The lonely death of Thomas Power in an ambulance near Dungarvan this week is far from the regional issue it might seem to people in other parts of the country.
Understandably, the southeast united in recent days behind calls for 24/7 cardiac care services in Waterford following the death of the 39-year-old, who died on his way to Cork University Hospital.
Fundamentally, the controversy is about what rights exist for access to top-quality health services, no matter where a person lives. This is a defining concern for our creaking health service.
Usually, it relates to important, but not life-threatening, situations. In this case, however, the non-availability of high-level cardiac treatment for Mr Power possibly cost him his life. His family certainly think so.
Doctors in Cork, where his ambulance was headed because the catheterisation lab in University Hospital Waterford (UHW) was closed for the weekend, told them, they say, that he would have lived had he received immediate treatment in Waterford.
His death prompted anger, raw with grief: the Health Service Executive had "blood on their hands"; newly-elected Taoiseach Leo Varadkar should resign, locals declared.
An inquest may eventually shed more light on whether the previously-fit farmer, only in his late 30s, who called into UHW with chest pains might have survived had he received the kind of treatment that is available in Cork or Dublin.
Campaigners say a death was inevitable, though the review by Belfast cardiologist Dr Niall Herity – which is relied upon by the Government in rebuffing calls to upgrade Waterford service– disagrees.
Last February, Dr Herity, under scrutiny from TDs at the Oireachtas Health committee, was questioned by Fianna Fáil Senator Keith Swanick, a GP based in one of the most remote parts of the country, Belmullet in Co Mayo.
Dr Swanick asked: “Does Dr Herity believe that in the absence of a second catheterisation laboratory and a 24/7 service, lives are being endangered and people are dying?”
Dr Herity replied, “The short answer is: no, I do not.”
Heart attack patients throughout the country need to be treated in high-volume regional centres, where staff are highly trained and can maintain high skills levels, he argued
Ideally, patients should live within 90 minutes of these centres but as he pointed out, a percentage of the population in every country lives further away: “This is the case in the United Kingdom, Denmark and the Netherlands. It is very much the case in countries like Canada. In those countries, the health care systems implement targeted systems for those populations to ensure they get equal quality of care,” he then declared.
Enormously expensive health services have to be rationed. It has been said during this week’s debate that “you can’t have a cardiac ambulance parked in everyone’s driveway”.
Over a decade ago, the drive to centralise cancer care in centres of excellence provoked fury from vested interests and regional campaign groups. Yet it succeeded.
It did so because the reforms were evidence-based, driven by a leading clinician, Prof Tom Keane, with strong political leadership from then health minister Mary Harney. Patients got better care. Lives were saved.
Consolidating cardiac services nationally will also save lives. However, the reorganisation, especially as it affects Waterford, has taken place in the absence of political leadership, with decisions made behind closed doors.
Deprived of 24/7 cover
Why is the southeast being deprived of 24/7 cover, leaving almost 175,000 people living more than 90 minutes away from a centre? Much remains unacceptably unclear.
Dr Herity’s contribution was made long after the process was under way, rather than at the beginning. The report, completed in six weeks last year, was not the instigator of change.
Instead, it was a political fix when the issue of Waterford cardiac services threatened to prolong political haggling over the formation of the Government in 2015.
Effectively, the Belfast surgeon had two options: he could recommend the expansion of expanding cardiac services in the Waterford hospital, or he could recommend that they could be cut.
Sticking with the status quo was not an option. Elective cardiac work in the existing catheterisation lab was often cancelled as urgent cases were prioritised. Frequent breakdowns meant Waterford often had no cath lab at all.
Two cath labs were needed if 24/7 emergency cover were to apply. However, Dr Herity concluded that expanding the service in Waterford to offer that was not sustainable.
Instead, he recommended that the single cath lab in UHW should focus on the larger volume of planned procedures. Emergency cases should be sent to Cork or Dublin.
For this to work, patients need to be within 90 minutes’ journey of a centre providing gold standard primary percutaneous coronary intervention care (PPCI), according to the British Cardiovascular Intervention Society.
Heart attack patients need to be treated as quickly as possible. Beyond 90 minutes, PPCI is minimally effective and the outlook for the patient will be very poor.
Having examined ambulance journey times between Waterford and Cork over a nine-month period, Dr Herity concluded that Waterford city was indeed within 90 minutes of Cork – by just two minutes.
Given the lack of a motorway, the many towns not yet bypassed and the vagaries of traffic on Irish roads, this conclusion has had numerous holes punched in it by local politicians and doctors.
"For a clinician in the emergency department in Waterford to say, 'you will probably get there in 88 minutes so I will let you off', is not an acceptable clinical scenario," UHW emergency consultant Dr Mark Doyle said.
Mr Power was only halfway to Cork when he died. He had come to UHW on a Sunday afternoon, when the cath lab was closed and PPCI (angioplasty, involving the unblocking of the arteries and the insertion of a stent) was unavailable.
He should then have received thrombolytic treatment (clot-busting drugs) before transfer to Cork. Outcomes for such patients, said Dr Herity, are usually very good.
However, Dr Patrick Owens, Waterford's senior cardiologist, said promptly-delivered PPCI treatment offers a 95 per cent chance of opening the blocked artery, against 65 per cent when thrombosis and medication is used.
The other option, briefly mentioned in Dr Herity’s report, is to transport emergency cases by air. Yet neither UHW nor University Hospital Cork has a helipad.
Instead, helicopters have to land on pitches, forcing messy transfers. The last air ambulance attempted from Waterford to Cork is said to have taken more than 2½ hours.
“The air ambulance service is non-existent, expensive and of questionable cost-effectiveness in a population of 450,000, compared to a PPCI service in the southeast,” says Dr Owens.
Thomas Power was not in Waterford when he felt unwell. Instead, he was 20km away in Dunmore. If he had been treated in Waterford firstly, then his chances of survival would have been much greater.
“Of course, that’s very different to saying he absolutely would have survived; clinical judgments based on medical research are all about statistical probabilities,” Dr Owens continued.
Dr Herity’s clinical credentials are not in doubt, but the marching orders he received from the Department of Health are. Waterford campaigners believe the department got the result it wanted.
Before he started, the HSE gave Dr Herity a note, arguing that extra services “in a geographical area which does not have the population base to justify such a service, would be wasteful of very limited resources”.
Effectively, the die was cast in 2012, when the decision was made to create a hospital group covering institutions from Cork to Waterford. Locals had wanted Waterford to be the hub of its own hospital group, but they lost.
The clue is in the name of the group, the South/South West hospital group. UHW is a long way from the south or southwest of the country, and some of the areas its serves in Wexford are even further away.
The Government’s decision left UHW feeling it was playing second fiddle to Cork, and fearful of further downgrading. Political assurances about cardiac services were sought and given, but ring hollow in the city today.
Mr Power’s death has brought a renewed light to the Waterford cardiac debate, but it has also changed the grounds of that debate. Up to now, the campaign has centred on the need for a second cath lab.
Scheduled treatment of cardiac patients accounts for 96 per cent of the work performed in UHW’s existing sole cath lab. Emergency work accounts for 4 per cent of case volume.
A cath lab would help clear long waiting lists. Yet this issue is being addressed. Hundreds of Waterford patients are being sent to Cork, successfully. This might cause suspicions in Waterford but it cuts numbers.
A mobile part-time cath lab for Waterford, now put out for tender, will cut lists further. However, these moves will do nothing to meet the challenge of treating emergency cases quickly.
Geography is geography: 175,000 people live more than 90 minutes away from the best treatment. Unless Mr Varadkar and Minister for Health Simon Harris address these gaps, it is entirely possible that further deaths will occur.