News Analysis

New data from nationwide survey sheds light on understanding of dementia

By sa | Sep 19, 2018 | 0 Comments

Every September, World Alzheimer Month raises awareness and challenges the stigma that surrounds dementia. Internationally, two out of every three people (67 per cent) believe there is little or no understanding of dementia in their countries. The ‘Dementia: Understand Together’ campaign, led by the HSE in partnership with The Alzheimer Society of Ireland and Genio, has been working to increase awareness and understanding of dementia in Ireland since 2016, and recently released the results of a nationwide dementia survey conducted earlier this year.

Survey

The survey of more than 1,000 adults offers a number of insights into changes in dementia awareness, understanding and attitudes among the population at large in Ireland since a similar survey was undertaken in 2016. The results highlight the success of the campaign and identify areas where additional work is needed. They also offer an insight into the impact and direction of the broader implementation of the National Dementia Strategy, published in 2014.

Early diagnosis of dementia is crucial so that people can access the appropriate services and supports and can help with making decisions about care and support for the future. More than three-quarters of respondents (78 per cent) understood the importance of being diagnosed early. However, a quarter (24 per cent) of respondents to the survey said that they would delay seeking help if they had concerns, highlighting that stigma and fear still exist as barriers to early diagnosis.

A visit to the GP is usually the first step for people who have concerns about their memory or cognition, with patients usually referred to a general outpatient clinic or a specialist memory clinic for further investigation.

A number of education programmes and resources have been developed to support GPs and members of the primary care team in this role and a dedicated primary care website — www.dementiapathways.ie — provides education, resources and signposting for clinicians. The National Dementia Office is also leading on a project which aims to develop a national diagnostic framework to ensure everyone has equitable and timely access to diagnostic services.

Support

Receiving a diagnosis is only the first step for a person living with dementia and it is essential that there are post-diagnostic supports available immediately after diagnosis and throughout the course of the condition. While there are still gaps in the availability of post-diagnostic services nationally, a number of new initiatives are addressing this.

‘Memory technology resource rooms’ are being established around the country to provide information and advice on the assistive technologies that are available to support people living with dementia to continue to live as independently as possible. The project aims to establish one memory technology resource room in every county, and 23 rooms will be open by the end of the year.

A number of grants were recently awarded to facilitate the provision of cognitive rehabilitation, cognitive stimulation and psycho-educational programmes around the country as part of a post-diagnostic support project being led by the National Dementia Office. The project is working towards the development of a national post-diagnostic support framework, which will provide guidance on the pathway of care after a diagnosis. In addition, The Alzheimer Society of Ireland provides a highly responsive and individualised information and signposting service through a network of dementia advisors who cover 11 counties nationally.

Over half of respondents (52 per cent) in the survey were aware that there are things they can do to potentially reduce their dementia risk — up from 46 per cent previously. Healthcare providers play an important role in highlighting the importance and benefits of staying physically, mentally and socially active, not only for general health, but as strategies for reducing the risk of developing dementia.

While health and social care services play an integral role in supporting a person with dementia and their families, a ‘whole-society’ approach is needed to ensure the person can live as well as possible, for as long as possible. Increasing understanding and reducing stigma is needed for this, and the results of the survey show progress, in that one-in-three (33 per cent) respondents described themselves as knowing a lot about the disease — up from 24 per cent in January 2016. Over half of respondents (52 per cent) recognised that people with dementia participate in a wide variety of activities and interests, and three-in-five people (59 per cent) who saw the ‘Dementia: Understand Together’ TV campaign said that they were impacted in some way as a result of the personal stories featured.

Next phase

The next phase of the ‘Dementia: Understand Together’ campaign is building on this increased understanding, creating inclusive communities, empowering individuals, businesses and service providers to raise awareness and take action to support people living with dementia and their families. The campaign is calling on people to become ‘Community Activation Champions’ and information, resources and supports are available at www.understandtogether.ie.

What’s another year: a look-back at 2018

By sa | Dec 19, 2018 | 0 Comments

We chart 12 months in healthcare in a year dominated by the CervicalCheck controversy

New faces, familiar themes

By sa | Nov 30, 2018 | 0 Comments

Calls for greater investment and concerns over the recruitment and retention of consultants are sure to figure at the 2016 IHCA Annual Conference, writes David Lynch

Pay discrimination must end

By sa | Oct 2, 2018 | 0 Comments

The failure to invest in essential acute hospital services and the blatant breach of the 2008 Consultants Contract combined with the persistent discrimination against new-entrant consultants have seriously undermined the capacity of our acute hospital services.

They represent serious mistakes by the State, which will adversely impact on services for decades to come unless rectified.

Overwhelming capacity deficits

The Association has repeatedly highlighted the extreme capacity deficits in our acute hospital services. The Capacity Review and the National Development Plan (NDP), published earlier this year, acknowledged the deficits, but there is a lack of urgency in addressing them.

The NDP provides €10.9 billion in funding for capacity expansion between 2018 and 2027, including an additional 2,600 acute hospital beds and 4,500 long-stay beds. The replacement of equipment and the extension of facilities have also been funded in the Plan.

””

Mr Martin Varley

The more recently published Sláintecare Implementation Strategy is less specific and over a longer time period. Neither document contains the required commitments on when the much-needed beds will be provided. This is a major concern as the unacceptable number of patients being treated on trolleys and the growing waiting lists confirm that the additional beds are absolutely required without delay. Similar problems exist concerning ICU beds. The HSE Prospectus Report in 2009 recommended a 45 per cent increase by 2010 and doubling by 2020.  Today we have fewer ICU beds than in 2009.

Ireland’s acute hospital capacity is significantly below the EU average, therefore if the State fails to increase the capacity urgently, it will be condemning the population to ever-deteriorating acute hospital services. This, after decades of insufficient capital funding, would be irresponsible in the extreme.

Recruitment and retention crisis

The State has driven and continues to drive highly trained specialists abroad to work in health services where they are valued, where they are not discriminated against, and where they are provided with facilities to treat patients. The result is a prolonged and deepening consultant recruitment and retention crisis.

The fact that about 700 IHCA members had to take High Court proceedings to vindicate their contractual rights highlights the State’s disregard for them. The High Court settlement in June is an important and essential development, but it does not represent the full solution. 

Our hospitals are increasingly uncompetitive in recruiting and retaining the number of consultants required.  They are in a serious crisis with nearly 20 per cent of the permanent consultant posts vacant or filled on a temporary basis through agencies and otherwise. The State’s discrimination against new consultants is preventing the filling of over 500 permanent consultant posts. On a population basis, Ireland has one of the lowest numbers of hospital consultants in the OECD, at approximately half the OECD average. It is clear that the Irish population and patients can ill afford to have nearly 20 per cent of the approved permanent consultant posts unfilled. This represents a false economy from both financial and patient care perspectives, with steeply increasing waiting lists due to a shortage of consultants and growing medical agency costs which exceed €100 million per annum.

Over the past three years the health service has failed to fill up to one-third of the consultant posts advertised by the Public Appointments Service. During those three years, 39 advertised hospital consultant posts received no applicants and a further 153 received only between one and two applicants. This is having a severe impact on practically all medical and surgical specialties and hospitals throughout the country. Unfilled posts in 2017 include the following: Medicine (9), psychiatry (9), obstetrics /gynaecology (4), geriatrics (3), emergency medicine (3), pathology (4), radiology (3), paediatrics (2), and gastroenterology (2).

These developments contrast sharply with the situation that pertained prior to 2008. Any employer knows that you will no longer be an employer of choice if you breach contract terms and discriminate against new appointees. It is unacceptable that the State, of all employers, has persisted with such behaviour. 

It is illogical that the State continues to perpetuate extreme levels of discrimination against new-entrant consultants given the growing number of vacant consultant posts and increasing patient demand for care. There is up to a 57 per cent salary differential between newly-appointed consultants and their colleagues appointed prior to October 2012.  This discrimination must be ended without delay if our health service is to attract back highly trained specialists who have gone abroad. This is especially relevant as hospitals are paying agency doctors up to three times the salary they are paying new-entrant consultants.

Furthermore, it is of even greater concern that approximately 80 such doctors who have been appointed since March 2008 to temporary consultant posts are not on the Medical Council specialist register and, therefore, are not in a position to practise as specialists. This is a basic requirement to be appointed to a consultant post.

Conclusion

Given the improving economic situation, there is an opportunity and a pressing need for the State to end the discrimination against new-entrant consultants and fill the vacant posts. This makes sense on every level.

Equally, given the NDP funding of €10.9 billion for the health service, there is no logical reason why extreme capacity deficits cannot be addressed.

Working together to implement Sláintecare and improve the health service

By sa | Oct 2, 2018 | 0 Comments

I am once again very happy to contribute to the Medical Independent’s IHCA Annual Conference Preview.

I was delighted to be in a position to submit the Sláintecare Implementation Strategy to Government in July and to have received significant support from my colleagues. The Government is committed to achieving the transformation set out in the Strategy and it will require investment, strengthened governance and accountability and a coherent programme of reform.

The Implementation Strategy, which I published on 8 August, is a further step in the detailed implementation process and sets out four over-arching goals and 10 high-level strategic actions, which will be the key focus for the first three years of the reform programme. The Strategy focuses on establishing the building blocks for a significant shift in the way in which health services are delivered in Ireland. A Sláintecare Programme Office in my Department, led by an experienced Executive Director, is currently preparing a detailed action plan, which will be published before the end of the year. 

””

Mr Simon Harris

I have always been clear that we must match reform with investment, and with an increase in capacity. The Health Service Capacity Review (2018) recommended an increase of 2,600 acute hospital beds and 4,500 additional long- and short-term community beds.  The Government’s National Development Plan 2018–2027 commits that €10.9 billion will be invested in health infrastructure and reform. This will support the Sláintecare reform programme; increased capacity, including the provision of three elective-only hospitals in Dublin, Galway and Cork; and additional facilities will also be provided for primary care, mental health services and disability services.

I have also obtained Government approval for the establishment of an independent Board for the HSE. The General Scheme of a Bill has been published and I hope that legislation will be enacted this year. I have already announced that Mr Ciarán Devane is my designated Chairperson for the new Board. Early tasks for the new Chair will be to participate in the selection of the CEO of the HSE, the process for which is underway and to participate in the process for identifying other Board members. This is another important step in the implementation of a key Sláintecare recommendation.

I believe it is unfair that private patients can access treatment more quickly than public patients. I understand, however, that removing private practice from public hospitals is a complex process and the consequences of doing so must be analysed and carefully considered. I expect to receive the report of the group established to examine the impact later this year.

The Public Service Pay Commission in its report, published last month, covering medical staffing, highlighted the recruitment and retention of highly-skilled, well-trained and appropriately qualified healthcare professionals in the public health service as a dominant imperative. In order to deliver high-quality care across the health services, the Government and I recognise that the recruitment and retention of highly-trained and skilled medical staff is essential.

I see the settlement agreement reached in June as an important step towards ensuring that we retain our established consultant cohort and I am pleased that most consultants have responded positively to the Agreement. New-entrant consultants are encompassed by the process announced for new entrants across the public service under Section 4 of the Public Service Stability Agreement. However, the Commission had noted the degree of pay differential that is likely to apply following the settlement agreement notwithstanding this process and proposed that the parties to the Public Service Stability Agreement jointly consider what further measures could be taken, over time, to address this difficulty. The challenge will be doing so in a manner that respects pay policy and our budgetary constraints.

The Commission also highlighted the need to ensure that the overall employment, professional development package, working conditions and culture available in Ireland be sufficient to attract the right people when and where they are needed. I recognise this as an equally significant challenge and one that must be met. The Medical Council has reported on the need to facilitate the training of not just junior hospital doctors, but also consultant trainers. It is evident that the current difficulties in ensuring protected time for junior doctors and consultants is indicative of the current level of demand for services and related work pressures. I believe that the Government’s commitment to increasing capacity across our health services and the full implementation of Sláintecare can have a significant positive impact on improving the working conditions of all of our medical staff.

Reform is challenging and requires leaders and champions throughout the system. As senior clinicians, members of the IHCA have a key role to play in providing this leadership. I am confident that they will play their part in transforming Irish healthcare and help to build a system that is both fit for purpose and a great place in which to work. One of the strategic actions in the Sláintecare Implementation Strategy is to build a sustainable, resilient workforce that is supported and enabled to deliver the Sláintecare vision. I look forward to working constructively with consultants and the IHCA to deliver this.

A generation of specialists will be lost unless consultant recruitment crisis is addressed

By sa | Oct 2, 2018 | 0 Comments

Our acute hospital and mental health services have suffered from decades of chronic under-investment. The health service has a much lower number of inpatient beds per capita in comparison to the average of the OECD countries.

There are growing demographic pressures. In the last decade the population served by the hospital system has increased by 12 per cent and is expected to increase by a further 4 per cent by 2021. The portion of the population over 65 is expected to grow more rapidly.

The challenges facing the healthcare system have a clear and growing impact on the care of patients. There is an increased number of patients being treated after hospital admission on trolleys this summer and this can be expected to become even more common in the winter months. The numbers on waiting lists for essential care are growing. This month 514,000 people are on waiting lists for consultant outpatient appointments and over 74,000 patients are awaiting surgical appointments.

Sláintecare

The Sláintecare Implementation Strategy, published in August, fails to provide real solutions for these capacity deficits in our acute hospital and mental health services. The Strategy’s proposal to introduce 2,600 new beds over the next 15 years fails to address the very urgent needs of patients who, in this year, need access to care in our acute hospitals. We need a clear year-by-year strategy for the delivery of increased capacity starting this year.

””

Dr Donal O’Hanlon

Currently, the health service is unable to attract sufficient suitably qualified candidates for consultant posts. In contrast to the situation in the past, there are much fewer candidates interested in vacant posts in recent years. During the three years 2015 to 2017, over one-third of the posts advertised received between zero or one application and over half received between zero to two applications. Fewer candidates are presenting for interview for posts and from 2015 to 2017 the health service has failed to fill up to one-third of the consultant posts advertised by the Public Appointments Service.

Over 500 consultant posts are not filled on a permanent basis throughout the country’s acute hospital and mental health services. This represents a serious crisis with nearly 20 per cent of consultant posts that cannot be filled on a permanent basis.

Survey

The IHCA survey of over 300 recently-appointed consultant members carried out in July confirmed that our acute hospital and mental health services face an escalating and unprecedented consultant recruitment and retention crisis. This is due to ongoing discrimination by the State and health service employers against new-entrant hospital consultants. Respondents to the survey confirmed that the lower salary terms are having an adverse impact on the delivery of patient care due to the large number of consultant posts that are unfilled or filled on a temporary basis. Of equal concern, over 70 per cent of the new-entrant consultants have confirmed that they will seriously consider resigning from their public hospital posts unless the discriminatory salary terms imposed on them by the State are corrected. The survey has provided categorical evidence that our highly trained specialist consultants will not continue to work in our health services if the persistent discrimination against them continues. This is not surprising as there is currently up to a 57 per cent salary differential between newly-appointed consultants and their colleagues appointed prior to October 2012.

On a population basis, Ireland has one of the lowest number of hospital consultants in the OECD, at approximately half the OECD average. Our health services are uncompetitive in attracting and retaining consultants given the high levels of international demand for specialists and considering the terms and working conditions on offer in other countries. The Government must, without further delay, address the capacity issues that make posts unattractive and end the discrimination against new consultants. The failure to fill a third of the advertised consultant posts is having an adverse impact on practically all medical and surgical specialties and most hospitals throughout the country. The country has already lost a large percentage of the highly-trained specialists who qualified in the past decade. If the Government does not end the discrimination, in another decade we will have lost most of a generation of the specialists that we need. We have taken the exceptional action of outlining the stark realities in letters to the Taoiseach, Ministers for Health, Finance, Public Expenditure and Reform and the main political party leaders and spokespersons on health, finance and expenditure.

Our acute hospital and mental health services will increasingly fail our patients due to the large number of approved permanent consultant posts that cannot be filled as a consequence of the discriminatory salary cuts imposed by the State on new-entrant consultants.

New data from nationwide survey sheds light on understanding of dementia

By sa | Sep 19, 2018 | 0 Comments

Every September, World Alzheimer Month raises awareness and challenges the stigma that surrounds dementia. Internationally, two out of every three people (67 per cent) believe there is little or no understanding of dementia in their countries. The ‘Dementia: Understand Together’ campaign, led by the HSE in partnership with The Alzheimer Society of Ireland and Genio, has been working to increase awareness and understanding of dementia in Ireland since 2016, and recently released the results of a nationwide dementia survey conducted earlier this year.

Survey

The survey of more than 1,000 adults offers a number of insights into changes in dementia awareness, understanding and attitudes among the population at large in Ireland since a similar survey was undertaken in 2016. The results highlight the success of the campaign and identify areas where additional work is needed. They also offer an insight into the impact and direction of the broader implementation of the National Dementia Strategy, published in 2014.

Early diagnosis of dementia is crucial so that people can access the appropriate services and supports and can help with making decisions about care and support for the future. More than three-quarters of respondents (78 per cent) understood the importance of being diagnosed early. However, a quarter (24 per cent) of respondents to the survey said that they would delay seeking help if they had concerns, highlighting that stigma and fear still exist as barriers to early diagnosis.

A visit to the GP is usually the first step for people who have concerns about their memory or cognition, with patients usually referred to a general outpatient clinic or a specialist memory clinic for further investigation.

A number of education programmes and resources have been developed to support GPs and members of the primary care team in this role and a dedicated primary care website — www.dementiapathways.ie — provides education, resources and signposting for clinicians. The National Dementia Office is also leading on a project which aims to develop a national diagnostic framework to ensure everyone has equitable and timely access to diagnostic services.

Support

Receiving a diagnosis is only the first step for a person living with dementia and it is essential that there are post-diagnostic supports available immediately after diagnosis and throughout the course of the condition. While there are still gaps in the availability of post-diagnostic services nationally, a number of new initiatives are addressing this.

‘Memory technology resource rooms’ are being established around the country to provide information and advice on the assistive technologies that are available to support people living with dementia to continue to live as independently as possible. The project aims to establish one memory technology resource room in every county, and 23 rooms will be open by the end of the year.

A number of grants were recently awarded to facilitate the provision of cognitive rehabilitation, cognitive stimulation and psycho-educational programmes around the country as part of a post-diagnostic support project being led by the National Dementia Office. The project is working towards the development of a national post-diagnostic support framework, which will provide guidance on the pathway of care after a diagnosis. In addition, The Alzheimer Society of Ireland provides a highly responsive and individualised information and signposting service through a network of dementia advisors who cover 11 counties nationally.

Over half of respondents (52 per cent) in the survey were aware that there are things they can do to potentially reduce their dementia risk — up from 46 per cent previously. Healthcare providers play an important role in highlighting the importance and benefits of staying physically, mentally and socially active, not only for general health, but as strategies for reducing the risk of developing dementia.

While health and social care services play an integral role in supporting a person with dementia and their families, a ‘whole-society’ approach is needed to ensure the person can live as well as possible, for as long as possible. Increasing understanding and reducing stigma is needed for this, and the results of the survey show progress, in that one-in-three (33 per cent) respondents described themselves as knowing a lot about the disease — up from 24 per cent in January 2016. Over half of respondents (52 per cent) recognised that people with dementia participate in a wide variety of activities and interests, and three-in-five people (59 per cent) who saw the ‘Dementia: Understand Together’ TV campaign said that they were impacted in some way as a result of the personal stories featured.

Next phase

The next phase of the ‘Dementia: Understand Together’ campaign is building on this increased understanding, creating inclusive communities, empowering individuals, businesses and service providers to raise awareness and take action to support people living with dementia and their families. The campaign is calling on people to become ‘Community Activation Champions’ and information, resources and supports are available at www.understandtogether.ie.

Health literacy is the best medicine

By sa | Sep 19, 2018 | 0 Comments

When patients and healthcare professionals are talking about a medical issue — big or small — both want to know that they have been fully understood. This is not always easy but improved health literacy, for both patients and healthcare professionals, can help.

For people working in the healthcare sector, health literacy is about communicating clearly and taking account of a person’s possible health literacy and numeracy needs. For patients, health literacy is the ability to understand and act on health information. It is also about empowering patients to ask questions, exploring their options and making informed decisions about their health.

Worryingly, a recent EU Health Literacy Survey showed that four-in-10 Irish adults had limited health literacy. This means that when dealing with health services, many adults find it challenging to fully understand health information and their health condition and treatment. They might also have difficulties working out and following instructions on medicine labels.

This is part of a wider literacy problem, as an OECD research study showed that one-in-six Irish adults find reading and understanding everyday texts difficult. For example, this could include bus timetables or restaurant menus. One-in-four Irish adults struggle with everyday maths, such as basic addition and subtraction.

However, even many patients who deal effectively with other aspects of their lives can find health information difficult to obtain, understand, or use. In fact, research shows that one-in-five Irish people are not fully confident that they understand the information they receive from their healthcare professional. In a survey conducted in 2015, 17 per cent of respondents said they had taken the wrong amount of medication on at least one occasion.

New research by the Healthy and Positive Ageing Initiative (HaPAI) also shows that a better understanding of health literacy by nurses and doctors could improve the health and wellbeing of people aged over 50. The findings show that:

24 per cent of older people said that their doctor or nurse rarely or never explains the results of medical exams.

26 per cent said that their doctor or nurse rarely or never explains different treatment options.

29 per cent felt discouraged to talk about emotional, nervous or psychiatric problems, such as stress, sadness or anxiety.

42 per cent felt discouraged from talking about sensitive problems, such as their sex life or incontinence.

The HaPAI outlines several steps that healthcare professionals can take to ensure older people feel more comfortable. These include explaining results and listening to opinions, and also supporting patients with cognitive issues and little or no education.

So, the benefits of improving health literacy for all concerned are clear. Patients who are better informed about their health have:

More effective consultations with their healthcare provider.

Are better informed about the medicines they are prescribed.

Are more likely to comply with their medication and as a result, have improved health outcomes.

People with improved health literacy skills are also more likely to make use of health screening programmes, tend to present at much earlier stages of disease and are less likely to be hospitalised.

Research has shown that health literacy interventions can significantly impact healthcare costs, outcomes and health disparities. Healthcare professionals have a real responsibility to engage in health literacy. However, they must be equipped with the awareness and tools to improve patient understanding. In practical terms, we need to undertake awareness-raising and training activities with healthcare workers at all levels, beginning in their undergraduate courses.

Health literacy also needs to be integrated into all national health campaigns and screening projects. Thankfully, many health services, including general practices, pharmacies and hospitals, are now looking at how they engage with their patients, particularly those with limited health literacy. By being aware and making it easier for all patients to use their services, they are becoming health literacy-friendly and delivering a better service.

A GP that is health literacy-friendly will look out for signs that a patient may not understand the instructions they just gave them. They might then use a ‘teach-back’ approach, where they ask the patient to repeat in their own words what they understand they have to do now. If the patient hasn’t fully understood the instructions, then this approach enables the GP to repeat them, perhaps using different terms and examples to explain what they mean.

Pharmacies also play a critical role in helping people understand their health issues and the steps they can take to improve their health. To help them achieve this, pharmacies can take part, along with general practices, in the Crystal Clear Programme. This national programme offers pharmacies and general practices the opportunity to gain a unique health literacy quality mark. It has been developed by the Irish Pharmacy Union (IPU), Merck Sharp & Dohme (MSD) and NALA. This Crystal Clear Mark recognises pharmacies and general practices that deliver a health literacy-friendly service to their customers. This means the service takes account of and supports the literacy and numeracy needs of its customers and regularly evaluates and improves its health literacy practices.

Leading from the front to get Sláintecare up and running

By sa | Sep 11, 2018 | 0 Comments

Sláintecare is a long-term plan to fix the health service.  It is the product of an all-party Oireachtas committee, with a commendable level of input from stakeholders, including patient advocacy groups.   From a service design perspective, it makes a lot of sense, even though there are some important omissions, including the need to embed clinical research into practice at all levels and a commitment to support academic clinical practice.

But over one year from its launch, we remain in the same  ‘crisis fire-fighting mode’ that led to the formation of Doctors Alliance in 2006/2007.  We were an advocacy group that came together to argue against privatisation of Irish healthcare. The financial crisis intervened, with the ensuing consequences for all services.

Eleven years on, strategic planning of the public health system  seems a luxury that is continuously deferred. Sláintecare is already behind target and there are real concerns that the necessary funds may not be available  to implement the required changes.    Cross-party collaboration appears to have fragmented and partisan politics seems to have re-emerged. 

This is a great shame. Without political will, the prospect of multi-annual budgeting with investment in the necessary changes is remote and Sláintecare is at risk of being relegated to the shelves containing all of the previous blueprints for reform.  

Staged implementation

But perhaps we should try to be more optimistic. Not all aspects of Sláintecare need to be implemented at the same time. Notwithstanding all of the crises, small changes that we make can positively impact on the lives of our patients. We must continue to advocate for the vision of a responsive healthcare system that is free at the point of entry, accessible and based on need and not on ability to pay. But it is possible, indeed imperative, to try to build upon what is good within our system. We should recognise the  initiatives that reflect the broad principles of Sláintecare, advocate on their behalf, and ensure that they are formally embedded within the system and replicated where possible. 

Patient groups

In this context, there is much that can be achieved with grass-roots support. There is a major and under-used role for patient groups here. In Ireland, many patient organisations already provide services that are part of standard healthcare systems in other countries. Harnessing this patient-oriented expertise, and embedding it within the existing delivery of care, can help to integrate services that are otherwise fragmented. There is considerable appetite within the voluntary sector in this regard. 

Examples of how this operates include the specialist nursing service provided by the Irish Motor Neurone Disease Association (IMNDA). These nurses, funded entirely from philanthropic donations to the Association, work closely with the National MND clinic in Beaumont Hospital, and ensure care is fully integrated between hospital and community-based services. The IMNDA also maintains an equipment bank that is available to patients based on clinical need rather than ability to pay. This is Sláintecare in action.  And the IMNDA is not alone.  Many other voluntary organisations provide similar types of clinical services. 

Mainstreaming funding for these services through well-governed patient advocacy groups could provide targeted and sustainable care for patients, fully aligned with the aspirations of Sláintecare. 

Community setting

One of the fundamental planks of Sláintecare is to provide appropriate care for patients close to their home, preferably within a community-setting. This requires that we value, promote and enhance the work performed by those working within primary care and that we seek to  enhance the co-ordination between specialist teams and primary care teams. 

There are many excellent primary care teams across the country. Clearly, the essential role of the GP must be recognised and valued. This is essential for Sláintecare to work.  In the meantime, we can seek to provide better integration between hospital services and professionals working within a community setting. This could  be achieved with some planning and modest additional investment of liaison services. 

It is also possible to think laterally about how we might address the long waiting lists for some of our specialist clinics in Ireland.  In many instances (including neurological care), Irish clinics  have a much  lower new-to-return ratio than in other countries. The reasons for this are multifactorial, including the perverse incentive that drives those without medical cards to hospital clinics (free) rather than GP services (payment required). Notwithstanding this, there remains considerable scope for referral of patients with stable conditions to community-based services. This could be achieved at modest cost by providing supportive outreach services, including specialist nurses and dedicated phone lines. Such a model has already been successfully developed for some conditions (eg, diabetes, epilepsy, etc) and could be replicated.

Moreover, audit of outpatient referrals to specialist services indicates that the most common referrals of new patients can be categorised into groups of common symptoms. For example, in neurology, the majority of referrals  include requests for assessment of headache, dizziness, seizures, falls, and non-specific neurological symptoms. A high percentage of these patients receive return visits, which would not be the case in other healthcare systems.  Return visits could be reduced if systems were in place for review of investigations and structured management plans implemented. This would require a modest investment in IT infrastructure, and a system of reliable communication between hospital services and primary care.

Standardising clinical practice

And with respect to hospital-based inpatient care, there is considerable variance in the utilisation of resources both within and  across hospitals. To date, there has been limited appetite for examining this variance to understand the underlying factors.  While clinical independence is highly valued by Irish clinicians, it is also important that wide variances in clinical practice are captured, evaluated, and where necessary, modified to ensure both  good clinical practice and responsible use of resources. 

A national audit of resource utilisation would be difficult to implement at present. However, a pilot study within a small number of teaching hospitals through the Clinical Leads programme could be feasible. Designated individuals could be trained in methodologies to measure variance. This in turn would provide an early indicator of the likely variance within and across centres in bed utilisation, resource utilisation and diagnostic complexity.

Sláintecare is the best chance that we have to develop a properly-functioning and integrated system of health. The roadmap to improve our healthcare system has been drawn. There is no doubt that we must hold our politicians and policy-makers to account to ensure the provision of  long-term, multi-annual funding to facilitate this.      

But at the same time, as healthcare practitioners, we also have a considerable opportunity to lead from the front. Anybody for  Doctors Alliance, Version 2?


A plan for implementation

More than a year after Sláintecare was released, the Government published an implementation plan for the strategy in August. This followed the appointment of Dr Tom Keane as Chairperson of the Sláintecare Advisory Council and Ms Laura Magahy as Director of the Sláintecare Programme Office.

Key actions in the first three years of reform include:

Establish HSE Board and reconfigure the HSE to improve accountability and support integrated care.

Deliver a new model of healthcare through the development of a Citizen Care Masterplan for the health service and new models of care that are population-health centred.

Launch a programme of public engagement on Health Outcomes and a nationwide series of events in 2019/2020 to promote health and wellbeing.

Enhance community care, including the expansion of community-based diagnostics facilities, a new community nursing service and a continued programme of investment in primary care centres.

Reform the GP contract, including providing for a greater role in chronic disease management.

Continue investment in community mental health services.

Introduce a new statutory scheme for homecare services.

Review the eligibility framework to develop a roadmap to achieve universal entitlement.

Increase bed capacity in public hospitals.

Choose locations and commence the planning process for new elective hospitals in Cork, Dublin and Galway.

Tackle long waiting times for acute hospitals by continued investment in the National Treatment Purchase Fund (NTPF) and the development of an integrated waiting list management system.

Develop a national clinical strategy and Hospital Group strategic plans to guide organisation of hospital services.

Roll out eHealth systems and infrastructure.

Source: Department of Health

Cancer screening is fallible but still saves lives

By sa | May 14, 2018 | 0 Comments

Doctors around the country have no doubt been listening to the questions of women confused and understandably upset by the CervicalCheck controversy. At the Irish Cancer Society, we are worried that this is creating wider concern about all cancer screening.

Screening for cancer is fallible and not diagnostic. A Cochrane Review published into studies of cervical screening from around the world found that for every 1,000 women screened with the PAP test (a forerunner of the current liquid cytology test), around 20 will have precancerous changes. But the review concluded that the test would only identify 12 of the women, missing eight of them.

The liquid cytology test employed in cancer screening cannot reliably detect adenomas, which arise deeper in the cervix.  Testing itself is also associated with a very small but finite risk of errors, which can occur from a number of sources: Administrative, technical or due to human error, as happens with all medical tests.

Screening is not perfect, but its advantages by far outweigh its pitfalls. The Irish Cancer Society firmly believes that attending cervical screening appointments is a vital way for women to protect themselves from this deadly cancer. Simply put, screening save lives.

Prior to screening, Irish cervical cancer rates were rising at 4 per cent per year.  In the decade since CervicalCheck was established, more than 1,300 cancers and 50,000 high-grade and 37,000 low-grade pre-cancerous abnormalities have been found, leading to preventative treatment that has meant that incidences of cervical cancer have decreased by 7 per cent each year.

As members of the medical profession, readers of the Medical Independent can do their part in conveying this life-saving message. Each year in Ireland, approximately 300 women are diagnosed with cervical cancer, but this number is falling. Thanks mostly to screening, almost half of them receive their diagnosis at stage 1 of the disease, with 95 per cent of these women surviving for at least five years post-diagnosis and the majority being cured.

In the case of more than 6,500 women each year, advanced precancerous changes will be found, which will need treatment to reduce the chance of them becoming a cancer.

But the fewer women who attend appointments, the more likely these precancerous changes will evolve into cervical cancer.

Clearly, confidence in the cervical screening service has been badly shaken. Not only does the medical community need to work with the HSE and organisations like the Irish Cancer Society in restoring such confidence, we also have to work to ensure a contagion of suspicion doesn’t spread to our breast and bowel screening services.

All three cancer screening services are designed to cut cancer deaths by trying to detect the likely presence of a target cancer at an earlier stage when intervention has a better chance to prevent the full-blown disease.

In 2016, BreastCheck had an uptake rate of 74.7 per cent among women in the eligible age group. As a result, 986 cancers were spotted, in many cases leading to earlier intervention that has saved lives. As the National Screening Service noted, this success surpassed the programme standard of 70 per cent.

BowelScreen’s latest figures show how the programme is saving lives — to date, it has detected 718 cancers and removed almost 19,000 pre-cancerous growths.

However, fewer than 40 per cent of eligible people — 35 per cent of men and 45 per cent of women — have availed of BowelScreen in the most recent screening round.

Unfortunately, BowelScreen already has its own challenges. Research commissioned by the Irish Cancer Society and undertaken by Dr Nick Clarke in UCC found that fear and fatalistic beliefs about cancer are leading to many not taking up the offer of the free, simple, life-saving test. 

Through a survey of around 2,000 people who were eligible for the Tallaght pilot, BowelScreen found that almost one-in-four (24.3 per cent) believe that cancer is a ‘death sentence’.

However, there is hope. Just over 96 per cent of survey respondents believed that going to your doctor as quickly as possible increases your chance of surviving cancer.

The importance of primary care in restoring confidence in screening cannot be underestimated. The long-held personal relationships between GPs, nurses and their patients is invaluable in conveying such life-saving messages.

The relationship will be vital in informing women about upcoming changes to cervical screening. HPV DNA testing is set to replace liquid cytology this autumn, after HIQA’s 2017 Health Technology Assessment found that this test would reduce the number of screenings each woman has in her lifetime, while providing better accuracy in detecting precancerous abnormalities and early-stage invasive cervical cancer, although this test will also have false positive and false negative error rates.

While women will experience no change in how the cervical screening sample is collected, HPV DNA testing will lead to 20 per cent more pre-cancers detected, 30 per cent more cancers and mean screening moving from every three years to every five years for women who have had the HPV vaccine, which prevents seven-in-10 cases of cervical cancer.

If your patients have any specific concerns about CervicalCheck, please direct them to the CervicalCheck helpline on 1800 454555. Separately, the Irish Cancer Society is also here to help. We’ve updated our website with important information at cancer.ie/cervical-cancer-controversy, while cancer nurses are available to speak with the public through our Cancer Nurseline — 1800 200 700 (lines open Monday-Friday, 9am-5pm).

The inquiry into CervicalCheck will hopefully give the public a clearer picture of the mistakes, but also the successes, of our national cervical screening programme. This work, ongoing political debate, and the harrowing stories of women with cervical cancer and the families of those who died but who have since been tangled in this controversy will no doubt keep the issue in the public’s mind for many months, and perhaps years, to come. A long road is ahead if the national screening service has any hope of restoring public trust. But it is important to know that we can all play our part in ensuring as many lives as possible can be saved.

Dr Robert O’Connor is Head of Research at the Irish Cancer Society.

Taking a closer look at therapeutic-use exemptions in Irish sport

By sa | Apr 12, 2018 | 0 Comments

Diabetes and asthma were the most common indications for approved therapeutic-use exemption (TUE) applications to Sport Ireland in 2017, according to data released to the Medical Independent (MI) following a Freedom of Information (FoI) request.

Last year, there were a total of 27 approved TUE applications, stated Sport Ireland’s Anti-Doping Annual Review 2017. This compared to 40 in 2016.

Five applications were incomplete at the end of 2017 and a further 49 were ‘not relevant’ (for reasons such as, the medication was used out of competition; the medication was not on the prohibited list; the application was for a threshold medicine where the athlete was below the threshold; the medication changed to an alternative; and the medication was given by a route not prohibited). The total number of applications (81) represented an increase of 10 on 2016.

A TUE allows an athlete to use a prohibited substance or method included on the World Anti-Doping Agency (WADA) Prohibited List, subject to certain defined conditions. Athletes can apply to Sport Ireland, or in the case of an international-level athlete, the international federation. The athlete must have “a well-documented medical condition supported by relevant and reliable medical data” for the TUE to be granted, according to Sport Ireland. The multi-specialty TUE Committee is chaired by Consultant Respiratory Physician Prof Sean Gaine.

Of the 27 TUEs approved by Sport Ireland in 2017, diabetes was the relevant indication in six instances.

The medications approved were insulin aspart in two cases; insulin detemir/insulin aspart in one case; and insulin glargine/insulin aspart in three cases.

Asthma was a relevant indication in five cases, including one combined case of asthma and rhinitis.

The medications approved were salbutamol, terbutaline, vilanterol in two cases, and vilanterol/terbutaline.

ADHD was the third-most common indication, representing three cases and involving the approval of methylphenidate.

Seven cases involved approval of a glucocorticoid, namely prednisolone in six instances, and fluticasone in one case. Glucocortioids were approved for a range of indications, including colitis, cerebral vasculitis and polymyalgia rheumatica.

Athletics and rugby

Last year, athletics and rugby accounted for the most TUEs granted by Sport Ireland — six in each sport. This was followed by shooting (three), rowing and cycling (two each). There was one application approved in relation to each of the following sports: Gaelic football, paralympic athletics, swimming, motorsport, equestrianism, triathlon, gymnastics and soccer.

Sport Ireland’s Anti-Doping Annual Review 2017 listed the numbers of TUE applications received and approved, but did not publish information on specific medications approved or relevant indications (this information was obtained under FoI, although not in a manner that could link the approved medications with a sporting category). Despite some calls for it to do so, Sport Ireland does not publish the names of athletes granted TUEs.

A spokesperson for Sport Ireland informed MI: “To confirm, TUEs are personal, medical records containing sensitive personal data, provided to Sport Ireland in confidence. Sport Ireland must ensure it respects certain privacy rights of the athlete. This assessment includes the possibility of singling-out and data-linking.

“This extends to the ability to single-out an individual from others by taking one or more pieces of information, which if viewed alone could relate to a number of individuals, but when linked together would narrow the scope of the individuals it would be applicable to and therefore identify them.”

Meanwhile, on the fact that valid and approved applications dropped from 2016, Dr Una May, Sport Ireland’s Director of Participation and Ethics, told MI there was “no clear or outstanding reason” for this.

Medical Council

Dr May also confirmed that work is ongoing on developing a memorandum of understanding (MoU) with the Medical Council, which would provide a formal mechanism to report concerns about the practice of registered doctors in respect of potential doping activity.

“The main purpose is about collaborating,” she said. “We feel very strongly about the importance of working in partnership and collaborating in sport. It is important to recognise it is not just the athlete [in terms of anti-doping]; oftentimes, there is more to what we see from a positive result and an adverse analytical finding — there is more to it than just an athlete taking something; sometimes there is somebody helping them to take that. So if we come across something, it would be appropriate that we share that information with the Medical Council. It has cropped up in the UK and a number of other countries, where it has been important to follow-up with the relevant medical authorities.

“Certainly, if we were to become aware of a doctor who was to be involved with doping, in some way, shape or form, we’d be very anxious to make sure the person is dealt with appropriately by the relevant medical authorities, as well as within sport… ”

Asked if Sport Ireland had, over recent years, any cause to contact the Council regarding a medical practitioner, Dr May said “no, we haven’t”.  In the absence of an MoU, she said, there would be “possible avenues” by which information could be forwarded to the Council if necessary.

“But the most appropriate way is to have a formal system in place for doing that, which fulfils totally any kind of criteria around data protection and everything else — that is what our vision is, that we have a strong system in place for doing it,” said outlined.

Dr May confirmed that Sport Ireland is working with the RCSI/RCPI Faculty of Sports and Exercise Medicine on developing ethical guidelines for medical practice in sport. This follows a Medical Council request to relevant medical bodies to produce specialty-specific ethical guides.

Last year, through the national testing programme, Sport Ireland conducted 989 tests of athletes. This included 318 blood tests and 671 urine tests. It undertook an additional 315 ‘user pays’ tests on behalf of 10 national and international organisations, marking an increase of 15 per cent on 2016. There was one positive finding from tests conducted last year and no further information on this has been released thus far. 

Supplements

Dr May advised that the issue of supplements “continues to be one of our bigger challenges”. In this respect, Sport Ireland has recently published a document titled Supplement use in Sport Guidelines.

According to Dr May, there has been an increase in the number of anti-doping rule violations globally that involve use of supplements, whether contaminated or otherwise.

She said Sport Ireland continues to work closely with the Food Safety Authority of Ireland (FSAI) and the Health Products Regulatory Authority (HPRA) on this matter. 

Last month, the FSAI announced it was recalling all Falcon Labs products due to the “presence of illegal steroids and stimulants that pose a serious health risk to consumers and also, as the location of the production site cannot be determined and traceability of the products is unknown”.

FSAI officers took possession of Falcon Labs products from food supplements and sports nutrition shops, gyms and online suppliers across the country. According to the FSAI, the products were sent to the State Laboratory for official testing for a range of illegal steroids and stimulants. The results showed that 1,3-Dimethylamylamine (1,3-DMAA) (also known as methylhexaneamine MHA) was detected in Falcon Labs Oxyburn Pro and Superclen products. Methasterone was detected in Falcon Labs’s Superdrive. According to the FSAI, 1,3-DMAA was not declared as an ingredient on any of the products and methasterone was misspelt on the label of the product in which it was detected. Nonetheless, neither substance is permitted in food.

The FSAI warned that 1,3-DMAA is a stimulant that can cause acute temporary increase in blood pressure, which may lead to shortness of breath, tightening of the chest and the risk of heart attack or cerebral haemorrhage. It was previously authorised as a nasal decongestant, but later withdrawn. Methasterone is anabolic-androgenic steroid which has been associated with a number of cases of liver injury. It has never been authorised as a medicine, but has been found previously on the black market under the name Superdrol.

There have been two publicly-reported rulings by Sport Ireland against athletes who tested positive for banned substances and who said they consumed Falcon Labs food supplements.

A need to know: Getting ready for the new data protection law

By sa | Apr 12, 2018 | 0 Comments

The General Data Protection Regulation (GDPR) is a new EU regulation and, as such, will have a direct effect in all EU countries, including Ireland.

The GDPR has been written to reflect the increasingly digital climate in which organisations now operate. It aims to enhance the current data protection rules by introducing a number of additional data protection obligations on organisations, increasing rights for individuals and allowing them greater control over their own personal data.

The GDPR will apply to all individuals and organisations that have day-to-day responsibilities for data protection. All doctors should consider, therefore, how the GDPR will impact on their practice. 

The Data Protection Commissioner (DPC) has published guidance titled The GDPR and You. This sets out the key changes, although it is by no means an exhaustive document.

The DPC has also launched a GDPR-specific website with guidance for both individuals and organisations, raising awareness of their respective enhanced rights and responsibilities under the GDPR.

Accountability

The GDPR introduces the principle of accountability and makes this mandatory. In short, as well as ensuring GDPR compliance, organisations must now be able to demonstrate this compliance. Organisations must maintain accurate records of all their data processing activities, including the purpose for collecting and holding personal data, how it was obtained, how long it will be retained, the security measures in place, and how and why data may be shared with third parties. 

It will also be important to document all advice provided by the Data Protection Officer (DPO) and any risk assessments undertaken.

All staff should be aware of their individual responsibilities and it is important to keep a log of staff training.

Lawful basis for processing personal data

Organisations need to identify their lawful basis for processing patients’ personal data (such as their name, address and date of birth). There are six lawful bases, which include patient consent; processing is necessary for the performance of a contract or provision of a service; processing is in the organisation’s legitimate interests, except where such interests are overridden by the interests or fundamental rights and freedoms of the patient; and processing is necessary in the vital interests of the data subject.   

Under the GDPR, certain ‘special categories of personal data’ — including data concerning health — cannot be processed (eg, collected, stored, used, disclosed or destroyed), unless one of 10 conditions is met. Organisations therefore need to establish this special category condition and ensure this, and the legal basis for processing personal data, is communicated to patients.  The most relevant conditions are patient consent; and that processing is necessary for the purpose of preventative or occupational medicine, medical diagnosis or the provision of healthcare or treatment that is done by, or under the responsibility of, a professional who is subject to an obligation of professional secrecy.

Consent 

The GDPR sets a very high standard for consent in relation to the processing of personal data. If organisations are relying on consent as a lawful basis for processing personal data, they must ensure that it is freely given, specific and informed.  It should constitute an unambiguous indication of the patient’s wishes, by a clear affirmative action to the processing of his/her data. Pre-ticked boxes will not count as consent and there must be a positive opt-in process, separate from other terms and conditions. Organisations will be obliged to demonstrate that the patient has given their consent. There must be an easy way for a patient to withdraw their consent.

Transparency and fair processing

As has always been the case under data protection legislation, organisations have an obligation to inform patients what they are doing with their data. However, the GDPR will bring in more detailed and specific rules on providing such privacy information.

Privacy notices should be used to inform patients at the time of collecting their data. A variety of communication methods could be used, such as posters, leaflets, letters and information on the organisation’s website.

The GDPR places emphasis on the importance of privacy notices being easily accessible to patients, including children and vulnerable adults. Information within such notices should be concise, truthful and written in clear, straightforward language. If your organisation has non-English-speaking patients, then privacy notices should also be translated into other languages, as necessary. 

The following information must be provided to patients within privacy notices:

The data controller’s identity.

The Data Protection Officer’s contact details.

The purpose of the processing.

The lawful basis for processing.

The categories of personal data processed.

The potential recipients of personal data.

How long the data will be retained.

The security measures in place to protect their data.

A list of the data subject’s rights.

Any safeguards that will be used if data is to be transferred to a country outside the EU.

In addition, patients must be informed that they can complain to the DPC if they believe there is a problem with how their data is being handled.

Subject access requests

The time scale for compliance with a patient’s subject access request will be reduced from 40 days to one month. Organisations will no longer be able to charge for the provision of copies of records, unless the request is ‘manifestly excessive or unfounded’ or is repetitive in nature. In these exceptional circumstances, organisations may charge a ‘reasonable fee’ based on administrative costs. If organisations refuse a subject access request, they must tell the patient why they have done that and inform them they have a right to make a complaint to the DPC. 

If a subject access request is made electronically, or if the patient requests it, information should be provided to the patient in a commonly-used electronic format.

The DPC advises that if an organisation handles a large number of subject access requests, the impact of the change could be considerable. Organisations may wish to consider whether it is possible to develop a self-service system that allows an individual to have remote access to their information.

Data breaches

In the event of a data breach affecting a patient’s privacy rights (for example, a breach of confidentiality), data controllers will be required to notify the DPC ‘without undue delay’, and where feasible, no later than 72 hours after becoming aware of the breach. Organisations will also have to notify the patient of the breach if it is likely to result in a high risk to their privacy rights. This is in addition to the duty of candour to inform patients of such breaches, outlined in paragraph 67 of the Medical Council’s Ethical Guide.

The DPC will have the discretion and power to impose higher fines for data breaches, as well any other infringement of the GDPR.

DPIAs

Data Protection Impact Assessments (DPIAs) are recommended as a way of assessing the level of protection in place to safeguard patients’ personal data. Whilst considered good practice in any case, DPIAs will be legally required where the processing of personal data is likely to involve high risks to the confidentiality of individuals. They are likely to be required when organisations introduce new technology, for example a new computer system or a new system of sharing data.

Data Protection Officer

Certain organisations will be required to have a DPO, including public bodies and organisations that process special categories of personal data (including health data) on a large scale. The DPC has provided further clarification  in this regard.

The DPO should have expert knowledge of data protection and their role will include advising on and monitoring compliance with the GDPR, providing advice regarding DPIAs and acting as an intermediary for patients and also the DPC.

Patients’ rights

Individuals will be given stronger rights under the GDPR, including the right to rectification, the right to erasure, the right to object to processing, the right to restrict processing and the right to data portability. These rights are complex and not absolute. Organisations should ensure that they understand when they apply and have a process in place to deal with them, should patients wish to exercise them.

Where to obtain further information

The DPC’s GDPR-specific website has a number of resources that you may find helpful. It is likely that over the coming weeks, there may be further clarification of the legislation and you should check this website regularly. The DPC has produced a checklist for organisations to prepare for the GDPR, available under the ‘Resources’ heading of this website.

Healthcare professionals can also contact their medical defence organisation if they have any concerns.

Patterns of presentation: Cancer diagnoses in EDs

By sa | Apr 12, 2018 | 0 Comments

Receiving a diagnosis as serious as cancer is never easy. However, ensuring the environment is appropriate for the diagnosis to be made and delivered is important for patients in order to start coming to terms with their condition and be properly informed about their future treatment plan.

One does not need to be a healthcare expert to know that a busy emergency department (ED) is not the ideal place to make such a sensitive diagnosis. This especially applies in the Irish health service, which has suffered from chronic ED overcrowding for more than a decade.

Another key point is that when cancer patients present at an ED, the cancer is invariably at an advanced stage. Therefore, the research into the subject conducted by the Irish Cancer Society and National Cancer Registry Ireland into cancers diagnosed as emergencies in Ireland each year, which was recently published, shines a spotlight on a neglected corner of the health service that is seldom discussed.

Main findings

According to the report, which examined patterns of emergency presentation of cancer in Ireland from 2002 to 2015, approximately 3,000 of the 22,000 invasive cancers diagnosed each year are diagnosed as emergencies. The figure does not include non-melanoma skin cancer. Overall, during 2010-2015, some 14 per cent of cancer cases presented as emergencies at the time of diagnosis. The report also compares Irish figures with those of the UK. It shows 16 per cent of all invasive cancers presented to EDs in the UK between 2006 and 2015. In Ireland, of the 24 individual cancer types examined, those with the highest proportion of emergency presentation during 2010-2015 were pancreatic; brain/central nervous system and liver cancers (all 34 per cent); leukaemia (27 per cent); ovarian (24 per cent); colon (22 per cent); and stomach cancers (21 per cent).

Demographics

For cancers presenting as emergencies, 30 per cent were in patients from the most deprived population quintile, compared with only 23 per cent for cancers presenting electively. According to the authors, cancer patients from the most deprived areas are 50 per cent more likely to be diagnosed via emergency presentation than those from the most affluent areas. There was also significant variation in relation to age. For cancers as a whole, 56 per cent of cases were diagnosed at ages 65 and over. However, for cancers presenting in EDs, 71 per cent were in patients aged over 65, compared with only 53 per cent for cancers presenting electively.

Expressed in a different way, cancer patients aged over 65 were twice as likely to present as emergencies (18 per cent) as patients under 65 (9 per cent). Age-related variation in emergency presentation likelihood was most marked for thyroid cancer (patients aged over 65 were 10 times more likely to present emergently than patients under 65) and least marked for multiple myeloma (no difference by age). Leukaemia was the only cancer group for which older patients were less likely to present in EDs.

Late presentation

One of the most concerning issues outlined in the report is that cancers presenting in EDs are invariably at a late stage. For cancers as a whole, about 58 per cent of known-stage cases were diagnosed at early stages (I or II), 42 per cent at later stages (III or IV). However, for cancers presenting in EDs, about 77 per cent were diagnosed at later stages, compared with only 38 per cent for cancers presenting electively. Stage-related variation in emergency presentation risk was most marked for breast cancer (late-stage cases 14 times more likely to present in ED than early-stage cases, adjusted for age) and least marked for pancreatic cancer (late-stage cases 1.3 times more likely to present in ED).

Positives

There are some positives to take from the report. Over the period 2002 to 2015, the overall proportion of cancers presenting emergently fell from 20 per cent to 14 per cent, the biggest decline occurring between 2005 (19 per cent) and 2009 (14 per cent), with little change subsequently. Of 24 cancer types examined, nine (colon, rectal, liver, pancreatic, breast, prostate, kidney, thyroid cancers and multiple myeloma) showed trends of significant decline in the proportion of cases presenting emergently over the whole period (2002-2015).

Only cancers of the brain/central nervous system showed any significant recent increase in emergency presentations (2009-2015, following a significant decline during 2005-2009, respectively).

Recommendations

The National Cancer Strategy 2017-2026 aims to reduce the proportion of cancers diagnosed in EDs by 50 per cent by 2026. In order to support this aim, and to achieve further reductions in emergency presentations, the document makes a number of recommendations for diagnoses to be made at an earlier stage. Chief among these is to allow GPs to have direct access to diagnostics at secondary care level. An Irish Cancer Society-commissioned report from 2016, Access to Diagnostics Used to Detect Cancer, highlighted that there were long delays for GPs accessing diagnostic tests for a suspected cancer; a lack of access to direct diagnostic tests; lack of community diagnostics; and a lack of access to rapid investigative tests for suspected cancer. Often, because of these problems, GPs are forced to send a patient directly to ED to access urgent diagnostic tests. The report also calls for the development of diagnostics in primary and community care settings and targeted public awareness campaigns on the signs and symptoms of cancer.

It also says that the development of a rapid-access pathway to treatment is necessary for people diagnosed in an ED, as is a significant incident case review for these patients. The report calls for further research to better understand the causes of emergency presentation.

Reaction

Speaking at the launch of the report, Director of the HSE National Cancer Control Programme (NCCP) Dr Jerome Coffey said the recommendations echo those contained in the national cancer strategy.

“I will commit to continuing the conversation between the [National] Cancer Control Programme and the [Irish] Cancer Society on sequencing and implementing these recommendations,” said Dr Coffey.

“If you look at the headline news, the headline news is that there has been progress. In 2005, presentations were at 20 per cent; by 2015, it was 14 per cent. We want to get down to 7 per cent. We want to get down from eight presentations to emergency departments per day, down to four in the lifetime of the strategy. That is doable; it is not too ambitious, it is appropriately ambitious.”

Dr Coffey said it is important to consider the biology of different cancers when it comes to emergency presentations.

“Cancers are different,” he said. “There is consistency in the numbers between this jurisdiction and our neighbours across the water. “So pancreatic cancer at early stage will present with obstructive jaundice or back pain. It is aggressive biologically. That does not mean the person has metastatic disease. It just means that this is a unique cancer. So some of the issues we are dealing with here are international issues.”

Dr Coffey said there is a need to consider regional factors.

“We need to take populations, go deeper into the data and look at the geography,” he stated.

“Which parts of the country are seeing more emergency presentations? Where are we seeing all the lung cancer presentations? We need to support GPs even more. We have had guideline referrals on our website for a number of years, we have electronic referrals, that is all done, so when we come back and look at this data again in a couple of years, we want to make sure there is a full impact from the work that has been done and the work that has only started this year.”

He said the funding released as part of the cancer strategy will support the implementation of the recommendations.

Dr Coffey concluded by saying the report is the most valuable public health initiative he has seen for some time.

“This fits with the cancer strategy, it fits with Sláintecare, it fits with other countries who may have started this project,” noted Dr Coffey.

“So it is great to have national data on an international issue. A lot of projects I get involved in, the first thing that’s asked is, ‘where is the data?’ Here, we are starting with the data, that is a huge step forward; it is a huge competitive advantage.”

Also speaking at the launch, Director of the National Cancer Registry Ireland Prof Kerri Clough-Gorr said the report was an example of what can be achieved through collaboration.

“What I want to focus on is partnership,” said Prof Clough-Gorr. “We can do more when we do partnerships like this. We are delighted to be involved in this type of research because it brings all of us forward. We are delighted to work with the National Cancer Control Programme, because with our funding from the Department of Health, together we can do a lot more for patients.

“We are all chasing the same goal here. We all want the best possible cancer patient experience. And when we come together for reports like this, we are able to see where more work needs to go, where policy needs to be focused. We can work with the National Cancer Control Programme to get at those targets. Our data is the basis of all that… when we do it together, we do it much better.”