Dr. Rónán Collins:

The committee is hearing many common themes from us. It is not that we sat across the road in Buswells this morning and planned this. We have many views in common on the importance of prevention, working together in primary and secondary care and through the integrated models and using technology to assist us. I agree with Professor Ken McDonald. I am waiting for our own subgroup to report but believe that what we really need is a national preventive strategy on cardiovascular disease that will serve everyone, not just those affected by stroke, heart attacks and heart failure but also those affected by dementia, falls and even incontinence in later life. Much of the latter is due to subtle brain damage over time from vascular disease. There is a significant reason to invest in this area over time.

I had a vision of Deputy Durkan and me doing memory tests like US President Donald Trump did recently in his health check. It would be humorous. The Deputy made a point on where one should advertise. I do not claim to be the expert on this. We certainly live in a time in which there are changes in the media by which we reach people. It is likely that we reach people in different age brackets in different ways, but we also need to make the message effective. There is no point in telling a young man he might get lung cancer because it is so far removed from where he is now and it might not be immediately relevant to him. If he is shown a picture of sexual dysfunction or impotence, he might be much more likely to hone in on it and say it could happen to him if he smoked. It is not just a matter of the message; we must fine-tune it so it is meaningful to people depending on their time of life. A message stating smoking causes premature wrinkling is much more likely to attract the attention of a woman than a message referring to something that might happen in the distant future. There is a mixture of messages involved, and there is probably a mixture of media. There needs to be a panel of experts to consider where we advertise.

Senator Dolan made important points on stroke survival and the impact of clinical nurse specialists' leave. He is right about the rule of thirds. That generally was the rule. I am very happy to say that our stroke mortality rate is now good in this country. It is down to approximately 12%. It has improved dramatically in recent times. It was 19% in 2008 and it is now down to 12%. As far as we can assess, this is not occurring at the expense of excess disability, in that nursing home discharge rates have remained constant. Therefore, not only are more people surviving stroke but more are going back home.

The point made on the impact of clinical nurse specialist leave was absolutely right. There is a danger with isolated positions. Someone will always have to go on leave, and someone will always have to attend to other aspects of life. Therefore, there is always a danger in trying to get a quick backfill. Perhaps we should be considering a model in which people are not working in specialist roles completely on their own. It does have an impact. At times in my hospital when a key member of staff goes, a memory clinic may fall or a falls clinic may fall. It can be challenging in terms of backfill where there are specialised roles.

Reference was made to a subject that is very dear to my heart, namely, soft assets and barriers in the area of disability. It relates to what Dr. O'Shea said about cultural change. In this regard, Professor Bernard Isaacs said that if one designs for older people, one will include everybody. He was the father of modern geriatric medicine and gerontological thinking. The problem with our society is that we are not designing for older people. In fact, we are very much designing, even in the corporate world, around hyper-cognitive people. This is a problem. Anyone who bought a software package could see how difficult and non-intuitive it was for a healthy adult to use. Imagine what that world is like for older people. Technology is forcing them out of our society when it should be including them. If I had my way, I would have a CE mark for technology and ensure it was road-tested for and accessible to older people in addition to younger people. We need to be doing this in society. It goes beyond software and technology. It also applies to building design, signage and all areas of life. These are soft assets, as the Senator said, but they are also barriers that we can easily surmount.

I was very interested in Senator Conway-Walsh's questions. Clearly, she has thought a lot about this. I will throw a grenade in her direction by saying that if one lives up the dales, one lives up the dales. When I worked in Yorkshire, that was the attitude taken to some of the high-technology medicine. It was said it could not be delivered to the deep rural areas. That is not our attitude but it does reflect the fact that there are challenges, as the Senator has identified.

The Senator alluded to a two-centre approach and asked whether it would disenfranchise people in terms of thrombectomy, which is mechanical clot retrieval. Clearly, we cannot do everything straight away. First, we do not have the specialists. Even if we had all the money in the world, we would not have the specialists. Second, there is a need for high-volume centres when carrying out very tricky and dangerous procedures. Our initial approach in the national stroke programme is to get two centres up and running vibrantly. I reassure the Senator that the centre in Dublin is regularly taking patients from the west, including Mayo, Galway and Letterkenny. Therefore, we are trying. It will not be the longer-term model forever. There will probably need to be a centre in the west and there may need to be two in Dublin, depending on how the city grows, but in the shorter term, we need to establish that we can do this well rather than diffusely and badly. Our initial strategy is to try to make sure the majority of the population has access to this really important treatment for stroke. We need to treat only three people with a thrombectomy to achieve one better, independent outcome than would obtain without the facility. This is a game-changer by any stretch of the imagination but it is a huge infrastructural challenge to get people to centres and find the staff who have the skills to do this. It is a challenge to get the radiography staff to work around the clock. The Senator referred to 24-7 care so we can do this. There are challenges but we are meeting them. We grew the thrombectomy service from nothing to one dealing with 120 or 130 cases in 2015. There were approximately 180 cases last year. There have been over 250 already this year. That is a huge increase without a massive investment necessarily. We do need some investment. I reassure the Senator that, as she can probably hear from my accent, I am not originally from an urban area. As with most people, I have family who live in rural areas. We are concerned to make sure people are served.

We have done several modelling exercises. We published a paper recently in the European Stroke Journalon what a drip-and-ship arrangement entails, given various logistical models. I am happy to give the Senator a copy of that paper because it makes interesting reading on the subject of whether one is better off going to the nearby hospital or bypassing it.

With regard to rehabilitation services in rural areas, as mentioned by Deputy O'Mahony, we are very anxious in the stroke programme to ensure everybody has equal access and what he or she needs to return to living. The second pillar of our strategy is restoration to living. There are challenges in this regard. For example, one of our models is to get people home quicker. It is psychologically better to go home. One can imagine the trauma of having had a stroke. One may be in a hospital environment that is frightening and noisy and one might be afraid about what life will be like and what one's relationship with one's family will be like. The sooner people can go back to the home setting, the better. Clearly, however, we have to have a radius around the hospital in which teams can work in order to be efficient. We need a different model for rural areas, perhaps working in conjunction with geriatric medical services and the national rehabilitation service whereby we could have satellite services centred in rural areas through which people with various problems could perhaps gain access to appropriate rehabilitation services. We certainly can do that.

To return to the comment on stroke unit access, we must recognise that although we had difficult times and but one stroke unit in 2008, 85% of our acute hospitals now have one. The national stroke programme is absolutely committed. An acute hospital accepting acute stroke patients should have an acute stroke unit by the end of this year or a bypass arrangement in place. I speak for the programme and personally in saying we cannot condone any longer a system in which patients with an acute stroke cannot get into an acute stroke unit in hospital.

To return to the comment on how many people access an acute stroke unit, it is correct that the rate used to be very poor. I am happy to say we have improved on the rate of many years ago, which was 29%. At present, 65% of our patients get into an acute stroke unit and that is still not good enough.

On our key performance indicators and the questions on whether we have targets, we do have targets. Our target or minimum acceptable standard is 90%. We are a bit away from that. The problem is that it relates to demography also. It is fine to have a stroke unit but the demographic make-up is changing. The Stroke Alliance for Europe is telling us we will have an 58% increase in the absolute number of stroke patients.

Clearly not only must one have a stroke unit, but we need to build in a review system to ensure that the stroke unit one has meets the number of admissions year on year. That is a challenge but in our five-year strategy, we are working to meet that challenge and we will try to model it on a population basis.