas as to the barriers to implementation at the end of the demonstration project, on which we hope to report this time next year. The aim is to have the demonstration project up and running in the autumn. It will run for six months but, realistically, it will be between three and four years before an asthma management programme is rolled out through the primary care strategy.

Dr. Pat Manning

The programme is based on the Finnish project which identified education on best practice guidelines as the way forward. In Ireland, as in other countries, there are indicators that asthma is not well managed. These indicators include deaths from asthma and increased hospitalisations which involve a very high cost. A programme such as the demonstration project will help us to identify such factors. It will be carried out by five regional primary care teams and serve as a template for a national programme. Implementation of the GINA, evidence-based guidelines is a recipe for the proper management of asthma and based on education, not just for GPs but all the players involved in asthma care in the community such as nurses and pharmacists.

We also hope the programme will be a template for the treatment of other chronic diseases. We will provide significant resources to ensure that in time the project will iron out any difficulties in order that when it is operational on a national basis, its implementation will be seamless. By following the Finnish model we hope to reduce the number of deaths from asthma by 90% within a very short time. We will substantially reduce hospital admissions, from which the savings will go towards the programme. It is a win-win.

A question was asked about prevention. There is a great deal of research into asthma and we know that most of those who develop it do so by the age of six years. We tend not to diagnose asthma before that age because many conditions such as wheezing or bronchitis can present and be treated like it. Finnish and other European groups are trying to develop prevention strategies such as having a vaccine for families who are potentially at risk in order that they can avoid developing an allergic response and actual asthma symptoms. We are a long way from developing such a vaccine but that is the intention.

Dr. Holohan has said €650,000 was spent over a total of ten years in Finland. She expects €250,000 to be the budget in this country.

Dr. Jean Holohan

In the first year of the Finnish programme €120,000 of the money was front-loaded. We have replicated this by providindg €210,000 in year one in Ireland.

This relates primarily to educating professionals in best practice such that there will be an impact on patients. I am not sure if there is free primary care in Finland. How do people access a doctor in Finland?

Dr. Jean Holohan

It is a mixed system, 80% funded by the State and 20% privately. There is a different philosophical approach to managing chronic diseases. They have tackled cardiovascular disease and diabetes through this all-embracing format.

I thank Dr. Holohan and commend her on her work.

Are there any further questions or comments?

Ms Angela Edghill

Deputy Conlon asked what the committee could do to assist. It can look for regular updates from the Department of Health and Children, the HSE and us on monitoring and progress. Deputy Kathleen Lynch stressed the importance of education and information. The Asthma Society of Ireland fulfils an important education and information role for patients and health care professionals. We have a continuing partnership with the ICGP and specialist respiratory groups. We also have a good website. It is important that members of the joint committee advise their constituents that we exist. Our asthma specialist, who is in the Visitors' Gallery, operates a live helpline to assist people.

I thank the Chairman for inviting us to attend for a second time. I hope that, as and when there is more progress to report, we will come before the committee for a third and fourth time.

The Senators were not present for part of the meeting because there was a vote in the Seanad. I offer our apologies and hope our guests do not think we were rude for not being here.

I thank the members of the delegation. Their comments were extremely positive. They are off to a flying start and, as we say as Gaeilge, tosach maith leath na hoibre. I hope the committee can remain in ongoing contact with them and that they can be used as a source of ongoing support. We will continue to engage with the HSE and the Department of Health and Children on their behalf.

Ms Angela Edghill

I thank the Chairman.

Sitting suspended at 3.50 p.m. and resumed at 4.05 p.m.