Dr. Tony O'Connell:

I thank the members for their questions. I thank Deputy Ó Caoláin for the clarification at the beginning on Belfast. I was very pleased the committee was able to hear from Ms Tufts, a recipient of deep brain stimulation, on the last occasion it discussed this issue. As stated, it is very powerful to hear the stories of the recipients. We believe the therapy is efficacious; there is no doubt about it. The issue is merely about where it is delivered and how much it costs. However, we would like to provide the therapy for all patients who require it.

I was asked whether we support the development and growth of a service which could well be an all-island service in Belfast. Clearly, we do so by agreeing costs with Belfast, by supporting the commencement of a service there and by our having already traded three patients there this year. I was asked whether we would support, in the long term, a centre in Dublin. It is quite possible. It is purely a matter of having a cost-benefit analysis of what critical mass of patients would warrant setting up a centre. Such a centre would possibly be in addition to that in Belfast although it might itself become the all-island centre, depending on the relative caseloads in the two centres.

Many members talked about travel for patients. This was a theme that emerged quite strongly in the previous meeting with the representatives of the service in Belfast, the patients and their representatives. The fact is that all patients will have to travel to have this kind of service, which could be provided in but one or, at most, two centres in a country the size of Ireland. Even if we had the service in Dublin, patients with Parkinson's disease from Letterkenny, Galway and Cork would still have to make a train journey of a couple of hours to get here to receive the treatment. There would be overnight stays. Cases are not necessarily day cases. This kind of neurosurgical intervention requires that some patients would have to have hotels. However, we would clearly like to minimise the burden of travel, which is why we are as keen as the committee to have an all-island solution that minimises the need for people to fly to Britain for treatment. To that end, we would like to develop the follow-up service, with a multidisciplinary clinic, so nurses and other health professionals working with neurologists and neurosurgeons could do the simple tasks, such as the battery changes, thus eliminating the need to travel.

We are very supportive of the concept of a multidisciplinary team approach both to the work-up and post-operative management of the cases. That does not necessarily have to be done by the same team that carries out the actual operation in the operating theatre. There are numerous examples of therapies and surgical operations in Ireland where the follow-up team is different from the one carrying out the operation. As long as the transfer of information about what actually happened and the requirements is smoothly managed, the potential risk of loss of continuity of care is managed.

We are very supportive of growing this. However, there is no funding in the current service plan for growing the team at present. If the current number of neurologists, neurology-linked nurses and other team members in Dublin were willing to take on this role, we would not step in the way. However, in terms of funding additional resources, there is simply no money to do that. There are more pressing requirements to increase the number of staff in a number of disciplines that are more severely embarrassed at present than those associated with Parkinson's disease, given that the condition is being managed on the island already this year.

I was aware that the neurologists and neurosurgeons from Belfast met the Minister for Public Expenditure and Reform recently. I was not privy to the discussion so I cannot really comment on it but it is clear to me there is growing interest in what can be done to address the issues to which the members all referred.

With regard to Senator Burke's question about future demand, we will eventually get to a point where we saturate the service and have a rate of treatment of patients that meets the demand. It is not really clear we are there yet because the patients who will be suitable will comprise a minority of all patients who have neurological conditions. They must all go through a phase of attempting pharmacological therapy. When that fails, they become suitable. There are numerous clinical gateways that need to be entered to establish whether one is suitable for a procedure.

It is worth saying that under the treatment abroad scheme, it is possible for a doctor to refer to a centre elsewhere in Europe if he has a relationship with that centre or knows it is a centre of excellence. The patient must be happy to travel to that centre in the expectation of a better outcome. The development of an all-island service does not necessarily preclude the possibility that Parkinson's disease and other conditions might be treated on the Continent.

With regard to an economic assessment of the cost-effectiveness of this approach and other therapies managed by the treatment abroad scheme, TAS, there is an ongoing awareness of the constant tension between the economic cost of adding travel and the inconvenience for patients of servicing someone overseas or in Northern Ireland compared to the infrastructural outlay and set-up costs of establishing a treatment centre for those conditions in Ireland. Every year the number of cases we are dealing with and the spend - which, as I said, now totals €9 million - is assessed and reviewed. The range of treatment therapies that are administered through the TAS is broad and there are individual assessments of each of the broad themes of work which occur. Ultimately, it is a matter of whether we get the greatest economies of scale by doing it overseas, and that will have to be assessed, or by doing it in Ireland, which also has to be assessed. The assessments must be done on a condition-by-condition basis each year. I will ask Ms Fitzgerald to speak on the cross-border directive.