Léim ar aghaidh chuig an bpríomhábhar

Tuesday, 9 Mar 2010

The Hospital Group.

I welcome Ms Aisling Holly and Ms Breege Doolan from The Hospital Group. I draw the delegates' attention to the fact that while members of the committee have absolute privilege, this does not extend 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 House or an official by name or in such a way as to make him or her identifiable. We have received the delegates' paper and I now invite Ms Holly to deliver a brief synopsis after which we will have a question and answer session.

Ms Aisling Holly

I thank the Chairman and members for giving us the opportunity to voice our concerns regarding the increasing numbers of obesity patients presenting to us on a day-to-day basis. I am accompanied today by our very first morbidly obese patient, Ms Breege Doolan, who will speak briefly about her experience. I offer apologies on behalf of Professor McMahon, our specialist bariatric surgeon, who is operating today on a very high-dependency patient in Leeds Hospital who has a body mass index, BMI, of 56.

Obesity is a medical term used to define when a person is overweight to the extent of it being harmful to his or her health. While a number of factors are taken into account, obesity is usually measured by calculating the BMI using a formula of weight in kilograms divided by height in metres squared. In general terms, a BMI of 25 to 30 is classified as overweight, 30 to 35 is class one obesity or simply "obese", 35 to 40 is class two obesity or "severely obese", and a BMI of 40 to 45 is class three obesity or "morbidly obese".

As of 2005, the World Health Organization indicated that globally, approximately 1.6 billion adults aged 15 and over were overweight and that at least 400 million adults were obese. The WHO further projects that by 2015, approximately 2.3 billion adults will be overweight and more than 700 million will be obese. Once considered a problem that only existed in high-income countries, overweight and obesity now are dramatically on the rise in low and middle-income countries, particularly in urban areas. To an increasing extent, the Hospital Group is being approached on a day-to-day basis by patients with a body mass index, BMI, of 50 and over, which is categorised as being super obese and morbidly obese.

As for the incidence of obesity in Ireland, there is no question but that obesity in Ireland is on the rise in line with global trends. Research conducted by the Hospital Group and feedback from patients and our senior consultants certainly suggest that 25% of the population of Ireland could be considered to be obese at present. Moreover, this number is growing by at least 1% per year, which essentially means that up to 60,000 Irish people could now be suitable for obesity surgery. Worryingly, we regularly hear from parents of severely and morbidly obese children. Unfortunately, the Hospital Group's guidelines preclude us from performing surgery on or providing advice to such children. At present, the only alternative we have is to refer them back to their GPs. It is almost like a vicious circle.

In respect of the financial and social cost of obesity in Ireland, figures from 2003 suggest that even then, approximately €30 million was being spent on inpatient costs related to obesity. In addition, with at least 2,000 premature deaths per year being attributed to obesity, we believe the cost to the State of obesity and its associated health issues could be as much as €4 billion per year. As well as the direct costs of treating obesity, associated indirect costs also arise, such as loss of productivity in respect of workplace days lost due to illness and a lower level of earnings capacity due to discrimination and so on. There also is a social impact arising from obesity. The general perception is that being obese is indicative of a loss of self-control or of putting oneself at risk of ill-health. Obesity often increases social stigma and contributes to low self-esteem, isolation and humiliation. This can even lead to overweight people being terrified or reluctant to approach medical organisations for help. Sometimes, they have a perception that they would be criticised or humiliated. There also is a lack of general knowledge on the part of GPs who essentially believe the only alternative to obesity is the promotion of health, exercise and dieting. However, we certainly have realised, given the 400 patients on whom we have operated in almost two years of business, that diet and exercise are not always options for every patient.

I will turn to how the obesity crisis is being dealt with in other countries. Obesity is a leading preventable cause of death worldwide, with increasing prevalence in adults and children. Authorities globally view it as one of the most serious public health problems of the 21st century. The obesity policy action, OPA, framework developed by the World Health Organization divides measures into upstream, midstream and downstream policies. Upstream policies look at changing society, midstream policies try to alter individuals' behaviour to prevent obesity and downstream policies try to treat currently afflicted people. While each country is tackling obesity in its own way and at its own pace, increasingly it is being realised that preventative and educational measures are not sufficient in isolation and the needs of the currently obese must be addressed.

As for how the obesity crisis is being dealt with in Ireland, obesity here is being tackled on many levels with the main focus being on prevention. However there always will be a proportion of people for whom diet and exercise no longer is an effective option. For the purpose of this presentation, we are focusing on our specialty, that is, weight loss surgery. The latest figures we could access were for 2005, which suggest that 12 people have died in the past three years while waiting to be seen at the country's only dedicated obesity treatment clinic, St. Columcille's Hospital, Loughlinstown, County Dublin.

The Hospital Group was established in 1992. It is a specialised company that deals with cosmetic surgery and non-surgical treatment. However, it has become the United Kingdom's leading provider of bariatric surgery. It has a team of 12 specialised surgeons who dominate Europe in respect of bringing obesity research to the next level. The group has four clinics nationwide located in Dublin, Cork, Galway and Belfast. Moreover, many of its staff have had obesity procedures. I refer to how The Hospital Group can assist in alleviating the existing backlogs. The Hospital Group is the United Kingdom's leading private provider of weight loss surgery and over the past seven years, it has helped thousands of patients to lose literally tonnes of weight. The Hospital Group Ireland, which at present elects to send all its patients to the United Kingdom for obesity surgery, has treated nearly 400 patients since May 2008 and offers comprehensive after-care packages. We have in place a multidisciplinary team that looks after the patient for two years. It has in place dedicated dieticians, psychologists and bariatric nurses in all its outlets to be able to give patients the support and encouragement they need throughout the process to achieve their weight loss.

The Hospital Group has an excellent expert bariatric surgical team, state-of-the-art facilities in the United Kingdom, unrivalled experience in the field of weight loss surgery and, in Ireland, a full multidisciplinary team and two resident surgeons offering a two-year pre-surgery and post-surgery care programme. Were The Hospital Group allowed access to or assistance to create a suitable surgical facility in Ireland, we could dramatically reduce patient waiting time. I will outline the options we would like to put to the committee. We would like Government assistance to create Ireland's first purpose-built bariatric centre for the treatment of obese patients. This would dramatically reduce patient waiting time, improve the level of care and have a positive impact on patient survival rates. By working with an expert private company such as The Hospital Group and taking into account the savings to the Exchequer arising from the reduction of obesity-related illnesses, such a centre would be a hugely cost-effective solution for the Government and the HSE. With regard to access to suitable theatre space in Ireland, at present the Hospital Group elects to send all its patients to the United Kingdom as private facilities in Ireland are under-equipped for high-dependency patients. While we have been offered private facilities in which to operate, as an organisation we have decided that we do not consider them to be properly facilitated to deal with high-dependency patients. We have a dedicated private facility in the United Kingdom with 31 beds. However, we do not wish to continue to export the problem but seek to deal with it internally. Therefore, The Hospital Group is committed to working with all relevant parties to tackle the obesity crisis in Ireland. We want the joint committee to help us to help it.

Thank you for the presentation. Does Ms Doolan wish to comment at this point? Perhaps she will address some of the questions as they arise.

Ms Breege Doolan

I will address whatever questions members have to ask of me.

We will turn to members and I again stress the need for brevity, if possible.

Where is Dolan Park Hospital? I apologise if Ms Holly already has told members but when did the Hospital Group open in Ireland? What are the morbidity and mortality rates from surgery at its clinics? Are the surgeons who the group proposes will operate here insured to do so? Do they have tail-off cover? Were the Hospital Group to open a clinic in Ireland, it would have to agree to be subject to HIQA. I hope this would not be an issue.

I query Ms Holly's statement that no private facilities in Ireland are capable of maintaining high-dependency patients. I note that cardiac surgery is being performed at the Blackrock Clinic and I would be interested to get input from the private facilities in that regard.

I thank the Hospital Group for its presentation. Before surgery is considered as an option, for how long does The Hospital Group see a patient? What measures are tried before surgery becomes the decided procedure? What length of follow-up is involved subsequently? What is the cost of a procedure involving gastric band surgery? As some of Deputy Reilly's questions mirror my interest, I will conclude in the interests of brevity.

The procedure itself sounds very painful and I know of people from my county who have gone through it. My understanding is that the stomach is bypassed and a form of pouch is inserted. Does the stomach ever take over again or is the process for life? What are the after effects on one's health? Why is this procedure not available in Ireland? Why must one go to England to get it?

What level of research on private facilities led to Ms Holly's statement that there is nowhere suitable for high-dependency patients? Given the number of Irish people who have gone to the UK for this surgery, is a gastric bypass the most common solution for people with severe obesity problems and what other surgeries are possible? How did the Hospital Group arrive at this costing? Did I hear correctly that the cost of obesity per annum is €4 billion?

Ms Aisling Holly

The cost of obesity and associated health issues.

Perhaps there is none to hand, but could the committee be given a breakdown of the costs in terms of lost employment days, etc.? How is the hospital in Leeds funded? The delegation has asked us to assist it in developing a facility in Ireland, but for how long has the Hospital Group been in operation in the UK and how is the hospital in question funded? We need insight into the hospital's operation in another country before deciding what to do.

Before running for the vote, I wish to say "Well done" to Ms Doolan. It is great to see her looking so gorgeous, well and healthy. From what I read, the situation must have been a nightmare for her and her family.

Deputy Flynn has asked my question. Our guests are looking for a facility, which I take to mean that the HSE will provide it. Are other private clinics prepared to help?

I welcome Ms Doolan and Ms Holly. The former is a neighbour of mine in Roscommon, so I appreciate what she went through. I did not realise how ill she was because she was always lively, vibrant, involved in sports and so on. I congratulate her on her example and she has given great leadership.

I know of difficulties with gastric bands. In Italy, for example, one case involved bad consequences after the operation went horribly wrong. Ms Doolan's case involved a gastric bypass, which seems to be a better process. I am sorry that she needed to go to England to get it done. Surely our health service should be in a position to carry out that surgery. It is not rocket science. It is an important and risky surgery through which Ms Doolan needed to go because she had no choice and I am delighted she came out the other end of it well. I look forward to her continuing her active life in Dunamon.

Senators are excused because they must attend a vote in the Upper House. Perhaps Ms Holly and Ms Doolan could address some of the questions.

Ms Aisling Holly

I shall give background information to Deputy Reilly. The Hospital Group was set up in Ireland on 21 May 2008. We have operated on 400 patients to date with no mortalities. We have a stringent selection process in respect of every patient who presents to the Hospital Group. Even if he or she is suitable for obesity surgery according to his or her BMI, the patient must tick all of the boxes — selection criteria, consultation process and psychological assessment — before being deemed suitable for surgery.

Ms Breege Doolan

I can tell my story. I have been an asthmatic since I was a baby. As I grew older, I was on steroids. I gained weight as a result, which caused further problems. I was on 22 tablets per day. Due to the steroids, I had such severe osteoarthritis in my knees at the age of 36 years that my surgeon told me they were the knees of a 90 year old. I needed the steroids to keep my airways open, but it was a vicious circle.

My medication cost €450 per month and two injections per month cost a further €1,200. This is what I have been saving the HSE since my operation, but it did not offer to give me one penny. When I presented at every consultant in Dublin and elsewhere, I was told that I was too high a risk. My finger could not even be operated on because using an anaesthetic would have been too risky, so never mind a gastric band or gastric bypass. No one would look at me, nor would anyone advise me on where to go, including my general practitioner. I was given three months to live, so I had no choice. Only for Professor McMahon and the Hospital Group, I would not be sitting here today. I would be six feet under pushing up daisies.

It is a bad situation that, having worked hard for all of my life and after paying taxes and PRSI, I needed to go across the water to get this operation because I was too high a risk for Ireland's surgeons. Any surgery carries a high risk and I was a high-dependency case because of the asthma, but surely some surgeon should have taken the risk. I tried to attend Loughlinstown hospital, but it has a five-year waiting list. Where would I have been then? The hospital wanted me to sit around a table there and discuss weight problems for six weeks as if it was all down to my mind. There was nothing wrong with my mind, only my body. Where would I be now had I waited those five years to have my operation in Loughlinstown? I was given three months to live. It is not good enough that people pay their taxes and must then go to England. Private health insurers will not pay anything if one goes across the water. If Ireland had this hospital, our private health insurers would pay for the operation.

Did Ms Doolan cover the entire cost of the procedure?

Ms Breege Doolan


What costs were involved?

Ms Breege Doolan

My operation cost €13,000. My health insurer gave me €6,000, but I was the only person it paid. Since my operation, I have helped 22 people who are with a different insurance company. I was on the telephone every day of the week. I never put it down until I got that money from my insurer. It was willing to pay for a gastric band surgery in Ireland, but no surgeon was willing to carry it out because I was too high a risk. This is not good enough.

Have any such operations been carried out in Ireland? Perhaps Deputy Reilly might know.

Perhaps some of the other witnesses would be in a position to tell us.

I do not doubt that Professor Donal O'Shea, who will be joining us later, will tell us the exact figures. Some operations have been carried out by Mr. Justin Geoghegan at Loughlinstown, but the list is horrendously long.

Ms Aisling Holly

That is the problem.

The service is insufficient to meet people's needs. People should not get me wrong, as I understand the need for bariatric surgery in specific cases. For this reason, I was interested in the mortality and morbidity figures. Ms Holly stated there had been no mortalities, but she did not tell us the morbidity figures. Notwithstanding this, it is clear that people have a significant need. The surgery is cost effective for properly selected patients. I apologise, but perhaps Ms Holly did not realise she should have been writing the questions down. There are issues around insurance.

Ms Aisling Holly

I will address the reason we have been unable to find a private facility. We use two facilities in the UK. One is our purpose built facility in Dolan Park, which handles cases in which BMI figures are between 30 and 40. The cut-off point of 40 has to do with the backup we need to perform such procedures. We perform operations on higher end BMIs at Nuffield hospital in Leeds because an obesity patient with a high BMI has many associated comorbidities and would be a high-risk patient. Professor McMahon has a team of surgeons. As in Breege's case, he had a cardiologist, neurologist and renal surgeon on site in case of complications. Unfortunately, we have not found this type of backup in private facilities in Ireland.

Many private facilities do not have appropriate transfer arrangements with local general hospitals. As a private company, we charge €7,995 for these procedures. We do not want our patients to be the HSE's problem. Rather, we want to deal with complications and the patients ourselves.

Given that the Irish population is less than the population of some of the UK's cities, would our population sustain a unit with the type of multidisciplinary team mentioned by Ms Holly?

Ms Aisling Holly

Yes. Research shows that 25% of our population is obese and suitable for obesity surgery. This figure is growing by at least 1% per year. The World Health Organisation projects that, by 2015, more than 700 million adults will be obese. Currently, all we are dealing with are preventive measures. Sometimes education in isolation is not enough.

My question is for Ms Doolan. Is it correct that she was assessed in Ireland as being unsuitable for the operation?

Ms Breege Doolan

It was not for the gastric bypass but for a gastric band. They would not consider me for a gastric bypass.

Given that the assessment was in Ireland, even if we had a facility the operation would not be carried out because of the clinical assessment. What is so different between the assessment here and the assessment of The Hospital Group? Why was there a difference between different clinicians?

Ms Breege Doolan

Better surgeons who are willing to take a chance on me.

Ms Aisling Holly

It is that Professor McMahon has a specialised team around him. It was an anaesthetist problem for Breege. She had been to three different organisations——

Or was it more a question of insurance?

Ms Aisling Holly

No, it was that the anaesthetist was not happy enough to anaesthetise Breege.

Ms Breege Doolan

I will give an example. I do not know if members are familiar with carpal tunnel syndrome. This is a tingling sensation in the fingers as a result of a trapped nerve. Nine years ago I needed to get a procedure done in my left hand and they wanted to give me a general anaesthetic. I had two anaesthetists, one on my right saying I could not have an anaesthetic and the other on my left saying we should go ahead. At the end of the day it was left to me. What kind of facilities do we have in Ireland? I had the same procedure done on my hand a fortnight ago. I was given three months to live and this represented a life-saving operation. One cannot have an anaesthetist on either side, with one saying to have it and one saying not to. This was only the case of a trapped nerve, a procedure that takes ten minutes, whereas the other case was a life-saving operation.

Consultation fees cost me €300 per visit and I had three before I was told I was too great a risk. It costs £50 in England and is reimbursed after the operation. It is no wonder this country is the way it is.

I am very impressed with the presentation and I congratulate Ms Doolan on getting to this stage. It is very interesting.

Is Ms Holly satisfied she has covered all the ground?

Ms Aisling Holly

I reiterate that we are The Hospital Group Ireland and we do not want to continue to export our patients. If the Government can give us access to HSE theatre facilities we can help alleviate these waiting lists. That is what we must address. We have patients on five year waiting lists. People are dying on waiting lists and we must realise obesity is an epidemic and is now affecting young children. If we do not take action the problem will not go away but grow.

I thank Ms Holly and particularly Ms Doolan for coming along and giving us the benefit of her experience. We have learned a great deal from what she said. It is great to see her looking so well and long may she remain healthy and happy.

Sitting suspended at 4.03 p.m. and resumed at 4.05 p.m.