Robert Dowds (Dublin Mid West, Labour)
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Guím Nollaig shona ar an Leas-Cheann Comhairle agus ar an Aire chomh maith le gach duine eile anseo sa Teach. I thank the Ceann Comhairle for choosing this matter for discussion and the Minister for being present.

The Minister got in first by saying there are so many demands in different areas of health, which clearly is true but I wish to make two initial comments. I acknowledge that there have been improvements in the services available for stroke victims in the past number of years, in particular in the past three years. I also acknowledge that it is difficult to deal with everything. However, good interventions for stroke victims, especially younger victims, pay off. These interventions bring a benefit to the State and I think the Minister would accept that point.

Stroke is the third most common cause of death in Ireland but audits have shown huge shortcomings in the nation's stroke services. Approximately 2,000 people die from stroke each year and they account for more deaths than breast cancer, lung cancer and bowel cancer combined. Proper rehabilitation in the community could make a major difference to these patients and, ultimately, save the State many millions of euro. Research carried out by the Economic and Social Research Institute and the Royal College of Surgeons in Ireland found that 54% of stroke survivors, approximately 3,000 people per year, could benefit from early supported discharge programmes. This would reduce hospital bed days by 24,000 and lead to a saving annually of between €2 million and €7 million.

Early supported discharge is used in many countries worldwide. It involves an intensive approach to rehabilitation. Unfortunately, it is not usually available in Ireland. The report notes that if it were to be properly introduced here, there would need to be a major investment in community staff such as physiotherapists, speech and language therapists, occupational therapists and community nurses.

If the additional staff were to be provided, the tools they use would have to be greatly advanced and modernised. In the Baggot Street centre where survivors are trained to get back to work, the IT equipment is totally out of date. Patients need constant physiotherapy and while this is driven on a personal level, it is greatly assisted if facilities are also provided in rehabilitation centres. These centres should not be using exercise equipment that is faulty or out of date, which is sometimes the case. Recovery methods are only effective when instruments are in good working order and up to date.

Stroke survivors say that the best thing after a stroke is getting out of hospital but they can only do this with proper assistance and community care. Centres like the one on Baggot Street do great work but are not accessible to everyone. There is a real need for community centres across the country to have proper and adequate staffing in order to continue the rehabilitation process. Without proper assistance, too many people are losing the chance to regain as much of their strength, speech and mobility as possible.

Less than half those of working age return to work after a stroke and most of these either leave soon after or take on a reduced role. In order for these statistics to improve, the Government needs to invest more in stroke rehabilitation services and infrastructure. This investment will allow stroke survivors get back to a normal life, both professional and personal.

Leo Varadkar (Dublin West, Fine Gael)
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I thank Deputy Dowds for providing me with the opportunity to speak on the subject of rehabilitation services for stroke survivors. The aims of the HSE's national clinical programme for stroke are to improve the quality, access and cost-effectiveness of stroke services in Ireland and I am pleased to report that significant improvements in stroke services have been made, as Deputy Dowds has acknowledged.

Emergency thrombolysis is provided now to patients in all regions of the country by improved hospital and ambulance protocols, health professional training and the appointment of new physicians. There is national 24/7 access to safe stroke thrombolysis, the rate of which has increased from 1% in 2006 to a current rate of 11.6%. This exceeds the national target of 9% and is among the best in national rates worldwide.

Access to stroke unit care has been shown to improve stroke patient outcomes through reduced rates of death, dependency and shorter lengths of stay. Since the commencement of the national clinical programme for stroke, nine new stroke units have been opened, bringing the total number of stroke units in acute hospitals to 22. New care pathways have also been developed to standardise stroke management. Early rehabilitation, including speech and language therapy, physiotherapy and occupational therapy are key parts of the care provided in these units. This is a major improvement from the first national stroke care audit report in 2006, which reported that there was only one stroke unit in the entire country.

As it stands, fewer stroke patients are dying in hospital, with the rate having dropped from 16.1% in 2009 to 15.1% in 2013. This represents an average of 36 fewer deaths a year. There are fewer stroke patients being discharged to nursing homes, which is an indication of reduced disability outcomes after a stroke and more stroke patients are being discharged home directly from acute hospitals. The average length of stay in hospital for stroke has fallen from ten days in 2009 to nine days in 2013. This is estimated to have saved 19,000 bed days in the 2011 to 2014 period.

The Deputy mentioned early supported discharge services for stroke patients which aim to accelerate discharge home from hospital and provide rehabilitation in the home setting. Three early supported discharge services for stroke patients have been established at the Mater Misericordiae University Hospital and HSE North Dublin, Galway University Hospital and Tallaght Hospital. Excellent clinical outcomes and very high patient and care satisfaction rates are reported across all three sites. The average bed days saved per patient range between 6 and 12.6 days across sites.

My Department is conscious of the business case for early supported discharge submitted to my Department by the HSE's national clinical care programme for stroke and the Irish Heart Foundation. This advocates a phased roll-out of early supported discharge services. It was considered as part of the development of the HSE's national service plan for 2016 but unfortunately, there was no scope to develop this initiative due to other funding demands. My Department will take account of the additional resources needed to expand this initiative gradually in the context of next year's Estimates process. These additional resources will then be considered as part of the HSE's service planning process next year. Funding for stroke rehabilitation is provided in the overall allocation to the HSE for acute hospitals and community services.

Robert Dowds (Dublin Mid West, Labour)
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I am glad that the Minister is committed to improving the services for stroke victims. Given our improved economic situation, the faster that can be rolled out the better, particularly for younger people who have a better chance of making a fuller recovery. I would also suggest that more targeting is required in this area because some people will need more support at home than others. For example, people who live on their own would need more support than those who live in family situations.

There is also a requirement for additional funding to provide psychiatric help for stroke victims because the impact of stroke is not just physical; it can have a major impact on people's state of mind too. At the moment, one third of stroke survivors have no access to physiotherapy, half cannot get any speech and language or occupational therapy and only one in ten get psychological help. More than one in three stroke survivors have to pay for their own rehabilitation and 60% of them are financially worse off after their stroke. Less than half of those of working age return to work after suffering a stroke and most of these people either leave soon after or take on a reduced role. In that context, any improvements in the services provided to stroke victims would have a positive impact. Given that around 40% of stroke sufferers have reported that their close relationships were damaged in the aftermath of stroke, improvements in services will not only have hugely beneficial effects for the individuals themselves but also for those with whom they associate.

Leo Varadkar (Dublin West, Fine Gael)
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Again, I thank the Deputy for raising this important issue. I worked for a period of time in care and medicine for the elderly and have a limited knowledge and a particular interest in stroke. The Deputy was in the Chamber for the previous discussion on heart failure which is another area in which we should do a lot more. We know that there are very cost effective interventions in the area of heart failure that we are not making at the moment but we simply cannot do everything. The same applies to stroke. There have been enormous improvements in stroke services in the last ten or 15 years and further development of those services would certainly be cost effective and not terribly expensive. However, the first priority must always be to maintain existing services and then with any additional funding available - which in any year and in any country, no matter how rich, is limited - one must prioritise those areas which will cost the least and be the most effective. We are very disappointed that we cannot proceed with a national roll-out of early supported discharge for stroke in 2016, which we would have loved to do. Unfortunately, it is not possible. However, it will be possible to ensure that stroke telemedicine is available and provided to all hospitals in the country, thus ensuring that we can maintain and improve on our thrombolysis and thrombectomy rates.