Joint Committee on Health and Children
Meeting 4th December
Opening Statement
by
Dr Tony O’Connell
National Director
Acute Hospitals Division
Deep Brain Stimulation Services and the Treatment Abroad Scheme
Joint Committee on Health and Children – 4h December 2014
Chairman and members I would like to thank the Committee for the
invitation to speak to about current arrangements in relation to provision
of Deep Brain Stimulation treatment under the Treatment Abroad
Scheme.
I would like to introduce my colleague Ms Angela Fitzgerald, Deputy
National Director, Acute Hospitals Division who will be joining me for
the session.
In this opening statement I want to provide you with what I hope will be
helpful background information on the current arrangements for treating
patients with Deep Brain Stimulation and the key considerations in terms
of shaping future provision
What is Deep Brain Stimulation and how is the treatment currently
provided?
Deep Brain Stimulation (DBS) is a neurosurgical intervention for the
management of movement disorders such as Parkinsons disease, dystonia
and essential tremor.
DBS is an established technology that uses a surgically implanted pulse
generator device called a neurostimulator, similar to a cardiac pacemaker,
to deliver controlled electrical stimulation to precisely targeted areas in
the brain. Stimulation aims to interrupt faulty communication between the
brain and the muscles that result in involuntary muscle movements. DBS
is targeted at those patients with movement disorders whose conditions
are no longer adequately controlled by drug therapy. Currently DBS
treatment is not available in Ireland and patients requiring treatment are
referred overseas under the Treatment Abroad Scheme.
The Treatment Abroad Scheme (TAS) is operated by the HSE and allows
patients access to proven treatments not available in Ireland, in another
EU/EEA country or Switzerland. The funding for the treatment is
approved under the TAS in accordance with the provisions of the relevant
EU Regulation (883/2004)
Under the terms of the Scheme, a hospital consultant must provide
medical evidence of the details of the patient’ condition and must certify
that:

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
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the treatment concerned is not available in this country
there is urgent medical necessity for the treatment
there is a reasonable medical prognosis
the treatment is regarded as a proven form of medical treatment
and
the treatment abroad is in a recognised hospital or other institution
and is under the control of a registered medical practitioner.
DBS treatment satisfies the Treatment Abroad Scheme criteria in terms of
the treatment not being available in this jurisdiction and the efficacy of
the treatment. However, there is still a requirement for patients to be
assessed on an individual patient basis to ensure that the other criteria are
satisfied consistently and there is equity in the application of TAS across
all patient cohorts.
In the absence of a DBS service in Ireland, patients are currently referred
to DBS centres abroad for assessment, surgery and follow-up care. At
present DBS patients are referred to two centres in UK – Oxford and
Newcastle.
The HSE has agreed costs with Oxford and more recently Belfast but
such arrangements do not preclude a doctor in Ireland referring a patient
to any other centre in the EU/EEA under EU Directive 883/2004.
Activity Levels and Associated Costs
Total Number of Patients
Total Number of
Applications
Total Number of Patients
with Private HI
Cost
2012
40
50
2013
71
102
2014
113
170
4
17
36
€379,227.53
€631,347.58
€1,550,177
Over the period 2012-2014, the total number of patients seeking to
access DBS abroad increased by 182% with a corresponding increase in
the cost of the order of €1,117,950. Over the same period, the number of
new patients remained relatively static with an average of 25 new patients
per annum.
The total cost of the Treatment Abroad Scheme in the current year for all
treatments is estimated at circa €9m.
HIQA Health Technology Assessment – Key Findings
In October 2012, HIQA published a Health Technology Assessment
(HTA) into the provision of DBS services via the TAS versus the
feasibility of providing the service here in Ireland. The HTA conclusions
are important in terms of informing future decisions about the
organisation and delivery of the TBS service going forward.
 Results of an economic analysis comparing the current TAS
service delivery to a prospective national DBS service show that
the current median cost per patient for the existing TAS-funded
service is €44,700 over 10 years; providing DBS services in Ireland
would cost the HSE an additional €20,900 per patient over 10
years. Over five years, the incremental budget impact of a national
DBS service is €1.84 million more than the estimated €4.29 million
to treat the same number of patients through the TAS over the
same period
 It also highlighted the importance of ensuring that there is adequate
planning for the establishment of a DBS service in Ireland
including the development of appropriate and consistent theatre
access and additional neurosurgical services.
 The Report acknowledged that while a national DBS service may
address the existing equity issues that exist in relation to those
patients that are unable to travel for DBS care, it may give rise to
new ethical issues due to the diversion of resources from other
effective treatments or from the overall healthcare fund.
The TAS continues to offer timely access DBS as evidenced by the
increase in referrals of 182% over the period 2012-2014, in the past
twelve months alone, the numbers have increased by 60%. Furthermore,
in order to improve timeliness of access, TAS has implemented initiatives
to streamline the application process.
Access to in Northern Ireland
The HSE appreciates that there are challenges for movement disorder
patients in terms of accessing this service abroad and therefore the recent
option whereby patients can avail of the service in the North of Ireland is
very welcome.
The referral of patients to Queens University Hospital, Belfast and The
Belfast Trust means that effective immediately DBS surgery will now be
available to movement disorder patients without the requirement for
overseas travel.
This will ameliorate some of the financial and logistical burden on the
patient and should also enable improved access for those patients who
were precluded from availing of the service under TAS. . For 2014, it is
expected that 10 patients will be treated in Belfast.
It is acknowledged that proximity to the service will also potentially
increase the demand, it is expected that the additional costs will be
partially offset by the reduction in the cost per case from availing of the
service in Belfast. The indicative savings are of the order of €7.200 per
case with further savings envisaged over time particularly with the
potential development of outpatient follow up in the Irish system. It is
expected there will be further savings in relation to the reduction in
pharmaceutical cost associated with DBS as a result of the patients
availing of DBS.
It is also anticipated that in time this service will be developed further
with the possibility that the out-patient follow up clinics could be
conducted in the South providing further convenience for the patients.
Future Development of the DBS Service
The option of developing a DBS service in the Irish health System will be
kept under continuous review within the context of the overall Estimates
process and other competing priorities. It is not possible in 2015 to
consider this service as the funding is already fully committed in meeting
existing service priorities. It is important to state that the TAS is a
demand led scheme and as such the funding arrangements do not enable a
transfer of funding to support the development of the service on a
continuous basis. We are confident that in the short term the combined
access to the UK and Northern Ireland will allow patients timely access to
the service.
This concludes my statement and together with my colleague Ms.
Fitzgerald we will be happy to take any questions.
Thank you