Wednesday, 13 May 2015
I welcome the Minister of State. The issue I wish to raise is the need to provide 24-7 cardiology services at University Hospital Waterford. Many people in Waterford city and county and across the south-east region have been involved in a long-standing campaign to secure improved cardiology services at the hospital, including the replacement of the current service which operates office hours with a service providing full-time cover. The previous Minister for Health promised to establish such a service as part of the reconfiguration process which involved Waterford and Cork university hospitals amalgamating in a new hospital group. A shift to 24-7 cover in University Hospital Waterford was regarded as a major plank of this configuration process. Unfortunately, the Higgins report did not specifically spell out the delivery of such a commitment and refers simply to enhanced and improved cardiology services in Waterford. On the other hand, the Minister made a clear commitment on 24-7 cover in his public announcements.
Last week, I met representatives of the management of University Hospital Waterford who indicated they did not envisage 24-7 cardiology services being delivered at the hospital in the short, medium or long term. They cited a national review of cardiology services which may result in the centralisation of cardiology services through the provision of full 24-7 cardiology cover in larger population centres such as Dublin, Cork and Galway. However, they stated it was unlikely that other regions, including Waterford, would secure additional cardiologists, support staff or resources to enable them to provide 24-7 cover. I am not being alarmist in this matter as management also defended the current system as safe and indicated that it was acceptable to airlift people to Cork, where necessary, because they can be transported in a timely fashion. This view does not wash with those who living in Waterford who may suffer a cardiac arrest and want assurance that they will be treated as quickly as possible in the nearest hospital. While I accept that specialist services cannot be provided in all locations, University Hospital Waterford is a regional centre providing services to a large population base in counties Kilkenny, Wexford and Tipperary as well as Waterford city and county. A 24-7 cardiology service is needed for the entire region and should be located in Waterford.
Is management at University Hospital Waterford wrong? Is it Government policy to provide 24-7 cardiology cover in Waterford Regional Hospital? If so, when will the service be introduced and the necessary resources provided? What new interventional cardiologist posts, additional resources and capacity will be provided? Will the Minister of State clarify once and for all whether 24-7 cardiology cover will be delivered in University Hospital Waterford ? The answer is either "Yes" or "No". The previous and current Ministers have fudged on this issue by using vague language and giving vague commitments. The Government and Department should be clear on this issue, one way or another, as the service will or will not be delivered. At least if the Government were honest about the issue, we could consider how to step up the campaign for a full-time cardiology service. I ask the Minister of State to indicate what is the Government's policy on this matter, what resources will be provided and if she is able to tell people in Waterford and the south east whether they will have 24-7 cardiology services in future.
I thank the Senator for raising this matter. It strikes me that we learn very little from the appalling circumstances in which people find themselves as a result of failures in the health service. The lesson we must learn from recent revelations about maternity services is that services must have continuous throughput and significant volumes if they are to be safe and this is not always the case.
Services at the regional cardiac catheterisation laboratory, cath lab, at University Hospital Waterford are led by three consultant interventional cardiologists and their teams. This service is developing in line with best practice and the national clinical programme for acute coronary care.The cath lab at UHW performs approximately 40 invasive cardiovascular procedures each week and offers a comprehensive range of invasive and non-invasive diagnostic services. These include the insertion of stents, pacemakers and implantable defibrillators. Almost 3,000 procedures were carried out in 2014.
Primary percutaneous coronary intervention, PPCI, is done on patients with ST elevation myocardial infarction, STEMI, heart attacks, which account for some 20% of all heart attacks. It is done in a cath lab by an experienced cardiologist. The cath lab in UHW is open five days a week from 8.30 a.m. to 5.30 p.m. Patients who require PPCI outside these hours are transferred to another hospital in the south-south west hospitals group, namely, Cork University Hospital, or to a Dublin hospital. It is important to note, however, that 24-7 consultant medical cover for cardiac patients and all medical patients is provided at UHW. For 24-hour emergency PPCI cover, there is a requirement, as a minimum, for two cath labs on site. It also requires a minimum of six interventional cardiologists.
As for any complex acute hospital service, a key criterion for deciding whether a 24-hour PPCI service should be provided is whether there is a sufficient volume of appropriate patient activity to ensure the safe provision of the service. Without sufficient volume of patients, staff will not be in a position to maintain their skills and, in those circumstances, it will not be possible to ensure a safe service. That is the most important consideration in all of this. The acute coronary syndrome, ACS, programme was established in order to standardise the treatment of patients with all types of cardiac arrests. The model of care produced by the ACS programme was informed by advice from the principals involved in centres in the United Kingdom and other European countries. The programme was also informed by models of care from the United States and Australia. Experience at national and international level highlights the importance of having sustainable rotas of clinical staff to support the 24-7 requirements of the service.
The designation of PPCI centres outside Dublin is based on the recommendations of the ACS programme report of 2012. These were that Cork University Hospital and University Hospital Galway should provide a 24-7 service, with University Hospital Waterford providing a 9 a.m. to 5 p.m. service. UHW is committed to the progressive extension of the current PPCI service and will be pursuing this in the context of service planning for 2016. An extension to the service would require three additional consultant cardiologists, extra support staff and a second cath lab. This would have a significant capital cost of €1.9 million and an even greater revenue cost of €2.7 million. Another factor to consider is that international best practice indicates a requirement for one PPCI centre per 500,000 to 1 million population.
UHW is a constituent hospital of the south-south west hospitals group. It will, therefore, be necessary for the latter, in the first instance, to consider the issue from a group perspective and plan for the cardiology needs of its group population accordingly.
The Minister of State indicated that the acute coronary syndrome programme report of 2012 recommended that outside of Dublin, full 24-7 coverage should be provided at Cork University Hospital and University Hospital Galway, with University Hospital Waterford to continue to provide a 9 a.m. to 5 p.m. service. The report identified additional costs in extending the service at Waterford and the requirement for additional interventional cardiologists, support staff and so on. Reference was also made to importance of having a critical population base. I agree that any service must be safe for citizens, but there is a critical mass of almost 500,000 people living in the south east. One of the concerns expressed by people in the region was that once the new hospital groups were in place, patients in Kilkenny or Wexford who were now grouped with hospitals in Dublin would no longer be seen as being in the catchment area of UHW. I hope what is happening here is not the first step in that direction and we do not end up with the hospital no longer performing the regional service it formerly provided.
Why did the previous Minister for Health give a clear commitment to the provision of full 24-7 cardiology care at UHW but we are now being told it cannot happen because of resources and because we do not have the critical mass? In fact, the numbers seem to be right, as set out in the ACS programme report. Will the Minister of State confirm it is the Government's view that it is unlikely 24-7 cardiology cover will be extended to University Hospital Waterford?
To say it is "unlikely" is not to give a clear answer. It is not a "Yes" or "No". What I am saying is that the people running the service in Waterford have indicated that it is a safe service, there is access for patients and they are still pursuing the possibility of extending and enhancing the cardiac service at UHW under the 2016 programme. It is an ongoing process. While I never answer for other people, I would make the point that the only way we should ever deliver our health services is on the basis of evidence-based research and not by way of promises at a particular time.