MEDICAL MATTERS:A NEW strategy for stroke must rise above gestures, and address the major care deficits for the tens of thousands affected by stroke in Ireland, writes PROF DES O'NEILL
Recent reports of a 4 per cent difference in cancer deaths between Northern Ireland and the Republic, as well as of the cancer audit in Waterford Regional Hospital, attracted big headlines and wide coverage in the media. Ironically, a story which affected more lives than either of these slipped relatively unnoticed into the public domain.
An audit released last month in the journal Strokelooked at the differences between stroke care practices in the Republic and the North of Ireland.
The study looked at 16 quality-of-care markers which are of major significance to good care of patients with stroke, such as early assessment, multidisciplinary review, medications review, and for discharge-rehabilitation planning.
There were staggering differences in the provision of care in 15 of the 16 quality indicators, all worse in the Republic. These deficits occurred by a factor of up to 10 times worse in the Republic: 8 per cent of those in the Republic had discharge/rehabilitation planning compared with 83 per cent of those in Northern Ireland.
These differences would be intolerable for cancer care.
These dismal findings illustrate and amplify the findings of the Irish National Audit of Stroke Carepublished last year, which showed that the 10,000 people who suffer an acute stroke every year and more than 30,000 people living with the consequences of a stroke in the community and nursing homes in the Republic are woefully under-served by the HSE and its agencies.
There is a telling irony of the proximity on the same island of one of the best regions of the NHS (Northern Ireland) for stroke care, juxtaposed with the very impoverished stroke services in the Republic. International evidence would suggest that our under-development in stroke services costs 300-500 lives a year: Ireland, wake up!
We have made major developments in cancer and cardiac care over the past decade, and any such development usually involves three cost elements.
The first is that service users are generally using some services anyway, so the spend does not arise from a cost base of nil – redirection and reorganisation accounts for a part of a new development. Secondly, organised care is usually more cost effective – and so will generate savings (but has to be funded and set up in the first place to generate these savings!). These savings can be considerable: for example, if stroke units were fully resourced, this would shave two to 11 days of inpatient stays, with a huge cost saving, and the use of thrombolysis (clot-busting drugs) a smaller but appreciable amount.
However, reorganisation and efficiencies depend on appropriate investment in specialist staff, support and facilities.
So, for the major developments in cancer and cardiovascular disease: the Department of Health has committed a cumulative total of €550 million of new spending on the former and 800 new posts for the latter between 1999 and 2002.
And so, what about investment in stroke? There is very major concern that services for stroke may be told to “get on their bike” and develop on the basis of reorganisation and efficiencies, but not have the investment that is critically needed in doctors, nurses and therapists for service development in both community and hospital.
Initial reports in the medical media suggest that there may not be any additional funding accompanying the forthcoming Cardiovascular and Stroke Review Group, which the Department of Health expects to launch in June. In parallel, there are worrying reports of “gesture politics” whereby hospitals may proclaim the existence of a stroke unit, without adequate facilities or staff in place to provide a service, or nursing homes may advertise a “stroke rehabilitation unit” without a rehabilitation team.
Stroke advocates and professionals understand that a big bang investment of everything needed immediately is not feasible, even in less straitened economic circumstances.
However, at the very least, we expect that the Cardiovascular and Stroke Review Group will lay out a clear programme of the staffing and structural developments needed to bring our stroke services to a level where lives will not be lost, major disability significantly reduced, and suffering for those affected and their families greatly relieved.
In addition, an implementation plan (the lack of which is the nemesis of Irish health strategies) needs to be clearly mapped out.
It is in all of our interests that our health services will be able, within the next five years, to produce an audit of stroke care where the quality of care is of the same high standard on both sides of the border.
- Prof Desmond O'Neill MD FRCPI is chairman of the Council on Stroke, Irish Heart Foundation