Heart Attack Care in Kilkenny?

JMT2016

Hey folks,

Just wondering with all the talk on the radio today about heart attack facilities in Waterford - what is the story with Heart Attack care here?

Here is the report that is being mentioned in the news:

health.gov.ie/wp-content/uploads/2016/09/Dr.-Herity-Clinical-Review.pdf

It seems to me that most of kilkenny is not being counted as part of the catchment area for 24/7 south east heart attack care because St. Lukes sends a lot of referrals to St. James Hospital in Dublin instead of Waterford.

There is a diagram on page 19 showing a big arrow from Kilkenny heading towards Dublin while the rest of the south east points towards waterford.

Then, on page 38 there is a picture showing that most of south kilkenny has no 24/7 cover within 1.5 hours?

Is this an issue here?

Cabaal

spotted this comment on the thejournal.ie which seems to offer some insight

http://www.thejournal.ie/halligan-government-impasse-2969838-Sep2016/

I think Minister Halligan needs to outline what services he doesn’t want provided to permit opening of an unused cathlab in Waterford. Patients from neighbouring hospitals e.g. Kilkenny or Clonmel are typically sent to Dublin or Cork for treatment. This is partially because those units do bigger volumes and have cardio thoracic surgery on site if the cath fails so they can proceed to bypass surgery. The biplane screening device necessary for a cath lab is €1.8 million on its own before building and appointing additional staff (if you can get them to a role where there would be very limited work). Remember there are theatres closed across Ireland because we can’t recruit specialist staff.

JMT2016

Cabaal wrote: »

spotted this comment on the thejournal.ie which seems to offer some insight

Thanks - yes an interesting comment - it's from someone who knows what they are talking about by the sounds of it!

Although the report contradicts it though because Clonmel mostly goes to Waterford:

"For most counties the admission profile at UHW is very similar to that of the total admission profile with the following notable differences: lower percentage admission rates for residents of Carlow and Kilkenny and higher percentage admission rates for residents of Wexford and Tipperary South
These patterns are readily explained by the professional linkages (and cath lab sessions) of the consultant cardiologists in the relevant local hospitals."

What are these "professional linkages"? Is the region as a whole losing out as a result?

road_high

Personally I'd prefer go to Dublin where the volume of specialists exist vs a half hour closer in a place I may not be as confident of. I assume in emergency cases they would have the ability to stabilise in St Luke's and transfer you to James's or wherever. I've not once heard this issue discussed locally so I don't think it's exercising people in the way it has in Waterford. I'm no expert anyhow and would be interested in everyone having access to the very best care regardless of where they live. If the appropriate Independent expert report has not recommended extension to Ardkeen well then I'm willing to listen to that. I appreciate not all specialist services can be in every city in the country- we are a very small country with limited resources.

road_high

JMT2016 wrote: »

What are these "professional linkages"? Is the region as a whole losing out as a result?

I'd say it's Doctors and Consultants in St. Lukes with links to Dublin Hospitals through training, inertia ("we always refer patients there") and just generally more professional contact.
Not sure if the SE as a whole is loosing out if more Carlow/Kilkenny patients are referred to Dublin- would that still create the critical mass required? - the cynic in me tells me it's probably convenient for the State to hive us off to Dublin, as they can then say there's not the critical mass there for the service at UH Waterford

road_high

Cabaal wrote: »

spotted this comment on the thejournal.ie which seems to offer some insight

http://www.thejournal.ie/halligan-government-impasse-2969838-Sep2016/

Waterford "General" Hospital?- I can hear the pitchforks sharpening as I type

JMT2016

road_high wrote: »

Personally I'd prefer go to Dublin where the volume of specialists exist vs a half hour closer in a place I may not be as confident of. I assume in emergency cases they would have the ability to stabilise in St Luke's and transfer you to James's or wherever. I've not once heard this issue discussed locally so I don't think it's exercising people in the way it has in Waterford.....

I appreciate not all specialist services can be in every city in the country- we are a very small country with limited resources.

Perhaps it's because kilkenny city is that little bit closer to Dublin - still almost 1.5 hours per google maps. I'm not aware of any reason to be less confident of cardiac specialists outside of Dublin?

I agree it doesn't seem to be exercising people - it's surprising given that much of kilkenny is outside that critical time boundary to access the healthcare.

Someone having a cardiac arrest at a match in Glenmore would have to get to St. Lukes to then be transferred to Dublin when a facility in Ardkeen would have had them saved in a fraction of the time that would involve.

We're not talking about "all specialist services" here - I just don't understand the general consensus to skimp on what is emergency life saving care in one of the few healthcare areas where every minute counts to save lives?

road_high wrote: »

I'd say it's Doctors and Consultants in St. Lukes with links to Dublin Hospitals through training, inertia ("we always refer patients there") and just generally more professional contact.
Not sure if the SE as a whole is loosing out if more Carlow/Kilkenny patients are referred to Dublin- would that still create the critical mass required? - the cynic in me tells me it's probably convenient for the State to hive us off to Dublin, as they can then say there's not the critical mass there for the service at UH Waterford

It could be read that way - use the current treatment patterns caused by underfunding to reduce the catchment area to justify more underfunding!

The cardiologists already based in waterford seem to think they had a lock-tight case based on catchment area - it's their reaction to the report saying that the catchment is roughly half what they say it is - is what I find most interesting!

road_high

JMT2016 wrote: »

Perhaps it's because kilkenny city is that little bit closer to Dublin - still almost 1.5 hours per google maps. I'm not aware of any reason to be less confident of cardiac specialists outside of Dublin?

I agree it doesn't seem to be exercising people - it's surprising given that much of kilkenny is outside that critical time boundary to access the healthcare.

Someone having a cardiac arrest at a match in Glenmore would have to get to St. Lukes to then be transferred to Dublin when a facility in Ardkeen would have had them saved in a fraction of the time that would involve.

We're not talking about "all specialist services" here - I just don't understand the general consensus to skimp on what is emergency life saving care in one of the few healthcare areas where every minute counts to save lives?



It could be read that way - use the current treatment patterns caused by underfunding to reduce the catchment area to justify more underfunding!

The cardiologists already based in waterford seem to think they had a lock-tight case based on catchment area - it's their reaction to the report saying that the catchment is roughly half what they say it is - is what I find most interesting!

As I say I'm no expert at all and will listen to all sides in this debate...reason I say less confident is partly the Primetime programme I saw last year with a lady on who's husband had sadly died as a result of not getting the care he needed on time in WRH- just me personally saying it that wouldn't fill me with confidence, Dublin would, as I know there's such a critical mass going through the system. I take the point of course that had the same level of funding been provided as Cork / Dublin to WRH then that wouldn't have been the case.
I think all International experts would say Large Centres of Excellence have the best outcomes.

As for the person in Glenmore or any where in South KK or South Wexford, I'd assume the ambulance would be bringing them to WRH anyhow and onto Cork not St. Lukes as that would be their immediate catchement.

JMT2016

road_high wrote: »

As for the person in Glenmore or any where in South KK or South Wexford, I'd assume the ambulance would be bringing them to WRH anyhow and onto Cork not St. Lukes as that would be their immediate catchement.

Genuine question - is that really the best we can do in this scenario?

It's not like the South East is as remote as the Skelligs here!

road_high

JMT2016 wrote: »

Genuine question - is that really the best we can do in this scenario?

It's not like the South East is as remote as the Skelligs here!

I can't answer that I'm afraid..but I do appreciate that we can't have every single service in each Region or city, we have good access to Dublin and Cork- they aren't that far away (as ya say we are not the Skelligs )
I trust what the medical experts will say, it's not their business to endanger lives or put them at risk I don't think and work within the funding constraints that the HSE live under.

Chiparus

road_high wrote: »

I can't answer that I'm afraid..but I do appreciate that we can't have every single service in each Region or city, we have good access to Dublin and Cork- they aren't that far away (as ya say we are not the Skelligs )
I trust what the medical experts will say, it's not their business to endanger lives or put them at risk I don't think and work within the funding constraints that the HSE live under.

The longer you wait for cardiac cauterization in a heart attack the worse the outcome.
Under the plan, kilkenny patients will get it the next day, Dublin patients will get it in an hour.
This is bad news for patients in the south east.

road_high

Chiparus wrote: »

The longer you wait for cardiac cauterization in a heart attack the worse the outcome.
Under the plan, kilkenny patients will get it the next day, Dublin patients will get it in an hour.
This is bad news for patients in the south east.

Are more patients in the SE dying or worse medical outcomes versus Dublin or Cork?

Chiparus

road_high wrote: »

Are more patients in the SE dying or worse medical outcomes versus Dublin or Cork?

Very difficult to say, but immediate cardiac catherisation within 90 minutes is the gold standard.
You have a 30% improvement in survival after a heart attack.

road_high

Do the regional hospitals in Galway and Limerick have similar levels of care to Dublin?
Also I do think the way the south east region is divided is too outdated...I consider most of Wicklow, south Kildare and south east Laois to be far more south east than most of Tipperary! Know for a fact a lot of the area use St Luke's in Kilkenny as its often nearer than Dublin. Yet the report doesn't mention these areas, it's assumed they're Dublin...
North Tipp is most definitely not the "south east" and in any case is beside Limerick.

JMT2016

Dr. Herity was interviewed this morning by Cathal MacCoille on Radio 1.

Was disappointed by it. Cathal was using the wrong figures in the report - he should have been using the table on page 20 and this wasted valuable time to discuss the key issues.

Cathal did mention the catchment area but didn't probe Dr. Herity's answer.

No mention of why 74% of the population of Kilkenny is left out of Dr. Herity's catchment area for example.

Also no questioning of the downgrade of the emergency care suggested by Dr. Herity - surely this controversial finding merited at least one question?

He did put it to Dr. Herity to explain how the people of South Wexford who would be well over 2 hours from the treatment would be treated? This was the only time Dr. Herity struggled throughout the interview and his answer was left wanting especially his need to point out that there were some other parts of the country in a similar situation.

Of course he didn't highlight that these areas were sparsely populated and not a regional hub of several hundred thousand people. (see the diagram for yourself on page 37 of the report)

The interview did get across that this is a regional issue which has been somewhat missed with several people and media outlets taking advantage of the opportunity to have potshots at John Halligan at the expense of the serious healthcare issues at play.

You can listen to a podcast of the interview here under the rather misleading headline "Substantial expansion of cardiac services was recommended - Herity" - funny how the reduction in emergency care never even made the interview - nevermind the headline!

http://www.rte.ie/radio1/morning-ireland/

JMT2016

There's an amazing article in the Irish Examiner today about Jennifer's story - I'm going to post it in full because everyone needs to read this

http://www.irishexaminer.com/ireland/id-be-less-a-child-if-she-had-cardiac-arrest-after-5pm-420317.html

Irish Examiner wrote:

‘I’d be less a child if she had cardiac arrest after 5pm’
If Willie Doyle’s daughter had been an hour later getting to Waterford hospital, he doubts if she would be alive today.

“My daughter [Jennifer Pheasey, 41] had a cardiac arrest at 4.30pm on a Friday. We were told that if it had happened an hour later she wouldn’t have survived. I’d be less a daughter, her children would be less a mother, and her husband would be less a wife,” he told the Irish Examiner.

“She had been moving things earlier in the day and thought it was just a muscle pain but she went to her GP. The GP sent her straight over to casualty in Waterford hospital.

“We got a call to say our daughter was dying and to come straight down. She was attended to straight away and had a stent fitted.”

This was two years ago now and, ever since, the family has campaigned as the ‘24/7 Cardiac Cover for the South East’ group.

At the moment, the cardiac unit of University Hospital Waterford (UHW) only operates on a 9am-5pm basis, Monday to Friday.

“If you have a cardiac arrest, it means the blood supply to your heart is interrupted. You need a stent fitted, and you have 90 minutes maximum in which to do that,” said Mr Doyle.

“So if you’re in Dublin, Cork, Galway, or Limerick and you have a cardiac arrest you can be treated 24/7, 365 days of the year.

“But if you’re in the south-east and UHW is your nearest hospital, you can only have a cardiac arrest Monday to Friday, 9am-5pm, that’s when the unit is open.

“When it comes to 5 o’clock, you’ve to go down to Cork. They say you can get down in an ambulance but, to get from the hospital out onto the dual carriageway, the ambulance has to negotiate 14 roundabouts.

“They also say you could go by helicopter but that means having a helicopter on standby from 5 o’clock. And furthermore, there isn’t a helipad in UHW or in Cork.”

Mr Doyle also explained the lack of services is not just an issue for the entire south-east region.

“If you look at the south-east — that’s Wexford, Waterford, city and county, Kilkenny, and south Tipperary; that’s a population of half a million for UHW to cater for. That’s the region,” he said.

“It’s about saving lives in the south-east and it doesn’t matter if you save one life or 10 lives — every life counts.”

Every life counts. Indeed.

road_high

Is the Air Ambulance service being used in the more remote parts of the s east at all that are above this time to get to Dublin or Cork?

JMT2016

road_high wrote: »

Is the Air Ambulance service being used in the more remote parts of the s east at all that are above this time to get to Dublin or Cork?

I don't know the answer to that one - but given that it says in the article above "there isn’t a helipad in UHW or in Cork.” I can't see how it can.

JMT2016

Lots of interesting coverage in the papers today about the South East Campaign for Emergency Healthcare.

Not least the headline in the Sunday Independent http://www.independent.ie/irish-news/politics/i-will-rain-hell-on-this-government-35039206.html

From what I have read in the coverage I am again disappointed that there seems to be the assumption that the report cannot be questioned.

One expert, who made the catchment area a matter of opinion rather than fact and who was told "the service would be a waste of very limited resources", made some real analytical howlers to justify the unacceptable status quo.

Now we must all bow in unquestioning reverence? It's so bad that Mr. Harris won't even meet the consultants in Waterford who clearly must know what is going on above everyone else.

Either way, it is now clear that this issue is not going away. It has gone nuclear and will now dominate the media for the next week, at least until John Halligan appears on the Late Late Show next Friday (according to the Sunday Independent).

Do people really think that Halligan got elected championing a total non-issue?

JMT2016

road_high wrote: »

Is the Air Ambulance service being used in the more remote parts of the s east at all that are above this time to get to Dublin or Cork?

I found this as well on the South East Cardiac Care Facebook page- any air travel seems to depend on the Coastguard service:

Why is it that once again the people of this region are brought to their knees and have to beg for a life saving service that the rest of the country has. Is it because some of the elected politicians in the SOUTH EAST are not vocal or strong enough to fight for this issue and deliver what we are entitled to. The Cardiac Unit at UHW is one of the 5 Centres Of Excellence in the country for cardiac intervention but only opens 9 to 5, Monday to Friday.

It is beyond comprehension for a report to suggest that critically ill cardiac patients should have to endure a road journey to Cork ( subject to ambulance availability ) or a helicoptor journey ( subject to availability as it is primarily for coastguard duties with no landing pad in either UHW or CUH) and all of this while your lifesaving minutes are ticking away.

road_high

JMT2016 wrote: »

I don't know the answer to that one - but given that it says in the article above "there isn’t a helipad in UHW or in Cork.” I can't see how it can.

Also go to Dublin. They possibly land at airport and onto the hospital

road_high

JMT2016 wrote: »

I don't know the answer to that one - but given that it says in the article above "there isn’t a helipad in UHW or in Cork.” I can't see how it can.

JMT2016 wrote: »

I found this as well on the South East Cardiac Care Facebook page- any air travel seems to depend on the Coastguard service:

Why is it that once again the people of this region are brought to their knees and have to beg for a life saving service that the rest of the country has. Is it because some of the elected politicians in the SOUTH EAST are not vocal or strong enough to fight for this issue and deliver what we are entitled to. The Cardiac Unit at UHW is one of the 5 Centres Of Excellence in the country for cardiac intervention but only opens 9 to 5, Monday to Friday.

It is beyond comprehension for a report to suggest that critically ill cardiac patients should have to endure a road journey to Cork ( subject to ambulance availability ) or a helicoptor journey ( subject to availability as it is primarily for coastguard duties with no landing pad in either UHW or CUH) and all of this while your lifesaving minutes are ticking away.

This is not exercising the rest of the SE in any great way though is it? Think
I'm the only poster to even comment here not from Waterford.

JMT2016

road_high wrote: »

This is not exercising the rest of the SE in any great way though is it? Think I'm the only poster to even comment here not from Waterford.

It's hard to know really - on boards I agree - but if you were listening to comments from radio programmes there were people from Wexford getting involved because of course it directly impacts us all in the South East.

I wouldn't read too much into it to be honest, I mean look at this wonderful announcement about Radiology services for Aut Even Hospital this week- this didn't get any mention here either or comments on the Kilkenny People website but yet I have no doubt there's plenty talk about it.

http://www.kilkennypeople.ie/news/home/215429/aut-even-hospital-kilkenny-announces-8-million-investment-plan-next-three-years.html

Kilkenny People wrote:

Aut Even Hospital, Kilkenny, has been given the go ahead for a major capital investment.

The €8 million - a major boost of confidence to the hospital - will include a state-of-the-art, purpose built, radiology suite.

The project will include upgrades within its six unique ultra-clean theatres.

The new diagnostics department will include the most technologically advanced diagnostic equipment available on the market.

The purpose built radiology suite will include a new MRI (Magnetic Resource Imaging), with Cardiac MR capability, CT (Computed Tomography), X-Ray and Ultrasound machines.

Patients will scanned using only state-of-the-art diagnostic equipment.

Diagnostic radiology is the field of medicine that uses imaging exams and procedures to diagnose a patient. In any form of medical care, diagnostic radiology plays an integral part in the diagnosis of disease or injury.

The hospital employs over 250 staff and is a major. With this announcement today, the hospital will create a further 20 positions, to include the building project along with administrative and allied health professional roles.

Speaking at the announcement Margaret Swords CEO, Aut Even Hospital said the hospital, which has been providing excellent clinical care for 100 years, is putting in place a foundation for another 100 years of excellence.

“Our patients and our clinical teams require the best of technology to provide all of our services and this investment will sustain and grow the suite of services we provide to the local and regional community.

“This investment speaks volumes in terms of our future as a private hospital and as a partner in support to St Luke’s hospital in providing medical care to the community of Kilkenny, Carlow, Tipperary and the wider geographical area on the south East and Midlands.”

“The construction work and the expansion of our Radiology Department will provide additional jobs for the local population and as with our recent refurbishment we will strive to use local suppliers and businesses in these developments,” she said.

The hospital has six ultra-clean laminar flow operating theatres, the upgrade will bring the already first-class facilities to the forefront of Irish Private Hospitals.

In 2015 Aut Even had over 14,000 admissions into its 100-bed hospital. Aut Even is a major player in the Private Hospital market in the South East and offers patients access to a broad range of surgical specialties. The tradition of care, upon which its foundations have been built, continues to be of paramount importance to the Hospital’s framework of quality and patient safety. Since 2008, Aut Even has been accredited by the US-based Joint Commission International (JCI) which represents the highest seal of approval for medical facilities that provide the safest and most effective quality care.

JMT2016

Eamon Dunphy was excellent on the Late Late Show this evening.

He highlighted that
1. Outside of business hours, the care being offered to heart attack patients is totally inadequate - helicopters to cork were mentioned!
2. This is a south-east regional issue not a waterford one
3. This affects hundreds of thousands of people
4. John Halligan is sincere in his efforts to highlight this disgrace

10 days on and this is still hitting the headlines.

Now that a public protest has been called for next Saturday 24th 2-4pm, The Glen, Waterford - it really shows that this issue is not going to go away.

https://www.facebook.com/events/1396305280398987/

South East Patients Advocacy Group appeal to the people of the South East to come out and voice your protest at the ongoing erosion of services including cardiology services at Waterford University Hosptial.

This protest is non political and there will be no political speeches - this is purely a protest by the people whose lives are being affected by the ongoing cuts to services available to them in University Hospital Waterford

The politicians had their say... the consultants had their say... now it's our turn... let's show them that we are not going to lie down and accept this despicable situation any longer

road_high

JMT2016 wrote: »

Eamon Dunphy was excellent on the Late Late Show this evening.

He highlighted that
1. Outside of business hours, the care being offered to heart attack patients is totally inadequate - helicopters to cork were mentioned!
2. This is a south-east regional issue not a waterford one
3. This affects hundreds of thousands of people
4. John Halligan is sincere in his efforts to highlight this disgrace

10 days on and this is still hitting the headlines.

Now that a public protest has been called for next Saturday 24th 2-4pm, The Glen, Waterford - it really shows that this issue is not going to go away.

https://www.facebook.com/events/1396305280398987/

Eamon Dunphy like Halligan is a freeloading anarchist, as I've said before this a non issue outside of Waterford. Your posts are not generating any interest here, I wonder why? I've no interest in his politics agenda (SF/AAA/anarchy), the independent report and the medical opinions of doctors on St Luke's do however. Let's have another march, sounds useful alright

Dunmoreroader

road_high wrote: »

Eamon Dunphy like Halligan is a freeloading anarchist, as I've said before this a non issue outside of Waterford. Your posts are not generating any interest here, I wonder why? I've no interest in his politics agenda (SF/AAA/anarchy), the independent report and the medical opinions of doctors on St Luke's do however. Let's have another march, sounds useful alright

Don't care about any of the party politics; this IS about loss of regional services which DOES affect Kilkenny as much as Waterford. I am, like you, interested in hearing the opinions of consultants in St. Lukes. If UHW had 24/7 cardiac services equal to the Mater or St. James, would you now refer your elective or emergency patients 30 minutes south or 90 minutes northeast?
Why wouldn't you throw your considerable clout behind securing equality for your region as consultants in Wexford and South Tipp have?

JMT2016

road_high wrote: »

Eamon Dunphy like Halligan is a freeloading anarchist, as I've said before this a non issue outside of Waterford. Your posts are not generating any interest here, I wonder why? I've no interest in his politics agenda (SF/AAA/anarchy), the independent report and the medical opinions of doctors on St Luke's do however. Let's have another march, sounds useful alright

I think we should be playing the ball here not the man.

I'm all for hearing the medical opinions of the consultants in St. Lukes.

For example, I'm sure the thoughts of St. Luke's consultant cardiologist Michael Conway (who wants Kilkenny to become 'little Oxford') would be very interesting. But then he wasn't asked unfortunately to contribute to the "independent report".

JMT2016

road_high wrote: »

as I've said before this a non issue outside of Waterford.

I can't see how you can back up the statement considering
1. the statistics in the report clearly show referral patterns from Wexford and Clonmel are to WUH -
2. the diagrams in the report show most of the southern half of kilkenny and wexford outside of the gold standard 1.5 hours from a 24/7 care centre
3. South East consultants (including from Tipperary and Wexford) appeared in a press conference together in Dublin this week which attracted considerable media attention - see here

Now why the kilkenny consultants never seem to have had any interest in WUH is a separate question, but certainly one that shouldn't keep the whole region to ransom over equal access to emergency healthcare - all centres of excellence nationally should be equal!

JMT2016

Oh look where the HSE is spending the South East Cardiac Care Money

The 1.8 MILLION Helipad mightn't be as priority if South East Cardiac Care patients didn't need to travel half away across the country to get basic healthcare outside of 9-5.

P.s. Can anyone send me on a link to the independent report justifying a 1.8 million conversion of car park spaces to a helipad?
Or are independent reports only needed if the South East needs basic emergency care?

http://www.eveningecho.ie/cork-news/helicopter-landing-site-cuh-needed/2533388/

Evening Echo wrote:

HELICOPTER LANDING SITE FOR CUH NEEDED

FRIDAY, SEPTEMBER 23, 2016
AN on-site helipad for Cork University Hospital is edging closer to reality, with confirmation that the HSE hopes to lodge a planning application shortly.

The issue of the ongoing wait for the helipad, which is projected to cost €1.8m, was raised at yesterday’s HSE Regional Health Forum South meeting in County Hall.

Cllr John Buttimer called on the health service to publish a full report on the development of a helicopter landing site at CUH, noting the timeliness of the motion given the airlifiting of three young children from West Cork to the hospital on Tuesday night after they sustained burn injuries in an explosion in their home.

The helicopter landed in Bishopstown, as is common procedure, where an ambulance was waiting to transfer the patients to hospital.

“Recent events in Cork this week and other separate incidents have highlighted the need for a helicopter landing pad at CUH. It is one of the largest university teaching hospitals and one of the largest trauma 1 centres in the country.”

Addressing Cllr Buttimer’s question, Gerry O’Dwyer, chief executive of the South/South Western Hospital Group, confirmed that the HSE is in advanced talks with the Irish Aviation Authority with a view to lodge planning permission shortly.

“The position at the moment is we’re in very delicate negotiations with the Aviation Authority because the type of helicopter that is required to land there is the coastguard helicopter which is based in either Shannon or Waterford along with the Air Corps helicopter which is based presently in Athlone.”

“The position is when we finish the final negotiations with the aviation authority, which are about to conclude shortly, we will then lodge planning permission.”

Mr O’Dwyer stated that the HSE’s priority is to ensure that patients can go straight to the hospital rather than have to go to any other location.

“We have a temporary location in Bishopstown at the moment and occasionally we use Cork Airport,” he added.

“We’re looking closely at the number of car parking spaces that we will have to remove and what locations we can put those in. Our priority is to get the helicopter landing pad in, even if necessary we have to lose spaces.”

road_high

JMT2016 wrote: »

Oh look where the HSE is spending the South East Cardiac Care Money

The 1.8 MILLION Helipad mightn't be as priority if South East Cardiac Care patients didn't need to travel half away across the country to get basic healthcare outside of 9-5.

P.s. Can anyone send me on a link to the independent report justifying a 1.8 million conversion of car park spaces to a helipad?
Or are independent reports only needed if the South East needs basic emergency care?

http://www.eveningecho.ie/cork-news/helicopter-landing-site-cuh-needed/2533388/

Just common sense. Waterford is right beside Cork, many places in west Waterford would be as near/nearer to a Cork city hospital than they would be WRH- illustrating how small we are as a state and can't afford to have duplicate specialist services adjacent to each other like this. I'm sure patients from Kerry and west Cork will avail of this helipad in emergencies, they are even further away. If it makes access to services easier for SE patients and elsewhere, then it's a warranted investment.

JMT2016

road_high wrote: »

Just common sense. ... If it makes access to services easier for SE patients and elsewhere, then it's a warranted investment.

Of course a helipad is "common sense" just like having emergency heart attack care within 1.5 hours for a region is "common sense".

That's not the point.

It's the incredibly expensive conversion of car park spaces to a helipad for the same amount of money as a "cath lab" without a murmur of contention or need for independent reports is what I am highlighting.

Helicopters currently land in Bishopstown with an awaiting ambulance which is only a short distance from the CUH, 10 minutes max per google maps. While not ideal, it is not completely unacceptable.

What is completely unacceptable is that heart attack patients, say from South Kilkenny or Wexford, have to get to Waterford to get to Cork to get the emergency life saving care they need - well outside of the 1.5 hours acceptable limit - and the amount of hostility this receives is remarkable in comparison.

I'm highlighting the utter double standard at play here.

road_high

JMT2016 wrote: »

Of course a helipad is "common sense" just like having emergency heart attack care within 1.5 hours for a region is "common sense".

That's not the point.

It's the incredibly expensive conversion of car park spaces to a helipad for the same amount of money as a "cath lab" without a murmur of contention or need for independent reports is what I am highlighting.

Helicopters currently land in Bishopstown with an awaiting ambulance which is only a short distance from the CUH, 10 minutes max per google maps. While not ideal, it is not completely unacceptable.

What is completely unacceptable is that heart attack patients, say from South Kilkenny or Wexford, have to get to Waterford to get to Cork to get the emergency life saving care they need - well outside of the 1.5 hours acceptable limit - and the amount of hostility this receives is remarkable in comparison.

I'm highlighting the utter double standard at play here.

Well clearly we do already, located in either Cork or Dublin either via ambulance or air ambulance for the more critical emergencies. We should be improving access to these major trauma centres that we already have, which is all that's going on here.
Plus a helipad is a one-off cost, running a duplicate cath lab would cost millions to set up and run once it's there. Therefore I fail to see the double standard.

Chiparus

road_high wrote: »

Well clearly we do already, located in either Cork or Dublin either via ambulance or air ambulance for the more critical emergencies. We should be improving access to these major trauma centres that we already have, which is all that's going on here.
Plus a helipad is a one-off cost, running a duplicate cath lab would cost millions to set up and run once it's there. Therefore I fail to see the double standard.

Even with a helipad , you will need one in Cork and Waterford and Kilkenny to be built, you probably won't get the patient transferred any quicker. There is also the issue of night flying where most helicopters are not allowed to fly at night in built up areas.

JMT2016

The Waterford News and Star this week had the reaction of regional TDs to the campaign for healthcare equality

Here are some quotes

John Paul Phelan FG (Carlow-Kilkenny) "I believe that 24/7 care for cardiac patients in the south east is essential and it should be fought for tooth and nail".

Bobby Alyward FF (Carlow-Kilkenny) "I'm not happy with the Herity Report... I hear a lot about how important this issue is from constituents, particularly in South Kilkenny"

John McGuinness FF (Carlow-Kilkenny) "Simon Harris needs to ask those who know best i.e. the consultants on the ground/at the coal face"

James Browne FF (Wexford) "At the end of the day we want as many lives to be saved as possible"

Paul Kehoe FG (Wexford) "I would like to the see productivity at the existing hospital maximised and upped and then we could review that in a year and then, prehaps, question the findings of the report."

Brendan Howlin Lab (Wexford) "I favour the best possible cardiac services in the South-East and this must include 24-hour cardiac diagnostic and surgical capabity in UHW. I believe that will require a second cath lab to be provided and that the Minister for Health, Simon Harris should act accordingly".

The call for equal access to emergency healthcare isn't going away - the next protest is already being planned at the South East Patient Advocacy Group (SEPAG) Facebook page
https://www.facebook.com/groups/609909642491552/?fref=ts

Schindlers Pissed

Just seeing this thread now so I'll stick in my tuppence worth.....the point on page 1 about a cardiac arrest in Glenmore being brought to St. Lukes is totally false. A cardiac arrest is completely different and if the person is lucky enough to regain a pulse you will be going to the nearest hospital, i.e. UHW.

The one about the Coast Guard being the only or most relevant air ambulance.....not entirely true. The Ambulance Service and Air Corp now have a resource during daylight hours called Air Corp 112 (checkout their Facebook page), this is crewed by an Advanced Paramedic unlike the Coast Guard helis who are crewed to Paramedic level. The Coast Guard obviously have night time capability and are cleared to fly over congested areas.

Helipads...as a previous poster said the Coast Guard and Air Corp land in Bishopstown for ambulance transfer to CUH.
In Kilkenny they land in James' Park for a 2 minute ambulance transfer.
In Waterford the Coast Guard heli fly into Waterpark for a 2 minute transfer. 112 can use the helipad at the hospital (smaller aircraft).

The 90 minute target is from "ECG to PCI" (the Cath Lab).....you get a chest pain, you ring 999, Paramedics (or Advanced Paramedics) are called and they do a 12 Lead ECG in your home. They diagnose that you are having a heart attack, or STEMI (ST Elevated Myocardial Infarction). They give you pain meds and meds to try stop the clot, they ring a STEMI hotline and speak to a Cardiologist, they then electronically send your ECG to the Cardiologist for a referral and a decision is made on which PCI you go to. The Paramedics make that decision, because they are in control of the heart attack victims care.

Kilkenny to St. James' is a little over an hour away under lights and sirens, UHW is about 35-40 minutes. I'm not sure of times from UHW to Cork. The PCI in Waterford is only open office hours Monday-Friday which isn't acceptable but in my humble opinion I think that before huge money is invested in it maybe they could try an experimental go at putting the existing lab on 24/7 as a trial to see if the region has the call volume to get the second lab built.....?

I think you can see I know the system pretty well but we are lucky that we aren't really THAT remote.....the west of Ireland has a helicopter flying into Galway at least every day with STEMI victims. I think a trial period might be the way forward and give all the nay sayers some peace of mind. Not sure if that's even an option but that's what I would suggest.

Chiparus

Schindlers Pissed wrote: »

Just seeing this thread now so I'll stick in my tuppence worth.....the point on page 1 about a cardiac arrest in Glenmore being brought to St. Lukes is totally false. A cardiac arrest is completely different and if the person is lucky enough to regain a pulse you will be going to the nearest hospital, i.e. UHW.

The one about the Coast Guard being the only or most relevant air ambulance.....not entirely true. The Ambulance Service and Air Corp now have a resource during daylight hours called Air Corp 112 (checkout their Facebook page), this is crewed by an Advanced Paramedic unlike the Coast Guard helis who are crewed to Paramedic level. The Coast Guard obviously have night time capability and are cleared to fly over congested areas.

Helipads...as a previous poster said the Coast Guard and Air Corp land in Bishopstown for ambulance transfer to CUH.
In Kilkenny they land in James' Park for a 2 minute ambulance transfer.
In Waterford the Coast Guard heli fly into Waterpark for a 2 minute transfer. 112 can use the helipad at the hospital (smaller aircraft).

The 90 minute target is from "ECG to PCI" (the Cath Lab).....you get a chest pain, you ring 999, Paramedics (or Advanced Paramedics) are called and they do a 12 Lead ECG in your home. They diagnose that you are having a heart attack, or STEMI (ST Elevated Myocardial Infarction). They give you pain meds and meds to try stop the clot, they ring a STEMI hotline and speak to a Cardiologist, they then electronically send your ECG to the Cardiologist for a referral and a decision is made on which PCI you go to. The Paramedics make that decision, because they are in control of the heart attack victims care.

Kilkenny to St. James' is a little over an hour away under lights and sirens, UHW is about 35-40 minutes. I'm not sure of times from UHW to Cork. The PCI in Waterford is only open office hours Monday-Friday which isn't acceptable but in my humble opinion I think that before huge money is invested in it maybe they could try an experimental go at putting the existing lab on 24/7 as a trial to see if the region has the call volume to get the second lab built.....?

I think you can see I know the system pretty well but we are lucky that we aren't really THAT remote.....the west of Ireland has a helicopter flying into Galway at least every day with STEMI victims. I think a trial period might be the way forward and give all the nay sayers some peace of mind. Not sure if that's even an option but that's what I would suggest.

The Herity report recommended that all primary PCI should stop in UHW - given that no one who presents to a southeast hospital will get primary PCI in 90 mins if that happens makes no sense.
The increased mortality that results may be used as a stick to close some of the A&Es in the region.

JMT2016

The south east cardiac care campaign featured again in Dr Gueret's Sunday Independent column:

An entertaining and controversial piece - but does it get to the crux of the matter?

"I am in trouble on my next trip to Waterford for daring to suggest that its politicians are not up to the mark, and that the county needs improved fertility services to rise its population. My flippant remarks followed the recent Herity report that advised against a second heart laboratory to keep local arteries open through the night. My letters tray brims with indignation. One city dweller wrote to tell me that I was being unduly harsh. "Mossy boy," he wrote, "were we to go chasing fertility services, as you helpfully suggest, we would, in all likelihood, be told to go **** ourselves."

There is a palpable sense of local injustice since the Independent Alliance were led up the garden path. The real story here lies deep in rivalry between Waterford University Hospital and neighbouring St Luke's Hospital in Kilkenny. Kilkenny sends many heart patients to St. James's in Dublin rather than Waterford, and this lies at the crux of the issue about whether Waterford rightfully has a regional population of half a million people, or a lot less.

Kilkenny is only a county hospital. Waterford is supposed to be the regional one, but local Fine Gael politics mitigates against it. Within days of the decision against them, Health Minister Simon Harris was down in neighbouring Kilkenny singing the praises of its local hospital. He was in the company of the party's TD for Carlow/Kilkenny, a man born and educated in Waterford.

This row has the potential to be a heartbreaker, and will run and run. Until it's decided how safe it is to keep critically ill patients waiting until morning, or rushing around backroads in the back of ambulances."

road_high

St Luke's hospital has a right to do whatever it pleases both in terms of building alliances with Dublin hospitals and what it says best care for its patients...it doesn't exist as some convenient satellite for WUH to use to bunk up its services to levels that population and Independent reports say don't justify. Attacking St Luke's will do nothing for the Waterford cause at all, just push KK further towards Dublin really. It's has huge support in Carlow Kilkenny community any attempt to belittle or talk it down or diminish it (as per that article) won't go down well.

JMT2016

road_high wrote: »

St Luke's hospital has a right to do whatever it pleases both in terms of building alliances with Dublin hospitals and what it says best care for its patients...it doesn't exist as some convenient satellite for WUH to use to bunk up its services to levels that population and Independent reports say don't justify. Attacking St Luke's will do nothing for the Waterford cause at all, just push KK further towards Dublin really. It's has huge support in Carlow Kilkenny community any attempt to belittle or talk it down or diminish it (as per that article) won't go down well.

Yes, as I said it was a controversial article! Though I didn't read that he was belittling St. Lukes hospital, more that it was involved in a political turf-war of some sort?

I don't know how hospital consultants build alliances but relying on alliances outside the region appears to be a particular issue for cardiology- I'd love to know why since a lot seems to turn on this. I don't think this is an issue for oncology for example.

I'd imagine it makes sense for regions to pull together in general for the good of all patients though. What good is a link with Dublin in an emergency if the distance to get to that expertise/equipment is prohibitively far or so far that is reduces the chance of positive outcomes?

For example, there is going to be a new A&E in UH Limerick next year, 3 times the size of the current one, to cater for Ennis and North Tipp as well as Limerick. If Ennis was referring all their A&E patients to Galway instead of Limerick for some reason, surely that would have had an impact on the A&E investment potentially to the disadvantage of everyone in that region?

At the end of the day, I hope that the best interest of patients is coming first and the turf wars second - it's because the article suggests the opposite is happening is what makes it so controversial!

gobo99

Hospital consultant s should do what's best for the patient in front of them. Be that refering them to Dublin, Ardkeen or anywhere else for that matter.
Doing what's best for "the regional hospital" should not be the first consideration.

Dunmoreroader

I think it's called 'cutting off your nose to spite your face'. Yes they should be doing whats best for their patients and advocating for 24/7 cardiology services on their doorstep (Arkeen as you call it!) falls into that category. So who's really putting the hospital before the patient?
Doing what's best for "the regional local hospital" should not be the first consideration.

road_high

Dunmoreroader wrote: »

I think it's called 'cutting off your nose to spite your face'. Yes they should be doing whats best for their patients and advocating for 24/7 cardiology services on their doorstep (Arkeen as you call it!) falls into that category. So who's really putting the hospital before the patient?
Doing what's best for "the regional local hospital" should not be the first consideration.

Are you a consultant in St. Lukes? How is it if they judge the care and relationship to be superior? I'd doubt the Consultants in St. Lukes are even from Carlow/Kilkenny- their over riding concern is patient safety and care as that's what doctors do. Just because something is on "your doorstep" it doesn't make it better. I'm not aware of any patients dying on the way to St. James or anything of the like because it happens to be further away- if it were an issue don't you think they'd see merit in WRH?

gobo99

Does anyone know the reasons some are referred to Ardkeen and others to St James?
This attitude that everyones out to get Waterford is getting tiresome and is doing nothing for the cause.

blue note

gobo99 wrote: »

Does anyone know the reasons some are referred to Ardkeen and others to St James?
This attitude that everyones out to get Waterford is getting tiresome and is doing nothing for the cause.

That's the most obvious question and one that I haven't seen an answer to. Whether or not UHW should have an extra cath lab and 24hr care seems to hinge on the catchment area. The report seems to most people downright dodgy in respect of the catchment area assigned to UHW. If we heard why 75% or so of patients from lukes are sent to Dublin the report might be more credible. But I haven't heard any attempt to answer that. I suspect you're using Dublin ahead of waterford because of waiting lists in waterford. I'd travel to Dublin from waterford if I'd get seen sooner. But the solution to that is to give UHW more resources based on how many people so people could be sent to their nearer hospital, not to assume people want a further travel time.

But this is a question that the government or the lukes consultants could answer very easily if they wanted to. But they don't seem to want to.

road_high

gobo99 wrote: »

Does anyone know the reasons some are referred to Ardkeen and others to St James?
This attitude that everyones out to get Waterford is getting tiresome and is doing nothing for the cause.

...likely because they believe it to be in the best interests of their patients and there's linkages between St. James and St. Luke's.

blue note

road_high wrote: »

...likely because they believe it to be in the best interests of their patients and there's linkages between St. James and St. Luke's.

Ah come on, because we think it's best is clearly not an answer to the question. Is it because of other services that the Dublin hospital has that may be needed? it's it because patients are requesting it? Is it a hospital policy that they just have to go along with? Is it to do with waiting times? Is it a better service in Dublin? Is it because the waterford one isn't open when they're sending people there?

It's a hugely important question for the people affected (including Kilkenny people) and people deserve an answer. And that catchment area figure deserves scrutiny, but the minister is refusing to defend it, he's just dismissing the criticism.

I don't really understand why the southeast other than waterford doesn't care about this issue because the whole region is affected. But it's one massive victory for the government that they've managed to pass this off as parish pump politics, to the point that even the majority of people affected think it's just an independent trying to get services for his locality. But the sad truth is about 400k people will have to travel further for emergency healthcare where time is apparently a crucial factor.

road_high

blue note wrote: »

Ah come on, because we think it's best is clearly not an answer to the question. Is it because of other services that the Dublin hospital has that may be needed? it's it because patients are requesting it? Is it a hospital policy that they just have to go along with? Is it to do with waiting times? Is it a better service in Dublin? Is it because the waterford one isn't open when they're sending people there?

It's a hugely important question for the people affected (including Kilkenny people) and people deserve an answer. And that catchment area figure deserves scrutiny, but the minister is refusing to defend it, he's just dismissing the criticism.

I don't really understand why the southeast other than waterford doesn't care about this issue because the whole region is affected. But it's one massive victory for the government that they've managed to pass this off as parish pump politics, to the point that even the majority of people affected think it's just an independent trying to get services for his locality. But the sad truth is about 400k people will have to travel further for emergency healthcare where is apparently a crucial factor.

LOL...So the Consultants should send them to Waterford against their best instincts and medical opinion just to satisfy another hospital.. I don't think so.... The reality here is Kilkenny to St. James' hospital is only an hour via ambulance(Carlow less which is served by St. Lukes)- it's a world class hospital vs a 40 min or so journey to a hospital not of the same facilities...of course they are going to send to St. James, you're speaking as if St. Luke's owes WUH something. As St. Lukes is part of the Dublin hospital grouping, of course they're going to foster this relationship and this will continue.
As a taxpayer I have to say we just can't afford these kind of facilities everywhere. I abhor the useless protest politics likes of Mr. Halligan and Cullenane which you elect- all they do is a feed of mentality of victimhood and chip on shoulder-ness!
And not sure where the 400k is coming from because practically all of Tipp is nearer to either Limerick or Cork, North Wexford and Carlow nearer to Dublin. Seems perfectly logical to anyone outside of Waterford that you'd exclude this population to avoid duplicating very expensive services.
And hence why it's really only an issue in Waterford and adjacent parts of S Wex/south Kilkenny.

JMT2016

Good to see even more coverage of the South East cardiac care campaign, this time in the Waterford News & Star.

First time I have seen comments from Dr. Michael Conway, consultant cardiologist at St. Luke's Kilkenny and this week there is an interview with him. If only he and consultants from Clonmel and Wexford had been asked for their input into the Herity report. It mightn't have resulted in 74% of Kilkenny and 94% of Carlow being omitted from the population of the South East!

Anyway the article says

"Dr. Conway said that he was personally "very keen" to support UHW but that "unfortunately things have arisen and Kilkenny and Waterford are not more in tow as a result of the Higgins Report".

"Overall, the design of the Higgins Report makes things impractical between St. Luke's and UHW. We would love to have more services available locally but it's quite complex. As as result of the hospital groupings, Cork are in the picture with Waterford and we don't have anything to do with Cork. I personally cannot do much. The interaction should be better and I'm sure it will be better in time. I would be able to work in terms of Kilkenny sending patients to Waterford but it's not for me to judge. The answers are not easy."

Every Wednesday University Hospital Waterford's Cath Lab is set aside for referrals from St. Luke's. However, instead of travelling to Waterford to carry out procedures like angiograms and putting in stents, Dr. Conway travels to St. James's, a referral practice that pre-dates UHW's Cath Lab. Consultants cardiologists in Wexford and South Tipperary both take up their weekly option in University Hospital Waterford.

Dr Conway reiterated that he would be interested in keeping services more local and aid he will discuss the possibility of doing more screening in Waterford and using UHW's services to start to do angiograms in the Cath Lab.

It is great to hear from the people actually involved "on the ground" - I think it goes a long way to explaining what is happening and how outcomes for south east heart attack patients can be improved.

Chiparus

road_high wrote: »

LOL...So the Consultants should send them to Waterford against their best instincts and medical opinion just to satisfy another hospital.. I don't think so.... The reality here is Kilkenny to St. James' hospital is only an hour via ambulance(Carlow less which is served by St. Lukes)- it's a world class hospital vs a 40 min or so journey to a hospital not of the same facilities...of course they are going to send to St. James, you're speaking as if St. Luke's owes WUH something. As St. Lukes is part of the Dublin hospital grouping, of course they're going to foster this relationship and this will continue.
As a taxpayer I have to say we just can't afford these kind of facilities everywhere. I abhor the useless protest politics likes of Mr. Halligan and Cullenane which you elect- all they do is a feed of mentality of victimhood and chip on shoulder-ness!
And not sure where the 400k is coming from because practically all of Tipp is nearer to either Limerick or Cork, North Wexford and Carlow nearer to Dublin. Seems perfectly logical to anyone outside of Waterford that you'd exclude this population to avoid duplicating very expensive services.
And hence why it's really only an issue in Waterford and adjacent parts of S Wex/south Kilkenny.

you will not get a patient to ST James within an hour of making the decision to transfer. The distance is 55km to Waterford regional and 123km to ST James's hospital. If you are going to bypass Kilkenny as you suggest with the Carlow patients this should apply to all patients in Kilkennys Catchment area who present with symptoms of chest pain.

In reality all patients who arrive with heart attacks into st Lukes will be treated with thrombolysis and transferred the next day, the mortality is 30% greater.

road_high

JMT2016 wrote: »

Good to see even more coverage of the South East cardiac care campaign, this time in the Waterford News & Star.

First time I have seen comments from Dr. Michael Conway, consultant cardiologist at St. Luke's Kilkenny and this week there is an interview with him. If only he and consultants from Clonmel and Wexford had been asked for their input into the Herity report. It mightn't have resulted in 74% of Kilkenny and 94% of Carlow being omitted from the population of the South East!

Anyway the article says



It is great to hear from the people actually involved "on the ground" - I think it goes a long way to explaining what is happening and how outcomes for south east heart attack patients can be improved.

That read like "it would be a nice idea to send patients to WRH but I won't be doing it any time soon." He was speaking to a Waterford paper so it looks like paying them a bit of lip service to get them off his back.
"I'm very keen to support WRH...but won't be..."

blue note

road_high wrote: »

LOL...So the Consultants should send them to Waterford against their best instincts and medical opinion just to satisfy another hospital.. I don't think so.... The reality here is Kilkenny to St. James' hospital is only an hour via ambulance(Carlow less which is served by St. Lukes)- it's a world class hospital vs a 40 min or so journey to a hospital not of the same facilities...of course they are going to send to St. James, you're speaking as if St. Luke's owes WUH something. As St. Lukes is part of the Dublin hospital grouping, of course they're going to foster this relationship and this will continue.
As a taxpayer I have to say we just can't afford these kind of facilities everywhere. I abhor the useless protest politics likes of Mr. Halligan and Cullenane which you elect- all they do is a feed of mentality of victimhood and chip on shoulder-ness!
And not sure where the 400k is coming from because practically all of Tipp is nearer to either Limerick or Cork, North Wexford and Carlow nearer to Dublin. Seems perfectly logical to anyone outside of Waterford that you'd exclude this population to avoid duplicating very expensive services.
And hence why it's really only an issue in Waterford and adjacent parts of S Wex/south Kilkenny.

The point I was making is that the Lukes didn't explain what was better about James that makes the added journey worthwhile. The post below yours is the first thing I've seen from them that says anything about it. And it's not too clear to be honest - they'd love the services to be more local but it's more complicated than that? What have Cork got to do with it - are they worried that they'll refer people to Waterford and they'll be in turn referred down to Cork due to capacity issues. This sounds to me like it might be his concern.

Both Waterford and Dublin are supposed to be Centres of excellence for this type of care. If that's not the case then he should say it. God knows that's relevant.

And the 400k figure? It's a bit of a guess really based on where the populations are closest to. The vast majority of Waterford and Wexford are would be closer to UHW than Cork or Dublin. The very west of Waterford would be better served by Cork, but there's only a few thousand there. And North Wexford would be closer to Dublin - maybe 20k people? So not far off a quarter of a million would be closer to UHW from those counties. Then I think all of Kilkenny would be closer to Waterford and the majority of Carlow? Out of that 155k probably about 130k closer to Waterford? Then a lot of the bigger towns in Tipp are closer to Waterford than Limerick - Clonmel and Carrick on Suir. You get up to the 400k figure very easily. Don't forget the HSE quote a figure of 506k for UHW in relation to cancer treatment. That figure sounds like an exaggeration to me. But the 280k figure sounds like a political one. I suspect just looking at a map and the populations that somewhere over 400k is a more accurate one.

An honest conversation about this is needed. But I don't think for a second we're going to get one. As I say, they've even convinced the majority of people affected by this that it doesn't concern them.

Another thing I'd love to see is how well the other centres meet the criteria set out to merit these services and how they compare to Waterford. That info has also not been shared.