Why Waterford needs a second cath lab

Interventional cardiac services provide treatment for acute and chronic heart disease. Catheterisation laboratories (cath labs) are the facilities in which these treatments are delivered. Other services are delivered here too, to treat heart rhythm disorders, and they are busy units.

Cath labs are unequally spread across the country. Some areas have a great many cath labs (Dublin has 20, at last count), others have sparse provision indeed; the South East region has one single cath lab offering to service half a million people.

Such is the backdrop to the current crisis in cardiac care in the southeast of Ireland.

For three years now, the stretched interventional cardiology service has asked repeatedly for adequate resources to address the gap between demand and capacity. In this time, the waiting times for elective outpatient procedures in the service have grown to dangerous lengths, at present in excess of 18 months.

Wait times for inpatients have ballooned, and inpatient treatment times are frequently in excess of a week, for procedures which international best practice identify as being ideally treated within 24 hours of presentation.

The Herity report, issued earlier this month, was commissioned by the Department of Health in May 2016, after local political lobbying for funding of the second lab. Independent Minister John Halligan played a prominent role.

Clinical risk

Our concern as clinicians was the addressing of clinical risk inherent in such an under-resourced service. The terms of reference issued by the department, which we had no part in drafting, tasked the reviewer with an entirely different question: what is the population incident in the South East, and what cath lab resources are required to address that population need?

The report eventually recommended there was no need for a second cath lab; that capacity could be increased adequately by expanding the use of the existing cath lab by an additional eight hours per week. This is a woefully inadequate calculation. The current waiting list for procedures contains 581 patients, and perhaps 30 per cent (a conservative estimate) of these would require stents.

Applying the benchmarking process as detailed in the Herity report, it would take 499 hours to address this backlog, or 62 weeks, using his additional eight hours per week. All this while, of course, the waiting list continues to grow from new referrals. Futhermore, this calculation does not address the excessive inpatient wait times, arguably a much more dangerous problem.

Finally, as has been demonstrated repeatedly since the opening of this unit, extra capacity immediately releases additional demand, as regional referral practice reverts away from Dublin and Cork, and returns to the "natural" referral pathways from Wexford, South Tipperary and South Kilkenny into the regional centre at Waterford. This is what the regional population want, and deserve.

Fundamental to the recommendations in the report is the calculation of the effective population who would use the cath lab in the South East. This gave a value of approximately 290,000. This was calculated by counting the numbers of patients actively treated in the unit in an index year (2015). But it is a nonsense to say the effective catchment of a service can be calculated in such a way for a service running at (and frequently beyond) full capacity. You can't just count the number of people in Croke Park on All-Ireland Final day and say that that is the total number of people who actually want to be there. It simply counts the number who were lucky enough to get a seat, and ignores those who went elsewhere because they couldn't get in.

Constrained resource

So it is with the Herity report and its calculation of population for the South East cath lab service, which returned a significant underestimate of population size by confusing constrained resource with low activity.

On the basis of this miscalculation, the recommended expansion of service is utterly inadequate. It will not address the activity incident on the unit, and will simply perpetuate its problems. Long waits produce unacceptable risks to patient wellbeing. The cardiac patients in the South East will continue to languish on static waiting lists, and lie in hospital beds for days on end, awaiting procedures that should take a day or two at most.

These observations are easy to spot from the vantage point of local clinicians, and it is a pity all their opinions were not sought in the review process. However, the decision to enact the recommendations of the report lies with the Minister, and it is incumbent upon him to ensure that local stakeholders, and their advocates, are heard, before decisions are made that irrevocably alter the provision of cardiac healthcare to the South East. A simple “no” will not suffice.

Patrick Owens is a consultant cardiologist based at University Hospital Waterford