Dr. Rónán Collins:

I thank the committee for inviting me to talk to it about stroke in particular. It is probably no accident that Professor McDonald, Dr. O'Shea and I are here because there is a common theme running through the topics being discussed this morning and a big challenge ahead of us in terms of our ageing demography and the cardiovascular disease that will be associated with it.

In Ireland, stroke is the third leading cause of death, the leading cause of neurological-acquired disability in adult life and one of the overall causes of adult acquired disability. The Stroke Alliance for Europe, SAFE, has estimated that in light of our demography if we do not change the curve of incidence, we probably will experience a 58% increase in stroke numbers over the next ten to 15 years, which will represent a massive challenge for us. We have come through a very tough period economically but it is important to acknowledge the considerable achievements to date in stroke. I have been working in stroke since I was a young doctor in 1995 and I have seen tremendous changes both here and in the UK. I returned to Ireland from the UK in 2005. In 2008, we had only one stroke unit in this country. Currently, 85% of our acute hospitals have acute stroke units, which is the foundation of all stroke care. In 2008 less than 1% of our patients were receiving emergency clot-busting treatment whereas now almost 12% are receiving it. While this is in line with UK and European norms we could do better. In addition, there has been recent technological advancements in the area of retrieving clots. For example, the majority of strokes are caused by a blockage, similar to a blockage in a pipe. The two analogies to clearing that blocked pipe are clot-busting - pouring Domestos down the sink - and Dyno-Rod. Dyno-Rod in this case is thrombectomy, which is a new technology available to us that is showing massive promise. It is now the single most important treatment for stroke. This service has been developed in Ireland over the past three years with very few extra resources.

All of these changes have had a huge impact in our country. We have reduced mortality from stroke from approximately 19% in 2008 to 12%. This has come without an increase in disability, in that the discharge destination to nursing home for stroke has remained constant at around 15%. More people are surviving stroke, and are doing so in an independent state that allows them to go home. We should acknowledge that tremendous work is being done by the stroke programme and my predecessors but, more important, by a committed multidisciplinary team involved in stroke across the spectrum throughout the country. In regard to mechanical retrieval, our stroke strategy was to develop a two-centre approach initially, one of which is currently working 24-7 at Beaumont Hospital and the other in Cork University Hospital, from 9 a.m. to 5 p.m., Monday to Friday, with plans to operate this centre on a 24-7 basis from the start of the third quarter. This will also cover the southern area.

With regard to rehabilitation services,recovery after stroke takes time, requires skilled multidisciplinary team working and appropriate staffing ratios for critically ill patients with significant physical and psychological difficulties. Rehabilitation is obviously a no-brainer in terms of reducing length of stay in hospital beds but, more important, it is a patient-centred model of rehabilitation and it is often better psychologically for patients to rehabilitate at home. The national stroke programme has introduced three early supported discharge teams, which have been operating for the last two years in the north and south of Dublin city and in Galway. We are happy to announce that this year, we have funded early supported discharge teams in Cork and Limerick, with plans to further extend this service.

In terms of cure and prevention, it is disappointing that the number of people attending emergency departments within an ideal timeframe remains low. At least 60% of patients who have a stroke do not present at our emergency departments in an ideal timeframe. When it comes to acute stroke treatment, time is of the essence. The brain does not survive for very long without its oxygen supply. I am sure the committee is familiar with the FAST campaign. We would like to see it reintroduced. We have strong evidence from this country alone that when the FAST campaign was running, there was a significant increase in the number of people presenting within a much shorter timeframe after onset of symptoms. The numbers now presenting have relapsed to pre-advertisement era, particularly in areas of lower socioeconomic resources. This is a concern for those involved in the stroke programme.

On future plans, the national stroke programme has a number of immediate challenges to meet. We believe that no acute stroke patient should be treated outside of an acute stroke unit. We still have a number of challenges in setting up acute stroke units in one or two hospitals. Stroke unit care reduces death and disability from stroke by 25%. It is the foundation of care that applies to all stroke patients. We must have stroke unit care for our stroke patients or, at least, bypass procedures if it is not possible to have an acute stroke unit in a hospital. As for the time to treatment, it is not all about simply presenting to the hospital. There is an onus on us to improve our assessment and door-to-treatment times. Our median times for door to needle or door to injection of clot-busting treatment have not been historically good but they are improving. While the median time in this regard in 2013 was approximately three hours it is now down to one hour and 40 minutes. Together with the Royal College of Physicians of Ireland, we have introduced a quality improvement initiative for all stroke teams throughout the country to try to improve the processes and to ensure local improvement in door to injection times.

With regard to rehabilitation, in particular for patients under 65 with stroke, services have been historically poor due to under-investment and an age cut-off to protect the over-subscribed services within geriatric medicine. The national stroke programme advocates an all-age approach to the funding of stroke rehabilitation and will be working with colleagues in the national programme for rehabilitation to explore areas of commonality and to ensure that our intersecting Venn diagram also meets the needs of younger people with stroke.

As I said earlier, Professor McDonald, Dr. O'Shea and I are here today because there is a common theme in the topic being discussed today. Approximately 40% of the patients who have stroke also have underlying heart disease and the majority of them are older. The national stroke programme has looked at how funding can be obtained for the stroke programme going forward and we reached the conclusion that we need a more organised strategy. We have decided to produce what will be a realistic five-year model for stroke in terms of treatment. We realise that this needs to be broken down into four areas, namely, acute care and cure, restoration, life after stroke and, most important as we move on in time, to change the demographic prediction from the Stroke Alliance for Europe. We need more investment in prevention and in primary care to prevent stroke.

We also need to have some investment in research and education. The stroke programme has organised four specialty focus groups led by individual chairmen in these areas who have been tasked with producing what is a realistically achievable strategy within five years - not everything we would ideally want - that will have the most impact in the four areas of acute care and cure, restoration to living, prevention, and research and education. We will cost the strategy and we hope to be in a position to deliver it to the health service commissioners and to Members of the Oireachtas later this year.

After the presentations I will be very happy to take any questions on stroke that members may have, but now I shall hand over to our chairman Dr. O'Shea.