Kathleen Lynch (Cork North Central, Labour) | Oireachtas source

I thank Senators Mary Ann O'Brien and Power and the Asthma Society of Ireland for their engagement over a long period in terms of the most Government appropriate response to asthma. I thank the Members who contributed to the debate. I say on most if not all occasions I stand up in the House that the Seanad gives people an opportunity to discuss issues that do not get the type of air time they may deserve.It is a very good platform in that regard. The most peculiar matters are discussed in here. In this instance, we are discussing something that could well affect each and every one of us. I thank the Senators who tabled this motion and the Cathaoirleach for the opportunity to discuss it.

I do not think there is any dispute between on us on this matter. I am delighted to support the motion before the House, which acknowledges the Government's commitment to the provision of primary care to people with chronic diseases such as asthma, which remains a significant challenge for our health services. The motion also recognises that we are promoting healthier lives for everyone in our communities. I agree with the point that has been made with regard to medication. I have read through the speech that has been prepared for me but I am not sure whether it includes a reference to this issue, which I discussed with the president of the Irish Pharmaceutical Healthcare Association recently. I understand that the Department will enter into further discussions with the association within weeks. I will ensure the cost of asthma medication is on the agenda for those discussions. I am happy to make that promise here.

I acknowledge those involved in the Asthma Society of Ireland and the HSE's national clinical programme for asthma. I pay tribute to them for their joint efforts in improving the lives of asthma patients. I am aware of the statistics highlighted in a report produced by the society, The Case for Change: Implementing the National Clinical Programme for Asthma, which was published in 2014. These statistics, which can also be found in other available data, make it clear that asthma is a serious burden for patients and our health services. This is compounded when one considers that up to 90% of deaths from asthma are preventable. I do not intend to get into a debate on statistics. One can get different statistics depending on what week it is and on what source one uses. We have statistics from the CSO. At times, we cannot be certain about the exact cause of death or the exact numbers. This point is sometimes made in debates about suicide. In 2012, the CSO recorded 39 deaths from asthma, 22 of which involved people aged 85 or older. There was an increase in 2013, when 54 deaths were recorded, 35 of which involved people aged 85 or older. This was followed by a decrease last year, when 37 deaths were recorded, 15 of which involved people aged 85 or older. This is still too many. I agree that we must strive to address this as soon as possible.

The HSE's national clinical programme for asthma was set up in 2011 to design and standardise the delivery of high-quality asthma care to everyone who needs it. The programme has made significant progress since its establishment. Initially, it focused on the development of asthma education initiatives for patients and health care professionals, the development, implementation and organisation of national asthma guidelines and better integration of national asthma services at primary and secondary care levels. This approach has been shown to be effective at international level with significant improved outcomes for patients and care givers. The national clinical programme for asthma is focusing on improving asthma control in the community. Its aim is to reduce acute asthma attendances at emergency departments, inpatient admissions and deaths from asthma. Among the specific priority solution areas being explored by the programme are the development of a national model of care with guidelines, care pathways and treatment protocols for use in primary and secondary care settings. This work is being carried out in conjunction with other national clinical programmes, including those in the areas of emergency medicine, acute medicine, critical care, obstetrics and gynaecology, paediatrics and neonatology and primary care.

The development and delivery of asthma education programmes for health care professionals to underpin the guidelines is an important aspect of the work of the national clinical programme for asthma. Integrated care initiatives that aim to improve the diagnosis and management of asthma patients in the primary care setting, with links to specialist adult asthma services, are also being developed. Those involved in the Asthma Society of Ireland are probably more aware than most that the doctor is not always needed in these cases. We can do far more if our approach involves getting specialist nurses or health care professionals involved in the management and education aspects of this matter. I know that is the society's approach as well. The national clinical programme for asthma has developed national asthma guidelines based on international best practice for acute care and ongoing asthma management, including emergency adult asthma guidelines and emergency paediatric asthma guidelines. These reports can be found on the HSE website. The emergency adult asthma guideline, which is a national clinical guideline for the management of acute asthma attacks in adults, has been prioritised and quality assured by the Department of Health's national clinical effectiveness committee. It is due to be published and launched next week.

Work is ongoing on the emergency paediatric asthma guidelines, known as the national clinical guidelines for management of acute asthma attacks in children. It is intended that these guidelines will be submitted to the committee in 2016. Guidelines for managing patients with asthma in primary care have been developed and approved by the Irish College of General Practitioners. They were launched in May 2013 and are available on the college's website. The national clinical programme for asthma is planning to work with the college to update these guidelines. The model of care for asthma has been prepared and is due to be launched in the coming months. The model details how physicians, nurses and other health care professionals will work with engaged patients to make the clinical decisions that are most appropriate to their circumstances. It also sets out how they can collaborate with specialist colleagues in providing a safe and seamless patient experience within our health system.

It is appropriate to say at this stage that an obvious need exists in this regard. The economic and health impacts of asthma on society and on patients are also obvious. That is why one of the first two chronic disease management programmes to be developed in the primary care sector relates to asthma. That, in itself, is an indication of the realisation that this is an issue about which we can and should do something. In anticipation of the launch of the model of care for asthma, the national clinical programme for asthma has been developing and preparing for the roll-out of the asthma integrated care demonstrator project across two initial sites. These are linked to the catchment areas of the Midland Regional Hospital in Mullingar and Connolly Hospital in Dublin. The demonstrator project plans to improve the diagnosis and management of asthma patients in the primary care setting with links to specialist adult asthma services. Its aim is to improve health outcomes and reduce service demand. Two new clinical nurse specialist posts have been approved for this project. They were advertised last week. It is hoped that the recruitment process will be completed before the end of the year. The HSE will consider expansion of this initiative based on the success of the demonstrator project.

The Asthma Society of Ireland's report, The Case for Change: Implementing the National Clinical Programme for Asthma, highlights the importance of asthma education for health care professionals and patients. The national clinical programme for asthma agrees with this approach. A modular self-learning programme, which is based on the national evidence-based guidelines and was developed by the national clinical programme in conjunction with the Asthma Society of Ireland, is available online for health care professionals who wish to update their knowledge. This programme will enable health care professionals to underpin their skill sets with theory. A similar programme for general practitioners is available on the website of the Irish College of General Practitioners. A practical workshop is being delivered by the respiratory clinical nurse specialists for staff in primary and secondary care. The national clinical programme for asthma is updating education programme materials to reflect the introduction of the free GP care contract for those under the age of six. Just as it is important to provide appropriate asthma education to health professionals, it is equally important that relevant education is made available to asthma patients. In this regard, up-to-date information is available for patients and their families and carers. The national clinical programme for asthma has implemented easily accessible patient asthma education supports in conjunction with the Asthma Society of Ireland to assist guided self-management for this chronic condition. These supports are available on the websites of the HSE and the Asthma Society of Ireland.

As I said earlier, deaths related to asthma are preventable. In this regard, the national clinical programme for asthma has initiated research work which will involve examining acute asthma deaths in Ireland. The aim of the project is to identify and understand preventable factors relating to the management and self-management of asthma so that we can improve the further care of people with asthma and prevent further asthma deaths.The objectives are to identify all asthma deaths in Ireland during the study period; explore the circumstances surrounding each death from asthma, including trigger factors, awareness at school or work, environmental conditions, lifestyles and activities, medication and adherence to treatment plans, and organisational aspects of care; analyse key themes, particularly preventable factors; and propose solutions for adoption by the national asthma programme in respect of clinical practice, service provision, education of professionals and patient education. This work will be led by the programme's clinical lead and its public health specialist. I have asked the HSE to start this work as soon as possible and I look forward to its findings, which I hope will lead to fewer asthma deaths in the future.

It is evident that the asthma programme and the Asthma Society of Ireland have been working strenuously together to address key issues relating to asthma care. Progress may be slower at times than everyone would like but it is encouraging that steady progress has been made, especially at a time of scarce resources. As our financial circumstances improve, I am confident that further improvements for asthma patients will be achieved.

I am pleased that the Government is playing its part in improving asthma care. It is reforming the system of health service eligibility and seeking to make it fairer. For many years, Irish patients have had universal eligibility for acute hospital services but the first point of contact with the health service, provided by GPs, has only been provided on a public basis to those on low incomes. The provision of universal GP access through greater public investment in primary care services is a critical reform in resolving inequities and rebalancing services towards earlier prevention. We want to shift the emphasis in our health system from an "illness model", dependent on care in hospitals, to a model where primary care services are strengthened and health and well-being are promoted. A number of building blocks are fundamental to this shift from reliance on acute care to where it is best accommodated at primary care level. GP care without fees is one of the principal building blocks to make this happen. The Government is committed to introducing, on a phased basis, a universal GP service without fees. Many people delay or even avoid going to their GP for essential medical care as they simply cannot afford the €50 or €60 fee per visit. When people delay going to their GP and getting regular preventative and screening care, it results in the late detection of illness, poorer health outcomes and greater pressures on our hospitals - pressures that our hospital system can ill-afford. The Government wants this to change and good progress has been made.

The new contract with GPs for children aged under six includes for the first time in primary care the provision of a cycle of care for child patients with asthma. The asthma programme and the Asthma Society of Ireland have welcomed the introduction of this first step in the provision of a comprehensive programme for asthma across primary and secondary care. The cycle of care includes key actions such as checking inhaler technique, provision of a written asthma action plan, review of asthma medications and recording of smoking status of the home. In addition to the introduction of GP care without fees at the point of access for children aged under six, GP care without fees to all persons aged 70 years and over was introduced. These represent the first phase in the delivery of a universal GP service. On reading the research into asthma, I was not as conscious that the majority of deaths occurred in the over 85s age cohort and, therefore, free over 70s GP care provision will be crucial. The under-six arrangements will also be important in the context of education and developing practice but the over 70s provision will be equally important.

Under the new arrangements, effective from 1 July 2015, an additional 270,000 children aged under six will benefit from GP care free at the point of access. The new extended GP service applies to all children in this age cohort, including the 166,000 who held a medical card or GP visit card. To date, more than 210,000 children have been signed up for the under six service, which includes age-based preventative checks focused on health and well-being along with the asthma cycle of care mentioned earlier. More than 17,500 children have been registered for the asthma cycle of care by their GPs, under which each one of them will be reviewed annually by their doctor. The introduction of GP care without fees at the point of access to all persons aged 70 years and over commenced on 5 August 2015. To date, in excess of 47,000 people have registered for this service.

The HSE, the Department of Health and the IMO have commenced talks on a new GP contract, and a priority of these discussions will be the inclusion of chronic disease management for patients. As a first step in this process, agreement has been reached on the introduction of a diabetes cycle of care for patients with type 2 diabetes who hold a medical card or GP visit card. The cycle of care aims to augment the service available to GMS diabetic patients prior to the introduction of a comprehensive structured chronic disease programme. The diabetes cycle of care commenced on 1 October and to date, more than 55,000 patients have been registered for the service by their GPs. Currently, in excess of 2.1 million people can avail of free GP services, more than 1.7 million of whom can also avail of free prescribed approved medicines, subject to the relevant prescription charges. The Government remains committed to expanding free GP to more patients and in this context budget 2016 committed to a further extension of GP care without charges to children aged 11 and younger.

This will be subject to negotiation with the IMO in respect of the scope of the service to be provided and the fee arrangements to apply and will be implemented in the context of overall new arrangements and not as a stand-alone extension or amendment to the current contract. If we were going to bring it up to the under 12s, we should have brought it down to the over 65s as well, but I did not get my way on that. I am confident that the ongoing work of the HSE's asthma programme and the Government's commitment to introduce universal GP care for the entire population will over time reduce the cost burden on asthma patients. Meanwhile, where asthma patients do not qualify for free medicines under the GMS or the drug payment scheme, they or their family have to pay a maximum of €144 each month for approved prescribed drugs, medicines and certain appliances for use by them or their family in that month. I hope the negotiations with the IPHA will reduce that burden on patients.

I am confident all these initiatives will have a positive impact on the health of our nation, including asthma patients, and will reduce the burden on those patients and on our hospital services. I thank the Senator again for raising this issue. It is an excellent subject for debate and it will raise awareness of this issue, which is crucially important. Somehow or other, we seem to look on asthma and other chronic conditions as ailments that people have to get on with when, in fact, there are mechanism for ensuring people can live a much healthier, longer and more productive life if they are managed properly.