James Reilly (Dublin North, Fine Gael)

I am grateful to have the opportunity to speak in Dáil Éireann on the subject of stroke, rehabilitation services for stroke survivors and persons with neurological conditions, and what can be done to prevent stroke. The Irish Heart Foundation's report, Cost of Stroke in Ireland: Estimating the annual economic cost of stroke and transient ischaemic attack (TIA) in Ireland, set out the burden of stroke. I thank the Technical Group, in particular Deputies Maureen O'Sullivan and Catherine Murphy, for raising the matter.

It is estimated that there are more than 10,000 acute strokes per year. There have been welcome advances in recent years in the investigation, treatment and rehabilitation following an acute stroke and, thankfully, mortality rates from stroke have fallen considerably. While many people are, therefore, spared the worst consequences of stroke, many more patients and their families live with the effects of residual disability from stroke. One in ten people remains heavily dependent on long-term institutional care. With an aging population and longer life expectancy after stroke, this condition will continue to pose challenges for individuals, families, communities and the health service for years to come.

In June 2010, Changing Cardiovascular Health: National Cardiovascular Health Policy 2010-2019 was launched. This policy establishes a framework for the prevention, detection and treatment of cardiovascular diseases, which seeks to ensure an integrated and quality-assured approach in their management in order to reduce the burden of these conditions. It set out a model for stroke care including rehabilitation through an integrated service.

Initial rehabilitation assessment begins within the first 24 hours of admission or as soon as feasible according to the patient's condition. Rehabilitation in stroke is multidisciplinary, involving clinicians, nursing, physiotherapy, occupational therapy, speech and language therapy, psychology, dietetics and medical social work. Many stroke patients have co-morbidities and the purpose of rehabilitation is to adapt to loss of function, to prevent further impairment and to promote a return to independent living and full participation in society.

The inpatient early stroke rehabilitation model involves a multidisciplinary assessment of rehabilitation needs with an appropriate care plan for the patient. The presence of on-site acute stroke rehabilitation units allows the timely transfer from acute care to rehabilitation with subsequent home discharge when appropriate. The aim is to have early supported discharge to home or to the patient's place of residence prior to admission to hospital. Integration between hospital-based and community-based stroke services is an important element of care to allow people living with stroke to function at home or return to work as appropriate. When a patient with stroke has benefited from the initial phase, he or she is transferred into the care of the GP and the primary health-care system.

The national stroke programme was initiated in 2010 to help lead and co-ordinate the development of stroke services in Ireland. It has operated under the auspices of the programmes directorate of the HSE and, more recently, the special delivery unit of my Department. The priority of the programme in the first 12 months was the development of acute stroke services - namely, to manage better in the first few hours, patients who have just suffered strokes in order to reduce mortality and disability.

The overall aim of the national stroke programme is to ensure national rapid access to best-quality stroke services; prevent one stroke every day; and avoid death or dependence in one stroke patient every day. The national model of care clearly sets out the care pathways for the patient with stroke as well as the best evidence for stroke prevention. In recent years, new techniques and strategies for improving the care of people with stroke have emerged. For example, the benefits of organised clinical services for stroke care have been clearly established. Hospital-based stroke units for acute and initial rehabilitation of patients with stroke and TIA are associated with a reduction in death and institutional care of approximately 20%, with one additional patient returned to community living for every 20 patients treated. While those might not sound like large numbers, it is truly great for the individuals concerned. Transient ischaemic attack is a minor stroke where the clot dissolves and the patient makes a full recovery. However, it may herald a more serious stroke to follow if the underlying causes are not treated. I offer an illustration of the progress achieved in the development of stroke units. The Irish national audit of stroke care reported one stroke unit with three under-units under development in 2006. The 2010 hospital emergency stroke service survey in 2010 reported 18 acute hospitals with a stroke unit. In 2011 the programme worked towards achieving stroke unit care for acute stroke patients through the establishment of additional stroke units. Of the nine units planned, seven are open and the remaining two will open early this year. At that stage, almost 94% of stroke patients will have access to stroke unit care. Additional therapy, nursing and consultant posts were provided to support the development of new and existing stroke units. The filling of all outstanding posts will be completed by the early part of this year. Despite budget reductions, we strive to improve these services. Not only will these units save money but, more important, they will save lives and improve the quality of live for people who have had a stroke.

Following emergency admission to hospital with stroke, administration of clot-busting thrombolysis therapy can reverse or substantially reduce disability in one third of patients treated within 90 minutes of stroke onset. However, strict administration guidelines mean that only one in ten or 10% of ischaemic stroke patients are suitable for such treatment. Given the potential for brain haemorrhage associated when thrombolysis is administered inappropriately and the brief time window for treatment, substantial organisation is needed to select patients on arrival in emergency departments and to safely deliver treatment to those most likely to benefit. It is worth recalling the work of Susan O'Reilly, who has shown that improved organisation of our cancer services can improve outcomes for patients by 10%. This is nothing to do with medication but rather better organisation. The same is true of stroke treatment.

The provision of 24 hour, seven day per week access to stroke thrombolysis is a priority for the programme. In 2011 the national clinical leads for stroke worked with hospital consultants and the national ambulance service to agree ambulance access protocols to ensure the safe provision of thrombolysis to eligible patients. The implementation of the telemedicine rapid access for stroke and neurological assessment, TRASNA, project in 2012 will further improve access to a 24 hour, seven day per week consultant assessment for thrombolysis. The delivery of acute stroke services is monitored through the national stroke register. A stroke register was piloted and implemented in partnership with the ESRI in six hospitals in 2011. All remaining hospitals accepting acute stroke patients will implement the register in 2012. There is substantial evidence that early supported discharge programmes for selected stroke patients are associated with reduced hospital costs, fewer bed-days used and greater patient satisfaction.

Planning for the development of stroke services in the community commenced in 2011. A community stroke services survey was completed and consultation has begun with other clinical care programmes to ensure stroke patients have access to rehabilitation and support services in community and primary care. Two early supported discharge programmes were implemented in 2011. Early results are promising and show patients having shorter lengths of stay in hospital without compromising quality of care. The work of the national programme continues in 2012 and includes: the implementation of the TRASNA project; the development of services for the investigation and treatment of patients with suspected transient ischaemic attacks; continued implementation of the stroke register; planning for services to identify patients with high risk factors for stroke, including atrial fibrillation; and working in partnership with other relevant clinical care programmes to ensure access to community-based services for stroke patients.

During the first 18 months of the stroke programme the HSE has been prioritising measures to limit the severity of the initial stroke by making stroke unit care and expert care available to as many people as possible immediately following stroke and by providing national availability of clot-busting thrombolysis therapy to all suitable patients. At the end of this process more than 95% of the population will live in the catchment area of a hospital with acute stroke unit care.

One area of concern is the early discharge of patients from hospital to the community in the absence of well-developed, community-based rehabilitation teams. There is evidence that generic community teams are less effective than specialist teams. Patients should not be discharged early from hospital unless adequate community-based rehabilitation is in place. The need for rehabilitation is recognised and the HSE has approved the appointment of 57 therapy and nursing posts with specific responsibility for stroke. This represents a substantial investment in stroke care and enhances existing stroke service availability throughout the country. The national stroke programme has also completed the largest and most comprehensive survey of therapy services in the country. The findings will be used by the national stroke programme, the rehabilitation medicine programme and the care of the elderly clinical care programme to plan, reorganise and develop rehabilitation services. This will result in more organised community-based rehabilitation services including stroke and neuro-rehabilitation, rheumatology, orthopaedics, geriatrics, primary care and others.

The care and support needs of people in Ireland affected by disabling neurological conditions or significant physically disabling conditions are individualised and varied and present a challenge to the health and personal social services, as well as to the wider public services. However, we know that in spite of the difficulties and the challenges involved people with these conditions, including acquired brain injury, cerebral palsy, multiple sclerosis and others, can get on with life and contribute to and be part of the community when appropriate supports are in place. This is why the publication of the report of the working group for the development of a national policy and strategy for the provision of neuro-rehabilitation services was important. Published by the Department of Health on 16 December 2011, it was jointly commissioned by the Department and the Health Service Executive. The report is entitled National Policy and Strategy for the Provision of Neuro-Rehabilitation Services in Ireland 2011 - 2015. A large number of people, including service providers, service users and their advocates, contributed in various ways to the development of the document. The report sets out a clear policy with a recommended service framework which, when implemented, will ensure that the services are delivered in the most appropriate, effective and efficient way. The report recognises that given the current economic climate the focus in the short to medium term must be on the reconfiguration of services, structures and resources and the enhancement of the skills and competencies required to meet the changing context. The development of joint working or inter-agency protocols is a key requirement and will be central to its implementation. Realising the actions recommended in this policy and strategy will provide real challenges, especially against a landscape of significant economic and resource constraints. However, with the commitment of the HSE and service providers to the implementation process, improved rehabilitation services can be achieved for those persons with a neurological illness or injury or with a significant physical disability.

The focus for service development in the first three years of this policy and strategy will be on network development, the integration of services, the development of protocols, the reconfiguration of existing resources, the achievement of greater cost-effectiveness through the development of greater competencies by those tasked with delivering services, increased teamwork and by more inter-agency collaborative working. The HSE is committed to developing an implementation plan and structure for the provision of neuro-rehabilitation services in close collaboration with the rehabilitation medicine clinical programme.

The aim of rehabilitation is to enable the person to achieve the highest possible level of independence. Desired outcomes range from a return to full independence in social and work activities to a person requiring long-term support and care but with a higher level of independence than in the absence of rehabilitation. As part of its development of clinical care programmes, the quality and clinical care directorate of the HSE has established a rehabilitation medicine programme. This programme will improve and standardise patient care throughout the organisation by bringing together clinical disciplines and enabling them to share innovative solutions to deliver greater benefits to every user of HSE services. The work of the rehabilitation medicine programme will aim to achieve three main objectives - to improve the quality of care, to improve access to services and to improve cost effectiveness. The HSE has appointed a consultant in rehabilitation medicine as clinical lead in respect of the rehabilitation medicine programme and it is committed to this programme.

Several Deputies have referred to prevention. Another important initiative under way in my Department is Your Health is Your Wealth: a Policy Framework for a Healthier Ireland 2012-2020. The aim of this public health policy is to develop a high-level framework for public health and it will address the broad determinants of health and health inequalities throughout our health services.

Smoking has been mentioned. It is a major risk factor for cardiovascular disease, including stroke and heart attacks. The Irish Heart Foundation reports that smoking is the cause of up to 2,500 strokes and 500 stroke-related deaths per year. At a personal level, I know all about this because at the age of 66 my father had a stroke and remained blind for the last 14 years of his life. Indeed, one of my brothers died at the age of 60 with lung cancer as a result of cigarette smoking.

This is a serious problem for our society and a serious risk to our children. It is an issue I am determined to tackle and we have introduced the tobacco policy review which will make further recommendations. We have managed to ensure more graphic images are displayed on cigarette packets to discourage people from taking up this desperately unhealthy and dangerous habit. I am also putting money aside to research a question, the answer to which has eluded me to date, namely, how the tobacco industry continues to attract young people as new recruits to a life that for 50% of them will clearly be destroyed by the habit.

Alcohol and cigarette smoking are connected. Alcohol can be a social lubricant and, used modestly, causes no harm, but every cigarette a person smokes damages the smoker. The Irish Heart Foundation's report on the cost of stroke in Ireland has placed an emphasis on the burden of stroke, the need to prevent it and the provision of rehabilitation services for stroke survivors with neurological conditions. There is broad agreement on the need for an intersectoral approach if the full continuum of care is to be addressed. Prevention is always better than cure. Many studies show that for every €1 spent on prevention, we save from €12 to €20 on treatment. It makes sense to opt for prevention.

I welcome the mention by some speakers of the FAST advertisement. It was instrumental in saving the life of a very good friend of mine last year. That advertisement has worked. Awareness works.

I thank the Deputies on the other side of the House who have raised this issue and thank them for the help it offers to raise awareness of the issue of stroke and the lifestyle issues that increase the risk of stroke, including smoking, abuse of alcohol and obesity. A simple measure for people would be to visit their GP once a year to ensure their blood pressure and cholesterol levels are okay and to check their body mass index. When I was in general practice and took an interest in obesity, half the people I saw in that connection just thought they were a bit overweight. If one does not know one has a problem, one cannot deal with it.

I thank the Members who raised this issue for the opportunity to address it tonight. I thank those Members of the Technical Group who proposed the motion for proposing one on which we can all agree. Let us hope it is the first of many collaborative approaches to health issues in society.

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