Tuesday, 27 June 2017
University Hospital Waterford Cardiology Services: Statements
I am grateful to get the opportunity to update the Seanad on cardiology services at University Hospital Waterford, UHW. First, I again extend my condolences to the family of the late Thomas Power on their extraordinarily sad loss. While I cannot comment on the detail of individual cases, I expect that all the proper procedures will take place with regard to the examination of the circumstances of Mr. Power's death.
Last year, in line with a commitment in A Programme for a Partnership Government, an independent review of the need for a second catheterisation laboratory, cath lab, at UHW was undertaken by Dr. Niall Herity, a world renowned cardiology expert. The review concluded that the needs of the effective catchment population of UHW could be accommodated by a single cath lab. However, investment was recommended to enhance cardiology services at the hospital and to provide an additional eight hours cath lab activity per week to address waiting times and to provide improved access for patients.
At the time of the publication of the report, I committed to providing additional resources to the hospital. I am happy to confirm to the House that the HSE National Service Plan 2017 identified the implementation of the recommendations of the report as a priority and, in that context, additional funding of €0.5 million was provided for the hospital.
I should also mention that the HSE issued a tender last week for a temporary mobile cath lab at UHW. No doubt this will contribute, on an interim basis, to the further reduction in elective cardiology waiting lists at UHW. I expect that the mobile cath lab will build on the significant progress which has been made following a targeted initiative by the South/South West Hospital Group to address cardiology waiting times at the hospital.
I also committed to a further review to assess the impact these improvements have had on the volume of patients attending the cath lab and this review will take place at the end of the deployment of the mobile lab. I am happy to keep Oireachtas colleagues briefed on this. Last week I offered in the Dáil to keep Deputies from the south east informed on this review and I offer in the Seanad today to keep Waterford and south-east Senators briefed. It affects, in particular, Senators Coffey, Senator Grace O'Sullivan and Murnane O'Connor. I would be more than happy to keep them briefed, along with their Dáil colleagues, on that review as it progresses at the end of the deployment of the mobile cath lab.
In regard to emergency care, Dr. Herity recommended that such work should cease in order to allow the hospital to focus on a much larger volume of planned work. I should explain that primary percutaneous coronary intervention, PCI, is used as an emergency treatment for patients having a heart attack. It is distinct from PCI work where scheduled procedures are provided on a planned or elective basis.
Planned work represents 96% of the overall caseload in the cardiac cath lab in Waterford and, as I mentioned earlier, this service will be enhanced this year. Funding has been provided for an additional eight hours activity per week - in other words, a 20% expansion in operating hours. The cath lab will now be funded to provide 12 sessions - in other words, 48 hours activity per week. It is expected that this additional capacity will facilitate the provision of an increased volume of scheduled cardiology care at the hospital.
However, the organisation of primary PCI services is an issue for the whole country, and this is an important point. It relates to how we provide services to our whole population taking account of the best evidence available.
Based on this country's population we can only operate a limited number of primary PCI centres in order to ensure that the services we provide achieve the required standards. We also need to ensure that we provide sustainable services.
I would point out that throughout the country patients are transferred to cardiac centres for primary PCI. Patients in Monaghan or Louth are transferred to Dublin, patients in Sligo go to Galway and patients in Kerry go to CUH or Limerick.
Highly specialised services, such as primary PCI, need to be carried out in a small number of hospitals where the volume of patients supports the provision of a safe service. Low volume services do not facilitate the ongoing and sustainable achievement of the patient outcomes required. That is obviously not my view but a clinical one. Clinical staff cannot maintain their skills where patient volumes are insufficient and there are recruitment or retention issues with staff in low volume units. On foot of Dr. Herity's recommendation with regard to primary PCI at University Hospital Waterford, I indicated that I had asked my Department to address the implications of this recommendation by undertaking a national review of all primary PCI services with the aim of ensuring that as many patients as possible have access on a 24-7 basis to safe and sustainable emergency interventions following a heart attack. I did so as I wanted to be certain that any changes to how a service is delivered will result in improved services for the patients using that service and the maximum number of people possible in this country living within a close and appropriate time range to a primary PCI service. I can confirm to the Seanad, as I did to the Dáil last week, that the national review will proceed. I have asked my Department to make arrangements for this review which will address the wider implications, for all parts of the country, of Dr. Herity’s recommendation regarding primary PCI services.
I want to repeat that extra investment is being provided to allow additional activity at the existing lab. Second, the mobile cath lab for Waterford is confirmed and on the way. Third, there will be a further review of the Waterford situation following the deployment of this mobile lab. Fourth, there will be a national review recognising the importance of access to primary PCI services for all citizens. I look forward, in due course, to the finalisation of both of these reviews and I will continue to liaise with all Members of the Oireachtas, especially those from the south east, on what I understand is a very important and sensitive issue. I will always be guided by clinical advice on this issue and should the clinical advice change, then I will change my position. We have two significant developments in the additional resources, the mobile cath lab, we have a review of the situation in Waterford and an ongoing national review. We need to continue to develop health services based on a medical evidence approach and one which is objective and independent, and that is what I intend to do.
I thank the Minister for coming to the House. I had asked that he come in to us today. I welcome my colleague, Senator Mary Butler, who has fought tirelessly for a 24-hour cardiac unit for Waterford hospital.
Both I and my party send deepest sympathies to Mr. Thomas Power's widow and family on their tragic loss. Thomas Power was in the prime of life, newly married and expecting his first child later this year. His death in an ambulance en route to Cork hospital following a cardiac incident has brought into sharp focus the lack of 24-hour cardiac care in the south east and requires an immediate and independent review of the case. We want to be clear that the people of Waterford and the south east deserve a 24-hour cardiac unit but also for a second cath lab to be established.
Many questions must be asked both in the context of the individual case and the broader issues. Was Mr. Power seen by a consultant who had travelled in the ambulance when he was being dispatched to Cork and were all protocols followed in the normal procedure of transferring a patient? That is the issue which really needs to be addressed in this individual case, for which we must have a full clinical review. We need to get to the bottom of this and learn from this tragedy. It must never happen again.
Some 170,000 people, including people who live in my locality of Carlow, are more than 90 minutes away from an acute cardiac service. This is because there is no 24-hour service in Waterford. There is considerable fear and anxiety in communities throughout the south east. This particular tragedy has brought fear to many. For years, those who have campaigned for 24-hour cardiac care, including the delivery of a second cath lab, have warned about the dangers of transporting patients after hours to Cork for treatment. The Herity report's recommendation can no longer be used by the Minister to justify not delivering 24-hour cardiac care in Waterford. We in Fianna Fáil believe these recommendations are flawed. The Herity report uses the 90-minute mark as though it is a target, not a limit.
Dr. Herity was before the health committee here last February. My colleague, Senator Swanick, asked him if he believed that our lives were in danger in the absence of a second cath lab and a 24-hour service. Dr. Herity responded that he did not think so. Senator Swanick disagreed with him.The expert report, the Higgins report, recommended in 2013 that Waterford Regional Hospital continue to provide a cardiology service for the south-eastern population and extend its services. This report appears to have been discounted for the sake of the 2016 Herity report. I have significant concerns about this. The Minister has two reports and is saying he is opting for the second. My colleague, Deputy Mary Butler, and I are not happy about this and it is uncalled for. It is simply not acceptable that time restrictions play such a role in the day-to-day lives of the people. The issue of cardiology cover at Waterford Regional Hospital is so sensitive. If any patient presents with a cardiac issue outside opening hours, his or her only option is to take an ambulance to Cork. There are in place what I would call office hours, from 9 a.m. to 5 p.m., from Monday to Friday. Someone should not have a heart attack outside these hours because, if he or she does, he or she will have to go to Cork. Statistics show that 80% of heart attacks happen after 5 p.m.
The death of Mr. Power was a huge shock to those living in Waterford and the rest of the south east, but, unfortunately, it did not come as a surprise. Those of us campaigning for a second cath lab and 24-hour cardiac care have been warning for years about the danger of transporting patients by ambulance for treatment. Dr. Paddy Owens, consultant, among other cardiologists, warned time and again that a death would happen. It has and is one death too many. It can never be allowed to happen again.
Why is our hospital the only one in the south east without 24-hour cover? There is a population of 170,000 in the south east and we have no 24-hour cardiac care service. That is unacceptable. The solution is additional resources in the form of a second cath lab with sufficient staff to resource it. The solution is also to have 24-hour cardiac care in Waterford. This would save lives and reduce waiting lists. The budget for health is extremely large, amounting to €14 billion. We are talking about a captial investment of €2.6 million and €2 million in running costs annually.
Dr. Herity appeared before the Oireachtas Joint Committee on Health and was questioned about three issues, namely, the catchment area, the commute time between Waterford and Cork and the single point of failure that we saw at first hand at the weekend. What occurred can never be allowed to happen again. It is shameful. My colleague, Deputy Mary Butler, who represents Waterford and I believe we really need to have a 24-hour service in Waterford. There is a service available from Monday to Friday that should be extended. People are living longer and it is crucial that a service be provided in Waterford and for the rest of the south east. I thank the Minister.
I will not take five minutes, as I am conscious that there are others present who are more involved in dealing with this matter.
I acknowledge Deputy Mary Butler's presence. I also acknowledge the enormous amount of work Senators Paudie Coffey and Grace O'Sullivan have done on this issue. I congratulate the Minister on his reappointment. Despite all of the speculation, it is great to see him back. The most important message coming out of this debate is that he is going to base all of his decisions on medical evidence. They have to be evidence-based and must stand up and be capable of being assessed on medical need and demand. That is important because it is so easy to keep wavering in politics and take the easy route. The proposal makes absolute sense and the Minister is correct.
I acknowledge the considerable work done by various Senators, including Senator Jennifer Murnane O'Connor. It is clear that there is a great demand in the south east for a 24-hour cardiac care service which needs to be provided at some stage.
I thank the Minister for attending and giving of his time. I shall cede the rest of my time to the Senators from Waterford who have done tremendous work in campaigning on this issue.
I, too, welcome the opportunity to debate this issue. I am saddened, however, that we are debating it after a week in which we saw a terrible tragedy in Waterford. I remember Mr. Thomas Power of Bell Lake in Waterford who last Sunday passed away at only 39 years of age in an ambulance en route from University Hospital Waterford to Cork. He left behind a young widow, Bernie, to whom I offer my sincere sympathy, as well as to his parents, Eileen and Michael; his sister, Catherine; and his extended family and friends. They are the people who must now endure this terrible tragedy, a tragedy that was avoidable. There had been enough warning signs and signals. Many of us who have campaigned for many years to have an essential service provided have noted that the warnings have fallen on deaf ears to date. It is an issue that transcends politics. All political representatives in Waterford, of all political parties and none, are fully behind the campaign to have an essential service delivered, not in a county hospital but a regional hospital that serves a catchment population of 500,000 people. That is a fact.
In 2017 we are experiencing health apartheid in the south east. As a Government Senator, a former Deputy, a former Minister of State and a colleague of the Minister, I take no pride in stating this in Seanad Éireann. People living in Dublin, Cork, Limerick and Galway are not experiencing the same problem because they have access to 24-7 cardiology services. We in the south east, a vast region with a large population, do not have access to a cardiology service. Therefore, we are being treated as second-class citizens. There is a population of 500,000 people and it is a regional hospital. We are not expecting 24-7 care in every hospital in every county, but we are expecting one additional cath lab to be provided in University Hospital Waterford to service the entire south-east region.
I have written commitments, dating from as far back as 2013, from the Minister's predecessor in the Department of Health, the architect of the new hospital groups, Professor John Higgins, the CEO of the South/South-West Hospital Group, Mr. Gerry O'Dwyer, and the director-general of the HSE, all of whom have committed in writing to the expansion of cardiac services in University Hospital Waterford. What has changed? The Herity report, commissioned by the Government, is, unfortunately, being stood over. With all due respect to the Minister and his officials, it is flawed because it takes into account only a fraction of the 500,000 people living in the south-east region. It states quite clearly that people living in the south east can be transferred to Cork University Hospital within 90 minutes. That is a patent untruth and not a fact. Anybody living in Waterford who has to travel to Cork will tell the Minister that it takes much longer than that to get to Cork University Hospital. The problem is that we cannot gain access to the vital services within the golden hour, as it is called. That is where the report is fundamentally flawed.
I do not want to criticise bureaucrats and officials in the Department of Health, but on this occasion I am going to do so because they are wrong. The advice they have been giving to the Minister is wrong. The advice and information the HSE gave to Professor Herity prior to the issuing of his report was wrong. It told him that extending the service in a geographical area that did not have the population to justify the provision of such a service would be wasteful of very limited resources. This tells me that HSE bureaucrats are considering budgets rather than the health needs of citizens.
I always have faith in politics, which is why I entered it. I believe politicians who have a democratic mandate and are elected by the people can overrule the bureaucrats who are number crunchers. That is all they are. That is why I appeal passionately to the Minister to revisit the issue. I am saying this on behalf of the people I represent in Waterford. The Minister should look under the rocks and take account of the population and travel times. People are being isolated and left to die. That is what is happening. We have one case that is very public, but I know of another, a case in which a man died while being transferred from University Hospital Waterford to Cork. He died in Clonmel, which is not en route and I still have not got to the bottom of it. That is what is going on in the country, but the Minister is not hearing it. He is only hearing one side from his officials and we need to get to the bottom of it. I join my Fianna Fáil, Sinn Féin and Green Party colleagues because we are united as citizens of the country in demanding a right for the people we represent. I will continue with that fight.
My colleagues and I extend our heartfelt condolences to the late Thomas Power's wife, Bernie, and their unborn child. I hope the closest in the family will protect, comfort and support them in such a time of need.
At the heart of this matter is the question of whether University Hospital Waterford is a level 4 regional hospital providing tertiary care for the people of the south east. This is decided according to population size and the size of the catchment area. There are considerable issues about the size of the catchment area and the population of the south east. The hospital claims to serve a population of almost 600,000 people, but the Herity report refers to a figure of 286,000.The model of care for acute coronary systems has been delved into. I note from replies to parliamentary questions from the Department that the following has been stated:
The designation of Cardiac units is 24/7 or 9/5 centres is based on current staff and facilities enabling them to deliver an acute coronary syndrome service.
Designations are linked to predicted volumes of activity based solely on population need but also on the link between outcome and activity.
There are major issues involving staffing and facilities across the board in the health care system. I am sure it takes up all of the Minister's time. This is all related to capacity. We have an ageing population. I was shocked to learn when looking into another matter that in 2004 we had a population of 3.9 million in the Twenty-six Counties and in 2016 the population had increased to 4.7 million, which is almost but not quite 5 million, and meanwhile our population is ageing and it is expected to continue to grow. People are living longer and services have to begin to match the needs of our population that is increasing in urban and rural areas across the country.
The programme for Government originally committed to a second cath lab for University Hospital Waterford subject to an independent clinical review. The review, which was the Herity report, recommended ceasing all primary PCI care causing huge shock and upset. The full implementation of the report is now subject to a national review. Sinn Féin respectfully challenges the findings of this review. It will not consider pre-existing HSE policy and the role of the hospital as a regional level 4 hospital. My colleague, Deputy David Cullinane has produced a report, Cardiac Services for the South East - the National Review of the PPCI. It is a discussion document. He asks that we take this into account in making sure that a second cath lab is delivered for University Hospital in Waterford. He will host a presentation on the report next Tuesday to highlight the lack of 24/7 cardiac provision for the south-east region. I ask everybody to attend it in the AV Room at 1 p.m.
Having been a nurse with more than 30 years experience I, and other Members, have much to bring to this debate. Previous speakers spoke of the need for services that they have identified in their areas. I am removed from that being based in Dublin but we all know what is needed in all the service areas. When somebody says a service is needed but it is pending an independent review, I become increasingly more cynical because that kicks the issue down the road and then another report can be published recommending that the service should not be provided.
We have had statements upon statements on serious issues of national importance in this House. I do not know what is the usefulness of having statements. I, and I am sure other Members, would much rather, in terms of respect for this House, if we spent much more time scrutinising legislation and analysing and implementing health policy rather than making statements. I am unconvinced that statements do much more than kick the problem down the road. They have the appearance of making us look like we are doing something but, in reality, we are doing very little.
I will conclude by extending my deepest condolences to Mr. Power's wife, Bernie, and acknowledge the traumatic and grieving time she faces in the period ahead.
The tragic death of Thomas Power has shown us that we cannot wait any longer - not for another review, not for another mobile cath lab that should already have been delivered by now, and not for more excuses. People have died and more will die unless the Government takes action necessary to deliver a safe and adequate health care system to the region. I have been talking to public representatives from across the region, councillors, Deputies and Senators from all parties and none in an effort to build support for a depoliticised approach that serves the region best.
I have also contacted consultants at University Hospital Waterford, those at the coalface of this crisis. They have a very clear and detailed analysis of what needs to be done, some of which I want the Minister to hear today. Their analysis is as follows. First, the south east region is the only region nationally without a 24-7 cardiac care service. Statistical analysis from studies compiled in the UK and Europe using similar demographics is compelling and demonstrates that the lack of a service in the south east is causing 6.3 deaths per year. Second, multiple worldwide clinical assessment of primary emergency coronary angioplasty and stenting for ST elevated heart attack has been demonstrated to be only effective if carried out soon after the first presentation of symptoms of a heart attack. After 90 minutes the benefits of primary PCI are negligible as heart muscle starved of oxygen and blood supply has already died and is not replaceable. Third, the cath lab at University Hospital Waterford in 2015 dealt with approximately 64 such events during open hours while 75 were sent outside the region for treatment. Fourth, referring patients to outside centres where travel times can be double the European standard of 60 minutes is proving to be a clinical sub-optimal treatment protocol.
Fifth, loss of heart muscle due to delays in assessing emergency care leads to both deaths and increased morbidity for survivors. The south east has many patients who have suffered damage and loss of heart muscle. Their resulting health profile and quality of life are severely impacted as a result. They are an increased drain on scarce health resources as they are forced to engage more often on an ongoing basis with primary and hospital services due to their compromised health status. This health discrimination is perpetrated on no other citizenry in the country.
Sixth, as evidenced by RTE Radio 1 coverage recently of this issue, a large number of people in the region suffer huge anxiety and stress as a result of having received previous cardiac treatment or having clinical conditions without treatment within 90 minutes travel time. These patients are well aware that their prognosis in such cases is probably a fatal outcome. Seventh, the subsequent recommendations of the Herity report to completely remove all emergency cardiac access at University Hospital Waterford and, furthermore, to remove all elective PCI procedures will significantly impact the direct provision of high value, acute medical services within the south-east region. Eighth, the Waterford cath lab is one of the most efficient in the country, despite its 37 hours per week restriction and it has one of the highest throughputs in patient procedures nationally.
The recommendations of the Herity report with respect to this centre are illogical and misdirected in terms of any measure of quality health care, economic impact or social deprivation one wishes to mention. There is no viable or feasible substitution for dealing with the south-east issue other than to immediately provide a second cath lab with the full medical attendant complement required to provide a comprehensive south east region cardiac rescue and elective service. The clinical case for this has long been made and recent events should now stimulate all elective representation of 24/7 care for the south east region. If the Department of Health wishes to review cardiac services on a national level, it should begin by concentrating on the less efficient labs that exist in the country and review the Waterford based service after one year's operation as a 24-7 centre. The current review pathway chosen by the Government will take at least a year to arrive at a conclusion. That is not worth 6.3 deaths while the south east waits.
I am standing here on behalf of people from the south east, from Waterford, and on behalf of the Power family. What happened recently is a disgrace. It is such a tragedy. Something must be delivered now, not a review but a 24-7 centre in Waterford.
I thank the Senators for their contributions to this discussion this evening, all of which I take on board.Members have been passionate, strong and genuine in their views and concerns about this issue, and I acknowledge that. The point Senator Coffey makes is valid. This is not a party political issue and I do not intend to approach it in such a way or in an argumentative way. This is an issue on which I accept the bona fides of all Senators, and Deputy Butler, regarding this matter. Undoubtedly, Mr. Power's death was extraordinarily tragic. My heart goes out to his family and my thoughts are with them at this sad time. I cannot imagine the terrible grief being experienced by his wife and by his family and friends. While as I said in my opening statement that I cannot comment in detail on individual cases, I want to reiterate on the record of the House that I expect that all the appropriate procedures relating to the examination of the circumstances of Mr. Power's death will be undertaken. It is vital that that happens and that all of the procedures can be examined in full so that information can be provided to the Power family on what happened to their beloved Thomas.
As Minister for Health, I have to base my decisions on clinical evidence and, in fairness, I think everybody in the House accepts that. As I mentioned earlier, I commissioned the Herity report last year to look at cardiology services in University Hospital Waterford. The report was undertaken by one of the foremost cardiologists on these islands, a doctor of international repute. While people in this House are entitled to their views, I believe everyone would acknowledge that Dr. Herity is a world renowned cardiologist.
I have heard a good deal of commentary in recent days to the effect that for a certain amount of money this facility could be opened on a 24-7 basis. I want to be very clear for the people of the south east. This is not a budgetary matter. In fact, when we put together A Programme for a Partnership Government it referenced providing this service, subject to a clinical review. That was also accompanied by a signed letter from the Minister for Finance, which was published at the time, promising that the funds would be provided. In debating this issue, let us park that aspect because it is not a budgetary matter. If there was clinical evidence that this second cath lab and a 24-7 service should be provided, the funding would be provided by this Government. It is a relatively small amount of funding so it is not a funding issue.
We cannot plan services based just on our views. We have to plan them based on medical evidence. We have a long tradition of doing that in a number of areas. A number of my predecessors from different political parties also found themselves having to make very difficult decisions relating to the provision of centres based on expertise and specialisms. We must take a similar approach to cardiology. Primary PCI is a highly specialised procedure requiring great clinical expertise. Clinical staff need a sufficient throughput of patients to maintain their skills and thus ensure that a safe service is provided. Not just in Ireland but internationally, the trend is towards consolidation of such specialised services on a smaller number of sites to allow for the concentration of volume and expertise. I need to make two points in that regard, not in an argumentative way but in a factual way.
I hear much talk about 500,000 people in the south east. The evidence in the Herity report was that when we look at the trends, many of those 500,000 people were going to different locations, be it Dublin but primarily Cork. If that evidence changes and more people start going to the service, the figures may change when it is reviewed again.
It is important to look at that. In providing the additional opening hours we are putting in and the mobile cath lab let us see the impact on volume, to take Senator Coffey's point. If it did open longer and if there is a second mobile cath lab, let us see the impact of that on volumes as we approach another review.
I have heard that this is just an issue for the south east but that is not the case. There is no PPCI centre in the midlands. Patients in Monaghan, Louth, Kerry, some patients in parts of my own constituency of south Wicklow, and patients in Sligo all travel for significant lengths of time to access services. I make that point because while it is a significant concern in the south east, equally, there are other parts of the country that have concerns about the location of PPCI services. That is why it is appropriate that we now examine the geographical spread of primary PCI centres to ensure that as many people as possible have access to this procedure in a timely way and that it is done in a fair and equitable way. We should examine the current geographical spread of facilities to decide if that is appropriate. That is the benefit of a national review in that we are not just talking about Waterford but all of the country and the division of PPCI centres in a fair manner based on clinical evidence.
There is a clear need to design the best future reperfusion protocol for patients who live outside the 90 minute transfer window, for the very reason Senator O'Sullivan outlined. This may be to thrombolise patients, in other words, to use clot busting drugs before transferring a patient to a cath lab. It might be in the area of helicopter transfer of such patients, an issue Senator Coffey has raised with me, or an alternative strategy, but we need to do this work, and we will.
In 2012, long before my appointment to this role, the Health Service Executive’s acute coronary syndrome clinical programme set out the model of care for acute coronary care and designated a number of cardiac units as 24-7 or 9 a.m. to 5 p.m. centres. It is timely to look again at how we deliver primary PCI services on a national basis to ensure that as many of our citizens as possible have access to what we all want them to have access to, namely, a 24-7 basis to primary PCI.
I am committed to and am announcing a national review, which will examine these issues and future configuration of primary PCI services in the south east, including the number and location of the centres required to serve our population needs. I have asked my Department to make arrangements for this national review, which will be undertaken based on independent clinical expertise. I cannot stress the importance of that independent clinical expertise. The review will also address the wider implications for all parts of the country regarding primary PCI services and devise a plan for the achievement of the best patient outcomes possible, and one that reflects patient safety as a paramount concern.
I repeat that extra investment is being provided to allow additional activity. The mobile cath lab is confirmed; it is on the way. I accept there was a tendering delay by the HSE. There will then be a review of the additional investment specifically relating to the south east to see if the question Senator Coffey asks is valid, namely, do attendances increase when hours are extended and more services are put in? There will also be a national review recognising the importance of having a fair, equitable and clinically based decision making process in terms of the location of 24-7 primary PCI centres across the country to provide services for the greatest number of our citizens possible.
I am committed to keeping in touch with the Senators and the Deputies from the south east as we develop this process.