Mr. Gavin Quigley:

I will leave the issue of when to Dr. Walsh.

Reference was made to the cost saving involved. We are not allowed to make a profit in the NHS. That is certainly the case in Belfast. That leads me somewhat to the HIQA report, in respect of which I played a part. Fundamentally, the problem is the unit cost - the cost of staff here. Staff costs are high in comparison with those in Belfast, Bristol and London. Part of the reason is the starting point here is more expensive. The cost of devices is largely the same.

That is why it is cheaper in Belfast. They pay me less. It is covered in terms of the medical card. Patients can go and the HSE funds that.

In respect of the numbers, I always work on a guesstimate. For every million people, about ten people with Parkinson's tremor or dystonia are suitable for surgery, regardless of whether they come forward and have it. That is the best guess - somewhere between ten and 15 per million.

In respect of capacity for the Royal Victoria Hospital, it should not make any significant difference to my service. We initially proposed to treat ten patients from Dublin, look at them after a year, make sure that everybody was happy, the surgical results were good enough and the neurologists here were happy, and then try to roll that out. Most of the work up would be done locally so the assessment and pre-operative screening would all be done in Dublin. Professor Tim Lynch is not here. He and I have been working to try to push this forward for about five years. Professor Lynch has been the driving force for much of this. The idea would be that patients would be worked up locally, there would be a set protocol that they would follow and, ultimately, I or Mr. Neil Simms would come and meet them in Dublin, so we would save them the initial journey as well. We would meet them, speak to them and go through the surgery. They would come up, have their surgery and go home. People like Dr. Walsh would do the programming and we would divest ourselves of that so that we are pushing the control of the patients back towards the local neurologist. In terms of bed implications, we are probably talking about a five-day stay in the Royal Victoria Hospital. I do not think this will have a huge impact on the numbers we are talking about.

Conceivably, I could start ramping up to do it next week if that was the desire but it really is not an issue. The infrastructure exists in the Royal Victoria Hospital and we do not need equipment, staff or anything like that. However, we do need two nurses to co-ordinate things in order that we have one North and one South who would be responsible for assessments, following up patients, looking up data and making sure the whole thing is co-ordinated.

The all-Ireland solution would be a means to dividing the country in two in terms of population because we undoubtedly have the numbers for two centres. I think Senator Crown alluded to it as well. Even if one divided the country in half, one has three million for each centre and a sustainable population at that level.

Why has this not happened previously in Ireland? That is my answer. I did not really have one. Historically, we provided lesioning surgery in Belfast and, as deep brain stimulation came in, the surgeon who did that retired. I was off training in places like Liverpool. When I came to Dublin, it seemed to be expensive and there was a reluctance to do it. Dr. Walsh might allude to it. Most of the neurologists have been away to do this in their work in Dublin.

What happens if patients get into trouble? Currently, there are many phone calls. The trouble mostly arises over Christmas and bank holidays. It involves things like a battery going flat and how to get it replaced. The logistics of having to book a flight for the following Tuesday to get from Galway to Bristol are very difficult. We have certainly had phone calls over the summer. We just brought the patient straight up to Belfast and fixed the battery and the patient was able to go home the next day. It should be relatively straightforward.

Surgical risks include a risk of stroke. Bleeding can occur when the electrode is put in. The risk is probably less than 1%. Wound infection is the largest single problem because one is putting something foreign under the skin. There is possibly a 2% to 4% risk of infection. That is where a local surgeon is easier because one can easily let someone have a look at it. If someone has to go all the way back to Bristol to be told their wound looks fine, it is a pointless journey. I think those are probably all the questions I can answer.

Most of the children with dystonia, to whom Dr. Walsh alluded, are currently being sent over to Evelina London Children's Hospital, which is part of Guy's and St Thomas' NHS Foundation Trust. Again, this is probably something that is going to expand. We have a children's hospital on site. It is something we can gear up to do but, ideally, that is something for the future. It is probably best at this point for them to be sent to Guy's.

The neurologists choose patients. I am a technician in all of this. The neurologists are the ones who own the patients. They look after them, deal with them and change their medication. In general, the less surgical interference with that, the better