Oireachtas Joint and Select Committees
Wednesday, 8 February 2017
Joint Oireachtas Committee on Health
Catheterisation Laboratory Clinical Review: Discussion
1:30 pm
Michael Harty (Clare, Independent)
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The purpose of this session is to engage with Dr. Niall Herity on the independent clinical review of the provision of a second catherisation laboratory at University Hospital Waterford. On behalf of the joint committee, I thank him for making himself available to engage in this discussion.
I draw Dr. Herity’s attention to the fact that, by virtue of under section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the joint committee. However, if Dr. Herity is directed by the committee to cease giving evidence on a particular matter and continues to do so, he is entitled thereafter only to qualified privilege in respect of his evidence. He is directed that only evidence connected with the subject matter of these proceedings is to be given and is asked to respect the parliamentary practice to the effect that, where possible, he should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.
I advise the witness that any submission or opening statement that he makes to the committee may be published on the committee's website after this meeting.
Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.
I invite Dr. Herity to make his opening statement.
Dr. Niall Herity:
Towards the end of May 2016, I was asked by the Minister for Health to undertake an independent clinical review of provision of a second cardiac catheterisation laboratory, also known as a cath lab, at University Hospital Waterford, UHW. The terms of reference were as listed in the published final report, which the committee has received. Following preparatory work, I visited UHW on 7 June, Cork on 16 June and had separate detailed meetings with representatives of the acute coronary syndrome, ACS, programme, the Department of Health, the national ambulance service and the Health Service Executive.
I applied the following principles to the work: the primary concern is the quality of care that patients receive; conclusions and recommendations will be driven by data; and conclusions and recommendations will reflect scientific evidence as summarised in the published guidelines of relevant professional bodies. The terms of reference required me to assess the needs of two distinct groups of patients, those undergoing planned, non-emergency procedures - approximately 96% of the patients - and those undergoing an emergency procedure called primary PCI, amounting to approximately 4% of the patients. Regarding the 96% of patients who required planned, non-emergency procedures, my analysis indicated that the effective catchment population for the UHW cath lab was 286,147. The cath lab procedural needs of this population could be accommodated in 12 weekly cath lab sessions of four hours each. Hence, a second cardiac catheterisation laboratory at UHW was not justified on this basis.
I made the following recommendations. The range of planned cath lab work that UHW currently undertakes for its catchment population should continue. The cath lab service at UHW should be funded and staffed to provide 12 sessions of planned cath lab activity weekly. A contingency for radiological equipment failure during a procedure, such as a portable fluoroscopy unit with an image intensifier, should be established if it is not in place already. The cardiology services in the south-south west hospital group, and especially the teams at UHW and Cork University Hospital, CUH, should agree a strategy that makes best use of their combined excellent skills, cath lab facilities and teams in order to optimise clinical outcomes for all of the patients across the hospital group.
Regarding the 4% of patients who undergo emergency procedures, I concluded that the limited-hours, daytime primary PCI service at UHW does not meet the British Cardiovascular Intervention Society, BCIS, minimum standard of 100 cases per year. BCIS has since updated its guidance and the absolute minimum standard is now 150 cases per year unless there is extreme geographical isolation. The updated BCIS guidance has been made available to the committee.
It was, and remains, my opinion that expanding the service to provide 24-7 cover is not a sustainable solution. Of the options available to resolve this situation, I concluded that UHW should cease the provision of primary PCI and that the interventional management of patients with ST elevation myocardial infarction, STEMI, from this region should be consolidated in CUH and St. James's Hospital, Dublin.
I made the following recommendations. The current limited-hours provision of primary PCI at UHW should cease so as to allow the centre to focus on the much larger volume of planned cath lab work. Patients arriving to the emergency department at UHW should be considered as within a 90-minute drive time of CUH and should be transferred there for primary PCI without delay, irrespective of the time of day or night. The interventional cardiologists at UHW should continue to make their primary PCI skills accessible for the benefit of patients by taking part in the 24-7 primary PCI rota centred in CUH. A group of local clinical stakeholders, including representatives of the ambulance service, should review the current operation of the optimal reperfusion protocol for patients with STEMI in the south east who are more than a 90-minute drive from a 24-7 primary PCI centre. The group should design the best future reperfusion protocol for these patients and should be led by the ACS programme of the HSE.
Michael Harty (Clare, Independent)
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I thank Dr. Herity. I will open the floor to members, whom I will call in groups of three. First will be Deputies Butler, Cullinane and O'Connell.
Mary Butler (Waterford, Fianna Fail)
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On 17 October, I wrote to this committee requesting that it examine the Herity report and invite the relevant stakeholders to a meeting. I thank the committee for facilitating that.
As Dr. Herity will be aware, there has been considerable fallout since the publication of the report. The consultants working in UHW believe that it is flawed and have rejected its findings.
In 2012, Professor John Higgins wrote clearly on page 87 of his report:
Waterford Regional Hospital will continue to provide invasive cardiology services for the South East population. Working in collaboration with the cardiology service in Cork the current service should be extended with new joint appointments of cardiologists.
Professor Higgins is a key stakeholder as author of the Higgins report and the chief academic officer of the hospital group. Why did Dr. Herity not consult him before undertaking this report?
I wish to address the apparent undercalculation of the catchment area. In Dr. Herity's report, his stated opinion was that 286,147 was the referral population for planned cardiac cath lab procedures. The 2016 census puts the catchment population at 582,000. I put it to Dr. Herity that the catchment area is somewhere between 350,000 and 400,000 people, that is, anyone living within 90 minutes of UHW. The report makes no reference to the 40% of patients who have private cover and travel to Dublin and Cork because there is no available capacity in UHW. The calculations used did not take into account all of the factors and the review is inadequate, given that it is based on incorrect population figures.
One of the most worrying aspects is the note prepared by the HSE prior to Dr. Herity commencing his deliberations. The note reads: "it has been the view of the Department that providing additional facilities and extending PPCI (angioplasty) services, in a geographical area which does not have the population base to justify such a service, would be wasteful of very limited resources." It is clear that the HSE was attempting to point Dr. Herity in the opposite direction prior to him commencing his deliberations. This was gross interference in an independent review. How did this recommendation from the HSE affect Dr. Herity's outlook and the overall report, including the findings?
David Cullinane (Waterford, Sinn Fein)
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I have a number of questions that require "Yes" or "No" answers. If I might put them first, they will inform my other questions. If I do not get answers in "Yes" or "No" terms, I will not be able to put my other questions. They are simple questions. I am using my time in whatever way I feel is best to get responses from the witness.
Mary Butler (Waterford, Fianna Fail)
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Would it be better if I received my answers first? There could then be toing and froing with Deputy Cullinane.
Michael Harty (Clare, Independent)
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We are grouping the questions in threes.
Mary Butler (Waterford, Fianna Fail)
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Okay.
Michael Harty (Clare, Independent)
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Deputy Cullinane will have an opportunity to contribute again.
David Cullinane (Waterford, Sinn Fein)
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I understand that, but these are simple questions that require "Yes" or "No" answers. I will then get to the substantive questions, if that is okay with the Chairman.
Has Dr. Herity ever worked in a cardiac unit with one catheterisation lab that does both planned and emergency work? Has he ever had any oversight of a single-lab unit that works with the two distinct patient groups to which he referred?
David Cullinane (Waterford, Sinn Fein)
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That is okay. In the preparation of his report, did Dr. Herity meet Dr. Aidan Buckley, the senior cardiologist in Wexford, Dr. Niall Colwell, the senior cardiologist in Tipperary, or Professor John Higgins, the author of the Higgins report and a senior academic consultant at the south-south west hospitals group? Did he meet those three individuals?
David Cullinane (Waterford, Sinn Fein)
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Dr. Herity either met them or did not meet them. Did he consult them?
Michael Harty (Clare, Independent)
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Yes, go ahead.
David Cullinane (Waterford, Sinn Fein)
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“No” is the answer. I have a number of substantive questions for Dr. Herity now. I am trying to contextualise the report’s recommendations. Please forgive me if I oversimplify them and if I am wrong in my analysis of the report, Dr. Herity can correct me.
If I am reading this right, from Dr. Herity’s report and his opening statement, he quite rightly makes a distinction between patients who are coming in for planned work and emergency work. We have one lab in University Hospital Waterford. At the moment it does emergency work from 9 a.m. to 5 p.m., Monday to Friday, and planned work as it can. Dr. Herity recommended that the hospital should focus on planned work almost entirely and that emergency work should be done in Cork. Essentially, all emergency patients in the south east should, at any time of the day or any day of the week, go to Cork or to Dublin. That was his recommendation. Would that be a fair summation?
David Cullinane (Waterford, Sinn Fein)
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Dr. Herity’s report has essentially been torn up because the Government is now saying that the emergency services - the 9 a.m. to 5 p.m. services - which are currently available at University Hospital Waterford will remain in place. The Minister and the Department have said that. If that had been in Dr. Herity’s terms of reference from the start and if he had known, while doing his work, that this was the outcome with which the Minister would run, would that have altered the final report?
The whole logic of Dr. Herity’s report is that the hospital should focus on planned work. How is it, then, that almost all of that planned work is now being outsourced to hospitals in Cork? We know that 130 patients who needed planned work have already been outsourced. I received a reply from the HSE which says that there is a service-level agreement in place between a number of private hospitals and a public hospital in Cork for the referral of patients from Waterford and that 130 have already been sent to Cork. The reply goes on to say that there will be three more phases, with 87 patients in phase one, 120 patients in phase two and 124 in phase three. What is happening in practice is the complete opposite of what Dr. Herity proposed and in that sense, we are getting the worst of all worlds. My simple question to Dr. Herity is a very obvious one. The logic of his proposition was that University Hospital Waterford should only provide for planned work and that emergency work should be done in Cork. However, the Minister is saying, quite rightly in my view, that Waterford should not lose any services and should hold on to its 9 a.m. to 5 p.m. emergency cover. The planned work is being outsourced to Cork. How is that in line with what Dr. Herity has recommended? Indeed, given that it is not in line with what he recommended, does that not show that this is a complete mess? If Dr. Herity had known what the outcome of the Minister’s interpretation of his report would be, maybe his analysis and observations would have been different.
Finally, the people of the south east and Waterford in particular were very upset with Dr. Herity’s report. Dr. Herity will justify his report but the people were upset for very obvious reasons. One thing that upset them the most was the notion that patients can get from any part of Waterford or the south east generally to a hospital in Cork or Dublin in 90 minutes. If a person has a heart attack, he or she has to call an ambulance and the ambulance has to come to his or her house. That takes time. The person then has to get into the ambulance and be transported to Cork. I do not know if Dr. Herity has used the Cork to Waterford road recently. It does not bypass a lot of towns or villages. When the person gets to the hospital, he or she has to be taken out of the ambulance and so on. What evidence does Dr. Herity have to show that this can be done in 90 minutes? In the context of those patients who have to be airlifted, did Dr. Herity know that helicopters cannot land in University Hospital Waterford or in any of the hospitals in Cork? They land outside the hospitals and patients have to be transported to and from the helicopters by ambulance.
I hope Dr. Herity will appreciate the wider point I am making. He published a report, which recommends that the hospital in Waterford prioritises planned work and outsources emergency work to Cork but the policy, it seems, is now the complete opposite of that. I ask Dr. Herity to respond to that point when he gets a chance.
Michael Harty (Clare, Independent)
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Thank you Deputy Cullinane. I now call Deputy Kate O'Connell.
Kate O'Connell (Dublin Bay South, Fine Gael)
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I thank Dr. Herity for coming in to speak with us today. The British Cardiovascular Intervention Society, BCIS, recommends that 100 to 150 cases should be seen per year. Perhaps Dr. Herity, in his professional capacity, could explain to the committee the basis for that figure. I would imagine, as a health care professional myself, that it is related to throughput of patients and maintaining skill levels. I also ask him to explain what the BCIS is and the relevance of the guidance that comes from that body. I ask him to outline how guidelines from certain bodies are fed down as best practice to clinicians. In the case of psychiatry, orthopaedics and so forth, guidance comes a particular body, is fed down and clinicians take that guidance on board. Clinicians do not just make up their own way of doing things as they go along.
I ask Dr. Herity to expand on his own background and experience. Questions have already been posed as to where he worked previously but I am interested in his professional experience and why he would be considered an expert in this field. From the data already supplied, I can see clearly that he is an expert in the field but I ask him to expand on that a little.
Does Dr. Herity believe that he undertook an independent clinical review? Does he still consider that to be the case? Does he feel, despite all that has been said, that he acted independently, in his professional capacity and that he was in no way pushed or shoved in any particular direction by anybody?
I understand what Deputy Cullinane is saying but invasive cardiology is a major specialty and it should, one assumes, be carried out in a centre of excellence. My understanding of the report is that standard, scheduled, elective procedures should be done between 9 a.m. and 5 p.m. and that emergency procedures should be sent to Cork, which has the facilities and expertise to deal with the complexities that might arise with emergency cases. Does Dr. Herity have any data on patient outcomes in centres of excellence as opposed to other centres?
Was Dr. Herity happy with the resources given to him to prepare his report? On reflection, given all that has happened and leaving politics out of it, does he still stand by his report from a professional perspective?
Michael Harty (Clare, Independent)
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I thank Deputy O'Connell. In deference to the Minister of State, Deputy Halligan, who is probably under pressure for time, I will allow him some short questions and he can come back in again later if he needs to.
John Halligan (Waterford, Independent)
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I will be very brief.
David Cullinane (Waterford, Sinn Fein)
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We are all under time pressure. I have no difficulty with that but, with respect, simply because someone is a Minister of State, it does not mean they should get special treatment.
John Halligan (Waterford, Independent)
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I do not mind. I will wait; there is no problem.
David Cullinane (Waterford, Sinn Fein)
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I have no difficulty but the distinction between Oireachtas Members is not helpful.
John Halligan (Waterford, Independent)
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Was I in line to ask this question?
Michael Harty (Clare, Independent)
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If there is a problem, we will go to Dr. Herity and we will come back to the Minister of State.
John Halligan (Waterford, Independent)
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I am okay with going to Dr. Herity to answers questions first and then coming back to me. That is fine.
Michael Harty (Clare, Independent)
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I thank Dr. Herity.
Paudie Coffey (Fine Gael)
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On a point of order, given what Dr. Herity has said, would it not be in order to take the five or six of us first? We will not delay too much longer and then Dr. Herity can give a more comprehensive reply.
David Cullinane (Waterford, Sinn Fein)
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I have no objection to that.
Michael Harty (Clare, Independent)
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I accept that. We will continue with the questions.
John Halligan (Waterford, Independent)
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I will be very brief. Some of the questions will require a "yes" or "no" answer. Did the review take into account the clinical risk and safety? Is it not general practice that the clinical safety of the patient is paramount in the review? Does Dr. Herity believe the recommendations of the report would have been different if clinical risk and safety were explicitly included in the terms of reference? I will refer to the briefing note from the HSE which was sent to Dr. Herity. It said the second cardiac laboratory at University Hospital Waterford, UHW, was not a top investment priority. Did Dr. Herity take this note into account when conducting the review? Did it influence the outcome? Was the HSE's reluctance to commit to the second cath lab raised during the various conversations that took place between Dr. Herity and the HSE officials? They are fairly straightforward questions.
Does Dr. Herity accept the methodology used to calculate catchment population for cardiac services in the south east and patient flows to the unit in Waterford did not take into account constraints on the capacity of UHW, which all of the consultants have noted? I am almost finished. In the report, it said it would be a mistake to assume the effective catchment area for UHW was represented by every resident of the counties in the region, as this would take into account the different levels of cardiac care provided by the different hospitals. Is it general practice to use the effective catchment area while undertaking reviews? Has Dr. Herity ever used this process previously?
I have two more brief questions. Dr. Herity said he did not make contact with the consultants, whom I have met, in Wexford and Tipperary, and they were not visited. Will Dr. Herity tell us why? He gave a direct answer and said he did not so I would like to know why. Does Dr. Herity accept that their inclusion would have brought the UHW unit above the minimum requirements? Cork University Hospital, CUH, performed 650 PCIs, which are cardiac stent procedures, in 2015, while UHW performed 580. In addition, CUH has a minimal waiting time for angiography, while wait times for patients in the south east averaged 18 months. Does Dr. Herity think, based on that alone, that there is a case for an additional lab at UHW on the grounds of equity of access?
Perhaps Dr. Herity will come back to me on the "yes" or "no" questions when he is replying.
Keith Swanick (Fianna Fail)
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I welcome Dr. Herity. I will follow up on something the Minister of State and Deputy Cullinane mentioned earlier with regard to the fact that 40% of the workload undertaken in UHW is performed by consultants Dr. Niall Colwell from South Tipperary General Hospital and Dr. Aidan Buckley. Why were these consultants not spoken to or consulted with? I would have thought it prudent for all stakeholders to be included in this process. Second, one of the recommendations in the report is an extra eight hours weekly in the cath lab in Waterford. It would take between 12 and 18 months using these eight hours to clear the current waiting list. This is not a solution; it is a sticking plaster. Why only eight hours? How many preventable cardiac deaths or events will have occurred in that 12 to 18-month period? In 2013, the lack of a second cath lab in UHW was noted by the HSE as being a "critical clinical risk on its risk register". Did Dr. Herity consider this when undertaking his report? In March 2016, the south west hospital group approved a second cath lab as a priority. It was signed off by the CEO and it was queued for funding? Did Dr. Herity consider this when he was conducting his report?
Paudie Coffey (Fine Gael)
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I commend the committee on this work because it is a very significant national issue in terms of equality of access for patients to specialist care but more especially patients in the south east. Given what we heard in Dr. Herity's opening statement and his analysis regarding population and catchment, I want, with the Chairman's permission, to put on the record of the House some commitments that were given to me in writing by significant people in the Department of Health and the HSE. In February 2013, the architect of the hospital reform group, Professor John Higgins, stated in his report:
Waterford Regional Hospital will continue to provide invasive cardiology services for the South East population. Working in collaboration with the cardiology service in Cork the current service should be extended with new joint appointments of cardiologists.
On 13 May 2013, in a letter to me, the former Minister for Health, Senator James Reilly, stated:
The establishment of Hospital Groups will enhance cardiology cover in Waterford regional Hospital. At present, this is provided 9am to 5pm. The increased flexibility of staff across the group will enable us to achieve our goal of providing cardiology cover at Waterford Regional Hospital 24 Hours a day, 7 days a week.
On 14 April 2014, the CEO of the south east hospital group, Mr. Gerry O'Dwyer, wrote to me about interventional cardiology services stating:
The Cardiology Department of Waterford Regional Hospital is the regional service for 500,000 people and offers a comprehensive range of invasive and non-invasive diagnostic services including: E.C.G., Exercise Stress Tests, 24 hr. Ambulatory monitoring, Permanent Pacing and Follow up ... The provision of invasive cardiology procedures is both a clinical and political priority. It is essential that this service is located at Waterford Regional Hospital to serve the population of the South East.
Finally, I will read from a letter from the director general of the HSE who is still in situ. On 16 October 2014, in a letter to me, he wrote:
A business case has been prepared and was forwarded as part of the 2015 Estimates, for expansion to a twenty four hour service, seven days a week ... and the associated requirement for a 2nd Cath Lab. This will be re-examined in the 2015 Service Planning process.
He then goes on to speak about the costs.
My question to Dr. Herity about those very significant written commitments, which are now on the record of the Houses of the Oireachtas, is when he was doing his analysis of the population and catchment, were those same sentiments from the Department of Health, the HSE CEO of the hospital group and from the director general of the HSE made available to him in his analysis of the population and catchment? It is a critical and fundamental issue in this debate.
Regarding the throughput, Dr. Herity says University Hospital Waterford is below the minimum of 100 per year. I take it he takes that standard from the British Cardiovascular Intervention Society. Is it any surprise to Dr. Herity that it is below 100 a year when it is a service that only operates between 9 a.m. and 5 p.m., five days a week? Would he contend it would be in excess of the 100 per year throughput if it had a 24-7 service, which would then justify the requirement for that full-time service at that location? Will Dr. Herity answer that question? The standard referred to by the British Cardiovascular Intervention Society refers to where there are exceptions, such as where there is geographical isolation.
I strongly contend - as, I am sure, would other colleagues - that the south east is being treated in a geographically isolated manner in the context of the provision of this vital and critical service, which, for some, can mean the difference between life and death, and how people can access it.
Dr. Herity is an expert in his field and 90 minutes is often referred to as being the critical period in terms of cardiac care. He refers in his report to the fact that a patient can travel from Waterford city to Cork on the N25 within that 90-minute period. Has he ever driven from Waterford city to Cork city and, if he has, how long did it take? Is he aware that there are many bottlenecks on the N25, with which we are very familiar? I contend that it is impossible to reach Cork University Hospital from Waterford city in 90 minutes.
Michael Harty (Clare, Independent)
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Quite a number of questions have been put to Dr. Herity and he might address them in so far as is possible.
Dr. Niall Herity:
I will try to answer the questions in logical sequence because there was some overlap among them. However, I will first speak about my own background. I am an interventional cardiologist and I practise in this field of medicine on a daily basis. I have been an interventional cardiologist for about 25 years. The centre where I work, which is the Belfast Trust, is a very large interventional cardiology centre, one of the largest in the United Kingdom. In addition to being a full-time practising interventional cardiologist, I am also the clinical director of cardiology in Belfast. This means that in addition to considering the work I do for the patients who come to see me, I also have an overarching responsibility for ensuring the quality of care in the service, which is delivered not just in the Belfast Trust but for patients across the Northern Ireland region, which is the population we serve. As part of my work as the clinical director of the Belfast Trust, I have overseen the merger of some very large hospital services, namely, the Royal Victoria Hospital, Belfast City Hospital and the Mater hospital into a single entity - the Belfast Trust. I found many striking observations when I was considering not the merger but the grouping of the Waterford and Cork teams and the opportunities this provided. That is my personal background and experience.
In the context of how I came to be asked to undertake this work, the Department of Health in the Republic of Ireland made an official approach to the Department of Health in Northern Ireland to nominate somebody who was thought to be an expert in this area. It is was on that basis that I was asked to consider whether I would take it on. In doing so, I asked a few questions of myself, including: whether I had any conflict of interest - the answer to which was "Absolutely not"; whether I had the expertise and experience, or more importantly, was there anybody else in the health service in which I work who has more expertise and experience in this field and my judgment on that was "No"; and whether I had the opportunity or the time to take on this job for the Irish Government, the answer to which was "Yes, I could make the time given that it is such an important consideration". That is my background and how I came to be asked to undertake this work.
Many of the members have made reference to the British Cardiovascular Intervention Society, BCIS, as have I. The BCIS is a professional body. It is not constituted by the Government, rather it is a body representative of the interventional cardiologists across the United Kingdom. That includes England, Scotland Wales and Northern Ireland. I am a member of the BCIS, which has many hundreds of members, pretty much all of whom are interventional cardiologists. As part of its remit as an interventional cardiology grouping, it produces standards in the field of interventional cardiology, to which most centres in the United Kingdom will refer and will seek to comply. It is interesting that even since this report has come out, the minimum volume standard which had been, as was pointed out, set at 100 cases per year for the emergency workload has risen to 150. If I was asked does that have a legal background, I would reply that it does not. What it does have, however, is a professional background, namely, that it is the considered view of the expert professionals in this field that when undertaking high-stakes emergency work in the context of patients who are very sick and have acute myocardial infarction, those patients should be treated at centres that have high-volume services and the minimum in that regard has been set at 150 cases per year. It is described as an absolute minimum. The professionals in question point to extreme geographic isolation. In the United Kingdom and every other country, there are percentages and populations that live outside a 90-minute travel time to primary percutaneous coronary intervention, PCI, centres. My sense is that when they refer to extreme geographic isolation, they are not talking about mainland towns or cities but to people who live on islands or in other extremely isolated areas.
A few questions were asked about who I consulted as part of the six-week process. I visited University Hospital Waterford on 7 June. I gave notice that I was coming and I made no restrictions on who should be invited or who should attend. This was absolutely at the discretion of the team in the University Hospital Waterford. If it was thought that the most suitable people to attend would be patient representatives, elected representatives, journalists, clinicians and hospital managers, this was entirely at the discretion of the team from University Hospital Waterford and I placed no restriction on that. As it turned out, there was a very representative team and a very representative presentation was given. At the time, the views of the teams from both Wexford and South Tipperary hospitals were, in my opinion, well represented. I left with the strong impression that the teams from Wexford and South Tipperary hospitals were very satisfied with the support they get when they work in University Hospital Waterford, that they do very high-quality work there and that they would be more than happy to continue both this work and referring their patients to Waterford. I also placed no restrictions on how long I would stay. I arrived at about 10.30 a.m. and had it been necessary to stay until 10 p.m., I would have been happy to do so. As it turned out, the meeting finished in the early afternoon at the decision of the local team. Subsequent to that, I travelled back to Belfast, but I would have been more than happy and delighted to meet anyone from the local area who could have been invited along on that day to meet me.
The issue of the catchment area was raised a few times.
Paudie Coffey (Fine Gael)
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On the issue of consultation, Professor John Higgins was the architect of the hospital groups and it is important that Dr. Herity addresses that.
Michael Harty (Clare, Independent)
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A huge number of questions were put to Dr. Herity and we should give him an opportunity to reply to them.
Paudie Coffey (Fine Gael)
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He was moving on from the consultation phase there.
David Cullinane (Waterford, Sinn Fein)
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With respect, it is a bit disingenuous for Dr. Herity to say that he turned up at the hospital and he was at people's mercy. If one is the architect of a report and one is carrying out an independent report, it is one's responsibility to ensure that one consults the appropriate people. Therefore, Dr. Herity should have made sure that cardiologists from Wexford and Tipperary hospitals were present. He should also have made sure that Professor Higgins was there. It is disingenuous of him to say that he turned up and he would have stayed all day but that they were not there. He had a responsibility in this regard. He was the person carrying out the consultations. He left the matter in the hands of the hospital management, as far as I can see, and now he is washing his own hands of it. He failed to consult the appropriate people, full stop. He should at least take responsibility for that failure.
John Halligan (Waterford, Independent)
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This is incredible and Deputy Cullinane is correct. It is incredible to think there would be people in other parts of the south east - for example, in Clonmel, Wexford, Kilkenny and so on - that Dr. Herity would have known would have been coming to perform procedures in University Hospital Waterford and would have been directed by the consultants there. It is also incredible that Dr. Herity waited for somebody in University Hospital Waterford to tell him to go and see them or that he wanted the consultants there to bring representatives from those areas to which I refer. Surely he would have been told by the HSE that the hospital was being serviced from Clonmel, Wexford and other areas. I would have thought that Dr. Herity would have said that he wanted to hear what those consultants are saying. The statement he made is outrageous, namely, that he did not think it appropriate or that he waited for somebody to tell him to meet consultants he should have met.
The south east is not Waterford. This is very important. Dr. Herity met the consultants in Waterford. It is a hospital representing the south east and not Waterford. Dr. Herity did not meet anybody else outside Waterford.
Kate O'Connell (Dublin Bay South, Fine Gael)
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With respect, Chairman, we said we would let everybody in and we would let the witness answer. I take exception to somebody being treated like this and the barrage he is facing. We said three and then we said six, and we said we would let the witness answer. I do not think it is appropriate to have all us all jumping in ad hocand making accusations. Let us do it afterwards.
David Cullinane (Waterford, Sinn Fein)
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That is why we are here - to hear statements of fact.
Kate O'Connell (Dublin Bay South, Fine Gael)
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I just think we are moving-----
Michael Harty (Clare, Independent)
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We are going to go back to Dr. Herity. We gave him many questions and we will give him an opportunity to speak. Everybody will have an opportunity to come in again. I call Dr. Herity.
Dr. Niall Herity:
Maybe I will move on to talk about the catchment area which generated many questions. I direct members to figure 3.5 on page 19 of my report, which they should have before them. I want to take members through the method for calculating the catchment area of this cath lab. Figure 3.5 is so important because it contains the data that were provided to me by the team in Waterford itself. It shows that patients coming for cath lab procedures from the south east tend to fit into a fairly defined geographical profile. For example, a large number of patients come from Wexford, Waterford and Tipperary South, a smaller number of patients come from Kilkenny, and then a very small number of patients come from Tipperary North, Carlow and Wicklow. These data were a good start to make a calculation of the effective catchment population for this cath lab.
I now go back a page to table 3.4 which shows a separate data source looking at the patients coming for cath lab procedures through the cath lab in Waterford, broken down by county. The second column from the right shows that during 2015, a total of 346 patients attended any cath lab for a cath lab procedure. The majority of these people actually attended the cath lab in St. James's Hospital in Dublin. A proportion did attend University Hospital Waterford. The last column on the right shows that proportion was 6%. We then go to Kilkenny, a larger county with a larger population. A total of 458 people attended a cath lab, of whom the majority, 307, went to St. James's Hospital in Dublin, but a proportion, 26%, did go to Waterford. From Tipperary North, the vast majority of patients went to Limerick. A smaller number of people went to other centres listed, including 9% who went to Waterford. Then 53% of Tipperary South, 86% of Waterford and 69% of Wexford procedures were done in University Hospital Waterford. The value of this table is that it comes from a completely different source, the HIPE dataset. It shows a pattern that mirrors exactly the data demonstrated by the Waterford team. That is likely to validate the accuracy of both datasets.
I now go forward two pages to page 20 to show how this percentage calculation is applied to the 2016 census. The 2016 census report came out during the week I submitted the report. I deliberately held it back because I knew the report was scheduled. We were able to produce exactly up-to-date data on the population of this area. It shows that the overall population of the six counties, including Tipperary split into north and south, was 582,440. If we then break down the effective catchment population of each of those counties, Carlow, Kilkenny, Tipperary North etc., based on the percentage of patients who attended Waterford cath lab during the calendar year 2015, we found that the 6% for Carlow translated to 3,413, the 26% for Kilkenny translated into 25,771 and on down, giving a final effective catchment population of 286,147. That is the basis on which that catchment population has been arrived at.
Somebody mentioned private patients. I did not have any available data for the movement of private patients. In a mixed health care economy, as the Irish health care economy is, certainly there are private patients who move from one county to another and get treated in different places. However, these data specifically refer to the public hospital population.
There were questions about undue influence, interference and briefings. I received multiple documents and briefings as part of this process. I received briefings from as many sources as I thought was relevant, including published documents in the public domain, including Professor Higgins's report, briefings from the Department of Health, and briefings and presentations from local clinicians and consultants, the Health Service Executive and the acute coronary syndrome programme of the Health Service Executive. All this background information provided context for my review.
The other background information was the professional advice issued by international guideline groups, such as the American College of Cardiology, the American Heart Association, the European Society of Cardiology, BCIS that we mentioned, the Irish Cardiac Society and so on. All of these background documents and briefings provided context for my review and I took all of it into account. However, my conclusions are completely independent. They do not reflect any one or single aspect of that briefing or those background documents. Everybody I met was at pains to point out the independence of my position in regard to writing this report. Nobody tried to influence the process inappropriately. I am happy to have reached the conclusions I did and they remain my conclusions.
There was a question about the Minister's response to the report and the implementation or otherwise of the report. It is now a judgment for the Irish health care system, the Government, the Minister for Health and anybody else whether and how to implement the report. I do not have any views on that. I would not agree with the terminology that the report has been torn up. I do not think that is the case. I am not in day-to-day contact with anybody in the Department of Health or with the Minister, having submitted the report. It is now a matter for the Irish health care system to take forward.
Two people separately asked about the travel times from Cork to Waterford. They were taken directly from real world emergency ambulance journey times from Cork to Waterford which actually took place between October 2015 and June 2016. They are specifically referenced in the report. The number of journeys undertaken was relatively small at 15 to 20. The median journey time by a blue light ambulance carrying an emergency patient from Waterford hospital to Cork by road, not helicopter, was 88 minutes. That is where that figure came from.
Paudie Coffey (Fine Gael)
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It does not allow for any stoppages along the way owing to, for example, roadworks.
Paudie Coffey (Fine Gael)
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The N25 is being renovated. I am just making a point for the record.
Paudie Coffey (Fine Gael)
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Some 88 minutes.
Paudie Coffey (Fine Gael)
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Two minutes margin.
Dr. Niall Herity:
----- the Deputy or me travelling between Cork and Belfast, Waterford and Belfast or Cork and Dublin. Of course, it reflects the real world everywhere else.
The 90-minute travel time is a standard set by the acute coronary syndrome programme of the HSE. Senator Coffey has pointed out the variability in transport time or travel time that can occur, but that is really an international phenomenon. That exists for people in the north and west of the country and so on. The point of setting a standard is at least to give clarity to the ambulance crews on whether to transport a patient.
It was important to get those real-world ambulance transport data because they showed that the catchment isochrones or time travel zones were substantially more or greater than elsewhere.
Was I happy with the resources I was given? I was. The six-week timeframe for this tranche of work was challenging. I recognised the urgency of the work being undertaken. I recognised the urgency of the context in which I was being asked to undertake the review and the impatience of people to see some sort of outcome or solution.
On reflection – someone else used the term earlier – I believe this is how all similar reviews should be undertaken in future. It was clear to me that by setting a six-week timeframe everyone involved in the process was fully concentrated on the job at hand. Every time I asked for data, information or anything, it came back to me within a day or two. It was a substantial body of work to undertake in six weeks. Someone described it as six months' work done in six weeks. I reckon that is not far from the truth. Anyway, I was more than happy with the resources provided to me and the responsiveness of those whom I approached for information, data, briefings and documents.
Michael Harty (Clare, Independent)
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I am going to allow some supplementary questions to go forward and back.
David Cullinane (Waterford, Sinn Fein)
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I wish to make a quick comment but I will give way to the Senator.
Mary Butler (Waterford, Fianna Fail)
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Senator Swanick has to leave.
Keith Swanick (Fianna Fail)
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My question is brief. The question is not in my role as a Senator but as a doctor. It is from one doctor to another. Does Dr. Herity believe that in the absence of a second catheterisation laboratory and a 24-7 service, lives are being endangered and people are dying? It is a simple question.
Dr. Niall Herity:
The short answer is: no, I do not. The management of the ST segment elevation myocardial infarction programme that has been set for the Republic of Ireland as a whole includes a certain number of standards. I will outline the standards. First, the programme should be provided on a 24-7 basis. Second, patients who are brought to a centre should be within a 90-minute travel time in order to be brought directly for primary percutaneous coronary intervention. The British Cardiovascular Intervention Society, BCIS, standard I have recommended is that patients should be treated in high-volume centres. Each of these aspects feeds in not only to the programme in the south east but to the programme throughout the country. This is the reason that these are the circumstances in which best quality care is delivered.
It is absolutely the case, not only in Ireland but in every country, that a percentage of the population sits outside those 90-minute isochrones. This is the case in the United Kingdom, Denmark and the Netherlands. It is very much the case in countries like Canada. In those countries, the health care systems implement targeted systems for those populations to ensure they get equal quality of care. I referenced some of those towards the end of the document.
I outlined the options. The first option is to do what they do in Denmark: accept that people may have an extra five or ten minutes of travel time and transport the patient anyway. The second option is to give a specialised drug, which committee members will be familiar with, called thrombolytic therapy, then put the patient in the ambulance and transfer the patient immediately to the centre that provides the service. That is called drip-and-ship. Another option is to look at alternative means of transport. The example I gave was the helicopter system implemented fairly successfully in Donegal, as I understand it, for bringing patients to Galway prior to the establishment of a 24-7 centre in Altnagelvin Area Hospital in Derry. I did not reach any final conclusion on how that additional protocol should be implemented for the patients of the south east because I thought it was too much work to reach a sensible conclusion.
Keith Swanick (Fianna Fail)
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Is that not the nub of the whole situation? As a rural practitioner, I respectfully disagree with the point made by Dr. Herity that the 90-minute target time is invariably an aspiration. A 24-7 service in Waterford would cater for those patients who are being disenfranchised.
Paudie Coffey (Fine Gael)
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Should we not do something to address this for the people of the south east?
Paudie Coffey (Fine Gael)
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I am simply making the point. Dr. Herity is pointing to areas where there are already deficits. We know that. We are trying to protect our citizens in the event of an emergency. I am simply making the point. Dr. Herity had an opportunity in this report to address that deficit and he did not do it.
Paudie Coffey (Fine Gael)
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The people there do not have time either, I respectfully suggest.
Michael Harty (Clare, Independent)
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Senator Coffey, please allow the witness to speak.
Paudie Coffey (Fine Gael)
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That is fine. I am simply making the point. This is a critical issue.
Michael Harty (Clare, Independent)
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I will bring in the people who have indicated: Deputy Cullinane, Deputy John Halligan, Senator Paudie Coffey and Deputy Mary Butler. Please keep your supplementary questions short.
David Cullinane (Waterford, Sinn Fein)
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I will not speak for anyone else. I cast no aspersions on whether Dr. Herity has any conflict of interest – I do not believe he does. I have not doubted Dr. Herity's professional experience. Let us park that for a moment, if we can accept that much. That is not at play.
What is at play is what Dr. Herity has stated in his report and what he has said in his opening statement. We have a responsibility to put robust questions to Dr. Herity on behalf of the people we represent. I am keen to be clear on that.
I will go back to what I said to Dr. Herity earlier. Dr. Herity glossed over it and somewhat ignored answering the question. However, Dr. Herity cannot ignore the implementation of his report or the selective implementation of his report from the logic of it. That would amount to standing logic on its head. Essentially, Dr. Herity is telling us that one laboratory is good enough for the south east to service planned work and that all emergency work should go to Cork. In other words, what Dr. Herity described as the drip-and-ship effect should be in operation 24-7 for people who live in the south east. If an emergency arises, the person goes to Cork or Dublin. In the case of planned work, the person goes to Waterford.
The problem is that the Government does not agree with Dr. Herity. If the terms of reference stipulated that 9 a.m. to 5 p.m. PCI cover in University Hospital Waterford was non-negotiable and was not going to be touched, would that have affected the outcome of Dr. Herity's report? How can one laboratory service the planned work, as well as the PCI work from 9 a.m. to 5 p.m.? Dr. Herity's report maintains that it cannot.
I wish to go back to the demographics referred to by Dr. Herity and population mass or criteria that he used. The Higgins report states that University Hospital Waterford should be the regional provider of invasive cardiology services for all of the 500,000 people of the south east. Page 18 of Dr. Herity's report cites, rightly, that patients in Carlow and Kilkenny are going to St. James's Hospital in large numbers and that patients in north and south Tipperary are going to University Hospital Limerick and Cork University Hospital. The reason is that we have only one laboratory. If we had a second laboratory in Waterford, then those hospitals could refer patients to University Hospital Waterford. The whole logic and recommendation of Dr. Herity's report was, in a sense, a self-fulfilling prophesy. If we only have one laboratory, how can we take patients from Kilkenny or Carlow? How can we take patients from Tipperary?
Dr. Herity missed the point entirely in respect of the criteria. He ignored the promise made and the policy set out – it was policy – to the effect that University Hospital Waterford would be the regional provider of invasive and interventional cardiology for the entire south east – for 500,000 people.
Will Dr. Herity respond to the specific issues of population mass, whether, if we had a second lab, we could take those patients who are being transferred elsewhere, and whether, if it had been made very clear in the terms of reference that the 9 to 5 PCI was non-negotiable, that have put a different interpretation on his recommendations?
Dr. Niall Herity:
On the first question, it probably drifts into speculation. It would be very hard for me to say that if the terms of reference had been in some way different, what result that would have had on the content of my report. I would never have reached the conclusion that I would support a 9 to 5, Monday to Friday primary PCI service. It has been part of services both in the Republic of Ireland and the United Kingdom but all of the professional organisations which I subscribe to have consistently said the same thing------
David Cullinane (Waterford, Sinn Fein)
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Can I just-----
David Cullinane (Waterford, Sinn Fein)
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I thought my question was very direct. I will speak briefly. Can I just put this to Dr. Herity?
David Cullinane (Waterford, Sinn Fein)
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In Dr. Herity's professional opinion, does he believe that if University Hospital Waterford has PCI 9 to 5 and is also doing planned work, all of that can be serviced by one lab?
David Cullinane (Waterford, Sinn Fein)
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It is what the Government is proposing.
David Cullinane (Waterford, Sinn Fein)
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That is not the question that I am asking. I am asking, in Dr. Herity's professional opinion, if one lab can do both? Yes or no?
David Cullinane (Waterford, Sinn Fein)
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Yes or no? Can University Hospital Waterford do both the planned and emergency work with one lab?
David Cullinane (Waterford, Sinn Fein)
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That is not the question I have asked. I am asking Dr. Herity to answer the question.
David Cullinane (Waterford, Sinn Fein)
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He has not. Yes or no?
Michael Harty (Clare, Independent)
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Deputy Cullinane, please let Dr. Herity answer the question.
David Cullinane (Waterford, Sinn Fein)
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So the answer is "no"?
David Cullinane (Waterford, Sinn Fein)
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I am asking Dr. Herity.
John Halligan (Waterford, Independent)
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It is disappointing that Dr. Herity did not answer that question straightforwardly. The very first question I asked him was whether the review took into account clinical risk and safety and if it is general practice that the clinical safety of the patient should be paramount in the reviews. Does he accept that the volume of complex procedures in the part-time single cath lab is a point of failure?
Perhaps Dr. Herity could give me a straight answer to this. During the review, did he know how many were being referred out of hours? Could he tell me how many he thought were being referred out of hours or were being referred to other hospitals? Was that taken into consideration in the review? This should be a very simple answer. When Dr. Herity undertook the review, did he have these numbers? Forget about what was going into the part-time cath lab up to 5 p.m. Does he have the numbers there in front of him, or did he have them, of people that were being referred out of hours to other hospitals? That should be a very straightforward answer. He should have statistics. I cannot see them in his report.
Second, is Dr. Herity saying that, based on the figures and in his experience, if there were a second cath lab, would there be a higher volume of people using the service? It is very important however that he answer the first question regarding the clinical risk factor and whether he had the figures when he went to the area? Does he have the figures for the number of people who were referred out of hours and to other hospitals?
Dr. Niall Herity:
There were three questions there. As I recall them they were on clinical risk, the number of patients referred out of hours and whether more patients would come if there were more capacity. On the last question, I would make no assumption that would be the case. The reason is that the referral patterns of cardiologists or other specialists to specialist centres focus on many different aspects. I am a referral cardiologist and a referring cardiologist so I know exactly how this works. Much of it has to do with where those cardiologists practise their cath lab sessions. In the case of south Tipperary and Wexford, naturally the patients follow them to Waterford because that is where they have their cath lab sessions. Similarly for patients from Carlow and Kilkenny, naturally those patients gravitate towards St. James's Hospital in Dublin because that is where the cath lab sessions are. The patterns also reflect many years of experience of how good a service has been received from the various options that they have referred patients to and, indeed, long-standing interpersonal and interprofessional relationships. I would not jump to an assumption that, if capacity were suddenly to change or to double, patient referral patterns, or so-called patient flows, would necessarily and automatically also follow.
I want to answer the Deputy's very specific-----
John Halligan (Waterford, Independent)
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I do not think there is practicality in that answer in the sense that if a person is living in Clonmel or Wexford, he or she will automatically consider whether he or she will go to Dublin or go to Cork. Is it not a fact that there would be a particular volume of people who will not go to Waterford because they know that they cannot be seen after 5 p.m. or on weekends?
John Halligan (Waterford, Independent)
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Based on Dr. Herity's statistics, I ask him again, as he still has not answered, whether he was aware of the figures for referrals after hours? Was he given a list? Did he know what they were after 5 p.m.? Did he know the number of people that were being transferred to other hospitals on a regular basis or a weekly basis?
John Halligan (Waterford, Independent)
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On a monthly basis.
John Halligan (Waterford, Independent)
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Does he have those figures?
Mary Butler (Waterford, Fianna Fail)
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No, it was actually 77. I have it here.
John Halligan (Waterford, Independent)
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I have it here myself. It is a big difference.
John Halligan (Waterford, Independent)
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It is not.
John Halligan (Waterford, Independent)
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I am astounded. It appears to me now, based on his answer, and Dr. Herity can say yes or no to this, that he did not take that into consideration. He did not consider the patients that were being transferred after 5 p.m., on weekends or to other hospitals because that would have added to it.
John Halligan (Waterford, Independent)
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He is not answering me. He took it into consideration or he did not.
Dr. Niall Herity:
All of these considerations are relevant but to consider the overall picture, perhaps I could direct the Deputy to page 39 of the report and the analysis of where patients came from to be brought to the University Hospital Waterford cath lab. There were 80 activations. I believe this answers the Deputy's question. The question that is addressed in this figure is how many of those patients were already within the catchment area of a 24-7 cath lab when they came.
John Halligan (Waterford, Independent)
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The consultants in Wexford and Tipperary categorically said, and I do not know if Dr. Herity knows this but he should know it, that they would send all referrals to Waterford. Did Dr. Herity know that?
John Halligan (Waterford, Independent)
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Yes, they would refer them to Waterford.
John Halligan (Waterford, Independent)
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The consultants in Wexford and Tipperary, but Dr. Herity did not meet them so he would not have known that.
Dr. Niall Herity:
I think Deputy Halligan is confusing the planned work, which is 96% of the work and in which the consultants would have direct input, as opposed to the out-of-hours work, for which it would be the physician on call who is making the decision.
I think we are talking about two different matters. I accept-----
David Cullinane (Waterford, Sinn Fein)
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If there were a second lab, would it improve the chances of increased services in Waterford?
David Cullinane (Waterford, Sinn Fein)
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Is that because of capacity or convenience? If that service were available in Waterford, could those patients be referred to Waterford?
David Cullinane (Waterford, Sinn Fein)
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If there were a second lab, then there would be more capacity and it would have the ability to receive more patients.
Dr. Niall Herity:
As I said earlier, I would not jump to the conclusion that provision of extra physical capacity would necessarily be followed by an increased number of patients travelling to that lab who are already being well supported and serviced in the lab, as for example, in St. James’s or Cork.
Can we talk about the question, which the Deputy said I had not answered, about clinical risks and safety as well as long waiting lists? I have a waiting list and pretty much everybody I work with has one too. I saw during the week that the number of people on waiting lists across the NHS in the UK has now risen to 3.5 million. It had been as low in 2007 as 2.2 million. Unfortunately, rising numbers of people on public hospital waiting lists is not a problem unique to Ireland. It is certainly a feature of life in the United Kingdom as well.
All of us would say we would prefer nobody was on a waiting list. It does seem to be a factor of where demand outstrips available capacity across the health care system. In terms of clinical risk, one can imagine somebody who has got a diagnosis of cancer and who is waiting for potentially curative surgery. The longer they wait on a waiting list, the greater their clinical risk. Undoubtedly, that would be the case and, accordingly, what happens for cancer patients is that they get clinical prioritisation. People with cancer do not wait a long time. There are certain standards and expectations which are typically met.
The people on my waiting list would be similar to those on waiting lists for procedures in Waterford, Cork, St. James’s or anywhere. These are typically people with suspected coronary artery disease who are awaiting a coronary angiogram, which is an investigative procedure and not necessarily a therapeutic procedure. A proportion of those patients will then go on to have a stent inserted or a bypass operation. These are not life-saving procedures. There is absolutely no evidence that people who undergo stent procedures or that most people who undergo bypass operations in the elective setting are actually at any less risk of having a heart attack or dying or surviving afterwards than if they had not done so.
A small number of people on my waiting list, and undoubtedly on waiting lists in Cork and Waterford, are at greater risk. I would particularly draw the Deputy’s attention to people with aortic valve disease, particularly severe aortic stenosis, structural heart disease or people with an adverse finding from a non-invasive investigation where we think they have multi-vessel disease. In those circumstances, we apply clinical prioritisation. I do not leave someone with severe aortic stenosis on my waiting list but bring them forward because I understand the benefit. Clinical prioritisation is extremely important.
One point which has not come up which I want to draw some attention to is that when I visited both cardiology services in Waterford and Cork, I was visiting them as part of the South/South West hospital group. Separately I met with the chief executive of the hospital group. I recognise that hospital groups, as they are constructed in the Republic of Ireland, are at a much earlier and less formed stage than hospital trusts in the United Kingdom. The point about any hospital grouping is that they provide a clinical opportunity. The opportunity they provide is that one gets a critical mass of capacity available across the hospital group to do, potentially, a better job for the patients across the group. When I met with the clinicians in both Waterford and Cork, it was clear to me that at that point they had not worked out the best way to pool their combined and greatly skilled resources to do the best job for patients. I understand that in the interim there has been work between the two sets of clinicians to make best use of that critical mass and the capacity across the hospital group. I am heartened and reassured that this has taken place. I do not believe it has threatened anybody.
What that means is that certain patients on the waiting list in Waterford, particularly, are now being offered their procedures in Cork. I am seeing that, however, as a short-term measure to address the large number of people on the waiting list rather than a long-term measure to somehow divert patients away from natural patient flows. In my report, I recommended that the capacity of the Waterford lab be increased from ten to 12 sessions. That was in recognition of the increased need for the catchment population. I am heartened to see the clinicians on the ground have taken up the opportunity to combine their resources for the benefit of patients.
Paudie Coffey (Fine Gael)
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I am deeply disappointed with what I have heard from Dr. Niall Herity with regard to the levels of consultation he had before he prepared and finalised his report. I find it unbelievable he did not consult with the cardiologists in Wexford and Tipperary. I find it completely unbelievable that he did not consult with Professor John Higgins, the architect of the hospital group reconfiguration and who published a report on it in 2013. That was a fundamental mistake. Why did Dr. Niall Herity not do that? It was his strategy which the Government and the Health Service Executive, HSE, adopted in creating the critical mass and efficiencies within the hospital group networks. We are talking about a regional hospital with a legitimate aspiration to level four. This is not a county hospital we are talking about.
With regard to the catchment population, the chief executive of the hospital group told me in 2013 that the provision of invasive cardiology procedures is both a clinical and political priority. Did he say the same to Dr. Niall Herity when he met him before the report was drafted?
While I do not doubt Dr. Niall Herity’s expertise, according to his analysis, if one cath lab is open 40 hours a week and draws a catchment population of 280,000, then that figure would not increase substantially if that cath lab were open for 168 hours a week, which is 24-7, with a second laboratory available. I contend it would. Any logical person would too. If it is available, then people will obviously use the service.
With regard to the 90-minute golden time to which we all refer, I find it deeply disappointing that Dr. Niall Herity has a two-minute margin in his recommendations to transfer people from University Hospital Waterford to Cork University Hospital. That is a critical life or death intervention but Dr. Herity allows a two-minute margin without any allowances for ongoing roadworks on the N25. More importantly, there is no allowance for people in my area who have to travel ten miles to get to University Hospital Waterford in the first place. It probably takes them 45 minutes to get there. They then have to add another 90 minutes on top of that, all going well. These people are outside the critical time. I respect Dr. Herity’s professionalism but he said he did not have the time to see how he would recommend that these patients outside the 90 minutes receive the best care. I am sorry but these people do not have the time either. They have had a heart attack and need critical intervention.
Dr. Herity, as a professional, had a clinical opportunity to give an entire region adequate cover for cardiology intervention. I do not doubt his aspirations and all he stands for but I am telling him passionately that there is a region left in deficit. He referred to other regions in the north west but they are also in deficit. In time, they will also have to be addressed. Here was the opportunity to address the south-east region, not a county, a parish or a little village. This is a regional and national issue. I am deeply disappointed this opportunity was missed.
Mary Butler (Waterford, Fianna Fail)
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I kicked off questions earlier today. Like my other colleagues, I am disappointed that two of the three questions I asked were not answered.
My first question relates to Professor Higgins. We all have the book. Dr. Herity was tasked with carrying out an independent clinical review of the provision of a second catheterisation laboratory at University Hospital Waterford. He stated he was the clinical director of cardiology at Belfast HSC Trust. I assume, therefore, that he would be the go-to person if there was a review taking place in Belfast. When one considers the likes of Professor Higgins who produced the report on the transition of hospital groups to independent hospital trusts and is the chief academic officer of the hospital group, how was Dr. Herity able to formulate his position when he did not speak to him? It beggars belief. I cannot believe and understand Dr. Herity could not speak to the chief academic officer of the hospital group.
My second point which I made clearly still concerns me and I do not believe it has been answered by Dr. Herity. It relates to the note issued by the HSE which stated that, in its opinion, Waterford would not benefit from having a second catheterisation laboratory. This had to have had some impact on Dr. Herity before he undertook the review. He had to examine all of the facts and figures he had been given, but the HSE told him that, from a financial point of view, it would not be in the best interests of Waterford to have a second catheterisation laboratory. That had to have had an effect and an impact on him. Dr. Herity did not address that point?
I would like to go back to the figures referred to by the Minister of State, Deputy John Halligan. Dr. Herity has told us that the new BCIS minimum is 150, but, when he undertook his report, it was 100. At the time, 62 emergency procedures were undertaken when the laboratory was opened in Waterford, but 77 procedures were bieng undertaken when the laboratory was closed. That gives us a figure of 139. The BCIS minimum was 100 and we had 139, but I do not think Dr. Herity included in his calculations the 77 emergency procedures that were taking place when the laboratory was closed. I do not doubt his integrity or abilities for one minute, but we are talking about the south east which has a population of 500,000. We can dispute the figures all we like, but, no matter how we go at the issue, there are still 350,000 or 400,000 people who will have nowhere to go in an ambulance if on a Friday evening at 5 p.m. someone has a heart attack except to Cork or Dublin. As everyone has stated, it is not possible to get to either place within 90 minutes.
I would appreciate it if Dr. Herity were to answer these questions.
Kate O'Connell (Dublin Bay South, Fine Gael)
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Am I reading it right that 4% of the procedures were emergency procedures and that 96% were regular or scheduled procedures? What is Dr. Herity's professional opinion on performing these primary PCIs which is how it was referred to at that low level without an extensive cardiology support network and the invasive surgery the lads and women can perform? What impact does that have on the health outcomes for patients? Let us take someone who arrives in an ambulance in under 90 minutes to University Hospital Waterford. He or she is in the 4% category and does not have access to the cardiology backup services. Does Dr. Herity have data on the outcomes for such patients? I assume that they are worse than if they were taken to a centre of excellence.
In reference to what many colleagues have stated, I am not disappointed with Dr. Herity's answers. From what he has stated, I am happy that he took all data into account. Perhaps he did not meet everyone, but I am happy that he took the Higgins report, etc. into account. I accept his professional view that increasing capacity does not necessarily correlate with an increased throughput of patients. As far as I know - I read it somewhere - there are data that prove this. However, I do not think we are all in the same boat and distinguish myself from certain groupings here.
John Halligan (Waterford, Independent)
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I am not a clinician and the terminology "clinical risk and safety" does not come from me. It is used regularly by clinicians in the south east. I asked about clinical safety in having a single point of failure. What I meant by this was simple. What happens if someone is in the laboratory having a stent inserted and an emergency patient arrives? To where does one or the other go? That is exactly what the consultants have been asking. That is where the issue of a single point of failure arises in having one laboratory, as the consultants will say when they come in later.
I am astounded and have been for a long time that the terms of reference the consultants put before him were not adhered to by Dr. Herity and that he did not meet Professor Higgins. I consider that to be outrageous. It is not a slur on Dr. Herity who I know is eminent. I do not question his eminence in his profession, but not to do that was appalling. For that reason alone - not meeting Professor Higgins and all of the consultants in the south east - the report is fundamental flawed.
Michael Harty (Clare, Independent)
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For those who receive thrombolysis and are referred to a catheterisation laboratory as opposed to those who arrive within 90 minutes and have a stent inserted, are there survival figures?
Dr. Niall Herity:
There are figures available. This exact question was looked at in a clinical trial, the STREAM trial. It demonstrated that the outcomes were very good for those outside the 90-minute catchment area and received thrombolytic therapy and were then shipped to either undergo an immediate or a delayed procedure. It is really important for the group to understand primary PCI is one of a range of procedures offered to those who suffer a heart attack, but, in fact, very good options are available across the spectrum of treatment.
This perhaps reflects the comments of Deputy Kate O'Connell, but I hear the reactions of elected representatives, particularly those in Waterford. What we probably do not hear are the reactions of others throughout the country who have contacted me directly to agree with the conclusions made in the report. I have received a lot more positive than negative feedback about the report.
Paudie Coffey (Fine Gael)
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Ninety minutes-----
Mary Butler (Waterford, Fianna Fail)
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Perhaps none of them had an ambulance outside his or her door like I did.
Dr. Niall Herity:
The relationship between volume and outcomes is especially clear in the case of emergency procedures. The more procedures the centre performs, the more rapidly the difference in the likelihood that someone will die as a result of a primary PCI procedure diminishes. That is the key part. This is not about a single operator but the team in the catheterisation laboratory and the support services available to them. That is why the BCIS recommends that these procedures be undertaken in high volume centres with concentrated expertise. It is the performance of the entire team that determines the outcome. The relationships between high volume and better outcomes are absolutely clear in the case of this procedure.
On there being a single point of failure, it does happen. The impact of an emergency PCI procedure on daytime activity is far greater than it is on night-time activity. That is the reality for all of us. In the centre where I work there are eight catheterisation laboratories, all working full-time. What happens is that notice is received that a patient is coming. We have enough time to complete a procedure; we do not put the next patient on the table and wait for the next patient to arrive. That is how one deals with it. I thought the Minister of State was referring to a single point of radiological failure; in other words, a failure of the radiographic equipment. I made a specific recommendation that backup radiographic equipment be provided in the catheterisation laboratory in University Hospital Waterford, a recommendation also made by the BCIS.
On meeting Professor Higgins, it is not obvious to me that the chief academic officer of a hospital group is necessarily the person I would be going to, but I want to assure people that I read the Higgins report and made my own decision on whether I needed to consult him specifically about the matter.
I decided that he was not someone who would change the content of the report. However, I agree with his strategy, which is to build networks of hospitals in groups that will work together in a joined-up fashion in order to achieve the best outcomes for patients. I am heartened to see that that is happening in the south-south west hospital group.
David Cullinane (Waterford, Sinn Fein)
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Dr. Herity cannot cherry-pick elements of Professor Higgins's report in the way he has done.
David Cullinane (Waterford, Sinn Fein)
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That is exactly what Dr. Herity has done. As he has read the report, he will know that in terms of cardiology services Professor Higgins committed to the south east being serviced by University Hospital Waterford. It is obvious that he does not agree with that analysis. The synergies mentioned between Cork and Waterford are the opposite of what he has proposed in his report, but that seems to have gone over his head.
David Cullinane (Waterford, Sinn Fein)
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Dr. Herity refused to answer my "Yes" or "No" question because he knows that the answer is "No". It is not possible for one laboratory servicing even the effective population of 240,000 people for which he opted to do both planned and emergency work. The logic of his report accepts that that is not possible, but that is what is happening.
David Cullinane (Waterford, Sinn Fein)
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Dr. Herity seems to be glossing over this completely as if it was irrelevant. It is crucial.
Dr. Niall Herity:
The answer to the Deputy's question is that the set-up described by him, that 96% of patients are being disadvantaged by cancellations resulting from the treatment of 4% of patients, led me to a clear recommendation, that it was not the optimal to have two sets of procedures working side by side in a single cath lab. My recommendation was that that small number of patients should be accommodated elsewhere in a 24/7 setting. I hope that is clear-----
David Cullinane (Waterford, Sinn Fein)
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Conversely, if there was a second laboratory, there could be two sets.
Michael Harty (Clare, Independent)
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Please allow Dr. Herity to respond.
Michael Harty (Clare, Independent)
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I will ask a question.
Mary Butler (Waterford, Fianna Fail)
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I wish to ask Dr. Herity about-----
Michael Harty (Clare, Independent)
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I am sorry, but I will ask one question. Does Dr. Herity have any doubt in his mind about the accuracy of the catchment population that he devised and extrapolated from other figures?
David Cullinane (Waterford, Sinn Fein)
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To keep things as they are.
David Cullinane (Waterford, Sinn Fein)
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That is what it means - to keep things as they are.
Mary Butler (Waterford, Fianna Fail)
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May I get an answer to the question on the note from the HSE? I have asked three times.
Paudie Coffey (Fine Gael)
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On the back of-----
Michael Harty (Clare, Independent)
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Please allow Dr. Herity to continue.
Dr. Niall Herity:
Of course, I will answer Deputy Mary Butler's question. I have laid out line by line what was included in my calculation of the size of the catchment area. Anyone else is at liberty to do the same with a different method. It would then be for the health care system to determine which was accurate. That is not a concern for me. I have set out my methodology and conclusions.
Paudie Coffey (Fine Gael)
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On that point-----
Michael Harty (Clare, Independent)
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No, we must-----
Paudie Coffey (Fine Gael)
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I will be very brief.
Michael Harty (Clare, Independent)
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I will allow the final remark to be made by Deputy Mary Butler.
Paudie Coffey (Fine Gael)
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It is on that point. It is relevant. May I follow Deputy Mary Butler?
Michael Harty (Clare, Independent)
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We have to-----
Paudie Coffey (Fine Gael)
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I promise that I will be very brief.
Mary Butler (Waterford, Fianna Fail)
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Of major concern to many, including me, is the fact that Dr. Herity received a note prepared by the HSE prior to commencing his deliberations. The note read: "However it has been the view of the Department that providing additional facilities and extending PPCI (angioplasty) services, in a geographical area which does not have the population base to justify such a service, would be wasteful of very limited resources". I will ask my question for the third time. How did this recommendation from the HSE affect Dr. Herity's outlook and the overall report, including its findings?
Dr. Niall Herity:
I will answer Senator Paudie Coffey's question subsequently if I am given time. I received multiple sources of information from many parties, including the Department of Health, the HSE, international and local advisory bodies, the Irish Cardiac Society, local clinicians and managers. I put all of it together in the overall review. I analysed and questioned the data, where necessary, and came to my own conclusions without any pressure being exerted from any quarter. In fact, the single most consistent message I received concerned my independence in considering the matter. All of the people I met were at pains to point out that they were applying no pressure on me but that they were putting the facts and context together in order that I would build on them.
Mary Butler (Waterford, Fianna Fail)
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Would Dr. Herity not have given extra weight to a note from the Department?
Michael Harty (Clare, Independent)
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Please, Deputy.
Mary Butler (Waterford, Fianna Fail)
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I can understand Dr. Herity obtaining advice on best practice in Europe, but the Department of Health had issued this note. Surely it had to carry extra weight.
Dr. Niall Herity:
No. I will answer the Deputy's question. If anything carried great weight for me, it would have been the voice of the clinicians and the professional societies, specifically the European Society of Cardiology and the BCIS. They are the one who would give added weight to the context.
Paudie Coffey (Fine Gael)
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May I receive a response to my question?
Paudie Coffey (Fine Gael)
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I appreciate that Dr. Herity has given of his time and provided comprehensive replies. I am not happy with many of them, but that is a matter of opinion. All of the HSE's acute service business plans are based on a regional catchment area population of 500,000 people. The CEO of the HSE south group, Mr. Gerry O'Dwyer, told me in writing in April 2014 that the "provision of invasive cardiology procedures is both a clinical and political priority." He went on to write: "It is essential that this service is located at Waterford Regional Hospital to serve the population of the South East." Did he give Dr. Herity the same information when the two met or did it differ? That is all that I want to know.
Dr. Niall Herity:
The Senator is right. I met Mr. O'Dwyer on the date I visited Cork. I think we agreed that the provision of interventional cardiology services in Waterford was a priority for the hospital group. It is strengthened and supported in the report and the recommendations I have provided. Furthermore, if members read the recommendations, they will see that I have recommended an expansion of interventional cardiology service provision in Waterford.
I remember something else well. It was a key theme, not just from Mr. O'Dwyer but from almost everyone I met, it being the concept of safe and sustainable services. It refers much more to the figure of 4% than 96%. A consistent message coming from the team in Waterford concerned the degree to which patients scheduled for planned procedures were receiving same-day cancellations as a result of the small volume of emergency work being done. That, undoubtedly, fed into the recommendation that the low volume of emergency work would be better consolidated elsewhere to enable the team to carry on with planned work. It already represents 96% of the overall work done and I have recommended that it be expanded by 20%.
Michael Harty (Clare, Independent)
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On behalf of the committee, I thank Dr. Herity for attending at short notice and engaging in an open and informative manner.
Michael Harty (Clare, Independent)
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We will now meet representatives from hospitals in the south east in regard to the Herity clinical review of provision of a second catheterisation laboratory at University Hospital Waterford. On behalf of the committee, I welcome Dr. Patrick Owens and Dr. Mark Doyle from University Hospital Waterford, Dr. Aidan Buckley from Wexford General Hospital and Dr. Niall Colwell from South Tipperary General Hospital in Clonmel. I draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They 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, persons or entity by name or in such a way as to make him, her or it identifiable. Any submissions or opening statements made to the committee may be published on the committee's website after the meeting.
Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.
Dr. Patrick Owens:
I thank the Chairman for the opportunity to talk to the committee. I am a cardiologist in Waterford University Hospital and I am joined by Dr. Aidan Buckley, a consultant cardiologist from Wexford General Hospital, Dr. Niall Colwell, a consultant cardiologist at South Tipperary General Hospital in Clonmel, and Dr. Mark Doyle, consultant in emergency medicine in University Hospital Waterford.
Again, we thank the committee for the opportunity to talk today about the cardiac services in the south east. The committee will know the narrative of how we got here today from the news coverage and the briefing document I submitted earlier this week, which hopefully it will have had the chance to review. The essence of the matter at hand is the parlous state of the cardiac services in the south east. We all work in different hospitals in the south east and all can testify to the great difficulties we encounter in trying to do right by our patients. We have come to realise that the unacceptable wait times we encounter for outpatient and inpatient care are seriously detrimental to their well-being. These delays arise solely because of the lack of an additional catheterisation laboratory facility on the UHW campus. This risk was identified by the HSE over several years, with the lack of a second facility identified as a critical clinical risk on the formal HSE risk register. As a result of this, we sought expansion of the service in the south east, with the building, staffing and running of a second catheterisation laboratory to increase our case volume to levels commensurate with the demand for service we encounter.
The Department of Health and the then Minister chose to ignore the HSE risk rating and submitted business case in this regard and instead commissioned an independent report into the matter. It is our contention that the report was not independent. It was constrained by its terms of reference. The reviewer's instructions were prefaced by the Department in biased terms. The review itself is flawed in its methodology, assumptions and, therefore, its conclusions.
I have outlined these in the accompanying briefing document.
In brief, we contend that the reviewer excluded a large number of patients from his counting of the catchment population for the cath lab, leading to a gross under-estimate, of the order of 50%, of the true value. The determination of the infrastructure needed for meeting with our actual service demand was based on non-real world estimates of the time required to perform procedures; the true estimate shows a need for just over two cath labs, running 9 a.m. to 5 p.m. The evaluation of the primary PCI programme - for treatment of acute heart attacks - at University Hospital Waterford actually exceeded the terms of reference of the review. The recommendation arrived at, however, is to withdraw the service as it exists and replace it with an unworkable alternative. We feel that this is an extraordinarily one-sided view, and does not take into account potential alternatives that would retain this vital service in the south east and with minimal investment would allow it to meet the minimum requirements of the national strategy, which would fit seamlessly into the broader picture of enhancing service delivery for cardiac care in the south east.
The report does not even mention the hard reality of a single cath lab, performing large volume and complex procedures. It is a single point of failure, and provides inadequate contingency for breakdown and co-incidental acute illness presenting to its doors. This has already happened on a number of occasions.
There is an assumption made by the people of the south east. It is that their Ministers must make decisions for the overall greatest good for the greatest number of people, but must also sometimes make decisions that appear to run contrary to their interests. Nowhere is this more the case than with health care. There is also an obligation, however, to ensure that the evidence on which these decisions are based is correct, irreproachable and stands up to robust scrutiny. I am sure that all would agree with that, not least Dr. Herity, the author of the report.
It is our contention that this review, on which so much depends, is indeed flawed, and draws conclusions that are therefore invalid. The Department went to great lengths to prevent the report being seen prior to publication and adoption as policy; so much so that the consultants who sit here today were not shown the document prior to its adoption as policy and were given no right of reply. My two colleagues from Wexford and Tipperary were not even consulted during the review process, although in fairness this was not identified as a necessity in the terms of reference. It is our contention that had either of those eventualities occurred, the flaws would have been identified and corrected and a more considered report would have been forthcoming that, importantly, would have reached a different conclusion.
It is within the terms of reference of this body to make representation to the Minister, and perhaps also to those who are unelected, unseen and unanswerable in the Department and who are at the heart of this matter. I would ask that representation be made, for the sake of the people in the south east of the State.
Michael Harty (Clare, Independent)
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I thank Dr. Owens. I will now open the meeting to the floor. We will take groups of three and the first group is Deputies David Cullinane, Mary Butler and Senator Coffey.
David Cullinane (Waterford, Sinn Fein)
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I welcome all the witnesses. I am not sure if they heard the exchanges with Dr. Herity who was with the committee earlier. He robustly defended his report in his opening statement and his answers to our questions. When asked why he did not consult with Dr. Buckley, Dr. Colwell and Professor Higgins he said he had put a day aside at University Hospital Waterford for consultation. It had been up to the hospital management or clinicians in Waterford to inform people that this consultation was on and it was up to people themselves to come on that day. Dr. Herity said that he had been in a position to make himself available from 9 a.m. right up to 10 p.m. that evening but because there was only a smaller number of people with whom he engaged he was actually out by lunchtime. Prof. Higgins is not present so my question to Dr. Buckley and Dr. Colwell is if they were aware that Dr. Herity was in town on that day and were they invited or given any notice of that engagement?
David Cullinane (Waterford, Sinn Fein)
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Okay. it should be noted that it was put to Dr. Herity that he had a responsibility to consult with people if he so wished and it was not the case that he should have to expect people to come. In any event, the witnesses have clarified that they were not even informed that this day of consultation was happening. I have tried to condense the report down into very simple language and a simple proposition because we could overly complicate this, but essentially Dr. Herity's main proposition is that there are two distinct sets of patients in the south east, the patients who need planned work and those who need emergency work. I also asked him if he had ever worked in, or been responsible for, a hospital or unit that has one cath lab, and he said "No". Obviously he had to do a piece of work for the south east and specifically for the University Hospital Waterford.
Dr. Herity's whole logic is that it is not possible for a single hospital with a single cath lab to do both planned and emergency work. It is not possible and this is why he recommended that all emergency work be outsourced to Cork so that University Hospital Waterford would not do any emergency work on any day of the week. All of that work would be transferred to Cork. People in Tipperary, Carlow and Kilkenny who would have gone to Dublin would continue to go to Dublin, and all of those in Waterford city and its hinterland would go to Cork. Waterford University Hospital would specifically deal with all planned cath lab work. Given that one cannot divorce implementation from the recommendations, it is also the case that the Government, the hospital and the south-south west hospital group have decided that University Hospital Waterford will continue to provide 9 a.m to 5 p.m. emergency cover. On the basis that Waterford University Hospital will continue to provide PCI cover Monday to Friday, and all the planned work that it already does, Dr. Herity conceded that this was not viable. His recommendation is that emergency work was to be shipped out to Cork.
We have heard from Dr. Herity as a clinician, and nobody is doubting his integrity, experience or work in this regard - I certainly did not doubt it and I am sure the witnesses have not. The witnesses here are also cardiologists and clinicians with experience. Dr. Herity's proposal is now not happening because, thankfully, Waterford will now maintain its 9 a.m. to 5 p.m. PCI cover at least but we want to go beyond that. In the witnesses' opinion is it sustainable for the University Hospital Waterford, with one unit and one mobile lab, to do both the planned work and the emergency work in the future even with the effective population criteria that he proposes? Is this feasible and possible?
Me second question concerns the scenario if the recommendation had been to not look at the effect of population criterion but to look at the entire south east with patients from Kilkenny, Wexford or Tipperary who are being transferred to Limerick, Cork or Dublin. If Waterford University Hospital had a second lab - we are moving towards enhanced services - would it be feasible for these patients to be referred to Waterford University Hospital? Would this increase the patient throughput into University Hospital Waterford? I know this is in two pieces, but can the witnesses understand the logic of it? The logic of the report is that one cannot do both, it must be one service or the other, in Waterford with one lab. That is now not the case so would the witnesses agree with Dr. Herity that it is not feasible in the first instance? Given that it is now the case, if we had a second lab, do the witnesses believe in their own professional opinion and the opinions of those who work in the south east, that patients who are currently being diverted elsewhere, would be referred to University Hospital Waterford?
Mary Butler (Waterford, Fianna Fail)
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I thank all the witnesses for attending the committee today to address this very important issue.
Whereas much of this has been said already in Waterford and the south east, this will be on the record of the House now, which is very important. On 17 October last, I wrote to the Oireachtas Joint Committee on Health to request that it examine the Herity report and to invite the relevant stakeholders. We are all aware of the fallout from the publication, and as has been stated by the consultants and clinicians working in University Hospital Waterford, UHW, and other places, the report is flawed and the findings are rejected. Senator Swanick, who is a doctor from County Mayo, in the earlier session asked Dr. Herity, as one doctor to another, whether he believed lives were in danger in the absence of a second catheterisation laboratory in Waterford and the lack of provision of 24-7 care. Dr. Herity replied he did not and that patients should be treated in high-volume centres. I seek the witnesses' views in this regard.
Dr. Herity also spoke about the length of time it takes to get from Waterford to Cork and referred to real world ambulance times, which he stated were 88 minutes with blue lights flashing. While Senator Swanick put it to him that this target time is an aspiration, Dr. Herity did not accept that. I seek the witnesses' thoughts on that as well.
Some of the questions I will ask have been answered before, but I think it is important that it is stated on the record in the House. Dr. Owens has said that the fundamental problem in Waterford and the south east is a capacity-demand mismatch, and I would appreciate it if he could elaborate on that. What happens if a patient is undergoing a treatment in the catheterisation laboratory in Waterford and another patient presents on an emergency basis? What happens to both patients in that instance? I ask Dr. Owens to talk us through that important point.
Is this a single point of failure when trying to perform the duties of a cardiologist? In the absence of a second catheterisation laboratory and 24-7 cardiac care, are lives being endangered? Will people die as a result? The last question is for any witness who wishes to answer. Is there a clear clinical need for 24-7 cardiology care in UHW?
Paudie Coffey (Fine Gael)
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I welcome the delegation to the Committee on Health. It is important that we hear their views on the record of the Oireachtas, and to publically acknowledge their efforts to address what they see as a deficit in terms of equality of access for patients in the south-east region. I believe they are delivering a public service beyond their remit.
A critical risk associated with a lack of a second catheterisation laboratory in UHW was identified. Who compiles the risk register, and who in the HSE has the authority to change the risk register? A critical point identified is that it has changed and this needs to be answered in the interests of transparency.
The Department was mentioned, and it was stated the instructions were "prefaced by the Department in biased terms". Can Dr. Owens explain how the Department has been biased on this very significant national and regional issue?
On the effective catchment population, there is a serious divergence of view between Dr. Herity and others. I am interested in hearing from the professional witnesses, being cardiologists and emergency services personnel, what is the definition of an effective catchment population? Is it, as Dr. Herity outlined, the existing patterns of throughput of patients to services at the hospital, or is it what I would consider the access within a 90-minute timeframe, which is the critical timeframe for percutaneous coronary intervention, PCI, for a catchment around a particular service? Some clarity on that point would be appreciated.
Dr. Herity puts much store in the BCIS, also known as the British Cardiovascular Intervention Society. That is from where he takes his standard. I would like to hear the views of the witnesses on that. Is it agreed that it is the recommended standard?
Regarding those who are outside the 90-minute PCI radius, the recommendation from Dr. Herity's report, without any specifics, is that those who cannot receive PCI within that critical timeframe of 90 minutes would receive what he calls an optimal reperfusion protocol. My question to the witnesses, as professional cardiologists and consultants, is on whether patients who are outside the 90-minute PCI and are transferred into that protocol are at a disadvantage in terms of survival rates? Has there been an analysis of patients in the past who received PCI versus those who received the reperfusion protocol, and what does that tell us about survival rates and where services should be located?
Dr. Patrick Owens:
I will answer in reverse order and start with the concept of effective catchment area. The first line of the report describes how the determination of any catchment area is a matter for interpretation, and that is true. The catchment area is almost a misnomer. What is important in any analysis of need is to identify the need of a given population. In a sense this report does things the wrong way around. What is needed initially is to identify the geographical area which feeds into UHW, to the south-east catheterisation laboratory service in this instance, and then apply normative data, which means to apply the percentages per million requiring angiograms, stents and pacemakers, and then work out what the actual need would be for that population. The value of doing it that way around is that the need is identified first. The need drives it. What has happened here is that the number of people who have had procedures has been counted but need has not been recognised. Delivery of service is recognised rather than the need for service delivery. The analogy I used several months ago was it is like trying to determine the number of people wanting to attend Croke Park on all-Ireland final day. What this methodology does in the report is that it counts the number of people in the stadium and concludes that is the number of people who want or need to be there. It completely ignores the fact that there are people streaming around shouting at touts and people in the pub watching the game because they know they will not get in. There is a need that is not being met, and a demand out there that is simply not being addressed because of the constrained nature of the service. The evidence for the constraint on the service is the fact that there was a 700-strong waiting list at the end of the year in which the report was done. This methodology cannot be applied to a constrained service; it simply is not logical.
Halfway through the report the logical inconsistency of that is borne out. Dr. Herity, having identified this catchment population, discusses briefly whether the activity carried out is consistent with that catchment population and finds that it is perfectly consistent. However, as he has determined the catchment population on the basis of number of procedures done, it is a completely circular argument that holds no water and is nonsensical. In fact, the only group of procedures upon which he did not make a judgment about the size of the catchment was pacemakers, which involves a separate technique we use in the lab. Not angiograms, not stents, but pacemakers. This was not used in his calculation of catchment. The pacemaker implant rate was far beyond what one would have expected for his calculated catchment. In other words, the strong implication is that his catchment area is a gross underestimate. The effective catchment area, therefore, is not correctly calculated. The methodology was never going to provide an accurate figure. It looks at the wrong thing. This should be a needs-based assessment, not an assessment based on treatment delivered.
There was another question on travel times. Dr. Doyle has carried out some independent assessments of the travel times from Waterford.
Dr. Mark Doyle:
We looked at the travel time issue when the acute coronary syndrome programme was first set up, because obviously there were implications for Waterford then. The determination in this report that an 88-minute timeline is somehow acceptable is totally unacceptable to me. Moreover, this is an average time. If that is average, by definition some of those times were well over the 90 minutes. For a clinician in the emergency department in Waterford to say, "you will probably get there in 88 minutes so I will let you off", is not an acceptable clinical scenario and it is not one the doctors in Waterford will stand over. That is one piece that simply does not stand up. Last week, members of the committee who live in that area will be aware that there were major road works on the road to Cork and there were huge traffic delays. Somebody told me that they saw an ambulance get through, but it got through slowly. It certainly was not going to get there within the timelines described. Again, the 90 minutes is an absolute figure. What should happen is that people should get this treatment as close as possible to when the diagnosis is made because every minute that passes without treatment is loss of heart muscle. One can pick this timeline but, in fact, that travel time is only a surrogate in any case from the internationally recognised time which is from point of diagnosis to point of the vessel being opened. When one adds in those parts at each end, the time is well exceeded. To assert that this timeline of 88 minutes is acceptable is just not okay, for a start.
Dr. Patrick Owens:
As a clinician and an interventional cardiologist I will talk about the single point of failure that was mentioned. The catheterisation laboratory is, by definition, a single point of failure. There is only one table and only one patient comes into the room at any single time. If a patient is on the catheterisation laboratory table and is having an angiogram or a stent inserted, the duration of a procedure can be very long. Somebody could be on the table for a couple of hours or more during complex procedures. Once one starts the procedure one cannot stop, or at least not safely stop. If somebody is brought in as an emergency to the emergency department or, indeed, is blue lighted in as a code STEMI - ST-elevation myocardial infarction - which is the phraseology for coming in with an acute heart attack, that patient must be accommodated as quickly as possible but if somebody is on the table that cannot happen. It is not just acute heart attacks. It might be somebody with a life threatening rhythm disturbance or with what is called a tamponade, which is where there is a fluid collection around the heart, and these all must be addressed. If there is only a single unit they must wait or one must stop one's procedure, wheel the patient out and take the acute emergency in. That has happened. Having two catheterisation laboratories greatly diminishes the chances of that eventuality.
Then there is the more obvious sense of single point of failure, which is that if the catheterisation laboratory breaks down everything grinds to a halt. If the laboratory is closed for maintenance, for example, which it was on Monday two weeks ago, the service stops. It does not stop just for emergencies but also for inpatients who are admitted with acute problems, need their procedure carried out but who must wait another day in their hospital bed. All of that has repercussions and knock-on effects on bed occupancy. Single point of failure is a major issue. The reason that ours remains the only unit in the country with a single catheterisation laboratory is that all the other laboratories and units realise that this is an issue.
David Cullinane (Waterford, Sinn Fein)
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I asked a question that was not answered. It is the most obvious one from my point of view. A decision was made not to remove emergency percutaneous coronary intervention, PCI, from University Hospital Waterford from Monday to Friday, which I welcome. If that is the policy, and that is not what Dr. Herity proposed, is it viable in the clinicians' view for one laboratory to service the population it currently serves and to provide both planned and emergency work into the future? Is it a safe service and is it a viable service?
David Cullinane (Waterford, Sinn Fein)
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What is the response of Dr. Buckley and Dr. Colwell, who are also cardiologists?
Dr. Aidan Buckley:
I am a clinician who works part of my time in Waterford and the bulk of my time in Wexford. Wexford is the most geographically isolated part of the south east. We are outside the so-called golden 90 minutes all of the time if Waterford were to close for primary PCI. We will never be inside that 90 minutes. Currently, we have access for primary PCI from Monday to Friday, 9 a.m. to 5 p.m. If one is fortunate or unfortunate enough, as the case may be, to have a heart attack during those hours, one will have one's primary PCI performed in Waterford. If it happens outside those hours, one will be put in an ambulance and brought to one of the Dublin hospitals. Under Dr. Herity's recommendations, that 9 a.m. to 5 p.m. service will be taken from us altogether, so we will have 100% of nothing. He alludes to the point in his report that perhaps some type of arrangement could be made to transport these patients faster.
The Deputy spoke about the optimal reperfusion protocol. That is a misnomer because it is a sub-optimal treatment. Thrombolytic therapy, which is the old-fashioned way of dealing with heart attacks, is an inferior treatment. That is not my personal opinion, but has been proven in trial after trial. We are now saying it is acceptable for the people in the south-east region to have an inferior treatment and then be shipped on for delayed treatment in one of the centres in Cork or Dublin. If the same logic were to be applied to Castleknock or Montenotte, I doubt that we would be having this conversation. The same should apply to the people of the south east. They should have access to optimal treatment in the real sense.
The Deputy asked about emergency and elective or planned work. There are two parts to emergency work. There are the acute heart attacks, or the code STEMIs, and the patients who come to the hospital with undiagnosed chest pain. They might not have a heart attack but a condition called unstable angina. When the catheterisation laboratory first opened in Waterford we were able to provide a very timely service for angiography for these patients, because it was building up. However, as the volume of referral increased the capacity was outstripped. Now we have the scenario where patients who come to Wexford hospital with undiagnosed chest pain who require angiography must now wait a week to ten days in hospital. This is a matter of public record in terms of data from Wexford about inpatient stays for people with acute coronary syndromes. These are people who are not having acute heart attacks but who have had chest pain that remains undiagnosed. They are occupying a hospital bed for ten days. The internationally recognised timeframe in which these patients should have angiography is 24 to 48 hours, at most. We are far away from that now because these patients cannot access the care they need in Waterford. Let there be no doubt about this - going to another hospital in Dublin or Cork is not an option. We ring these hospitals daily. There are no beds, as anybody who has been listening to the news in the last few months knows. They cannot take our patients, so it is not an option for the people of Wexford. Waterford is our only option. This is not emotion. It is reality.
Mary Butler (Waterford, Fianna Fail)
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I mentioned that the Senator, Dr. Swanick, had asked Dr. Herity, doctor to doctor, whether he believed that lives are in danger as a result of there not being a second catheterisation laboratory and Dr. Herity said he did not and that patients should be treated in high-volume centres. Will the witnesses address that? Do they agree with his opinion?
Dr. Patrick Owens:
As far as the high-volume issue is concerned, that is subject to interpretation.
In 2016, we did just short of 1,000 PCIs, which is a large volume by Irish standards and would certainly be up there with other units. The specific number, for the record, is 805. I suspect what Dr. Herity may be referring to is high-volume centres for primary PCI. Primary PCI, for clarity, is PCI for the acute heart attack and that is a very small percentage of the total work we do. The current recommendations are that the bare minimum a unit should be doing is 100 primary PCIs per year, although I understand that there may be moves to increase that number. In terms of the 100 value, we did 75 in 2016 out of total of 102 code ST-elevation myocardial infarction, STEMI activations. In other words, 102 patients were flagged as needing to get into the unit, 75 of whom ended up having heart attacks and stents. Some of those 102 patients would have had other diagnoses. Those figures arise at a centre that is working from 9 a.m. to 5 p.m., Monday to Friday. Clearly and self-evidently, if we were operating on a 24-7 basis, the figures would be far higher. We would certainly be in excess of the 100 minimum and the 150 minimum. Those are the current definitions and we would exceed them comfortably if we were operating on a 24-7 basis. The criteria for the minimal standard set would be achieved.
Dr. Aidan Buckley:
If I could just make one point on the back of what Dr. Owens has said. The volume at any centre is constrained by its capacity. That is pretty self-evident. We would regard ours as a pretty high-volume centre in any event but it would be a higher volume centre if we had more capacity.
Dr. Niall Colwell:
I would also like to echo Dr. Buckley's statement about getting early access to catheterisation. I would like to thank my colleagues in Cork who are very supportive and who work unbelievably hard to provide a service. That said, I had a patient today who had come back from Cork having waited seven days for his non-STEMI angiogram. It is not the case that I have ready access to immediate catheterisation in my facility either. This leads on to the sin of unintended consequences when patients are in bed for seven days waiting for a procedure. My frustrated surgical colleague noted today that he could only get access to one out of five elective surgical cases because four had been cancelled. There is a ripple effect from not getting ready access. That also needs to be looked at and has not been mentioned today.
Michael Harty (Clare, Independent)
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Before I bring in Deputes Halligan, Kelleher and O'Connell, I have a question for the witnesses. I understand that Waterford is the only catheterisation lab in the country that does not provide 24-7 cover. Is that correct?
Michael Harty (Clare, Independent)
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Is it Dr. Owen's belief that it needs to be a 24-7 unit? What would be required for the unit to operate on that basis? What would be the infrastructural requirements?
Dr. Patrick Owens:
The infrastructural set would be a second catheterisation lab, six to seven interventional cardiologists and an on-call registrar. At present, we have three interventional cardiologists and one catheterisation lab so there is a little bit of ground to make up. It may be possible to have a staged progress towards a 24-7 model. Like all of these things, it would take time to put in place. On the basis of the arguments that we have made about the volume requirement for a second catheterisation lab, were that to be met, then the minimum dataset for a non 24-7 primary PCI unit operating, for example, from 8 a.m. to 8 p.m., Monday to Sunday, would be four interventional cardiologists. There is a kind of stepping-stone process that could bring us, ultimately, to what the region needs.
Michael Harty (Clare, Independent)
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Would that be the first stepping stone, to go from 9 a.m. to 5 p.m., five days a week to 8 a.m. to 8 p.m., seven days a week?
Michael Harty (Clare, Independent)
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Does Dr. Owens believe the volume is there to justify that?
John Halligan (Waterford, Independent)
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There is no question but that the Herity report is fatally and fundamentally flawed. Meeting Dr. Herity earlier has copperfastened my opinion in that regard. The objective of inviting the consultants here today was to put everything on record. In the last six months, the consultants have been - on both local and national media - comprehensive in their analysis of the Herity report and of its failings and flaws. There is no point in me going through the list of questions I put to Dr. Herity and putting them to the consultants because they have answered them in the media time and time again.
I would like to point out that I received information from the National Roads Authority, NRA, that there has been a 40 minute delay in Killeagh, on the road from Waterford to Cork, since last September and that this delay will persist for the next three months. That is Dr. Herity's 90-minute timeframe shot down straight away.
Regarding the recommendation to increase the opening hours of the lab from 8 a.m. to 8 p.m., do the witnesses think there is a danger that it could actually pose an increased risk to patients, in the sense of heart attack patients being delayed outside the door of a single catheterisation lab while waiting for the facility to be vacated by cases that are already on the table? That is very important because great store is being put in this 8 a.m. to 8 p.m. proposal. I am aware already that many of the consultants here today are working way beyond the official hours.
What do the consultants want this committee to do? What recommendations do they think the committee should make? Committees can make recommendations. I am not a member of this committee and I thank the Chairman for allowing me to attend this meeting and to speak at it. It is imperative that the consultants tell the committee what recommendations it should make in terms of pushing forward. I am particularly interested in hearing their views on the 8 a.m. to 8 p.m. proposal.
Dr. Patrick Owens:
The recommendation is to extend the hours from 8 a.m. to 8 p.m. Monday to Thursday, which is, effectively, an addition of 12 hours per week. The catheterisation lab would already regularly go over the current 5 p.m. deadline. I would not see 8 a.m. to 8 p.m. as a meaningful increase in the capacity of the lab. It certainly would not get within a mile of what is actually required; it would make no dent into that. Waiting lists have been in the news recently. A waiting list such as ours, which has accrued over the past three years, is directly as a result of a lack of capacity but an additional 12 hours a week would not address the pressures that have created that waiting list. It really would not even come close. One of the criticisms I would have of the Herity report is that the historical waiting list does not feature in it at all and the waiting list itself only features towards the end of the document. It is not included, at any stage, in the catchment calculations. There are patients who, by definition, have a need for the service and yet they are not identified in the calculations. The answer to the Deputy's question is that I would not see it making a great impact at all.
Billy Kelleher (Cork North Central, Fianna Fail)
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I welcome the witnesses. I was here for Dr. Herity's testimony earlier. He stood over his report. I would have expected nothing less from the author of a report but it was important that we heard him. Clearly, there are very divergent views on the report and it is important to hear the views of the witnesses before us as well. In that context, we now have a situation where that report has been more or less accepted as the basis upon which we will provide cardiac services in University Hospital Waterford. One of the reasons I was anxious to bring this issue before the committee, on foot of representations from Deputy Mary Butler and others, is that a review of cardiac services nationally is also planned. My concern is that if we are accept the Herity report in its totality that will form the basis for the assessment of all cardiac services across the country. There would be a knock-on effect in terms of catchment areas, demand and the potential ways of addressing the needs that exist.
These are not my views but questions I want to ask to clarify certain matters. In the context of code st-elevation myocardial infarctions, STEMIs, in the catchment area we are proposing, if there is a code STEMI in north Wexford, I assume, regardless of the services in Waterford, that would go to St. Vincent's hospital.
Billy Kelleher (Cork North Central, Fianna Fail)
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As it stands, they go to University Hospital Waterford.
Billy Kelleher (Cork North Central, Fianna Fail)
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I should have said they go to Dublin; I apologise. Is it the case that nobody goes from Wexford to Dublin?
Billy Kelleher (Cork North Central, Fianna Fail)
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If it is in hours, however, they automatically go to Waterford.
Billy Kelleher (Cork North Central, Fianna Fail)
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If it is out of hours, they go to Dublin because there is no service in Waterford.
Billy Kelleher (Cork North Central, Fianna Fail)
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I ask that because 4% of the procedures carried out in Waterford are primary PCIs, in other words, acute heart attacks. As it stands, how many primary PCIs are carried out in a year in Waterford?
Billy Kelleher (Cork North Central, Fianna Fail)
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If the figure was, say, 65, the accepted standard now is approximately 150 for a unit to ensure it would have the skills set mix and so on; it was previously 100. Dr. Herity says it has been increased to 150. If the service was provided 24 hours a day, seven days a week, what would be the expected throughput in terms of primary PCIs?
Dr. Patrick Owens:
I am sure we will follow the British Cardiovascular Society, BCS, recommendations but I believe it is still 100 her although it may very well move to the 150 standard. The answer is that if we were doing 75 cases 9 a.m. to 5 p.m. Monday to Friday, bizarrely, disproportionately larger numbers of the week's take, so to speak, of heart attacks tends to be within working hours. The Deputy can read into that what he will but we would expect the total to be somewhere between 150 to 200.
Billy Kelleher (Cork North Central, Fianna Fail)
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Is Dr. Owens satisfied from a clinical point of view that if there were 24-7 catheterisation laboratory facilities in Waterford, there would be enough throughput to keep teams skilled as required?
Billy Kelleher (Cork North Central, Fianna Fail)
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Yes, but statistics are available for clinical reasons.
Billy Kelleher (Cork North Central, Fianna Fail)
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The Herity report says what it says. The witnesses have varying views. The committee does not have the authority to sanction catheterisation laboratories, or public expenditure for that matter, but what we would like to do is determine how we can address this issue. I do not believe there is a big bang solution to it. Dr. Owens said at least six or seven interventions cardiologists would be needed to have a 24-7 service.
Billy Kelleher (Cork North Central, Fianna Fail)
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That is a 24-7 service for planned procedures and primary PCIs.
Billy Kelleher (Cork North Central, Fianna Fail)
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Yes, but a five days a week-----
Dr. Patrick Owens:
That is for doing, for example, an 8 a.m. to 8 p.m. provision Monday to Sunday. One would not need that for a true 50% of the real week time. One would need two catheterisation laboratories and four interventional cardiologists. We are only one away from that, and the Herity report recommends an additional consultant appointment, albeit non-interventional.
Billy Kelleher (Cork North Central, Fianna Fail)
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The key point is to accept Herity's recommendations on the planned non-emergency procedures. To provide a 24-7 service on primary PCIs, in other words, acute heart attacks, how many interventionist cardiologists would be needed?
Billy Kelleher (Cork North Central, Fianna Fail)
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To fulfil the recommendations in Herity's report regarding planned non-emergency procedures, in addition to 24-7, seven days a week emergency cover, how many-----
Billy Kelleher (Cork North Central, Fianna Fail)
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In terms of a phased increase, what would be the first steps and the priorities?
Dr. Patrick Owens:
One would have to see a phased increase as being part of a rollout to a 24-7 primary service. I would suggest a phased increase would be an 8 a.m. to 8 p.m. Monday to Sunday service, and in that context we would need four interventional cardiologists and a second catheterisation laboratory.
Billy Kelleher (Cork North Central, Fianna Fail)
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The bottom line is that a second catheterisation laboratory would be needed.
Billy Kelleher (Cork North Central, Fianna Fail)
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This question is to all four witnesses, and I thank them for their evidence. I have raised this matter with Health Service Executive, HSE, officials, not only in the context of Waterford but nationally, also. At what stage does a clinician feel obligated to express the view that practices are unsafe and the services cannot be delivered because of a lack of supports from management? Have those views been expressed formally to local management and to national management in Waterford in the context of clinical outcomes and safety for patients?
Dr. Patrick Owens:
Concerns have been expressed through standard channels since 2013. That is when the risk register was originally utilised, and it is there to flag risk. That is since 2013, and it has been consistently identified as a critical risk up until the start of last year. At the end of 2014, I wrote both to local management and to the Minister at the time, and again at the end of 2015, identifying this as being a real and present clinical risk which endangered people's lives. In that document I identified that people on the waiting list had had heart attacks already because of the delay in getting patients off the waiting list and into the catheterisation laboratory. It was in that context that, ultimately, the business case was submitted by the HSE management in South/South West nationally for funding and when the formation of Government came around, it was queued for funding, to use the phraseology, centrally. That is where the negotiations started and, subsequently, the Herity report.
Billy Kelleher (Cork North Central, Fianna Fail)
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The views on patient safety, from a clinical point of view, still stand as we sit here today.
Kate O'Connell (Dublin Bay South, Fine Gael)
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I thank the witnesses for coming in today. I am sorry for leaving but I had to be in two committees at the same time. I am not sure if I am done with hearts or water at this stage. When I came in somebody was answering a question on the effective catchment area so I will not go over it again, but in any other assessment in which any of the witnesses have been involved throughout their professional careers have they used the effective catchment area metric? That is my first question.
The witnesses may not have Professor Herity's report in front of them but on page 20 he outlines the census figures and then the effective catchment figure. The 2016 figure indicates that 582,440 people live in the area. I would assume that that involves all people. I am not being smart but there is an age when heart attacks generally tend to occur. I assume that if this is a census figure it includes children. One could not argue, although I could be wrong and the witnesses are experts on this, that we should not be including a group of the population in this that will never want to access to catheterisation laboratory facilities. I respect the witnesses' views on effective catchment but in terms of these figures, I assume that children are not suited to be treated in their facilities and that they go to a children's hospital or wherever. This data, therefore, is not the right data either because it is looking at everybody in the area, including people who are highly unlikely to require the services. I contest that using the total population data is flawed also.
The witnesses explained very well the need for the second laboratory if one breaks down or somebody is admitted in the middle of that or whatever but I refer to the wider argument of the hospital group idea, and it is still just an idea.
If we had two catheterisation laboratories in Waterford or one laboratory with six or seven consultants operating 24-7, with Cork operating as the centre of excellence, would it be okay to have this level of cardiac care within one hospital group? The legislation does not provide that the current configuration of the hospital groups will remain in place. While I may be wrong, the proposal has the potential to be a move towards having two cardiac centres of excellence in a region covered by one hospital group. Is that the direction in which we are moving? Is what the witnesses are asking for okay or is it part of a wider plan to expand cardiac services in University Hospital Waterford, which may result in two cardiac centres of excellence being provided in one hospital group? Obviously, all the witnesses are interested in saving lives.
The latest information is that 150 patients per day is definitely the new minimum standard. Do the witnesses have a graph indicating times spent in an ambulance versus outcomes, in other words, the amount of cardiac damage done when patients do not reach the right location on time? If so, will they arrange to have this information circulated to members? While I accept that there are other factors involved, what impact do travel times have on patient outcomes?
Dr. Patrick Owens:
I will answer the Deputy's first question, which was potentially the easiest, on the 500,000 people, including children, who would not normally be included in the at-risk figures. The international standard is to express normative data, in other words, the number of heart attacks in a certain population and the number of stents required`, on a per million basis. I guess this reflects the fact that, historically, it has been easier to count totalities than to subdivide and count people aged over 40 years or whatever it happens to be. Incidence rates for myocardial infarction, the need for angiography and so forth are expressed in per million population. Hence, the total number of 500,000 is the number to which one would apply the normative data.
As far as two cardiac centres of excellence are concerned, I see the issue not in those terms but in terms of need. It is as simple as that. A centre of excellence is another phrase that is subject to interpretation. I consider it to mean a centre with a very strong academic cardiological pedigree. Cork has such a pedigree and that is great but the purpose of expanding the service in Waterford is not to set us up as a competitor but simply to deal with the work we have to do. It is worth pointing out at this point - this is particularly acute for Wexford and I am sure Dr. Buckley will speak to this issue - that Wexford is outside the South-South West hospital group, yet its activity funnels into the catheterisation laboratory for the south east in Waterford. This is one of the unintended consequences that have followed from the Higgins report in that the report identified University Hospital Waterford and South Tipperary General Hospital as being in one group, yet answering to the need of a much wider population that crosses borders. This is an incredibly messy solution but that is where we find ourselves. Professor Higgins identified it as a messy solution but one that required the service in Waterford to be developed to the point where the hospital could answer to the population.
Dr. Aidan Buckley:
To follow on from Dr. Owens, there is no suggestion of empire building in Waterford. That is not what we are about. We are not discussing airy-fairy esoteric treatment but standard treatment that patients need. There is clearly unmet need, both on an outpatient and inpatient basis. We can talk about code ST-Elevation Myocardial Infarction, STEMI, and travel times but that is a very small part of our work. We have 700 people on a waiting list as a result of a capacity issue. This is not about trying to build a competitor centre to Cork or anything of that nature. It is an effort to fulfil unmet need in the south east in general, as opposed to Waterford.
Dr. Niall Colwell:
I did a list in Waterford on Monday and I asked if I could get some patients on the next list in the hospital. I was given a date of 22 February. We need to be given the tools to do our trade and at the moment we are miles behind the curve.
As regards damage in terms of ambulance transfer, there are experimental models which show that if one ties an artery of a dog, 70% of the heart muscle is dead and will not come back after three hours. Time is muscle, muscle is time and every minute counts.
Kate O'Connell (Dublin Bay South, Fine Gael)
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It is, therefore, a progressive or straight line graph.
John Halligan (Waterford, Independent)
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I was wondering where we go from here. Will the consultants issue a recommendation or what is the next step?
Michael Harty (Clare, Independent)
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We will have to discuss that in private session.
John Halligan (Waterford, Independent)
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Can the consultants make a recommendation to the committee?
Michael Harty (Clare, Independent)
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They can express a recommendation. I have one or two questions. Is primary percutaneous coronary intervention, PCI, still being provided at University Hospital Waterford?
Michael Harty (Clare, Independent)
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Has the position remain unchanged or have changes been introduced as a result of the Herity report?
Michael Harty (Clare, Independent)
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Have consultants working in centres providing a 24-7 service expressed a view on the Herity report? Are the witnesses at one with their colleagues on this issue or is there a divergence of views across cardiology?
Dr. Patrick Owens:
It is safe to say there are diverging views. It is perhaps a negative for all medical specialties, and cardiology is no exception in this regard, that people defend their own patch. Many would see service expansion in Waterford entirely in terms of it having a potentially detrimental effect on their own resourcing. However, views on the issue are mixed. I have received calls from individuals who have been incredibly supportive and have expressed astonishment at the outcome of the review and onward deliberations. Others have said they believe the report is valid. There is a divergence of opinion.
Michael Harty (Clare, Independent)
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I asked Dr. Herity a question on thrombolytic therapy as opposed to primary PCI. What are the figures on outcomes because these are two different areas? Do the witnesses have comparative figures on outcomes for these areas?
Dr. Patrick Owens:
This can be done in two ways, one of which is to say that the thrombolytic trials, that is, those trials that have studied thrombolysis as an effective treatment for unblocking an artery, suggest that thrombolysis alone gives about a 50-50 chance of unblocking the artery. This ratio can be increased a little by giving other medications. While we routinely give these medications, one is still talking about a 55% to 65% chance of opening the artery. Primary PCI gives as close as one can get to a guarantee that the artery will be open. Patency rates, the rate at which the artery is rendered open, would approximate to around 95%. That is one way of expressing the comparison.
Primary PCI is clearly a highly superior treatment for opening the artery. The critical issue is that it takes longer to do using primary PCI because of the transfer time. It is for this reason that the whole concept of the time delay to treatment has come to the fore. While this is something of a generalisation, essentially what the figure of 90 minutes represents is the time point beyond which there is no superior benefit from primary PCI.
That does not mean, however, that at 89 minutes one accrues the entire benefit. It means that the benefit arguably is one ninetieth of what it might otherwise be. The 90 minute goal has become a hackneyed phrase and its meaning must be seen in those terms. It is a question of relative benefit and the relative benefit is felt to be lost once the 90 minutes has elapsed, but the benefit is so much greater if one is at 60 minutes. Perhaps an under-emphasised element of having a primary PCI unit in Waterford is that people from all over the south east, including south Tipperary and west Waterford, are within the 90 minute window for Cork, for example, or for St. James's but they are within a 60 minute window from Waterford and arguably a 30 minute window and that implies a much greater benefit from the procedure.
Billy Kelleher (Cork North Central, Fianna Fail)
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From what we can gather, the new international norm is or will be 150 primary PCI procedures per annum. The HSE and others very often withdraw a service by stealth by slowly squeezing it, and when an assessment is made by HIQA or others, they find there is not enough throughput and then the service is withdrawn. In the context of primary PCI, is there a danger that if Waterford does not get the second cath lab and the catchment area that should be made available to Waterford and the international norms for the number of procedures are not met in the future, HIQA or others could call it a day in respect of the existing cath lab?
Dr. Patrick Owens:
The short answer is "Yes" and that is a very real risk. I will respond to Deputy Kelleher on the point he made about the catchment area being transferred to Waterford. That catchment area is there now and for the past ten years. It will be there ten years from now. That population is there and requires that service. Redefining it using methodologies to recalculate it does not change the reality. Those people are still there.
Dr. Mark Doyle:
The population at issue is growing. We all know about the demographics around the increasing numbers of people over a certain age and their requirements for this kind of intervention is growing incrementally the longer people survive. It is a good thing but one needs more of this kind of facility. That was not really factored in to any extent into the figures.
Mary Butler (Waterford, Fianna Fail)
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Could I have a "Yes" or "No" answer to my final question? Have any of the recommendations in the Herity report been implemented to date?
Dr. Aidan Buckley:
It is entirely appropriate that people ask questions about primary PCI, but to reiterate, it is a small part of our work. We also deal with 700 plus people on an outpatient waiting list and countless others, hundreds per year, who lie in inpatient beds waiting for semi-urgent procedures. They are the bulk of our day-to-day work. I know people understandably get drawn towards the primary PCI, which I count as a very important facet of the process, but we must not lose sight of the other unmet needs that exist.
Deputy Halligan asked what we would like to see as an outcome from the committee meeting. One thing we would like to see is the rejection by the committee of the Herity report. I have said this in a public forum and I will say it again. If this were a scientific paper - in a sense that is what it is - it would not make it as far as the editor because of its flawed methodology. Professor Herity could only have arrived at the conclusions he arrived at because of the methodology he adopted. It was a self-fulfilling prophesy from the beginning. It was asked at the beginning by Senator Coffey where the biases were. A briefing document was issued by the Department of Health giving its views on the situation so the reviewer was given the Department's opinion. Nobody asked me for my opinion.
Mary Butler (Waterford, Fianna Fail)
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I had to push him three times on that before I got an answer.
Mary Butler (Waterford, Fianna Fail)
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Absolutely.
John Halligan (Waterford, Independent)
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Very briefly, I am not a member of this committee and I thank you, Chairman, for inviting me here. Could you direct us, Chairman, as to what will happen after the meeting?
Michael Harty (Clare, Independent)
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We will discuss the views of the doctors from the south east in private session prior to our next meeting.
John Halligan (Waterford, Independent)
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Okay, thank you Chairman.
Billy Kelleher (Cork North Central, Fianna Fail)
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In view of the evidence we have heard from eminent cardiologists and the word of Professor Herity, as we cannot question the integrity or validity of that, could we recommend an independent assessment of the evidence presented by the cardiologists and the Herity report? Everything is peer reviewed regularly and if the report is to be validated, then it should stand up to scrutiny. Perhaps we could look at something like that in terms of the report itself. My view, and that of many others, is that there should be an enhancement of cardiac services in Waterford, but in the meantime this report is a stumbling block in terms of policy. I suggest we need independent assessment, scrutiny and validation of the report in light of the evidence we have heard today.
Michael Harty (Clare, Independent)
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We can bring that suggestion back to the full committee at its next hearing in private session.
Kate O'Connell (Dublin Bay South, Fine Gael)
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Perhaps this question was answered and I missed it, but were any of the witnesses involved in any study that used the effective catchment metric? Have they ever stood over any report, review or data that used the metric?
Dr. Niall Colwell:
I just do not believe in it in my practice. I have to make a couple of comments. We audited the number of patients treated as inpatients in the hospital but because they did not get to a hospital bed and they languished on trolleys for hours or days before discharge, 17% of our acute work last year was ignored. If one translates that over four hospitals and then translates it into the Herity report, one underestimates the work that we do.
Kate O'Connell (Dublin Bay South, Fine Gael)
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For balance, I think this committee should perhaps invite the consultants from those hospitals that were mentioned who might agree with the Herity report. It was said the view was not unanimous. We have an independent review and exceptionally qualified people who all have the same view. Perhaps in the interests of balance we could speak to those who hold an opposing view. We could have an independent assessment of an independent review but the question is where it will all end. Are we going to get someone from the university of life next to tell us how to do things? We have experts involved and the question is who we would get.
Michael Harty (Clare, Independent)
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Perhaps Deputy O'Connell could send her suggestion into the secretariat and we will feed it into the discussion next week.
Kate O'Connell (Dublin Bay South, Fine Gael)
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Yes, absolutely.
John Halligan (Waterford, Independent)
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I have one brief comment. I fundamentally oppose what has been said for two reasons. First, the Herity report was centred on the south east and the opinions should have been taken from all of the consultants in the south east, not those in Dublin or anywhere else, in terms of the input into cardiovascular services in the south east. If it had reached the stage that another cath lab was sought in a different part of the country, I do not think anyone would call for the input of the Waterford consultants who might vehemently disagree with a cath lab in Dublin, for example. I also disagree with what has been suggested that we do an independent review of an independent review.
I agree with the Deputy on that. Where is that going to go? I am not a member of this committee but a suggestion has been made by the consultants who are eminently placed, more than any of the members here, to assess the Herity report and their suggestion is that it be rejected by the committee. I am not a member of this committee but it should debate their proposal. I do not know who is on this committee. Deputy Butler and I are not members of it but we have made our points. We cannot make that decision. In any committee I have been on, if people appear before it and make a recommendation, it is discussed and a decision is made. The committee may decide to throw out their suggestion but it may very well decide to take it on board.
Billy Kelleher (Cork North Central, Fianna Fail)
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Deputy Halligan is a Minister of State and if things were different, we might not be here at all. I was only trying to be helpful.
John Halligan (Waterford, Independent)
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I know that. I am not criticising the Deputy.
Billy Kelleher (Cork North Central, Fianna Fail)
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We have a report which, as things stand, is framing policy.
John Halligan (Waterford, Independent)
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I accept that.
Billy Kelleher (Cork North Central, Fianna Fail)
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Until such time as that report is removed from policy formulation, it is there, and that is the difficulty.
John Halligan (Waterford, Independent)
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We could go on like this all day but the fundamental point remains that the report was to deal with a particular issue, that is, cardiovascular care in the south east. The people who are most eminently placed to assess that report are the witnesses and not politicians, including myself, or the members of the committee but we should take on board the recommendations they have made because of their expertise, if for no other reason.
Michael Harty (Clare, Independent)
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That is correct and the committee will consider the recommendation of the doctors from the south east when it meets next week.
John Halligan (Waterford, Independent)
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I thank the chair.
Dr. Niall Colwell:
There are 13 public catheterisation laboratories in Northern Ireland for a population of 1.869 million. That is 144,000 persons per catheterisation laboratory, and that figure does not exclude age. The figure is exactly the same in Dublin where there is nine catheterisation laboratories for a population of 1.3 million. We are being asked to continue to work with one catheterisation laboratory for over 0.5 million. That makes the case.
Kate O'Connell (Dublin Bay South, Fine Gael)
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Could Dr. Colwell repeat those figures?
Dr. Niall Colwell:
There is a population of 1.3 million in the greater Dublin area and nine catheterisation laboratories. There are 13 catheterisation laboratories in Northern Ireland, two of these are open in the western trust which has a catchment area of 300,000 people, both have 24-7 laboratories. In the island of Ireland, we have resource replete and resource deplete areas. Under the ethical guidelines of the Medical Council, we have ethical standards to advocate for our patients. We are being asked to look into the future and have an inadequate service. We must advocate for our patients and say that what is being provided at the moment is inadequate. We are just asking for it to be made adequate, not any more than anywhere else.
Michael Harty (Clare, Independent)
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On behalf of the committee, I thank Dr. Owens, Dr. Doyle, Dr. Buckley and Dr. Colwell for giving us their expert opinion on the services and on the report.