Catherine Byrne (Dublin South Central, Fine Gael)
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I remind members, witnesses and people in the Visitors Gallery to ensure their mobile telephones are switched off for the duration of the meeting as they interfere with the broadcasting of the proceedings.

Witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if witnesses are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person by name or in such a way as to make him or her identifiable. I remind members of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against any person outside the House or entity by name or in such a way as to make him, her or it identifiable.

I welcome the witnesses and thank them for attending this meeting. At our meeting on 6 November, witnesses briefed us on deep brain stimulation treatments and on Parkinson's disease.

Our Vice Chairman has arrived now and will take over.

Ciara Conway (Waterford, Labour)
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My apologies for being late. A journey that normally takes 15 minutes took an hour this morning. Our guests this morning are Dr. Tony O'Connell, national director of the acute hospital division of the HSE, Ms Angela Fitzgerald, deputy national director, and Dr. Áine Carroll, national director of clinical strategy and programmes in the HSE. I thank them for being with us this morning and invite Dr. O'Connell to make his opening remarks.

Dr. Tony O'Connell:

I thank the committee for the invitation to speak about the current arrangements regarding the provision of deep brain stimulation treatment under the treatment abroad scheme. I would like to introduce my colleagues, Ms Angela Fitzgerald and Dr. Áine Carroll from the HSE. In my statement I want to provide the committee with what I hope will be helpful background information on the current arrangements for treating patients with deep brain stimulation and the key considerations in terms of shaping future provision.

Deep brain stimulation, DBS, is a neurosurgical intervention for the management of movement disorders such as Parkinson's disease, dystonia and essential tremor. DBS is an established technology that uses a surgically implanted pulse generator device, called a neurostimulator, similar to a cardiac pacemaker, to deliver controlled electrical stimulation to precisely targeted areas in the brain. Stimulation aims to interrupt faulty communication between the brain and the muscles that result in involuntary muscle movements. DBS is targeted at those patients with movement disorders whose conditions are no longer adequately controlled by drug therapy. Currently, DBS treatment is not available in Ireland and patients requiring treatment are referred overseas under the treatment abroad scheme.

The treatment abroad scheme, TAS, is operated by the HSE and allows patients access to proven treatments not available in Ireland in another EU-EEA country or Switzerland. The funding for the treatment is approved under the TAS in accordance with the provisions of the relevant EU regulation. Under the terms of the scheme, a hospital consultant must provide medical evidence of the details of the patient’s condition and must certify that the treatment concerned is not available in this country; there is urgent medical necessity for the treatment; there is a reasonable medical prognosis; the treatment is regarded as a proven form of medical treatment; and the treatment abroad is in a recognised hospital or other institution and is under the control of a registered medical practitioner. DBS treatment satisfies the treatment abroad scheme criteria in terms of the treatment not being available in this jurisdiction and the efficacy of the treatment. However, there is still a requirement for patients to be assessed on an individual patient basis to ensure that the other criteria are satisfied consistently and there is equity in the application of TAS across all patient cohorts.

In the absence of a DBS service in Ireland, patients are currently referred to DBS centres abroad for assessment, surgery and follow-up care. At present, DBS patients are referred to two centres in the UK, Oxford and Newcastle. Recently, three patients have gone to Belfast for treatment. The HSE has agreed costs with Oxford and, more recently, Belfast, but such arrangements do not preclude a doctor in Ireland referring a patient to any other centre in the EU or EEA under EU Directive 883/2004.

Over the period 2012 to 2014, the total number of patients seeking to access DBS abroad increased by 182%, from 50 to 170, with a corresponding increase in the cost, of the order of €1,117,950. Therefore, the overall cost increased from approximately €400,000 to €1.5 million. Over the same period, the number of new patients remained relatively static with an average of 25 new patients per annum. The total cost of the whole treatment abroad scheme in the current year for all treatments is estimated at approximately €9 million.

In October 2012, HIQA published a health technology assessment, HTA, into the provision of DBS services via the TAS versus the feasibility of providing the service here in Ireland. The HTA conclusions are important in terms of informing future decisions about the organisation and delivery of the DBS service for the future. Results of an economic analysis comparing the current TAS service delivery to a prospective national DBS service show that the current median cost per patient for the existing TAS-funded service is €44,700 over ten years. Providing DBS services in Ireland would cost the HSE an additional €20,900 per patient over ten years. Over five years, the incremental budget impact of a national DBS service is €1.84 million more than the estimated €4.29 million to treat the same number of patients through the TAS over the same period.

The assessment also highlighted the importance of ensuring that there is adequate planning for the establishment of a DBS service in Ireland, including the development of appropriate and consistent theatre access and additional neurosurgical services. The report acknowledged that while a national DBS service may address the existing equity issues that exist in regard to those patients that are unable to travel for DBS care, it may give rise to new ethical issues due to the diversion of resources from other effective treatments or from the overall health care fund.

The TAS continues to offer timely access to deep brain stimulation treatment, as evidenced by the increase in referrals of 182% over the period 2012 to 2014. In the past 12 months alone, the numbers have increased by 60%. Furthermore, in order to improve timeliness of access, the TAS has implemented initiatives to streamline the application process.

The HSE appreciates that there are challenges for movement disorder patients in terms of accessing this service abroad and therefore the recent option whereby patients can avail of the service in the North of Ireland is welcome. The referral of patients to Queen's University Hospital, Belfast and The Belfast Trust means that, with immediate effect, DBS surgery will now be available to movement disorder patients without the requirement for overseas travel. This will ameliorate some of the financial and logistical burden on the patient and should also enable improved access for those patients who were precluded from availing of the service under the TAS. For 2014, it is expected that ten patients will be treated in Belfast.

It is acknowledged that proximity to the service will also potentially increase the demand. It is expected that the additional costs will be partially offset by the reduction in the cost per case from availing of the service in Belfast. The indicative savings are of the order of €7, 200 per case, with further savings envisaged over time particularly with the potential development of outpatient follow-up in the Irish system. It is expected there will be further savings in regard to the reduction in pharmaceutical costs associated with DBS as a result of the patients availing of the surgery. It is also anticipated that in time this service will be developed further, with the possibility that multidisciplinary out-patient follow-up clinics could be conducted in the South providing further convenience for the patients.

The option of developing a DBS service in the Irish health system will be kept under continual review within the context of the overall Estimates process and other competing priorities. It is not possible to consider this service for 2015, as the funding is already fully committed to meeting existing service priorities. It is important to state that the TAS is a demand-led scheme and as such the funding arrangements do not enable a transfer of funding to support the development of the service on a continual basis. We are confident that in the short term the combined access to the UK and Northern Ireland will allow patients timely access to the service.

This concludes my statement. I and my colleagues will be happy to answer any questions.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I welcome Dr. O'Connell, Ms Fitzgerald and Dr. Carroll. We recall that they were unable to join us at this happy committee event because only a short number of weeks ago they were summoned by a less happy committee of this institution - just to clarify, I am referring to the Committee of Public Accounts. We are glad that they are able to join us here today.

Ciara Conway (Waterford, Labour)
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I am under no illusion.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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As Deputy Byrne noted when she was in the Chair, we had a very useful and informative engagement with representatives North and South and indeed with a sufferer with Parkinson's disease who has had DBS and whose testimony was powerful. Dr. O'Connell speaks of the costs of providing the service in Ireland. My head works in an all-island dimension and I was saying, "No, that can't be right because there are savings to be made". I understand that it related to establishing the service in this State. I am clarifying that for colleagues who may also on first reading Dr. O'Connell's presentation have understood that there were no savings to be made. Dr. O'Connell goes on to clarify later that in his presentation in terms of access to the North of Ireland and the service there. There is no hospital called Queen's University in Belfast. I know it very well. It is the Royal Victoria Hospital and we should just acknowledge it for what it is and what it is known. However, Queen's University would have an interest in the Royal Victoria Hospital and that is, of course, a positive.

It is very important to note that Dr. Quigley and his colleagues there have already performed a very small number of cases. My understanding is that this was where people were not in a position to travel for complicated circumstances relating to Parkinson's disease for whom the journey or flight was just not a prospect. They shared some of that detail with us here. Dr. Gavin Quigley indicated some of that. However, they have had the experience and are up for the task. Without any question in my mind, making DBS available on the island of Ireland is a powerful and positive development for everyone who regards this island as home. This must be a great encouragement to us to facilitate this development.

I take from Dr. O'Connell's position as national director of acute hospitals that he and the HSE are supportive of this access being provided at the Royal Victoria Hospital. Could he clarify whether this is the case in his response? That is my interpretation of his contribution. As he said, it is not about just the saving that can be made. There is an estimate of some €7,200 per case. There is also the significant saving to the individual themselves that is not reflected in his contribution. They no longer have to book flights and make hotel arrangements. For somebody facing a first surgery or consultation involving DBS and even subsequently for battery changes, the challenge of airport terminals is quite something. It is a challenge for any of us who are in full health. The people affected usually cannot travel alone so there is a multiplication of cost in terms of travel, hotel accommodation, etc. That is a huge improvement for people here.

It was indicated by Dr. Gavin Quigley that critically what was required at the outset to facilitate the establishment of an all-island service based at the Royal Victoria Hospital was the appointment of two DBS nurse specialists - one based at the Royal Victoria Hospital and another presumably based at the neurological institute at the Mater hospital. It would be a case of one north and one south. Their role would be in assessment and, very importantly, follow-up as it is crucially important. Could Dr. O'Connell indicate to us his expected response to that identified need? On the last day, a panel appeared before us on this issue. Is that being provided? Can we have certainty that this is included in terms of the national service plan for 2015?

I know this matter was addressed earlier this week with the Minister for Public Expenditure and Reform in the broader context of neurological issues. I am not sure if it involved Dr. Carroll but I know it was attended by Dr. Gavin Quigley, Dr. Richard Walsh and Professor Tim Lynch. I regard that engagement as very positive and indicative of good intent. While it had a wider remit in terms of neurological issues, my understanding is that DBS was addressed in the course of that engagement.

Are Ms Fitzgerald, Dr. Carroll and Dr. O'Connell in a position to expand on the opening statement to give us the certainty with regard to the HSE's support for the establishment of this all-island service with the resultant savings to our health budgets and significant improvements in convenience for sufferers seeking access to this procedure and its follow-on supports? I again that the witnesses for their presentation and I look forward to hearing more in their response to our respective questions.

Colm Burke (Fine Gael)
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I thank Dr. O'Connell for a very comprehensive presentation and for setting out all the issues and the way the HSE is approaching it. Dr. O'Connell gave the figures for 2012 up to 2014. There is a substantial increase. Could he clarify whether he sees a further increase over the next two to three years or whether he thinks it has levelled out in respect of the numbers who will be seeking the assistance of the HSE?

The second issue is the economic assessment of working with medical providers abroad. In his presentation, Dr. O'Connell set out where the HSE has looked at this and decided that this is the best way of approaching it. Is the HSE looking at other areas where it is more cost-effective to link up with institutions abroad rather than try to develop a service here? I know there would be a number of areas where that would happen. Is an overall review taking place in respect of that? Medicine is getting specialised within each different area. There might be four people specialising in a particular area between Ireland and the UK. Have we looked at that in an overall context?

The third issue I wish to raise concerns the cross-border health care directive issued in February 2011. We have gone beyond 30 months for transposing it into Irish law and this directive must be transposed. Does Dr. O'Connell see issues we need to start planning for when that is transposed to make sure we have a comprehensive way of managing that issue in respect of cross-border health care and the right of people to travel to another jurisdiction to get treatment not only if it is not available here, but also where there is undue delay in getting the treatment here?

Could we examine this? I realise I am straying slightly from the subject matter of the presentation this morning but believe we need to examine this in our long-term planning.

Catherine Byrne (Dublin South Central, Fine Gael)
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I will be brief because Senator Colm Burke covered one or two of the points I wished to raise.

When I was growing up, I regarded Parkinson's disease as an older person's disease. The first time I really understood it was when a good friend of mine got it at a very young age. The world opened its eyes to the disease when actor Michael J. Fox got it. It was driven home to many young people then that the disease was not peculiar to older people.

We had great presentations three weeks ago, as Deputy Ó Caoláin stated. What impressed me most was the presentation by the lady with Parkinson's disease. I cannot remember her name. She outlined how deep brain stimulation had changed her life. It changed not only her life, but also circumstances for her family. She referred to having regained the ability to dress and wash herself and sew on buttons, which we take for granted every day. I went home thinking about how privileged we were to hear the lady's insight into the effect of deep brain stimulation on her and her family.

Most things are down to cost, which we all understand, but as Deputy Ó Caoláin said, remarks were made on the last occasion on having two nurses, one in the South and another in the North. Senator Burke is always talking about doctors and other health professionals. I am always amazed at the work nurses do before patients even see a consultant or anybody else. We must acknowledge that.

I would love it if those who want deep brain stimulation, whose number seems to have has increased by 60%, did not have to travel, particularly across the water. I accept that the North is not too far away. I hope that we will soon be able to have a facility in Dublin. If we do not have the relevant expertise, perhaps surgeons could travel here to carry out the work. It is wonderful work and a huge step in the right direction for those living with Parkinson's disease.

I was speaking briefly to a friend of mine who has just contracted the disease. She was a nurse. She spoke of deep brain stimulation with great respect and interest. She referred to what it would do for her as an individual living alone.

I welcome the delegates and thank them again for outlining the benefits of examining all the figures. It is important that we continue to work together as a committee to have a facility in the southern part of the island.

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.

Ms Angela Fitzgerald:

The cross-border directive is not specifically about the Border within Ireland; it relates to all European borders. I am sure the Senator is well aware of that. A process is currently in place between the HSE and the Department of Health to look at the implications with specific reference to the North of Ireland. It is more likely that we will see migration in the other direction, because their access issues are just a bit better than ours, but I suppose there are other concerns around the wider European context. There is a process under way to look at how we manage that.

With specific reference to the matter in hand, it is probably less relevant because there is access in the North and we seek to access its service. What is probably of equal relevance, as Deputy Ó Caoláin is well aware, is the conduit by which we have achieved other all-Ireland solutions, such as Co-operation and Working Together, CAWT. If we were seeking to develop an all-Ireland service, we would try to do it under that construct, and we have done that quite successfully in other areas, particularly complex areas.

We do need to distinguish the current arrangements for delivering the service under the TAS - in which case we would expect the treating hospital to have a lot of the infrastructure in place, and that is what we are paying for - from a scenario in which we develop an all-Ireland service and put the infrastructure in place ourselves. The questions around cost savings are relevant in that context as well, because the cost savings referred to in the document show that we have now got a better price than we were getting when we were sending people overseas, so it would possibly allow us to treat more patients. The cost implications of setting it up here largely relate to the set-up costs.

To answer the question, there is a process under way, with particular reference to this, but it will not result in increased demands that might displace us; it might just enable patients to access it without reference to the treatment abroad scheme. Because Tim Lynch and his colleagues have worked very closely with the treatment abroad scheme, they have tried to make sure that this service almost behaves as if it is a cross-border one. Patients who meet the clinical criteria are getting relatively free access. That is evidenced by the increase in referrals in the past three years. The point is well made; we do need to consider the implications. It is less relevant for this than, perhaps, for other services, but in the context of an all-Ireland solution, we have good mechanisms already in place to enable some of that to be considered, and we are talking to the Department of Health about it.

Colm Burke (Fine Gael)
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In the context of cross-border health care, I wish to ask about undue delay. Is that being looked at currently? Are there consequences in terms of the implementation of the directive? How do we plan to deal with the issue?

Ms Angela Fitzgerald:

I think it is the single biggest issue, because we have waiting lists and delays. A number of patients, particularly at outpatient level, are waiting longer than 12 months. It is an area we need to consider. From our point of view, we are likely to see patients seeking access elsewhere, but equally, eastern European countries will have access to our services. The question of delay is a significant one. We have a programme of access reform to address delay for our own patients. The challenge is that we could attract patients from other countries. The only issue is that there is a level of reciprocity. Every country is being faced with the same challenge. Because the expectation has been raised, there are other burdens on the patient in terms of travel costs. That will possibly be one of the limiting factors. It is the single biggest issue member states are now having to consider and there is no easy answer to it. Perversely, if a country improves access, it leaves itself slightly more open to inward migration. That is a challenge we will have to walk through carefully.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I thank Dr. O'Connell for his responses and for the indication of a positive disposition to the whole project. In relation to the additional personnel needed, the number really is very small. What was identified by the team in Belfast was a single nurse there, a deep brain stimulation, DBS, nurse specialist and one here. The remark was made that the money is not there. I would not expect it to be a full-time post of itself, but I stand to be corrected on that. Dr. O’Connell said there would be no issue if somebody volunteered to take on the position. Could we not have a more proactive approach in terms of establishing the availability of somebody within the neurological service at the Mater hospital who could perform the specific role of DBS nurse specialist? The assessment will presumably be progressed by Professor Lynch and Dr. Walsh, among others, but a nurse is a critical support element within the team, especially so in terms of follow-up. The issue is being addressed again. It has become current following on from the paediatric cardiac decisions. The health Minister in the North, Mr. Wells, has taken a significant step in supporting and facilitating that. We all want to be on the one page. I do not want to go to the next meeting of the North-South Interparliamentary Association in Stormont in May and be embarrassingly slapped back on the basis that we could not even secure a single appointment of a DBS nurse specialist in Dublin in order to properly facilitate the advent of an all-island service at the Royal Victoria Hospital.

Dr. O’Connell is looking at the matter from his perspective, but I must look at it in terms of the political engagement that is my life - sadly, I might add, but I have to do it. I know the difficulties and the challenges involved. I have been working at it for many years. We need to make sure all our ducks are in a row in regard to the matter. It is not a big ask. I want to know and I need to be able to understand, as a layperson in these matters, exactly what it is that we are willing and prepared to do. We have not been asked for very much. There are significant savings involved, and I need to be able to say something other than that a person needs to put up their hand and say they will do something on a voluntary basis.

Ciara Conway (Waterford, Labour)
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It is worth noting, as well, that the committee intends to have a joint meeting with our colleagues in Stormont on this very issue. The point raised by Deputy Ó Caoláin is pertinent. We do not want to go to the North with our hands hanging. Perhaps Dr. O’Connell could respond in light of what has been said.

Dr. Tony O'Connell:

I will start by talking about savings. The savings I mentioned in my opening statement I compared to the cost of delivering the therapy in the UK.

Doing it on an all-Ireland basis is cheaper than doing it in the UK. That is where the savings come from, but establishing a completely new service as identified in the HIQA HDA would be more expensive because of the set-up costs in Dublin. I will ask Dr. Carroll to answer the specific question about nurses.

Dr. Áine Carroll:

My colleagues have alluded to the importance of a full spectrum of services for individuals with movement disorders. In my own clinical practice, as well as from a clinical programme point of view, it is very important that individuals have access to diagnosis and a full range of treatments, oral and parenteral, and then the higher-specification treatments such as deep brain stimulation. It is important that we consider the treatment of these individuals as a whole and develop care pathways that will take care of all the needs of these individuals.

The neurology clinical programme has developed a model of care which is currently under consultation. One of the care pathways is for individuals with Parkinson's disease, and DBS is part of that treatment pathway. That is the first step in identifying exactly what the pathway should be, and access to a full multidisciplinary team is extremely important for all aspects of the management of anybody with a significant movement disorder. By a full multidisciplinary team I mean physiotherapy, occupational therapy, speech and language therapy and psychology. Individuals with a significant disability as a result of movement disorder really require access to a full multidisciplinary team. The nursing piece aspect of DBS is very important, but it is only part of the jigsaw of treatments that these individuals need access to. They also need access to rehabilitation services. In the course of my work I worked in the movement disorder service in Newcastle-upon-Tyne. It was a multidisciplinary team not only in terms of specialist disciplines but also with neuro-rehabilitation, neurology and neurosurgery, with which we worked very closely in providing services to patients. What we would like to see in Ireland is access to that full multidisciplinary service for patients right along the spectrum of disability associated with movement disorders. That is what we intend to work towards.

Ciara Conway (Waterford, Labour)
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I refer to the issue of the nurse to be provided here in the South and working in co-operation with the service in Belfast. Is it an ambition to provide that nurse service?

Dr. Áine Carroll:

Within the neurology programme we have only taken the first step in terms of identifying what the patient pathway will be, and the model of care has not been signed off yet. It is out for consultation. As soon as we have agreement about that, with regard to clinical strategy and programmes in acute hospitals, we can look at the next steps in phasing in where we want to get to and what we can do immediately. We agree that it makes sense to have an all-Ireland service for movement disorders and access to deep brain stimulation. It may be that one of those first steps would be access to either a movement disorder specialist nurse or a deep brain stimulation nurse specialist. We have to look at the steps that are required to get us to the service that we want to see, which is access to full multidisciplinary services for our patients.

Ciara Conway (Waterford, Labour)
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When is the consultation due to conclude?

Jillian van Turnhout (Independent)
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What is the timeframe?

Dr. Áine Carroll:

The document has just gone out for consultation. We hope to have the responses back in a timely fashion. We will have that model of care signed off as quickly as we can. I do not think there needs to be any significant delay while we are waiting for that document to be signed off. The temptation is to rush ahead and decide on a deep brain stimulation nurse specialist when what we really need to do is find out what is the greatest need for these individuals and how best can we provide that in an all-Ireland capacity.

Ciara Conway (Waterford, Labour)
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What is Dr. Carroll's best estimate of how long the consultation will take?

Dr. Áine Carroll:

I can find out the closing date for comments and I will inform the committee.

Ciara Conway (Waterford, Labour)
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I thank Dr. O'Connell, Ms Fitzgerald and Dr. Carroll for their attendance. It is the intention of the committee to draw up a report following our meeting in November and this follow-up meeting today. It is our intention to present the report to the Minister. We will ask him to raise the issue at the next North-South Ministerial Council. We will also be seeking a joint committee meeting with our colleagues in Stormont in the very near future. I imagine that this topic will be one of the issues to be discussed.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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It is very important that the health services are at least on the same page - which I accept is the case - but I would also appreciate if they were at the same pace, because not only are we most certainly committed to co-operation in this regard, but we see all-island co-operation on health care delivery as a hugely important area which is under-explored in so many ways. This is an indicative issue in terms of the scope of what can yet be achieved. I emphasise that it is very important in terms of the ongoing engagement, not only at ministerial level but at inter-parliamentary level, the very point being that it has been collectively agreed by all of the political parties on this island that this will be a substantive issue for address next May in Stormont. I do not want to go there if we are still not across the line with this. I appeal to people at the helm of our health services to move at the same pace so that we get this across the line and are happy to say, "Look what we have achieved here." We now need to be looking at what else we can achieve to our mutual benefit and to the benefit of the cost element of health delivery systems North and South.

Ciara Conway (Waterford, Labour)
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I thank Deputy Byrne for deputising for me this morning. I apologise again for my late arrival.