Heart (TAVI) Operations Suffering Due to a Lack of Co-ordinated Planning and Funding by the HSE

Speaking in the Seanad during Commencement Matters on “The need for the Minister for Health to address the inadequate and inefficient organisation of the TAVI (transcatheter aortic valve implant) programs across the State, causing delays and lengthy waiting lists for patients.”

Watch the video of this short debate here:

Senator John Crown: Cuirim fáilte roimh an Aire Stáit. I wish to use these few minutes to bring to the Minister of State’s attention a very frustrating problem which has arisen in the health service. It relates to a very promising, relatively new but well established technique called transcatheter aortic valve implantation, or TAVI. To put the Minister in the picture, aortic stenosis is a condition in which the aortic valve, which is one of the four major valves of the heart and the last place through which blood goes as it leaves the heart and goes out to the rest of the body, becomes narrowed. In sad bygone days we used to see this very frequently in times of social deprivation as a consequence of things like rheumatic fever. It is now mainly a disease that occurs in older people as a result of degeneration of the valve with age. This degeneration occurs in approximately 2% of older people and has a 50% mortality rate over two years. If it is severe and causing the patient to have symptoms, the mortality in one year is 50%. The symptoms tend to be shortness of breath, blackouts, chest pains, etc. Basically, the blood cannot get out of the heart and into the rest of the body.

I am old enough to remember that when I was an intern in the national cardiac centre at the Mater hospital, we had to go around getting consent forms from patients who were to have the very significant and intrusive operation of aortic valve replacement. Their chests would be opened, they would be put on the bypass machine and their hearts would be opened. There was an appreciable chance of dying on the operating table, despite the great skills of surgeons such as the late, great Maurice Neligan and others who brought this procedure to Ireland. Through one of the great miracles of innovation, there is now a way of doing this in a minimally invasive fashion by threading a catheter through the blood vessels to the heart and, by way of wonderful skill and technology, implanting a valve without having to open the patient’s body or heart. This is obviously a vastly better way to proceed because, in the past, many patients who needed this procedure could not have it done as they were too sick for the operation. It was a vicious circle. They had a serious diagnosis and needed the operation but they could not have it. They needed a general anaesthetic and intensive care. In our system, of course, there is a desperate shortage of intensive care beds. One can understand, as such, how difficult this problem became.

The new technology is wonderful. People are in hospital for as little as two nights and they do not have to go into intensive care. Some of them avoid a general anaesthetic altogether and the operation is done under a deep level of sedation without the input of an anaesthesiologist or anaesthetist to put them to sleep. This is a win-win situation. The actual piece of hardware that is put in – the valve – is more expensive than the valve that is put in through the traditional big, onerous and dangerous operation. It costs approximately €16,000 to €17,000, as opposed to €5,000 to €7,000. The Minister of State has been in the health service for a few years now and will understand the potential for colossal cost savings if people do not need to go into intensive care, do not need all the tests carried out and are not subject to the complications of major surgery. Instead of being in hospital blocking up beds that could be used for other people, people would have access to a simpler and safer procedure with good outcomes and with less time in hospital. The problem at the moment is that it is done in an uncoordinated fashion. We have three centres, at the Mater, St. James’s Hospital and University College Hospital Galway, staffed by extraordinarily skilled and dedicated people who are doing the best job they can. It is not a national service, however.

The case that precipitated this particular discussion arose in St. Vincent’s Hospital, where this procedure was recommended to a patient by skilled cardiologists. They correctly arranged for the patient to go to the Mater hospital, which is our designated centre, but the Mater has imposed a limit because it is not a national centre. That limit is 17 procedures per annum. The 17th procedure will take place in August, which means the Mater cannot do any procedures after that. The Mater is asking hospitals that are referring patients for a procedure which by definition can only be done in a small number of hospitals to bring their own funding. This is a colossal problem and, unsurprisingly, the number of TAVI procedures carried out here is only one third of the number carried out in the United Kingdom. In truth, the UK is pretty poor on most metrics. It has a mediocre health service by the standards of the better social democracy medical systems in Europe, such as those of Germany, the Nordic countries and France. If one looks at the European league table, Ireland is at the very bottom. We are the lowest in terms of TAVI procedures.

We have a real problem here. It is a classic example of a problem which is purely administrative. If there were a recognition that this was a national need and not a matter of a number of isolated islands of excellence that, understandably, are giving priority to patients within their own catchments, we would not have developed a sort of geographical or postcode apartheid for the procedure. I happen to know that my good friends and colleagues in the Mater, who have been doing a phenomenal job – for which I thank them on behalf of patients from their hospital, St. Vincent’s and all other hospitals that are sending them patients – have been beating the bushes to try to get this problem rectified. One of them told me that clinicians are attempting to bring this to wider attention, but their concerns are falling on deaf ears. This could be a win-win situation. The procedure is good for patients, waiting lists and economics and it is something we should do very quickly. The problem is that we are too used to the abnormalities of our health system, whereby people can be on waiting lists for six months or two years.

One cannot be on a waiting list for two years for this procedure, as one will disappear from the waiting list on average after one year. These people are no longer a vocal group pushing for reform, because they have died. It is a matter to which the Minister of State should give urgent attention.

Minister of State at the Department of Health (Deputy Kathleen Lynch): I could start by reading out the first two pages of my speech, which tells me exactly what Senator Crown has told me, if not in the same language. I thank him for sparing me the medical terms, which I am not very good at. There are some things we should point to. I thank the Senator for raising this matter, because when he raises issues here, it is usually in order to find a solution rather than to pour scorn. Very shortly, we will enter a process on the Estimates and the budget for October. One of the things that was raised around two years ago – I saw a documentary about this on Monday night on RTE – was cochlear implants. It was something that affected a considerable number of people. We were doing some of it but not enough of it. That programme has now come on stream because of the type of focus and attention that was given to it. This is another area to which we will need to give particular attention, but there are competing issues within the health service, as the Senator knows better than most, as he works within it every day of the week. Sometimes, I highlight one among those competing programmes. We have a clinical programme and are making advances. As Senator Crown pointed out, a number of hospitals are carrying out the procedure, including St. James’s, University College Hospital Galway and Mercy Hospital in Cork. However, until there is a co-ordinated approach in a national clinical programme, the benefits of which we have seen in other areas, the numbers will not be coming through and will not be able to retain the necessary skills. We all know where that leads us.

I thank the Senator for raising the issue. It is an issue about which we should all be concerned. If we are lucky enough to get to later life, it is a procedure we may need ourselves. It would be nice to know it was available. Among those who have received the treatment, some have been hospitalised for only 36 hours before returning home to a new life, able to do far more physical activity. I will ensure that this is brought to the attention of officials as they prepare the health Estimates. I am not promising the Senator anything, but when we shine a light on certain areas, we have a degree of success. I hope that by raising the matter today and getting this attention, the Senator will see that something is done about it.

Senator John Crown: I am very grateful for that. My cardiology colleagues and I will eagerly follow the debate as it evolves. For clarity, I am not advocating more centres or any attenuation or dilution of the numbers coming through.

Deputy Kathleen Lynch: I understand that perfectly.

Senator John Crown: We have about the right number of centres now. With Cork semi-officially open, that makes four, which is probably enough, as it has to be linked to places where cardiac surgery is done. The problem is that it is being done in an uncoordinated fashion and without a designated budget. When someone comes from another hospital that does not have a budget for cardiac surgery, he or she has less chance of getting the procedure than someone in a hospital where it is designated. The people in the latter hospital are limited also, because it is not seen as the national service.

I am more aware than most of competing demands. In fact, I gave a lengthy interview in a newspaper today about immoral and predatory pricing by drug companies with respect to new cancer drugs. This will save money. The problem is that it might not save it this year; that is the catch. We have to have Japanese style forward thinking in terms of health economics which, with great respect, the officials are very bad at, as are politicians, who tend to see things in terms of the next budgetary and electoral cycle. There is a need to understand that if we do this right now, we will save money.

Deputy Kathleen Lynch: I agree with the Senator. We have enough centres. It is not something that needs to be available to every hospital. We will probably have enough with the four, although if one were sensible about it, one might add one more in terms of the west, but hospital groups will help regarding the development, delivery and co-ordinating of that. I would like to think we are getting a little better at advance planning. It is not always about what we can do within the coming week. We have to plan for the future, as one usually plans for one’s own.

Senator John Crown: I would make the point that the Mater and St. Vincent’s hospitals are already in the same hospital group.

Deputy Kathleen Lynch: Yes.

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