Dr. Rónán Collins:

There is a breadth of interesting and insightful questions. Returning to Senator Burke's question on the culture of change, I very much agree with Dr. O'Shea. My experience, having followed the leader and now being the lead, is that I have not seen barriers or resistance to change in the health service once clinical leadership and direction is given, and there is involvement, particularly among the multidisciplinary team and the stakeholders, and where a cogent argument is made. While there is a pervasive sense of doom and gloom and we have come through a difficult period in Ireland, for a small country with very limited resources, together we have achieved quite a bit. Most of that has come by pulling together and enacting change rather than as a result of receiving huge resources. I replied to Senator Burke about the fractured relationship between general practice and the hospital system. Speaking personally, not on behalf of the HSE, I have never seen such a fractured relationship between the two. There is a real onus on fixing general practice, which will remain broken without investment and a new contract. Fundamentally, that needs to happen because our whole health service is built on what happens in primary care. If that is wrong, the rest of the system will be wrong.

Deputy Kelleher asked specifically about stroke prevention. He is correct. There is an acute aspect. When a patient arrives in hospital there is a question of whether we can prevent disability but neither Deputy Kelleher nor myself wants to be on a table sweating it out, wondering if a treatment will work or not when facing the prospect of being paralysed down one side of the body and being unable to talk. We would by far prefer not to have been in that situation in the first place. Personally, as current lead but also on behalf of the clinical advisory group in the national stroke programme, we are wholly committed to seeking increased investment for prevention. It is the third leading cause of death in this country and our leading cause of acquired adult disability. We reckon we could prevent one third to half of all strokes through lifestyle change as Deputy Margaret Murphy O'Mahony alluded to, in areas such as exercise, weight, not smoking, keeping alcohol consumption levels low and even managing blood pressure.

Getting blood pressure right at 60 or 70 years is important but if we get it right in middle age, such as my own age or that of Deputy Kelleher, we can half a person's risk of stroke. That is a screening target which needs to be tackled. The other big target in prevention relates to irregular heart rhythms. For laymen, irregular heart rhythm, atrial fibrillation, can be completely silent. A person will feel nothing, but it is analogous to having a cement mixer which is not mixing the cement correctly leading to clumps forming in the cement. If that clump falls into the pump chamber of the heart, it fired like a bullet from a gun down the pipe until it gets jammed. It is a very important concept to understand. Most people in Ireland know nothing about the problem, yet it causes one in three of all major strokes in the country. Moreover, if one gets a stroke due to this mechanism, one is more likely to be disabled as a consequence and the acute treatments are less likely to work. That is another screening target for prevention. Through the national stroke programme, in collaboration with the HSE, we have demonstrated that we can introduce an effective, simple screening tool in primary care which has been through a health technology assessment and has been approved. However, to return to my remarks at the start, if the primary care end of things is wrong, we cannot do any of this. It is very much dependent on our getting the situation sorted out in primary care.