Professor Ken McDonald:

I am grateful to the joint committee for giving me the opportunity to provide information on the NCPHF. I have circulated my opening statement and associated information, on any of which I am happy to take questions. I will concentrate on the central, important achievements of the NCP and how they relate to other chronic illnesses that we face.

Heart failure, HF, is generally recognised as one of the most challenging chronic diseases. It affects upwards of 90,000 people in the State. A total of 250,000 people are at immediate risk of developing it, with 10,000 new cases every year. The disease significantly curtails longevity, but of equal importance to those with the disease and their family members is that it curtails quality of life, which is probably best exemplified by the fact that 20,000 hospital admissions every year are directly related to it. These hospitalisations usually result in a stay of ten or 11 days. The HF hospital requirement drives the budgetary demand associated with the condition - €700 million annually. The fact that we are focusing on hospitals underlines what the NCPHF is trying to do. It is attempting to transfer what has been historically and still is, to a certain extent, a hospital-centred, reactive care process to one that is community-centred, proactive and preventive, involving at its centre the patient and his or her family and a GP-led, well resourced, HF service with unfettered access to specialist opinion and diagnostics outside the footprint of the standard secondary care service as we know it. That is the umbrella goal of the programme. In many generic ways, it is similar to that of the NCPs in dealing with many chronic illnesses.

I refer to what has been achieved. It may seem to be a contradiction that the first achievement I will outline is hospital developments under the NCPHF. For us to securely provide a community-centred chronic disease management service, we need effective hospital management of heart failure in all our regions. That was the initial goal of the NCP when it commenced. Clinical programmes are available in 12 admitting hospitals. We would like to have them available in all admitting hospitals, but resources are the restraint in that regard. The programmes that are in operation, however, have been effective in reducing the numbers of readmissions with heart failure and length of stay.

I would like to focus on three developments under the NCPHF in respect of community care. I would like to conclude on one on which I want to put a great deal of emphasis because it has pertinence throughout the chronic disease environment. Given that 250,000 people are at immediate risk of developing heart failure, with 10,000 new cases every year, as Dr. O'Shea said, prevention has to be a strong component of a chronic disease programme. In this country we are fortunate to have developed the first internationally proven preventive strategy in one of our units. The HSE NCP has seeded it as a pilot study in one region. The NCPHF not only prevents heart failure but it also prevents other cardiovascular admissions to emergency rooms. If it were rolled out throughout the State tomorrow, it would have a dramatic impact on these admissions, saving up to 100 trolley bays a day, which would be a significant impact.

Moving from prevention to the disease, I mention the demonstrator project which is part of all clinical programmes. As part of it, we place clinical nurse specialists in the community. The purpose is for these well trained nurses to be assistants to GPs in the management of chronic disease, freeing up the GPs to focus on the more medically demanding aspects of chronic illness management, in particular, heart failure, and to have someone specialised at nursing level who can deal with the housekeeping but nonetheless important aspects of chronic disease management. Our experience with the process within the NCPHF has been relatively modest to date. The programme has been in operation for the past 18 months. However, according to the preliminary information we have received, it has improved the overall quality of HF cases and GPs are positive about the development.

I will conclude with a strategy that has been pioneered by the NCPHF. It is an important development, not only in dealing with heart failure but also with cardiovascular disease in general. It will also have an impact on the wider chronic disease framework. I refer to the concept of virtual consultation. It can have an impact on two central problems that we encounter every day in our discussions on health care and the media - waiting lists for outpatient appointments which are increasing and the use of acute medical units and emergency rooms. Virtual consultation is an online, real time, interactive case discussion between the GP and specialist. Multiple GPs can be online at any time; therefore, there is a group learning aspect. The cases usually take five to ten minutes to discuss and six to seven can be dealt with per clinic session.

Returning to the two metrics I mentioned, what was interesting was the impact on waiting times or referral into the outpatient system and on the acute medical unit, AMU. In respect of the approximately 400 cases discussed in the pilot area, GPs have informed us that 80% of this would have been referred into the outpatient system, with a similar percentage referred to the emergency room, ER. This highly innovative way of dealing with heart failure and chronic disease could have a dramatic impact on outpatient waiting times, preserving real outpatient slots as opposed to virtual outpatient slots for people who truly need them. The ancillary benefits of this are self-evident. First, the patient no longer has to travel. The patient must always be at the centre of all we do. Travelling for a patient invariably in heart failure and also having other chronic illness or an elderly individual with multiple diseases is never easy and it often involves taking a family member out of work. The second benefit is group learning.

That is an overview of our achievements to date. As clinical lead, I would like to see us focus into the future on all four of those strategies and to continue their development, namely, development of the hospital programmes, the STOP-HF prevention strategy, the demonstrated project and, in particular, virtual consultation. I am happy to take questions on any issues.