Mark O’Donnell, Croí COO & Head of Foundation, and Dr Lisa Hynes, Health Psychologist and Croí Head of Health Programmes, attended an Oireachtas Committee Hearing on Health today at Leinster House to speak on issues related to Cardiovascular Health, Stroke, Heart Attack, Programmes, Services and Prevention

Thank you Chairman, and firstly, I would like to thank the committee for the invitation to speak with you this morning.  My name is Mark O’Donnell, and I am the Chief Operations Officer of Croi, the West of Ireland Cardiac & Stroke Foundation. I am joined by my colleague Dr Lisa Hynes who is a Health Psychologist and is Croí’s Head of Health Programmes.

By way of introduction, Croi is a charity, based in Galway, which was established in 1985 (www.croi.ie).  Croí’s mission is to prevent heart disease and stroke, save lives, empower and support families, communities and future generations to take control of their health and well-being.

Croí has almost four decades of experience working with communities across the country, from prevention of Heart Disease and Stroke, through aftercare and rehabilitation, providing patient and family support, working to advocate for and empower patients, and effect policy change. 

With this in mind, I would like to briefly outline some of the key challenges and unmet needs, and also set out some of the high-level actions that we believe can and should be taken to address these challenges. 

Firstly, it is important to understand the burden of disease that we are facing.  Cardiovascular disease is the biggest annual cause of death globally accounting for 33% of all global deaths, and 1 in 5 of all premature deaths. The burden of this disease is enormous and growing, particularly driven by the increase in diabetes and obesity.

Cardiovascular disease is the second leading cause of death in Ireland, with an average of 10,000 deaths per annum.  Approximately 7,500 people have a Stroke each year in Ireland, and Stroke is the leading cause of acquired adult neurological disability in this country.

In addition to the human toll and trauma caused, research published last August by the European Society of Cardiology [1] estimated that CVD costs  EU member states €282 billion annually, or an average of €635 per person across Europe.   This report estimates that the overall cost of CVD to Ireland in 2021 was in the order of €3.44 billion, which includes economic costs through productivity losses as well as health and social care costs.  The study estimated the productivity losses to the Irish Economy alone amount to some €855m in a single year, which is an important factor to consider in any thorough and robust cost-benefit analysis of healthcare provision.

Against this stark backdrop, we do not have a current National Cardiovascular Health Strategy – the last CVD Strategy expired in 2019.   We urgently need a comprehensive National Strategy to address these critical challenges, and the development of such a strategy needs to embrace the views and needs of all stakeholders.  A strong patient voice is an essential element of any strategy formulation, and 2023 saw the launch of Heart & Stroke Voice Ireland.  This initiative, supported by Croí, is a new alliance of Heart and Stroke patients, and will provide an effective structure to ensure the patient voice is heard.

Aside from the more comprehensive strategy piece, I must highlight that the National Cardiac Services Review which was carried out some years back and contains key recommendations to improve services has still not been signed off.  We understand it is currently with the Minister and would urge that it is progressed without further delay.

Given that up to 80% of premature deaths due to CVD are preventable, a preventive approach to Heart Disease and Stroke is needed at all stages, from primary prevention to early identification and treatment of people at high risk through to comprehensive rehabilitation to reduce the risk of repeat events or further disease progression.    

Earlier this year, Croí’s sister organisation, the National Institute for Prevention and Cardiovascular Health (NIPC) published a key position paper on Advancing a Prevention Agenda for Cardiovascular Care in Ireland[2].  This paper, which was prepared in collaboration with Croí, colleagues in the Irish Heart Foundation, and leading healthcare professionals, with a strong patient input, is an excellent summary of the key issues, and sets out a broad range of policy recommendations, based on international best practice.  In addition, our colleagues in the Irish Heart Foundation recently launched an excellent document on primary prevention of CVD, which adds to the growing body of knowledge and best practice.

Early detection and risk-factor management have been key components of our work in Croí for many years, and it is clear that simple checks and diagnostics can be very effective preventive tools.  For example, taking Hypertension (High Blood Pressure) which is one of the most prevalent risk factors for heart disease and stroke and accounts for about half of all heart disease and stroke-related deaths worldwide.   Croí regularly works with partner organisations to deliver free blood pressure checks in the community.

Results from a recent campaign in County Mayo involving 1,200 people found that just under half of the people tested had high BP at the time of measurement.  About half (46%) of the people with high BP were already aware of their condition, suggesting that the other half were unaware.  That’s roughly 25% of the people tested who had high blood pressure readings and were completely unaware. 

Timely access to diagnostics is another key part of the solution.  In 2023, Croí published a National Survey on Echocardiography Services in Ireland. [3]  The results of this survey highlight significant inequities between public and private patients in terms of timely access to cardiac diagnostics. For those dependent on our public health service there are delays to appointments and diagnosis with obvious consequences for patients’ health.

In terms of Stroke, approximately 6,000 adults are admitted to hospital each year with a stroke, and research on the burden of Stroke in Ireland predicts a 59% increase in numbers.  The National Stroke Strategy 2022-2027 has set out a very clear roadmap over a five-year period with key objectives across four categories:

Stroke Prevention, Acute Care & Cure, Rehabilitation & Restoration to Living, and Education & Research.

At Croí, Stroke has been a major area of focus for our organisation for many years and it is in the post-hospital discharge phase of recovery that we see some of the most significant gaps in the current environment – when people have finished their immediate rehabilitation programme emerging from acute hospital care, they require an essential network of co-ordinated supports to continue their recovery at home, including ongoing physiotherapy, occupational therapy, exercise, speech and language therapy, and critically, ongoing psychological support. 

Stroke survivors and their families, already in a time of great trauma and emotional distress, have to self-navigate a landscape where there is a huge shortfall in essential supports and services.

This year, with the support of a very generous legacy donation, we have been able to invest significantly in our range of Stroke supports.  We have developed a Stroke Day Programme, acquired a Community minibus to meet the transport needs of those we serve, we will shortly begin construction on a new, dedicated stroke wing in at Croí in Galway which will be operational next year.  In 2024 we will also launch a new mobile health infrastructure to carry out preventive health checks, research as well as raising awareness and education throughout the country. 

This investment is very positive and represents a step-change in the level of services we can deliver, but in the national context, far more needs to be done in terms of resourcing and implementation across all four categories set out in the National Stroke Strategy, especially in the area of prevention.  We work closely with the acute hospital Stroke teams in our region, and we are deeply concerned at the impact that the moratorium on recruitment will have for a service area that in many respects was under-resourced to begin with, and would urge that this matter is reviewed.

In summary, we face significant challenges from the burden of Heart Disease and Stroke in the short to medium term.  We need to prioritise and expedite preparation of a new National Cardiovascular Health Strategy, and ensure that the National Stroke Strategy is fully and properly resourced.  Both strategies need clear implementation and delivery plans, with definitive metrics and timelines, underpinned by a proper resourcing and financial base, to address what are some of the most pressing public health challenges we face as a society.

Compared to the medium-term issues, given an ageing population, rising levels of obesity, sedentary lifestyles, and a raft of broader environmental factors, the longer-term challenges will be immense, but they are not insurmountable.  The solutions will require the political will to make brave decisions to drive major policy changes on a societal level, taking a much broader perspective and a population level approach to prevention, such as embedding clear health criteria and objectives into our spatial and land use planning framework at national, regional and local level, to give just one example.

Many of our existing approaches are not adequately addressing the current burden of cardiovascular disease – the same approaches certainly won’t be enough to meet increased needs in the future.  We know what’s coming down the track, we know the challenges will increase significantly, and we know we need to take radically different approaches to get ahead of the problem, and we need to start now.

[1] Economic burden of cardiovascular diseases in the European Union: a population-based cost study

[2] https://nipc.ie/wp-content/uploads/2023/02/National-Prevention-Council-Report.pdf

[3] https://croi.ie/wp-content/uploads/2022/12/Croi-Echo-Report_Final-ecopy.pdf