Kathleen Lynch (Cork North Central, Labour)

I move:

That Dáil Éireann,

concerned at the impact on patients and those dependent on the health service of continuing cutbacks, staff shortages and under-resourcing; and noting in particular:

that there are an estimated 10,000 people who acquire a brain injury in Ireland every year;

that up to 2% of all people have disabling problems following an acquired brain injury, whether from traumatic brain injury, stroke or other causes;

that there is only one rehabilitation hospital in the country, with just 110 beds, for those who suffer from acquired brain injury;

that the number of neurologists, neurosurgeons and rehabilitation consultants available to treat these patients are well below the levels available in other countries; and

deplores the long waiting times that can see patients waiting up to two years for rehabilitative care;

calls for:

the establishment of a regional network of rehabilitation facilities and services to be established in the context of a national rehabilitation strategy;

the immediate publication of the national review of neurology and clinical neurophysiology services;

an increase in the number of approved posts for consultant neurologists from 24 to 42 and neurosurgeons from nine to 16;

a significant increase in the number of rehabilitation consultants to reflect demand for these services; and

the provision of effective community rehabilitative and support services for post-medical ABI patients.

In putting down this motion, the Labour Party hopes this debate will have some impact on a much neglected area. It is estimated that approximately 30 people a day suffer some kind of brain injury and a further 30 people suffer a stroke, which can also lead to brain injury. It is also estimated that approximately 30,000 people have an ongoing disability due to brain injury. Services are woefully inadequate to cope with these kinds of numbers; they are also inconsistent across the country. The majority of services are provided by voluntary organisations, but all of them have waiting lists and they know they are only scratching the surface.

Acquired brain injury, ABI, can happen at any time to anyone. It can happen after a road accident, assault or other blow to the head, as well as after a stroke, infection, haemorrhage or cancer. It means someone's life can change overnight, as well as that of their family and friends. The impact can be lifelong. It is not always obvious that someone has been affected, as the effects are not always physical, but can lead to memory, planning, emotional and behavioural problems.

Many organisations are to the forefront of highlighting this situation such as Headway Ireland, Brí — the advocacy group for people with acquired brain injuries — Brainwave, the Irish Epilepsy Association and the Peter Bradley Foundation. All claim there is a chronic shortage of beds for patients with acquired brain injuries and a complete lack of such beds in some regions. With a serious head injury, immediate intervention is essential to ensure the person returns to normality, if normality can be achieved.

It is conservatively estimated that there are 10,000 new brain injuries every year but there are just 110 beds to deal with these people. This does not make sense at any level. A recent report stated there are 20 neurologists when, given our population base, there should be 42. We have nine neurosurgeons when we should have 16. The Netherlands has 12 times the number of rehabilitation consultants per head of population than Ireland. Approximately 700,000 people have a neurological condition and, because of the process of ageing and with people living longer, it is estimated there will be 800,000 in ten years' time.

People with a brain injury may spend three years in a long-stay care bed. However, if they were to receive the proper treatment and rehabilitation process, they could be up and about, returning to normality and looking after themselves. This is where our resources should be invested because the impact a brain injury has on the individual and his or her family is immeasurable. The cost of keeping someone in long-term care is equally immeasurable when that person could return to a productive life.

Cork University Hospital has estimated an average 3,825 acute bed days are lost annually due to inadequate access to rehabilitation beds. The recent Health Service Executive, HSE, document, Acute Hospital Bed Capacity Review: A Preferred Health System in Ireland to 2020, estimated the daily cost of an inpatient bed in a major teaching hospital as €1,917, which implies the waste of €7.7 million annually in that hospital alone due to inadequate access to rehabilitation beds.

The annual cost of just two beds in Cork University Hospital, put beyond use due to cumulative discharge delays, is more expensive than a team consisting of one consultant, two occupational therapists, two physiotherapists, one speech and language therapist, one psychologist, one secretary and an equipped office.

Rehabilitation has the potential to reduce long-term care costs and enhance prospects of return to work for affected patients. Previous studies in other countries have demonstrated that rehabilitation services are cost effective and result in savings for the national economy in the long run.

While optimally people who suffer brain injuries through trauma, illness or stroke should be treated in an hour, or at worst 24 hours, it is seldom the case. Rather than waiting 24 hours, people wait 24 months or two years for treatment. If that is not remarkable enough, some doctors are not referring patients who need rehabilitation services to a consultant because it is seen as a pointless exercise as waiting lists are endless.

Anything beyond a two-week delay is unacceptable. The tragic certainty that a sick person has to wait two years for an initial assessment is nothing short of abandonment of its obligation to the public by the HSE. This is a sad commentary on our times. The HSE has a national annual budget in excess of €14 billion, a sum that would float some of the newer economies in the EU. It should be giving us a much better service.

This cannot be ignored and must be tackled. Proposals have been made to deal with this problem but all have been ignored. The stated intention to await the development of an overall strategy and action plan for the development of rehabilitation services is regularly given by HSE and the Department of Health and Children as the reason for not developing services at present.

The action plan creates a false impression of ongoing progress in the development of services. It was first proposed in 1997 in response to the report of the national advisory committee on medical rehabilitation. Its alleged imminent arrival has been quoted in a multitude of reports since then, including health strategies, national partnership agreements and national development plans.

This prolonged period of anticipation has had only one effect, that of preventing any development. The stated need for a strategy as a prerequisite to any service development has resulted in the rejection of various proposals by health services and voluntary sector bodies. It has delayed approval of capital funding for the redevelopment of the National Rehabilitation Hospital. This approach based on figures from health services documents results in an estimated 1,600 new patients with neuro-disability being denied accessible rehabilitation services each year. The plan is now mythical in status, frequently referred to in national partnership agreements and health service strategy documents.

The development of a service that is fit for purpose requires the involvement of appropriately trained clinicians who are intimately aware of the extent of the problems and resources to implement any proposals. Locally based expertise is necessary to identify local needs and propose realistic solutions. More importantly, only locally based professionals can take ownership of the recommendations and commit to implementing them.

In the absence of locally employed trained professionals, one has to rely on expert committees, the majority of whose members probably have no rehabilitation expertise. Those who do could be based outside the region. Many will be based in clinical areas, the needs of which will compete with rehabilitation services for scarce resources and funding.

Even narrowly focused reviews take a long time to produce. A current example is the recently published report of the committee to review neurosurgical services. Neurosurgery is provided on two sites and has relatively few links to other specialties or disciplines. Despite this narrow focus, it took five years to produce the report, having been commissioned in March 2002. Given that rehabilitation services have a much more diverse role across all sectors of the health service, how long would it take to produce a comprehensive report on it?

To manage this diversity, a review of rehabilitation services would be much more manageable if compartmentalised into priority areas. Thus, individual focus groups with relevant expertise could deal with those aspects with which they are most involved. For example, individual groups might focus on areas such as power wheelchair provision, amputee-limb deficiency rehabilitation, transition for disabled school leavers or services for multiple sclerosis patients, the experts recruited in each of these areas having different backgrounds depending on the focused topic. The recently produced stroke review is an example of this type of focused approach, an example that should be used in respect of the sector under discussion.

Our experience is probably the greatest argument against the action plan approach. Previous action plans, such as those developed by the former health boards, have been ignored. The report of the national advisory committee on medical rehabilitation has been largely ignored, the national action plan being one of the few recommendations that attracted the Department's attention. Those recommendations that required action were set aside. The appointment of regional teams with specialist expertise and the development of regional planning were core recommendations, but they were dropped. The national action plan has failed to materialise after ten years of planning stagnation. The HSE has been in existence for three years and has not managed to progress the plan. This lack of progress is not due to neglect on anyone's part, but it is an inevitable consequence of an unrealistic approach. However, to persist further with a failed strategy would be difficult to justify.

Most new services arise when a clinician or manager in an existing service identifies a local need. Following a period of advocacy and negotiation, the need is usually addressed through a service that starts out as a subdivision of the parent organisation. Several specialties and therapy disciplines in the HSE south region have identified this need in respect of rehabilitation, but none has the capacity to provide it from existing resources. The only comparable Irish model for this dilemma is that of palliative care, which started with an approach of developing specialist teams in each region and evolved into an inpatient service, at which stage the 2001 strategy document Design Guidelines for Specialist Palliative Care Settings was produced. This action plan was able to be produced having the twin benefits of relevant input and a limited focus based on identified needs.

In all other developed countries, rehabilitation services have evolved from within other services through one of a number of routes, those being progression of the role of community-based rehabilitation teams and extension of services from within other specialties, such as rheumatology, geriatric medicine and neurology. We should remember that there is no model whereby an entire regional service has been developed in a single operation. For example, it is universally acknowledged that there is an overwhelming need for a regional rehabilitation service based in Cork, nor is there any doubt that initial emphasis for this service would be to provide neurorehabilitation for patients of working age with brain injury, stroke and progressive neurological disorders.

It is equally uncontroversial to state that any rehabilitation team appointed would need to include relevant expertise drawn from rehabilitation medicine, rehabilitation nursing, physiotherapy, occupational therapy, speech and language therapy and psychology. Based on experience elsewhere, there is no option but to consider that this team will need to be outpatient-based initially as the design of any inpatient unit should be strongly influenced by the team that will want to make the most efficient use of it. I am conscious of the time.

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