JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Tuesday, 9 Mar 2010

Health Service Executive.

Chairman

I welcome Professor Donal O'Shea, Ms Maria Lordan Dunphy, and Ms Louise McMahon from Loughlinstown hospital. 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 longstanding 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 received a submission and the delegation has had the benefit of listening to the previous contributors, who lent interest — to put it mildly — to the debate. Perhaps the HSE delegation can provide us with a synopsis of the presentation and we will take questions afterwards.

Professor Donal O’Shea

I thank the committee for the invitation to address it. I will return to some of the earlier comments. Deputy James Reilly and I were interested medics who set up the forerunner to the obesity task force. I have debated with Deputy Jan O'Sullivan on discrimination against people with obesity and I have had dealings with other members of the committee. This afternoon is about the treatment of morbid obesity but the totality of the HSE response and necessary prioritising and prevention as the future for dealing with obesity is paramount. In synopsising our submission I wish to highlight some of what is going on.

Some 25% of adults are obese and 25% of children are either overweight or obese. Following the task force in 2005, the HSE put together a working group to implement the health aspects of it. The five-year plan was set up to ensure we got proper figures on obesity, to ensure we set up a treatment arm for obesity, to prevent it and to get the message out there. The message is getting out more than ever in recent weeks, which is excellent. Crucially, we needed a cross-sectoral group and that group is now in place. It is working to implement the wider recommendations of the obesity task force.

Regarding the management of obesity and primary care, as the primary care teams get going local initiatives are working very well. However, many primary care teams are not in place.

St. Colmcille's Hospital in Loughlinstown is the only hospital providing a multidisciplinary approach to managing obesity, including surgical management. When the unit was established in 2005, the vision was that there should be four treatment units in each of the four HSE areas providing active management of obesity and complimenting work at primary care level. That St. Colmcille's Hospital remains the sole unit up and running means that we are way under capacity.

We have developed weight management treatment algorithms for overweight or obese children. The guidelines we are working on for adults emphasise the importance of people who are of normal weight or slightly overweight being aware of it and having a management plan for their weight. We are probably the first country to include normal weight people in the plan for managing weight. Lifelong weight awareness is needed. It should be developed from an early stage and reference was made to primary and secondary school. Education about obesity needs to begin in antenatal classes with parents-to-be. The message will be taken forward with more belief and passion than if the process starts later.

Other areas of activity include the national physical activity guidelines. These are well supported by literature and a GP exercise referral programme, which is being expanded. There is a great deal going on and prevention must be 80% of what we do now and for the future. Having a developed health care system without the capacity to treat obesity is not sustainable.

Deputy Jan O’Sullivan

I welcome the HSE and I will follow up on a question I asked the first group to come before us. I believe very strongly that the earlier the intervention the better and I was interested to hear that the place to start is ante-natal classes. If it is contained in ante-natal classes pregnant mothers can be given information on bringing up their children in a way that prevents them from becoming obese. Are there any other ideas on developing what happens in those very early stages? We now have one year free pre-school education for all children. Are there food, exercise and healthy living elements to this? I know there is no curriculum for it but will this area be included? This is the area I am most interested in because prevention is far more important than the services in place for when people have become obese. That might be hard on those who have become obese but for future generations we must focus on ensuring that we bring up healthy children. If one looks at photographs of school children from the 1940s and 1950s it is striking how thin they were compared to those in similar school photographs now.

Deputy Dan Neville

What is the HSE's view on the intervention proposed by the Hospital Group? We would like to see the views of the HSE on what was suggested, which the committee supported.

Deputy Bobby Aylward

I too would like to know the doctor's views on gastric bypass surgery and gastric bands. Why are gastric bands not available here? In the previous presentation we heard from a lady who had to go to England to get a gastric band. She stated that this was because anaesthetists will not take on the risk. Is it a problem of risk or insurance? I would like the HSE's views on why it is not available and whether it will become available.

Deputy James Reilly

I welcome the witnesses and thank them for coming. Loughlinstown is the only centre in the country that deals in a complete fashion with obesity and some of my questions will relate to that. Will Professor O'Shea say how many of the recommendations of the task force on obesity have been fully implemented, partially implemented and not implemented at all? At what body mass index figure would he consider surgery for patients? I was quite taken aback that somebody with a BMI of 35 or 33 would be considered for surgery; that would not happen in my practice unless there were extenuating circumstances. What capacity do we need for the surgeries required? Having only one surgeon and one location does not meet patients' needs. What capacity is required for the obesity specialist service that is provided? There is a massive waiting list for it. In an ideal world what would be the requirement and how would it be spread around the country? I apologise in advance if I am not present to hear the answer; I must do a radio interview.

Deputy Beverley Flynn

I welcome the group and what was stated about prevention being 80% of the solution, which is true. It will be done through primary care, which this group supports, and this is how health care will be delivered to the community in future. It is important that it will be part of that. With regard to the role of private groups, whether The Hospital Group or other groups, the point was made that capacity is required to be able to treat obesity. Prevention is being dealt with and that is fine but there is still a problem with those who are obese. What does the HSE see as the role of various private groups? Will they help what the HSE sees as a solution to the problem? I am concerned about clinical assessment and we can discuss the case of the woman who came before the committee. I would have thought that clinical assessment was something for a multidisciplinary team, if one were in place. I know doctors differ but will the witnesses speak about the suitability of patients for a particular type of surgery. Is it because in Ireland we do not have multidisciplinary teams available to perform the number of gastric bypass surgeries that the witnesses would like to see happen here? It is disturbing for people to hear about the case of a person who has only three months to live and the opportunity is not offered to that person when there is probably no alternative.

Senator Phil Prendergast

I would like to focus on what we consider to be normal. I worked as a midwife for many years and on many occasions I have spoken about the fact that breast-fed babies seem to be within the normal confines, plus or minus on the percentile chart, of what is an accepted measurement of what is normal. The idea of normal has gone beyond what normal is. As we know, a baby that is overfed or not monitored carefully leads to all types of complications with childhood illnesses, perhaps leading to childhood obesity and the social factors involved in that.

Taking out the health risks, which are undeniable, and considering the economic factors, breast feeding should be highly promoted in all hospitals and in every aspect of everyday life. During my training when I did parentcraft classes we received posters from Australia which were very comment-provoking. They showed breasts being used for their natural function. People had issues with it or they did not but at least it provoked conversations, particularly on radio talk programmes. It was an accepted norm.

I also discussed in the past the breast feeding rates in the country and the fact that we have a multicultural clientele. Women who are not indigenous to here breast-feed for far longer and it seems to be more their social norm than it is for us. We need to change the mind set in that regard. We should address the issue at the stage where women are very receptive and where the programme should be very receptive to making changes that will have positive benefits throughout life. It is now accepted that changes made at the age of five or seven will have long-term benefits so it is about prevention. I know prevention is very hard to measure in a financial sense but it makes every sense to do it.

Deputy Jimmy Devins

I thank the Chairman for allowing me to sit in. I welcome Professor O'Shea and his group. I am delighted that the committee is examining obesity. It is a topic that is very high on the interest scale at present and I know Professor O'Shea's involvement with Operation Transformation was received very positively throughout the country. It appears from listening on the monitor upstairs that the committee is examining cure rather than prevention. I agree with Deputy Jan O'Sullivan that prevention is better than cure and I am a very strong advocate of that. If a fairy godmother asked Professor O'Shea today what two things would he like to see happening in this area, particularly with the emphasis on cure rather than prevention, what would be his response? We are all aware that we are in a very difficult financial situation but mortality and morbidity from obesity is so high that the State must act on it as a matter of urgency.

Professor Donal O’Shea

My colleagues may assist with answers and as Deputy Reilly has to leave shortly, I will begin by briefly answering his questions. He asked a critical question regarding the BMI at which one would perform surgery. There is an international evidence base for a procedure where the BMI is more than 35 with complications. There is no evidence for such an intervention in respect of a BMI of less than 35. The procedure is being performed on patients with body mass indices of 28 but there is no evidence for this approach. The maximum benefit is seen in patients with a BMI of more than 45 and those who have the bypass operation described earlier.

Any self-respecting unit performing to international standards will work to a ratio of two bypasses for every band and I would imagine an even greater majority of patients in this country would receive bypasses. We have carried out only 140 procedures in St. Colmcille's, of which 120 were bypasses, and we have had one mortality. We publish our findings in the Irish Medical Journal and the international literature indicates this procedure carries risks of mortality and morbidity.

In regard to the capacity for surgery, it is estimated that 10% of people with significant obesity are suitable for surgery and the remaining 90% require conservative management and physical fitness regimes. The unit in Loughlinstown is part of the HSE and does not have a financial imperative. We are currently dealing with a patient who has a BMI of 116. I thought that figure was wrong but when I repeated the calculation, I arrived at a figure of 115.8. I do not usually conduct house visits because that is the role of the GP but I did so in this instance. We refuse nobody and we are working with this lady with a view to giving her exactly what she needs. That is the philosophy the HSE observes in respect of all the patients for whom it provides primary and secondary care. I believe the 10% figure is a conservative estimate and that 20% of patients with a BMI of more than 40 probably should have surgery. I will ask Ms Maria Lordan Dunphy to address the task force recommendations and their implementation.

Ms Maria Lordan Dunphy

It is the responsibility of all sectors to reduce the obesity problem in Ireland but the HSE is keen to lead by example. We translated the recommendations that are relevant to the health sector into a tangible set of actions across five areas. Where they are finite in nature, we have implemented the main ones. For example, we developed national physical activity guidelines and conduct a cross-Border media campaign on an annual basis with other stakeholders. We have also organised a North-South obesity conference. We are in the process of developing a national database on height and weight but this is a developmental rather than a finite project because it requires ongoing work.

The action plan forms part of our ongoing strategic planning and delivery and it has also been included in the business plans for primary care, hospitals and population health, which is now part of integrated services delivery.

We have not made significant progress in respect of only one recommendation, namely, the undergraduate and postgraduate curricula. We are working with the Irish College of General Practitioners to develop the weight management algorithm to which Professor O'Shea referred and guidelines for managing the spectrum of weight categories from healthy to morbidly obese. The intention is to produce a clear pathway for all health professionals.

We have made significant progress not only on recommendations which are relevant to us, but also with other sectors. We are, for example, involved in the health component of the social, personal and health education, SPHE, programme and we have entered a partnership with the Department of Education and Science to deliver this programme nationally. In the south, we have designated 300 health promoting schools, which means they have healthy policies for food, include food and nutrition on the curriculum and build physical activity programmes into SPHE. We provide additional physical activity programmes in schools in partnership with the Sports Council of Ireland and the Irish Heart Foundation. We are working with the national youth health programme to focus on the out-of-school setting in disadvantaged areas. In partnership with the Sports Council of Ireland, we targeted more than 5,500 people last year for physical activity programmes in the context of sports and tourism and this work is continuing. At present, we are preparing integrated business plans with the Department of Transport and pooling our resources with several Departments in order to lead by example in terms of using all available resources to deliver tangible measures for 2010. We have the backing of our Ministers in that regard.

Deputy James Reilly

Perhaps a report can be prepared for the committee on the 128 recommendations.

Ms Maria Lordan Dunphy

I can report on the health sector and the work we have done with other sectors.

Professor Donal O’Shea

A report on the number of recommendations that have been implemented has been produced and we can forward it to the committee.

Deputy James Reilly

I thank the witnesses.

Professor Donal O’Shea

To return to Deputy Jan O'Sullivan's questions, much of our discussion today has been about treatment but prevention has to be the dominant concept in our heads. If one is obese as a child, one is twice as likely to be obese as an adult. The largest people who have presented to our adult service are those who became obese before the age of five. If we do not act in the early years, therefore, we are already losing the battle. An antenatal component has been built into the midwifery curriculum.

Ms Maria Lordan Dunphy

Antenatal care includes advice on nutrition and physical activity. We provide a series of training programme to midwives and all health professionals who interact with the public in regard to healthy eating and physical activity. However, there is a need for a more concentrated effort in maternity settings to integrate nutrition and physical activity into the antenatal services.

We feel strongly about healthy weaning and have produced a breastfeeding action plan which includes programmes such as the baby friendly hospital initiative. We also provide training on healthy weaning because weaning practices are poor in many cases. We offer programmes in disadvantaged areas, such as the healthy food made easy programme, to give support and advice to parents on buying and preparing healthy foods. This helps to build capacity within the community.

We are doing considerable work with the preschool sector on nutrition and physical activity policies. As many preschool facilities are privately operated, we depend on their goodwill but we are developing a national health model for the preschool sector. We hope to work with the Office of the Minister for Children in this regard. If we could integrate this activity into our preschool inspections, a very effective response to the preschool setting could be developed.

Professor Donal O’Shea

Deputy O'Sullivan mentioned photographs from the 1940s. We were underweight in the 1940s. We were probably about right in the 1960s and 1970s. Approximately 8% of adults and 1% of children were in the obese category and it has ballooned since then.

Deputy Neville inquired about the views on the previous presentation. Deputy Aylward's point on bypass v. band might address that to some extent. The need outlined by The Hospital Group is clear. The estimate for the number of surgeries required for obesity in this country per year is approximately 400. To date, we have not carried out any surgery in St. Columcille’s this year because of pressure on beds. We have 90 people on a waiting list. The mortality rate for those on the list is 6% over a two year period. We need to step up the capacity or outsource it elsewhere. It would be a negative step for a developed health system not to provide upper GI elective surgery for patients in a slightly high-risk group who need it. That is all this is; there is nothing magical about the surgery. Some of those requiring surgery are in the high dependency category.

Chairman

Is that best done privately?

Professor Donal O’Shea

It is best done in an appropriate environment. It has to be done.

Deputy Bobby Aylward

Is it a last resort?

Professor Donal O’Shea

It is the only option for about 20% of severely obese patients. It is not to be considered in patients with a BMI less than 35. It is only to be considered in patients with a BMI of 35 to 40 where there are comorbidities. There is a significant need for it that has to be met and that should be met within the public health system. That is what delivering a health service is about.

A report indicated that based on our population size we should carry out approximately 400 surgeries per year and that is likely to grow. In the United States they have just reported on the first 1,000 adolescents who have had bariatric surgery to manage their obesity. That is not where we want to go as a country.

Chairman

In terms of looking at that cohort of people who urgently require that surgery, is it an option to use the National Treatment Purchase Fund and to have those people treated abroad?

Professor Donal O’Shea

All options must be explored. Some of our patients who are on the waiting list for surgery have attempted to source it through the National Treatment Purchase Fund but have been unsuccessful. I do not think it is covered under the National Treatment Purchase Fund.

Chairman

Is that because of the complexity of the surgery?

Professor Donal O’Shea

It just was not on the list of treatments when the fund was set up. The band v. bypass argument is closed. The band is suitable for certain individuals and the bypass for more people in a unit that is functioning to international standards.

In terms of Deputy Flynn's comments, this is a treatment that needs to be available in the same way as coronary artery bypass graft to public patients and private patients when they need it. If it is in the public system, it will also be in the private system, as all procedures are. It is being done here in one or two private institutions of good repute to a reasonably good standard.

In terms of the clinical assessment and more of the multidisciplinary teams, MDTs, at the high end of obesity it is a complex problem with psychological and physical issues. Education in cooking is also important so a dietician is required as well as a psychologist. A physiotherapist is also required. A decision needs to be taken on medication, of which there should be very little, and the role of surgery. That demands a multidisciplinary approach and it needs to be available to each region of the HSE so that the primary care teams would ideally feed the patients with whom they are not making progress into the MDT.

Senator Prendergast referred to breast-feeding which sets the tone for life in terms of nutrition and the emphasis the parent will bring to ongoing nutrition. The jury is well gone on that. Perhaps Ms Lordan Dunphy wishes to comment on that.

Ms Maria Lordan Dunphy

We are trying to get an agreement with a number of stakeholders on growth measurement charts. That is important in terms of considering height and weight. We spent a significant amount of money on purchasing equipment, more than €300,000 for primary care teams so that we can measure the height and weight of children at various stages, as described in the task force report. Staff have also been trained in doing those measurements which will enable the accurate measurement of children.

Senator Phil Prendergast

Developmental check-ups at nine months often do not happen now due to pressure on staff for reasons of resources or other reasons. Perhaps there should be a role for the public health nurse in school visits so that we could get a standard of what an expected weight for each child should be. I accept there are cultural variations but we should have a measurement that would alert us to when someone is going off their percentile so that we can take action before it becomes problematic.

Ms Maria Lordan Dunphy

It is critically important that parents recognise when their children are overweight. Assessment is important. We were involved recently in a WHO study of height and weight measurements of a cohort of a few thousand children aged seven years. That showed what we know already; that we have a significant problem in terms of children being overweight and obese. We need to consider the measurements to keep track of the issue but also to review our progress. The national database of height and weight will be important in that regard when it is developed.

Deputy Rory O’Hanlon

Have the recommendations of the obesity task force been implemented and is progress being made?

On food labelling, from my brief study of products in shops and supermarkets it appears that labels are not user-friendly in that one is not comparing like with like. If we want people to take an interest in the nutritional value of food they should be able to easily understand what is on labels and to compare different foods.

Chairman

I ask the delegation to conclude and reply to the questions in the concluding remarks.

Professor Donal O’Shea

Food labelling was discussed on more than one occasion with the Food Safety Authority of Ireland. We addressed the task force recommendations to Deputy Reilly. We have to come back with the comprehensive report on that.

One point I left out earlier is that patients who have had a bariatric procedure require lifelong follow-up. We learn that things happen three years and five years after the procedure. It is not one to be undertaken lightly. In addition, it is not appropriate to set a defined follow-up period.

I refer back to the point made by Deputy Devins. If I had a wish, in the context of treatment and knowing that prevention is at the core of our approach, it would be that the primary care teams as they develop have weight management awareness and programmes embedded, that there would be treatment units within each of the four HSE regions that patients at the high end of obesity could be referred to for multidisciplinary management and that we would urgently get the surgical arm of obesity management established and up and running at this point in the one existing unit and then in the other three existing units as they become staffed. Hopefully the process can be progressed through the committee.

Chairman

I thank the delegation very much. Does Ms McMahon wish to add anything?

Ms Louise McMahon

No.

Chairman

I thank the members of the delegation for the presentation and I congratulate them on the work they are doing. If some points have not been addressed to their satisfaction, perhaps they would correspond with us in the aftermath of the meeting.

Sitting suspended at 4.40 p.m. and resumed at 4.45 p.m.