Professor Tom Keane:

Maybe I will deal with the issue of the forum, as it has arisen a couple of times. I cannot be sure about when the forum published its document, but I believe that it was April or May of 2006. The forum had been in session for a year and a half to two years prior to then. It was a group of 20 or so people representing a broad cross-section of the oncology community with some representation from the Department. I never heard people criticising the forum as being unrepresentative. Generally, people accepted that it was a legitimately constituted group. Its report is still available through the Government Publications Office.

The forum's members approached its work entirely on the basis of evidence. They examined best practice. Indeed, many of them had first-hand knowledge of what best practice looked like in other jurisdictions.

It did not have any ideological viewpoint and it did not essentially tread on the public-private issue. I will come back to that later. Essentially, the strategy document was endorsed by Government as the way forward. However, there was a level of detail missing from the strategy document in terms of implementation. It was not an implementation strategy. In that regard, the then Minister and the senior officials in the Department visited a considerable number of jurisdictions, including Germany, the UK, the United States, Toronto and Vancouver, where I was, where they engaged with successful transfer programme operators on what they were doing and achieving. This informed the Minister and the Department, in addition to the strategy, as to where they needed to go. In essence, they decided to model the implementation and many of the features of the cancer programme in British Columbia, BC, which has a similar population in size to Ireland. They saw that much of the BC programme was implementable in the Irish setting, which is what led to me being seconded from the University of British Columbia to Ireland. For me, it was incredibly important to have a strategy document which the cancer agency in British Columbia had already reviewed and found to be excellent. I had confidence that the strategy was good and did not require any further discussion. When people would say we needed to re-open the strategy I would quote General George Patton, "A good plan violently executed now is better than a perfect plan executed next week", because I knew once the strategy was reopened all hell would break loose.

In terms of the timelines, the strategy was published in 2006. Some time later in that year a commitment was given by Government to move ahead. There was a national radiotherapy plan as part of that, that was the so-called Hollywood report, which was separate but part of the same broad initiative. I was seconded briefly in late 2006 to assist in the drafting of the national radiotherapy plan. However, an election intervened in 2007, the date of which I am sure members of the committee will recall. Implementation by the HSE was very slow. When the then Minister, former Deputy Harney, was returned to Government, she decided to retain the health portfolio and I then noticed a dramatic shift in the level of urgency from the Minister and the Department around implementation. There was a period of delay between the publication of the strategy and the decision to have a more rapid implementation plan of two years, which I essentially drafted for the Minister and the HSE in August 2007.

We were not separate from the HSE. At the time, I reported to Mr. Brendan Drumm and I did sit on the HSE executive but my focus was not around being a full and active member of the HSE executive. I was situated in the BreastCheck office complex in Parnell Street and I had significant support from within the HSE in terms of HR and some other functions, which were very helpful. I truly did have autonomy. The Minister had told me I would have autonomy and that she would trust my decision-making but that she and Government needed to be kept in the loop. To that extent I met with the assistant secretary, Fergal Lynch, every month and I gave him a heads up in terms of what was coming. Basically, that interaction was all around communications. At no point did the Minister or the Department ever push me in any particular direction. If anything, they always reassured me to stay the course and to keep going. The committee will recall that there were two Deputies from a constituency in the north west who pressurised the then Taoiseach, Mr. Ahern, and subsequent Taoiseach, Mr. Cowen, to yield on this issue. I received phone calls from both of those individuals telling me to go ahead and that they would deal with the political issues. That political support was incredibly important. I did have autonomy. Obviously, autonomy sounds like one-man rule but we still have a very good process within the programme for prioritising decision-making and for making decisions based on evidence.

On the question regarding public versus private and whether I looked at the private system, the committee will recall that the Health Information Quality Authority, HIQA, was very active at the time I was here. We laid out standards for the performance of breast cancer surgery, multi-disciplinary teams, MDTs and other technical processes. Within a short time the private sector withdrew virtually completely from breast cancer surgery. They essentially saw it as being incredibly resource-intensive and they did not necessarily have all of the personnel required to meet multi-disciplinary requirements. There was no particular friction with the private sector. Many of those involved viewed cancer surgery as being very resource-intensive and felt that in many cases they were not capable of meeting the requirements. HIQA did commit at the time - which I thought was very important - to push for legislation which would ensure that were private hospitals to engage in cancer surgery they would be held to the same standards as the public system. To my knowledge, that legislation was never introduced. I believe that to ensure completeness that should occur.

I was part of the HSE but given the HSE brand was not exactly a popular brand at the time it suited my purpose to be able to operate in an apparently independent mode. The budget for the cancer programme was largely written into the HSE budget by the Minister and her staff. I did not have to participate in the endless wrangling within the HSE over the HSE budget. Essentially, the cancer budget was dropped in on top of the HSE budget by the Department. That was incredibly helpful for me because I did not have to waste hundreds of hours engaging in negotiations with the HSE structure. We were coming from a low base. I found that people were genuinely appalled to see Ireland at the bottom of the league table. We are a sporting nation and the idea that we were at the bottom of the league table and wanted to move up was picked up immediately by the media and it constantly repeated the message. It is probably still true that we are not there yet. While significant progress has been made there is still a lot of work being done and to be done. The cancer programme has not gone away. Owing to the demographic shift in the Irish population in terms of the population getting older Ireland is going to see a dramatic increase in cancer incidence over the coming two decades, irrespective of any prevention measures that might or might not be in place. I think I have covered most of the questions. If I have not, the Chairman might let me know.