Seán Crowe (Dublin South West, Sinn Fein)
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I welcome our witnesses. They will present their concerns on the impact of Covid-19 pandemic on cancer services. I welcome: Ms Averil Power, CEO, and Ms Rachel Morrogh, director of advocacy, from the Irish Cancer Society; Dr. Clive Kilgallen, chair of the consultant committee and Dr. Denis McCauley, chair of the GP committee at the Irish Medical Organisation, IMO; and Dr. Gabrielle Colleran, vice president and Professor Robert Landers, vice president, at the Irish Hospital Consultants Association, IHCA.

Before we hear the witnesses' opening statements I must point out that there is uncertainty as to whether parliamentary privilege will apply to their evidence if it is given from locations outside the parliamentary precincts of Leinster House. If, therefore, they are directed by the Chair to cease giving evidence in relation to a particular matter, they must respect to that direction.

I call on Ms Power to make her opening remarks. She is very welcome.

Ms Averil Power:

I thank the committee for inviting me and my colleague, Rachel Morrogh, to the meeting. The Irish Cancer Society is pleased that the Joint Committee on Health is continuing to focus on the impact of Covid-19 on cancer services and cancer patients. We are incredibly worried for current and future patients, as well as for those who provide their care.

Cancer is a disease where time matters, but hammer blow after hammer blow to cancer services over the past 15 months means that patients are not guaranteed to get the care they need when they need it. Cancer is a continuum and Covid has disrupted every aspect of it, from screening to diagnosis and treatment. International experts are warning that these disruptions will lead to an increase in cancer deaths over the next ten years.  We are here today, however, to tell the committee that if we act and put in place the right resources and make the right investments, we can reduce the level of suffering and loss that lies ahead.

GPs, our first line of defence against cancer, have been pleading alongside the Irish Cancer Society for anyone with niggling health concerns to seek medical advice during Covid. Our research shows that one in four people did not go to see their GP in 2020, even though they said that they needed to. Our most recent research, which was conducted in May, shows that one in six people reported that they are still choosing not to attend a GP with health concerns. Our healthcare professionals are already seeing the results of people presenting later, with patients presenting at more advanced stages for certain types of cancer.

We are also seeing delays to diagnosis for symptomatic patients after they have been referred by their GPs. The long waiting times that characterised public healthcare before the pandemic have been further compounded by Covid. We do not yet have the full picture of the numbers of cancers that have gone undiagnosed during Covid, but figures from the national cancer control programme for the referrals to breast, prostate and lung rapid access clinics imply that diagnoses in 2020 were at least 10% lower than expected. This means that potentially more than 2,000 invasive cancers went undiagnosed last year.

Covid is not the only enemy that cancer services are battling. The devastating cyberattack on the HSE is crippling a system that was already on its knees. In a tweet, St. Vincent's University Hospital has said that referrals to its skin cancer clinic were down by more than 90% due to the cyberattack.

Some rapid access clinics that we have spoken to report that the cyberattack has had a much worse impact on their services and patients than Covid.

As I speak to the committee, our health system is under intolerable strain. Our cancer services are delivered by some of the most passionate and dedicated healthcare professionals in the world but members will hear from the IMO and the IHCA that our healthcare professionals are burned out. Cancer patients are also at breaking point. Every day on our support line, our cancer nurses hear the stress, anxiety and exhaustion in their voices. For 15 months they have cocooned and socially distanced from their loved ones. They have attended appointments and heard the worst kind of news completely alone. They have recovered from surgery and attended chemotherapy and radiotherapy without anyone to hold their hand. The psychological and emotional effects of Covid on cancer patients will stay with them and their loved ones for the rest of their lives.

While there has been a drop in cancer diagnoses in Ireland since the start of the pandemic, those cancers have not gone away. They are hiding underneath the chaos that Covid has visited on an already overwhelmed healthcare system. Those cancers will eventually surface, but for some, at a much later stage. That means more difficult treatment options for patients, reduced survival rates and a devastating impact on our stretched cancer services. We need to prepare for a surge in more advanced cases of cancer in the coming months and years. At the Irish Cancer Society, we appreciate that the Government started to do that at the end of last year when it provided significant extra funding for the national cancer strategy in budget 2021. However, much more will be needed in the years ahead.

We also need much better data to ensure we are tackling the right issues and investing in the right places. We are in the Stone Age when it comes to collecting real-time information on cancer services. That means we are fighting Covid and cancer blindfolded. Therefore, I appeal to members to support the adoption of the individual health identifier across cancer services and the development of robust data systems to inform policy as a priority.

What we do today really matters to the future of cancer patients in our country. This is an opportunity to blunt the worst impact of Covid and simultaneously revolutionise how we deliver cancer care. We have made such advances in cancer care in this country in recent decades but, as things stand, our healthcare and social care systems are not ready for the cancer epidemic that is coming down the tracks. We must act now and build a sustainable and resilient cancer service that can cope with the inevitable surge in cases in the years ahead.

Cancer screening needs to return to 100% screening capacity as soon as possible. We need to establish diagnostic centres that can provide predictable and timely cancer diagnoses. We need dedicated cancer infrastructure so that cancer services no longer have to compete against emergency and unscheduled care. We need dedicated theatres, beds, day wards, ICU capacity, staff and equipment to ensure predictable pathways to treatment for cancer patients. Underpinning this revolution needs to be a focus on our healthcare workers and future-proofing this vital workforce. We need to rethink the way that cancer care is delivered, not just play around the edges. There is so much to do and it must be done urgently. With sufficient priority and investment, we can reduce the long-term impact of Covid on cancer services and stop lives being needlessly lost in every community in Ireland.

Dr. Clive Kilgallen:

The impact of Covid-19 on our health services, and particularly on our cancer services, will be felt for years to come. Up to 45,000 people in Ireland are diagnosed with cancer each year. Approximately 9,000 people, or one in three deaths each year, are from invasive cancer. While survival rates vary depending on the type of cancer, it is estimated that 190,000 people living in Ireland have survived cancer. Early detection is key both to survival rates and to good outcomes for patients. Delays in treatment can mean the difference between routine surgery for early stage cancer or more complex surgery, radiotherapy or chemotherapy at a more advanced and aggressive stage.

Covid-19 has had a significant negative impact on our cancer services, with patients presenting late or in some cases even declining appointments for fear of catching the virus. In addition, social distancing and infection control measures have restricted both diagnostic and treatment capacity within the hospital system. We have a growing backlog of patients waiting for urgent time-critical diagnostics services and treatment services, while, for reasons connected to the pandemic, our life-saving screening services are falling below annual targets. The recent cyberattack on the HSE has compounded delays, with radiotherapy and screening appointments having to be postponed or rescheduled.

On diagnostics, in March and April 2020 during the first wave, rapid access clinics for breast and lung cancer saw referrals fall by a third and referrals for prostate cancer fell by half. While referrals have recovered, they remain significantly below 2019 levels, particularly for lung and prostate cancer. Many patients have also experienced delays in accessing services. In September 2020, just 60% of new patients attending rapid access breast, lung and prostate clinics were seen within the recommended timeframe. More recent figures show that for the first three months of this year, 450 people per month were not seen within the recommended four weeks for an urgent colonoscopy.

Treatment activity has also declined. Figures for 2020 show that activity in medical, radiation and surgical oncology services fell well below the equivalent 2019 levels, despite the fact that demand for services is predicted to increase by 5% per annum. Chemotherapy activity in 2020 fell 12% below 2019 levels, while radiation therapy fell 10% below and urgent cancer surgery cases in public hospitals fell by 24%, although some of this decline was offset by surgery performed in private hospitals. Data gathered by the faculty of pathology in the Royal College of Physicians of Ireland in the March to June 2020 period, show that there were 668, or 12.5%, fewer cancer resections performed. That is the surgical or precision removal of a tissue or organ that has cancer in it. Non-urgent cancer care has also declined. In 2020, there were 36,120 fewer elective cancer admissions compared with 2019. Since pre-Covid times, the number of people waiting more than three months for a gastrointestinal endoscopy service has doubled to 23,800.

Our cancer screening services have also been affected. They were paused in March 2020. CervicalCheck and BowelScreen resumed in the summer of 2020, while BreastCheck resumed in October 2020. However, as a result, all screening programmes still fell far below their annual targets for 2020. The full impact of Covid-19 on cancer care has yet to be assessed. However, without urgent investment, we will be dealing with a backlog of patients with much more complex and advanced stage cancers for years to come, with all the complications and side effects they will have.

The IMO recommends that we urgently invest in a national public health messaging campaign to help patients identify the signs and symptoms of different cancers, as well as encouraging individuals to visit their GP at the first sign of symptoms and to attend for hospital appointments. These messages should be communicated widely. It needs to be emphasised that patients will be cared for in a safe environment. National cancer screening programmes should be fully reinstated. We need an urgent and rapid expansion of access to diagnostic infrastructure, including radiography, endoscopy and laboratory services.

To date, there has been no assessment of diagnostic requirements to deal with our growing population, let alone the requirements to deliver this service under pandemic conditions. Cancer care is multidisciplinary, with patients requiring input from a range of different specialties involved in diagnosis and treatment and depending on the type of cancer diagnosed. Consultants are working flat out to catch up but we need to increase the number of consultants across our services, including specialists in diagnostic and clinical radiology, pathology, haemotology, radiation and medical oncology, colorectal surgery, urology, and ear nose and throat. Some one in five consultant posts are unfilled on a temporary basis, while between 1,600 and 2,000 additional consultant posts are required to meet current population needs.

In addition to employing consultants, we need to increase capacity across the system including, staffed theatre space and additional ICU, inpatient and day case units. There is no point in employing a surgeon if he or she does not have an operating room to work in. We need investment in secure IT systems, including investment in electronic health records and the roll-out of the unique patient identifier.

Additional supports are required to support follow-on care in general practice for cancer patients, where appropriate.

Seán Crowe (Dublin South West, Sinn Fein)
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I thank Dr. Kilgallen and call Dr. Colleran.

Dr. Gabrielle Colleran:

I thank the committee for the invitation to join in its discussions. The IHCA represents 3,200 hospital consultants, approximately 95% of the total in Ireland.

As Ms Power has articulated so well, there can be no doubt that the Covid-19 pandemic has caused delayed diagnosis and suboptimal care for people with cancer. As some cancers develop slowly, the impact of the pandemic on cancer cases and deaths will not be clear for many years. There is a grave and realistic concern that these delays in diagnosis and treatment will lead to increased cancer mortality over the next decade or more.

Growing waiting lists, a low number of consultant posts on a per capitabasis and vacant posts will severely limit the wider health system's ability to catch up after Covid and the cyberattack. In excess of 11,600 more people were waiting for an inpatient day case gastrointestinal, GI, endoscopy at the end of April compared with before the pandemic, an increase of 51%. Colonoscopies are the gold standard of diagnosis for bowel cancers. Pre pandemic, urgent referrals were seen within one month, but now 60% of referrals are waiting longer than three months. This significantly increases the risk of delayed diagnosis of cancer in these patients.

Difficulties in getting timely access to consultant appointments, diagnostics and tests to monitor cancer treatment response, regression or progression and to treat patients with other conditions were a problem prior to Covid, but the situation has deteriorated sharply. Unfortunately, the HSE's cancer services were already missing targets for cancer referrals, assessments and admissions in 2019. What is new is the scale of the growing waiting list crisis and the backlog of care that has accumulated in all specialties.

The cyberattack on the HSE and its public hospitals has had a devastating impact on the health service's ability to treat and manage not only those suffering from cancer, but all patients. It has especially impacted on patients awaiting medical and surgical assessment and results of biopsies, scans and other investigative procedures.

As we recover from Covid and the cyberattack, hospital management must work with consultants to design solutions to address the large backlog and other service delivery constraints that have been known about for more than a decade. The filling of one in five vacant permanent consultant posts and the appointment of additional hospital consultants on terms to be agreed with the association is the key enabler that is required to tackle the unacceptable waiting lists and the backlog of an estimated 700,000 fewer hospital appointments last year due to the pandemic and the expected reduction of 200,000 this year. The fact that the National Treatment Purchase Fund, NTPF, could only outsource approximately 7,000 scopes for patients in 2020 highlights that it is not the magic bullet the Government believes it to be. Expansion of public hospital capacity, including additional consultants and physical capacity, represents the effective sustainable solution.

Regarding the shortage of consultants, the failure to fill the one in five permanent specialist consultant posts that are vacant in our public hospitals is undermining public hospital capacity to provide high-quality and timely patient care. In addition to filling the vacant posts, our public hospitals need to appoint more specialists, as we have the lowest number on a per capitabasis in the EU. In cancer services, for example, there will be a need over the next eight years for Ireland to increase the number of medical and radiation oncologists by 111% and 72%, respectively. Meeting this level of staffing will require the recruitment of 73 additional oncologists, that is, the creation of and recruitment for an average of ten additional cancer specialists per year between now and 2028. Overall, an increase of 1,653, or 53%, in the number of consultants working in acute hospital specialties is required by 2028 to address current shortfalls and meet increased patient demand. That is in addition to filling existing vacancies.

There are a record 883,000 people now on some form of NTPF waiting list due to hospital consultant vacancies and other capacity deficits. This is an increase of 45,000 so far in 2021. More than 21,000 patients are now waiting longer than one year for essential hospital treatment, representing a 70% increase. In addition, more than 200,000 people are waiting for diagnostic scans such as MRIs, CTs and ultrasounds, with a quarter of these waiting for longer than one year. They are not on any NTPF list, so public hospital waiting lists already exceed a million people waiting for hospital treatment. Coupled with the backlog of 900,000 fewer hospital appointments in 2020 and 2021, there is a high risk that these delays will cripple public hospitals and the health system. Failure to address these issues urgently will lead to impaired patient outcomes, a scenario that the Government has a duty to avoid.

Ireland has one of the lowest acute hospital bed capacities in the EU and the highest hospital bed occupancy rate in the developed world. Considering these and other factors, the IHCA recommends that a minimum of 6,000 additional public hospital beds must be funded in a revised national development plan, which is due in July, in order to reduce bed occupancy rates, operate with appropriate infection controls, including single occupancy rooms, and deliver more timely, safe care. This is in contrast with the increase of 2,600 acute beds included in the 2018 plan.

It is essential that we expand and develop additional protected elective-only surgery facilities across our hospitals rapidly. While plans are being advanced for the three elective hospitals in Cork, Dublin and Galway, it is known that it will take time before they are operationalised and it is not expected that this expansion will be sufficient. We believe that dedicated theatre and bed capacity to deliver elective scheduled care must be expanded across our acute hospital base, not just in three locations. The recently opened day surgery centre in Tallaght hospital and the additional theatre and related facilities in Croom are practical examples of what can be delivered to expand capacity.

A national electronic health record is a vital part of an efficient and effective health service. It needs to be properly planned, resourced and implemented without delay.

Ireland trains enough doctors every year, but they are leaving for or remaining in other English-speaking countries because they are not being treated in an equitable manner here and their working conditions are much better abroad. Our highly trained specialists will remain in Australia, New Zealand, Canada and the US or they will practise outside the public hospital system in Ireland unless the Government ends the 2012 inequity and ensures our public hospitals' capacity deficits are remedied. These are the basic essentials that are required to ensure that our public hospitals recruit and retain the talent we need. This is vital if the country wants an effective public hospital service, particularly as medical and surgical care are evolving at pace. We need an environment that supports hospital consultants who provide the essential care to treat patients successfully. We also need an environment where there is demonstrable equity of treatment for consultants who have taken up contracts since 2012 as was unambiguously committed to by the Minister, Deputy Stephen Donnelly, last October. The Government's failure to address the recruitment crisis and restore pay parity is driving our highly trained specialists abroad and exacerbates the extremely challenging task post Covid with the significant backlogs and waiting lists across all specialties, including cancer.

In conclusion, our ability to respond to the backlog of care that has built up involves many factors, with recruitment of consultants and physical capacity being the principal two. Without addressing these twin deficits, the structural mismatch between capacity and demand will continue to increase waiting times rather than decrease them. We are, like Tennyson, climbing the ever climbing wave. The solution is obvious: we simply must appoint additional consultants on terms to be agreed with the association. This action now will prevent the current crisis from continuing for the rest of the decade and beyond.

Seán Crowe (Dublin South West, Sinn Fein)
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I thank Dr. Colleran. I call Deputy Colm Burke, who might indicate who he is putting his questions to as part of his contribution.

Colm Burke (Cork North Central, Fine Gael)
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I will, and I thank our guests not only for participating in this meeting, but for all the work they have done over the past 15 months. It has been challenging for everyone in the healthcare sector, especially those on the front line.

We have had to deal with the cyberattack recently and with Covid on an ongoing basis, but if the IHCA was in charge over the next six months, what would it prioritise in order to fast-track some of the backlogs? What action can be taken by the Minister and the HSE over the next six months?

Professor Robert Landers:

I will take that question. In cancer care, we need to prioritise access to the diagnostics and surgeries that patients need. We must rapidly increase our diagnostic capacity in terms of radiology and laboratory specialties and improve theatre access for cancer surgeons.

We have to reopen our hospitals after Covid and the cyberattack, which will be very difficult. The cyberattack has set us back months, not weeks. It will take months to recover from the cyberattack in the context of diagnostic specialties.

In summary, we need to get over the immediate crisis of the cyberattack and the disastrous effect it has had, improve our capacity in terms of diagnostics, radiology, laboratories and endoscopy and increase our theatre access. There is no quick fix here but we must put a plan in place because, otherwise, we will be treading water for a long time. Our worry is we do not see a plan from the HSE or the Department of Health to get us out of this. We are available to discuss this with them but there seems to be no focus on how we will get out of this at a departmental level.

Colm Burke (Cork North Central, Fine Gael)
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If Professor Landers were setting out bullet points for the HSE, what would they be? Where could immediate action be taken? I know we have to deal with the computer issue first and that has to be resolved, but what five or six other issues would the IHCA highlight to assist in dealing with the backlog? Has the association communicated to the HSE what needs to be immediately prioritised?

Professor Robert Landers:

A key point relates to empowering local decision-making. The HSE is a massive centralised bureaucracy that hinders fast and effective decision-making. The responses to the Covid crisis and to the cyberattack have shown that when local hospital managers and clinicians are empowered, they will come up with solutions. We have to empower local decision-making at a clinical level. That is one of the first steps I would take.

At ministerial level, we have to recruit more consultants. It is a scandal that we have the lowest number of hospital consultants in the EU. We have to attract and employ more hospital consultants. The Minister must immediately regain trust with hospital consultants by resolving the pay disparity, which will allow us to recruit.

Dr. Gabrielle Colleran:

It is important for people to understand the impact of the cyberattack on cancer services. We are having issues with accessing prior results and imaging. We have not been able to deliver our multidisciplinary team meetings, at which we discuss radiology, pathology and clinical updates and decisions are made, for the past three weeks. That all causes delays in treatment and, ultimately, impacts on prognosis, so addressing the cyberattack is key.

What we have learned from Covid is that when local decision makers are empowered, such as the doctors within specific hospitals in Wexford, Galway and Limerick, they know where the capacity deficits are and where the blocks in the system are. In the pathway, as Ms Power articulated well, the patient first has to present to the GP, who then has to refer him or her on, and the referral has to be promptly seen. The patient has to get access to the radiology, biopsies and diagnostics and the space has to be available in theatre. There has to be a bed in ICU for someone to return to afterwards and then there has to be a spot in the day ward for chemotherapy.

There are so many potential places where we can have a gap or a backlog, and it is the people on the front line who know where that specific local gap is and can say what is needed, such as more radiologists or radiographers in order that the diagnostic scans can be processed. They will know where the backlog is in Wexford or Galway, for example. It is about empowering local clinicians to put in those fixes because they know where the blocks are locally. That is how we can make the fixes specific to the areas. A blunderbuss central approach is too slow and too reactive. We saw that during Covid and again following the cyberattack. It is about empowering and giving the resources to the people on the front line who can offer the solutions. That is how we will provide excellent outcomes.

Dr. Denis McCauley:

To respond to the question about bullet points for the Department for the next six months, in the context of the patient journey from developing symptoms to cancer being diagnosed through screening and then treatment, the important message for the HSE is that we in general practice have found that people are presenting later. There is still a fear of going to see the GP. General practice is open and we advise people that if they have symptoms, they should not delay but see their doctor. That is one roadblock that is easily overcome by simple messaging.

The major roadblock relates to a worried patient or a patient who has had something seen on a screening test actually having the test. According to the figures, the delay in diagnosis is the major primary issue. There are many bumps on the road but the diagnostic aspect is vital. The waiting lists for endoscopy have increased such that the number of patients not being seen within the defined period of appropriate time has increased from 15 per month before the Covid crisis to 450 per month, a factor of 30. People who should be getting urgent assessment, therefore, are not getting urgent assessment. I would concentrate on that. All politics is local. The endoscopy list in Letterkenny is one of the longest in the country, even though we have one of the smallest populations.

It is about the messaging to encourage people to see their GP, as well the roadblock in cancer diagnosis. If I were to go down one road, I would address those issues first.

Colm Burke (Cork North Central, Fine Gael)
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My final question relates to elective hospitals. I am very unhappy with what Sláintecare has proposed, namely, a day facility, six days a week, 50 weeks a year, with no reference to beds. Do our guests and others on the front line believe that what is being proposed in Sláintecare is adequate if we want to expand those services?

Dr. Clive Kilgallen:

I support everything that has been said by the other guests. My job and that of my colleague Professor Landers involves looking down microscopes and diagnosing cancer. We are in the thick of it. We know what is going on and we talk to our clinical colleagues. One story they tell us is that patients are presenting late because they have been at home worried, which goes back to what Dr. McCauley was saying. We need a public health programme to tell patients that if they are at home and have symptoms, they will be cared for and that it is safe for them to come to the hospital environment and be seen.

One issue with cancer surgery is that it is more complicated than the simple elective surgery for, say, a hernia, so the backlog will need complicated surgery. In some units throughout the country, surgeons have access to surgery for only about half a day a week. Imagine if a senior plasterer or master craftsperson was allowed to work for only half a day a week. I know what the response in north Dublin would be. That has to change. Surgeons need to have access to theatre space to do their work. This is so frustrating. They are becoming deskilled and worried and they want to leave for the private sector. On the issue relating to elective work proposed in Sláintecare, there obviously needs to be room for less complicated surgery but there also needs to be provision for "bigger" surgery for cancer, and that may require intensive care units.

In regard to local responsibility, where I work at the Royal College of Surgeons in Ireland, RCSI, centre at Beaumont Hospital we have access to some elective beds. In skin cancer and plastics, that comes through and we are really busy in that regard. Where there is capacity to perform to look after patients and carry out complicated surgery, patients are seen. Professor Landers and I look at and diagnose the slides under the microscope and then also deal with the cancerous section specimens. The faculty of pathology at the Royal College of Physicians of Ireland is working to examine the cancer biopsies and cancerous sections. Every time a patient has a new cancer, he or she has to have a biopsy, and when he or she has a cancer removal, he or she has to have a cancerous section specimen. All those data are examined at the Royal College of Physicians and it will produce a report in two or three weeks that will show exactly what has been happening since Covid, mathematically, down to the last histological slide.

Ms Rachel Morrogh:

The Deputy asked what could be done now. There are examples of great innovation happening and if we look at what is happening in the area of endoscopy there is an opportunity to try out the list that exists at the moment as well just to ensure that those people who require the most urgent care are getting it. There is a plan to supply fit tests to routine patients. As was outlined earlier, the waiting list is extremely long. People have been waiting considerable periods. That would help prioritise the patients.

Other aspects of endoscopy have not been funded, such as advanced nurse practitioners who could play a key role in this. There are also a number of capital projects. Dr. McCauley mentioned that Letterkenny is on the list of capital projects. It is really important that those get funding. It is an opportunity for innovation but those examples of innovation also need to have a sustainable funding footing to ensure they can have the impact that they should.

Seán Crowe (Dublin South West, Sinn Fein)
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The difficulty with chairing this section is that it is in ten-minute slots and then it goes to seven minutes, meaning that the longer the answer is, the less opportunity that other members or witnesses will have to come in. It is difficult to try to chair it on Teams. I ask everybody to bear with us and hopefully everybody who wants to come in will get in.

David Cullinane (Waterford, Sinn Fein)
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I welcome the witnesses. To get in as many questions as I can, I will direct my questions to the individual witnesses. I will not need everybody to answer the same question, but if somebody has a point to make that will obviously be fine as well.

I thank Ms Power for her powerful opening statement. I echo the call that was made for a strong public health campaign and a strong public health message that if people have a concern or if people have symptoms, they should go to their GP. That needs to be a very strong message coming from the meeting. After today's session perhaps the committee could issue a statement calling for that because it is a really important point. If people do not go to their GP, they will not be able to get the rapid access to the diagnosis and treatment that they need. That is an important point for the committee to make.

We know that screening services were curtailed in 2020, which was very difficult. Ms Power said that a reduction in screening can have an impact on cancer burden. Specialists would also say that cancer screening is not a substitute for a diagnosis and people obviously still need to go and get a diagnosis. However, screening plays a significant and important role. Would Ms Power like to see additional capacity or maybe the rebooting or restarting of screening services?

Ms Averil Power:

The Deputy is correct about the public health campaign. We have partnered with GPs over the past year in encouraging people to go to their GPs. We will keep doing that and it really is the most important message. If people have worrying symptoms, such as unexpected weight loss, bleeding or a lump, the chances are it will not be cancer but it could be. If it is, it is critical that it is identified as early as possible so that people can get into treatment. With cancer timing is everything. The earlier it is diagnosed, the better the treatment options are. They are less severe, the impact on patients' quality of life is much less and their chances of survival are greater. The Deputy is correct that this is a key issue. It would be great if the committee were to send a strong message today to encourage people to present to their GP with any niggling concerns.

Regarding screening, most cancer diagnoses come through the diagnostic services. Most cancer diagnoses are picked up where somebody either attends at GP or an emergency department with a concern and then is referred through the pathways that were mentioned earlier and identified as having a cancer. Screening is also important in picking up precancers and in some cases cancers in the population of people who feel healthy, those who are not experiencing symptoms and think they are healthy. Through our screening programmes, for example through CervicalCheck, we can identify precancerous changes long before they go on to become problematic. That is why it is so important for people to attend their screening appointments.

It was really disappointing that screening had to be paused during the pandemic and a substantial backlog has built up. To clear that we need not just to return to the capacity that we had prior to the pandemic but to increase capacity so that we are able to get through that backlog as soon as possible. Pausing for the kind of period that we have had is problematic. The diagnostic services are at greater risk because of people with symptoms who are much more likely to have cancer but when screening is paused we are losing out on people who would have been identified really early and would not have developed cancer at all.

David Cullinane (Waterford, Sinn Fein)
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My next question is for Dr. Colleran. Diagnostics is one of the most important steps in treating cancer patients. Rapid diagnosis is important. The IHCA, IMO and the Irish Cancer Society have referred to increased investment in diagnostics which is important. The society mentioned having established diagnostic centres for cancer. Does the IHCA support that?

Dr. Gabrielle Colleran:

Ms Power has outlined what we have seen during the Covid pandemic when capacity for cancer care is not ring-fenced. If there is not enough capacity in the system and we have something like a pandemic or when the needs for unscheduled care at acute hospitals increases, there will be an impact on access for cancer patients. Ireland has had great success with cancer care through the establishment of specialist cancer centres. We need to continue that model. We need to ensure, as Professor Landers and Dr. McCauley have outlined, that at every step in the pathway we have enough capacity. When patients go to their GPs, the GPs need to be able to refer on promptly to the-----

David Cullinane (Waterford, Sinn Fein)
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Is Dr. Colleran talking specifically about equipment or are more staff and equipment needed?

Dr. Gabrielle Colleran:

It is both. We do not have enough consultants. We field half a team every day and we do amazingly well for the number we have. However, as we have the lowest number of consultants per capita, it affects how early people can be seen in outpatient settings. We just do not have enough staff on the team. Equipment is also an issue, as we have highlighted many times. We need enough investment so that we have the most up-to-date machinery. We always need to fight for a new CT scanners and new MRI scanners. The MRI scanner in Temple Street Hospital is 22 years old this year and is on its last legs. Many scanners around the country are like that.

The standard of care in other European countries is such that they would be automatically replaced after ten years. We constantly need to fight for things that are routine in other countries. Of course, if we do not have enough staff and if our equipment is out of date, and if we do not have enough equipment or enough staff, that will impact access. Everybody having access within six weeks feels like a pipe dream at the moment.

David Cullinane (Waterford, Sinn Fein)
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My next question is for Professor Landers. The IMO and the IHCA referred to the impact the cyberattack has had on cancer care. It seems to have had an even greater impact than Covid, which is extraordinary. I ask him to give us a flavour of what is happening on the ground. He works in University Hospital Waterford, which is a cancer centre. Many services there have been affected from diagnosis through to various treatments. What types of problems has the cyberattack caused for those who are trying to provide cancer care in acute hospitals?

Professor Robert Landers:

As a pathologist, I diagnose cancer biopsies and look at cancer resection specimens. The cyberattack has had a devastating impact. It brought us to a standstill. Everything we do is IT dependent and IT driven, which meant that we had to stop. Our laboratories went from processing 150 tissue samples a day down to three, four or five tissue samples a day. With those that we are processing, the risk of a mistake is red hot. Many of our IT systems are installed to help us prevent mistakes, but these are missing.

It is like driving a car without a safety belt or airbags. It will take months, not weeks, to recover. Patients will have operations and their diagnoses delayed and there is a risk that the diagnosis would be wrong. I am sorry to say that but it is a fact. We just do not have the safety systems in place to deliver safe diagnoses at the moment. This has had a worse impact on diagnostic services than Covid-19.

David Cullinane (Waterford, Sinn Fein)
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Professor Seamus O’Reilly made the point last week that any six-month delay in diagnostics in cancer care will have a ten-year impact on increased cancer deaths. In Professor Lander’s professional opinion, is that a view that he would support?

Professor Robert Landers:

That is something that I completely agree with. The effects of this will be seen in five, eight, ten or 15 years where patients are just not getting the diagnosis or starting treatment as early as they should be. The effects will be seen far into the future.

David Cullinane (Waterford, Sinn Fein)
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I have two more quick questions and I will finish then. One is for Professor Landers and the other for Dr. Kilgallen. Addressing Professor Landers on the issue of elective-only hospitals, this is something I support and will have an impact in reducing waiting times but it is not a substitute for investing in elective capacity in other hospitals in the State. Professor Landers is based in the south east and others will give examples across other regions. How important is it as we move to elective-only hospitals - the point was also made by our first questioner as to whether there should be beds as part of those hospitals - to stress that it cannot be a substitute for increased capacity for electives in other acute hospitals, especially regional hospitals?

Professor Robert Landers:

That is a good question. We need to be very careful here and to differentiate between protected elective capacity and elective-only hospitals. The elective-only hospitals is not necessarily a model that the IHCA would support. The current model, as proposed, which is to have three elective hospitals in the country, is flawed. It is not adequate geographically to expect the patients of the country to go to three elective centres in Cork, Dublin and Galway for all elective care. We feel that we would be better off putting protected elective capacity into our major hospital sites across the country. In that way all of the expertise would be on the one site and we would be able to attract and retain a higher quality of staff because of the breadth of service that we would provide.

The other worry among consultants on the ground is that the proposed elective-only hospitals do not have adequate ICU facilities to deal with the higher risk patients. They are still going to have to be looked after in the major hospitals. We strongly feel that we would be better off putting protected elective capacity into our existing centres.

David Cullinane (Waterford, Sinn Fein)
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My final question for Dr. Kilgallen concerns the opening statement of the IHCA, which mentioned new hospital consultant contracts and the pay inequality issue. This is also supported by the IMO. He said that there needs to be an agreement on hospital consultant contracts on terms that are agreed by the IHCA, which I assume he would also agree with from the point of view of his own organisation, the IMO. Has there been any negotiations with the Department, the HSE or the Minister on new contracts for dealing with the existing pay inequalities in consultant contracts in recent times?

Dr. Clive Kilgallen:

I thank the Deputy for his question. We have only received the draft contract very recently. Discussions have started but they are at a very early stage. It is very important to understand for everybody that the healthcare system in our nation is very complicated and changing the contract of one group is not going to be the answer for everything. We need more consultants employed on a contract that is fit for purpose and will meld into what is happening and allow them to be attracted back, which is of great importance. The post-2012 consultants whose pay scales were reduced over and above other public sector workers has been a significant issue and has been one of the factors in recruitment and retention. Certainly the IMO, IHCA and HSE all want the same thing. We want more doctors working and seeing more patients. That is what we want to do. Surgeons love doing surgeries, endoscopists love doing endoscopies and so on. We want to be allowed to do what we have trained to do which is to see and care for our patients.

Róisín Shortall (Dublin North West, Social Democrats)
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I thank the Cathaoirleach, and wish good morning to all of our guests and thank them for their presentations. They certainly paint a very stark picture of the impact and devastating double blow from both the pandemic and the cyberattack. They have all, I believe, referred to the fact that pre-pandemic, there were major shortcomings and under-resourcing in cancer services in any event. Our witnesses I am sure can gather from committee members that we are very keen to take a practical approach to this to see what can be done in the short to medium term. The point that was made by Dr. Kilgallen on public health messaging is the key one that I support. The Chairman also pointed out that the committee needs to work on that straight away.

There are obviously much more fundamental issues involved, which I will come to in a moment.

What is the current position on the cancer strategy and its governance? There was a sense a number of years ago when the strategy was agreed that there was strong leadership on it. Has that fallen away now? Why is it that each of our witnesses individually representing their different sectors have to lobby for proper investment? Is the governance of the cancer strategy inadequate at the moment?

Ms Averil Power:

I will take part of that question if that is okay. I thank the Deputy for her question and for raising the national cancer strategy. It is very important that we do not lose sight of it. We are in this mire because of Covid-19 and we are also supposed to have a long-term national plan to improve our cancer services. From the Irish Cancer Society’s perspective, significant progress was made under the previous two strategies, which increased investment in the centralisation of services and greatly improved outcomes for patients. There is still a gap.

We were delighted when this national cancer study was published because there was a commitment to address the remaining gaps and bring cancer services up to a world-class standard. Lack of investment has been the problem. We are now a number of years into the strategy and last year was the first time, which we very much welcome, that the Government put very significant investment into the national cancer strategy. In the previous two budgets there was next to nothing and as a result things did not move.

The other difficulty from our point of view is monitoring progress because the data are not available for us. We go to great lengths in this area and my colleague, Ms Morrogh, can speak more to that issue on the lengths that she goes to try to get data from the National Cancer Registry Ireland, the National Cancer Control Programme, hospitals and different places to see if key performance indicators are being met. There are no ready sources of data to do that. As with any plan, it is very difficult to see if it is being implemented or if the resources are going to the right place if we are not collecting the data to hold the Government to account on it. We are investing and have a research call going out shortly where we are going to try to do that but it should not be up to the Irish Cancer Society to do this. If the committee can impress upon the Government and the Department to step up, that would greatly help all of us, the committee included.

Róisín Shortall (Dublin North West, Social Democrats)
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I thank Ms Power for that. Did Dr. Kilgallen wish to contribute on that specific point?

Dr. Clive Kilgallen:

Yes, and I thank the Deputy. In summary, she said it was stark but in some ways, a great deal of good work is being done behind the scenes. In the faculty of pathology, for instance, we have the histopathology quality assurance programme, where we look at all of the blocks and quality data. That is one example of the quality initiatives that are happening behind the scenes almost under the radar and that are working very well. It is stark but given the fact that our healthcare system was struggling previously and now we are hitting a crisis, this is the time to do a systems reset and to rethink what we are doing. Let us do it as we know what we need to do. We have the will and we need the capacity, we know what we need to do and now is the time to do it. We can use this combined Covid-19 pandemic and cyberattack to do this.

Róisín Shortall (Dublin North West, Social Democrats)
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How should that be led within the health service?

Dr. Clive Kilgallen:

It has to be a kind of team approach between the people on the ground, and then obviously the HSE and the Department working together. A forum like this is a very good place where both parties can hear what is going on.

There are several issues. One is obviously the investment, but there is also the idea of having local groups that are able to see and respond rapidly to what is happening around them. Rather than being stuck by a nurse, they would be able to identify specific issues and move on them quickly. They would not be able to solve everything but could identify cohorts of patients they could deal with immediately. For example, there may be a waiting list in a breast cancer unit. Not all of the people on this list may have obvious breast cancer but they may have breast pain or ill-defined symptoms and some will have cancer. It is about being able to target and move on cohorts of this kind. These groups are supposed to be able to respond rapidly within their local areas.

Róisín Shortall (Dublin North West, Social Democrats)
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If I may stick with Dr. Kilgallen at this point, he referred to something very specific, which is the fact that some surgeons only have half a day's access to theatres. That is unbelievable in this day and age. Can he identify the specific reasons for that? Is it inadequate numbers of theatres or numbers of theatre staff? What exactly is causing that incredible logjam in the system?

Dr. Clive Kilgallen:

I suppose it is an acute and chronic problem. There was always a difficulty with surgeons getting access to theatre time. I am on the consultant appointments committee and this is something that comes up in the meetings when we are looking at job specifications and proposed jobs plans. Sometimes we look and see that surgeons only operate once a week and say that they should be doing more theatre time. This is a thing on which we are always picking up. Covid has made it worse in that the reconfiguring of hospital beds to allow for Covid areas has meant it is harder to get access to theatres. Some theatre space has also been reconfigured into ICU space. An existing shortage has been made worse by the Covid crisis and has really thrown a spotlight on it. It is a matter of physical space, theatre nurses and staff; it is obviously not just a matter of consultants. There is a particular problem with a shortage of theatre nurses. That is a major issue.

Róisín Shortall (Dublin North West, Social Democrats)
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I am keen to identify whether things can be done in the short to medium term that do not necessarily involve big building projects. Such projects also have to go ahead, but what can be done in the short to medium term to improve the situation. I am trying to identify if there are issues there. Dr. Kilgallen has identified problems with theatre staff. There may also be organisational issues within hospitals.

I also want to raise the issue of diagnostics. Several of our visitors have referred to this. What can be done in the short to medium term to improve access to diagnostics? Dr. Colleran said that buying services in from the private sector has not been that successful. Are there proposals in this regard? Perhaps Dr. McCauley will respond followed by Dr. Colleran.

Dr. Denis McCauley:

I thank the Deputy. On that matter, and going back to the national cancer strategy, we on the ground level can only look at the parameters of the performance measures that are in place. I must admit that the overall governance arrangements are probably above us. From a general practice point of view, the national cancer strategy had two main aspects. One related to giving us access to more diagnostics. Quite a lot of the time, we find we are taking up space in outpatient departments because we are referring people for tests. We are actually quite good gatekeepers. We give access to tests that we can make good use of, particularly if we get feedback on them. The crisis has sometimes given us an unexpected pathway to diagnostics. For instance, during the malware attack currently ongoing, we have been given direct access to MRI scans and CT scans and more access to ultrasounds. That is probably a short-term force majeuremeasure but something like that would allow us to help in early diagnosis, taking pressure off of hospitals while ultimately increasing the health of the population. From the point of view of the national strategy, we can only look at bits we can improve on in our own sectors. That is one offshoot that has helped in that regard.

The other aspect of the strategy to consider from the general practice point of view is something like the chronic disease management model, under which GPs were to get involved in cancer aftercare. That was a good idea which has run into the sand. It is something the IMO promotes would take pressure off of the hospitals, giving them more of a chance to do acute work rather than chronic work.

Dr. Gabrielle Colleran:

To come in on the cancer strategy, it is a great strategy but the reality is that there has been no real funding for it until this year. For it to succeed and be implemented, there must be year-on-year support. The costs were clearly outlined at the time of the strategy's publication in 2017 but putting in the governance without the funding impairs success. There is a need for separate infrastructural funding. If the strategy is to be implemented properly, we need sustained funding. When I say infrastructure, I am talking about dedicated beds, theatres and diagnostics. Many of the recent increases in funding were required to increase resilience in the system that had been weakened by a lack of funding in previous years. That was particularly necessary as a result of Covid.

With regard to diagnostics and how to increase access within our public hospitals, it is often the case in public hospitals that staff are willing to do evening or weekend lists but that the hospitals cannot get funding to pay radiographers time and a half to provide the service. The public hospitals are told that staff have to do this at the basic rate. One cannot realistically expect staff to do that in the evening and at the weekend when childcare costs are higher. We have this awful situation whereby diagnostics are outsourced at a cost higher than that of paying agreeable rates locally. That is a short-term measure. The long-term and medium-term solutions are to get more radiologists and radiographers and to have more equipment. In the short term, however, we could make better use of the scanners and staff we have by doing lists evenings and weekends. The Haddington Road agreement and pay scales cause issues with such insourcing. Insourcing takes away the quality issues that sometimes arise with outsourcing and address the issue of being unable to compare to priors. As to the cost of outsourcing, it is cheaper to insource but we run into issues around pay scales. If we could get a bit more flexibility in that regard, we could do more insourcing in the short term. It is really critical that we do because the backlogs and waiting lists for diagnostic imaging are now very long.

I will make that point again with special regard to children. It is one thing to wait a year or two for an MRI scan when someone is 40 but if someone is four and waiting for an MRI scan for a scoliosis operation, he or she will not get on the waiting list for that operation until he or she has had an MRI. Many of these children are having trouble with running around the playground. They are breathless. It really impacts their quality of life and their schooling. As a State, we are really failing them. We just have to do better. It is just not excusable.

Róisín Shortall (Dublin North West, Social Democrats)
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That is exactly the kind of thing I was talking about. The original idea behind the cancer strategy was to cut through those blockages with strong leadership and to make things happen and move things along. I am not aware of the cancer strategy operating like that at the moment.

Dr. Gabrielle Colleran:

I believe the Deputy is referring to the concept of integrative autonomy. We need to have enough integration with the central HSE to ensure the key performance indicators and standards are uniform across all hospitals while having enough autonomy locally to empower clinicians to address specific blockages locally. That is what we are missing. There is a command and control model and Covid has taught us that does not work. What we really need is empowered local services. Integrative autonomy brings us to the sweet spot at which we have both.

Ms Rachel Morrogh:

To quickly answer the question as to how the national cancer strategy is progressing, an interim report was recently published. The Deputy may be aware of this report. Of the strategy's 23 key performance indicators, 14 expired between 2017 and 2020. Of the 14 targets associated with deadlines, there were no data available on eight. That highlights what colleagues have said with regard to the lack of data. How can we expect good-quality progress and real change for patients when we cannot even measure what it is we are meant to be doing? We are now five years into a ten-year strategy. The fact that there are no data available for eight key performance indicators that have expired is pretty revealing.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I thank all of our guests. They paint a very stark picture with regard to the ongoing public health emergency. Another emergency relating to another kind of virus is the cyberattack. The health service needed that like a hole in the head. It has caused a great deal of disruption in every sphere of the service. It is very concerning. I have a number of questions.

My first question is about the impact on cancer services during the ongoing public health emergency when the Government acted in respect of the availability of the private sector. What impact did this have on cancer services in respect of diagnosis and the backlog prior to the public health emergency? Would the witnesses see a basis for continuing this service through the public sector in respect of addressing some of the historical backlogs in cancer services?

Ms Averil Power:

From a patient point of view, it helped at the start. In particular, we saw a lot of things like chemotherapy moving to private hospitals, which meant that we were able to provide safe Covid-free pathways for patients at the start of the pandemic. It also helped to get some of the other lists down in areas like surgery and clear backlogs. I will not comment on the commercial arrangements for that but I definitely think the more capacity there is for the system the better. If there are ways of making good value-for-money arrangements with private hospitals and being able to have access to that capacity for public patients, that is a good thing, although Dr. Colleran's point about the advantages of insourcing is very well made. Insourcing is obviously far better where that is possible. It is much better to build capacity in our public hospitals.

That was just one thing. Positive things have happened during Covid as well with the use of the private hospitals being one of them. Other innovations that have benefited patients include things like chemotherapy in the community. The Mater Hospital has a really good project delivering chemotherapy in Glasnevin. There have been other innovations. Where they have had that local autonomy that was mentioned earlier, our healthcare staff have really stepped up. People have stepped up and found creative and good ways of delivering services. Another thing that has worked well is giving more responsibility to nurses. We have fantastic nurses in this country who are such an untapped resource, particularly compared with their colleagues overseas. The advanced nurse practitioner posts were mentioned earlier. We really need to invest in upskilling our nurses and giving them more responsibility and a key role to play because they are a key contact for patients and can really help to address some of the capacity issues relating to staffing in hospitals.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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My second question is directed at Ms Power. It concerns breast cancer screening, which is not available to the under 50s. This was new to me. A very good friend of mine under the age of 50 had breast cancer. In the meantime, we put forward a motion in the Dáil relating to breast cancer screening for the under 50s. It is stark. There are reasons it does not happen but I will give the reasons it should happen. Breast cancer makes up 30% of all invasive cancers in women and there are around 30,000 cases of it per year while Ireland has the eighth highest incidence rate and the fifth highest mortality rate in the EU. Why is breast cancer screening not available to the under 50s?

Ms Rachel Morrogh:

I will take that question but may need to refer to one of my clinical colleagues on the call. As far as I know, the international evidence is not there to support extending it to the lower age group but the screening service constantly reviews evidence as it comes through the international channels and works with colleagues internationally concerning best practice. I assure the Deputy that these things are constantly kept under review and that screening programmes must be delivered under the guidance that is there.

Bernard Durkan (Kildare North, Fine Gael)
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I have a general question for everybody. To what extent have they discussed the requirements of cancer services with the management of the Sláintecare programme and the director whose responsibility it is to bring it on stream, Laura Magahy? Have they intimated to her their requirements in terms of infrastructure, extra consultants and diagnostics? Who wants to answer?

Professor Robert Landers:

Unfortunately, the harsh reality is that there has been very little consultation between Sláintecare and the consultants delivering care on the ground. We wish there was more but it is just not happening. We have sought meetings many times but we have not been successful in getting them. I am not even aware of the plans for cancer care in Sláintecare. Sláintecare should be consulting with us. We were not consulted with in respect of the elective-only hospitals plan either. Sláintecare needs to broaden its consultation process and listen to the people delivering the care.

Dr. Clive Kilgallen:

It needs to be emphasised that the IMO has been advocating on many subjects, including cancer care for a very long time. At individual unit level, one of the major jobs of the clinical leads is advocating for clinical services. All of this has been done through the HSE and the local units for years so there has been no shortage of advocacy on our part down through the decades.

Bernard Durkan (Kildare North, Fine Gael)
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I accept that and realise what Dr. Kilgallen is saying. At the same time, there is a new structure with responsibility for welding together all the services in a way that makes it relevant, relative to demand and responsive. That is the Sláintecare programme, which is supposed to bring us up to date in terms of the delivery of services, infrastructure replacement and staffing level requirements. We have all talked about that in these meetings over the past five to seven years. It is imperative that the witnesses have discussions with Laura Magahy and her team. Otherwise, although both parties are planning for the future, they will take parallel routes when the crossover needs to take place. How do the witnesses want the committee to proceed? My feeling is that we should have a meeting at the earliest possible date where both parties are represented. I await the witnesses' response.

Dr. Gabrielle Colleran:

We have offered our services. The first time I met Laura Magahy with the Irish Hospital Consultants Association in the context of contract negotiations, we very clearly said that we felt excluded from the Sláintecare process, were very keen to be involved in helping and shaping it and want the health service to be a success. Dr. Laura Durcan and I said that we would be only delighted to join committees to help with planning and solutions. Unfortunately, we have not been invited to join those committees. I cannot speak for the Sláintecare committee or Laura Magahy so the Deputy probably needs to address that question to her but I can clearly say that we have offered our services and for some reason, those services have not been considered necessary.

Bernard Durkan (Kildare North, Fine Gael)
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As a committee, we should facilitate a meeting where the two groups could come together. There is no sense in people operating separately. We know what each group wants, is supposed to do and hopes to achieve. We accept all that but we cannot continue to have a health service where the staff are drained on an annual basis and go elsewhere.

We have heard this again and again. They go elsewhere to serve in other health services. We seem to have a relatively expensive health service in this country. It is not the most expensive but very nearly the most expensive. At the same time, we do not have the best services, notwithstanding the fact the people who provide the service at the front line are second to none and have done a great job throughout the pandemic and at other times. We need to bring reality to bear on the situation in trying to ensure we have a continuous smooth line through the system whereby patients can expect to be diagnosed, treated and discharged within a reasonable time.

Seán Crowe (Dublin South West, Sinn Fein)
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We will discuss that at the next private meeting.

Martin Conway (Fine Gael)
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I thank the witnesses for their presentations. I was going to ask about the cancer strategy but I think it has been covered fairly substantially. Obviously, there is a serious problem as a result of the pandemic and Ms Power outlined it in great detail in her presentation. Is there any idea of the number of people who have sadly lost their lives as a result of late diagnosis? Given it is very difficult to tell, are there any statistics in that regard?

Do the witnesses have any comments on the suspension of the HPV roll-out in second level schools? Over 80% of young people were getting the HPV vaccine and a lot of that was down to the work of Laura Brennan before she passed away. I have concerns that this has been compromised because there has not been any real confirmation from the HSE about a follow-up or catch-up programme. I believe local pharmacists should be included in providing the HPV vaccine. I also believe that where there is spare capacity at the mass vaccination centres, the HPV vaccine should be offered there. I am very concerned about that issue and I would like to hear the views of the witnesses.

On another question to Ms Power, the Irish Cancer Society clearly relies on funding from the public. How much impact has there been on its activities as a result of not being able to do substantial fundraising? Has the State in any way stepped in to alleviate the pressures the Irish Cancer Society has been under as a result of not being able to raise funds? Is there anything Ms Power would like the committee to do to highlight any gaps that may exist?

Dr. Gabrielle Colleran:

On the first point regarding the data on delays in diagnosis, my colleague, Professor Seamus O'Reilly, who is a medical oncologist in Cork, spoke very well on this during the week. There is good data coming out of the United States on the impact of the Covid pandemic on cancer diagnosis and it is expected the delays will impact mortality for over a decade. As Ms Power articulated earlier, the reality is that because cancer develops over a period of time, it will take up to a decade for us to see the impact, but we know that up to six months of an impact has been shown to have an impact on morbidity and mortality in the US. We have had longer than that here and, of course, our access issues and our capacity issues are worse than they are in other countries; for example, we have the longest waiting lists in Europe. Therefore, it is reasonable to expect that the impact will be worse here but, without concrete figures, I do not think it is fair to speculate other than to say that, unfortunately, the impact is real and we will be seeing it for over a decade. That is why it is key that we implement the cancer strategy in full and put in the additional resources to address the backlogs so we can try to minimise that. We cannot change what has happened up to now but we can impact the future by taking proactive measures now.

We agree strongly that HPV vaccination for our young boys and girls is the way we are going to eradicate cervical cancer, regressive throat cancers and head and neck cancers for the next generation. Therefore, we do not want any delays because those teenagers can get exposed to HPV and have that risk of progressive cancer in the interval. Of course, in the context of the Covid pandemic, given we do not have enough staff and resources and staff had to be redirected, that was one of the areas affected. What is key now is that we get the catch-up. We are looking for solutions like those suggested by the Senator and those innovative, "think outside the box" solutions, using any potential spare capacity. There rarely is spare capacity but we have to use every bit that we have to get that catch-up in place so we do not see the knock-on effect for those teenagers. As Dr. Nóirín Russell has said, we want to be like Australia and looking at eradicating cervical cancer for the next generation.

Ms Averil Power:

I thank Senator Conway for mentioning our good friend, the late Laura Brennan, and the amazing work she did on increasing uptake of the HPV vaccine. It is amazing that we have a vaccine that can eliminate a whole form of cancer in a generation and that we can get rid of cervical cancer and stop women like Laura and other young women tragically losing their lives. We feel very passionately about making sure that every young girl and young boy, now that the programme has been extended, avails of the vaccine. It is so important that we get back to school-based vaccination, which is probably the easiest in terms of increasing uptake.

I agree we should also be looking at pharmacists and other areas, and at anything we can do to make vaccination convenient. I was at a talk recently with a vaccine expert from the WHO who said that we sometimes think about vaccine hesitancy but it is not that people are hesitant about getting the vaccine, it is just that it is not convenient enough, particularly for those from disadvantaged areas, and that any extra burdens such as having to travel can be the reason they do not get it. Therefore, getting back to a school-based system is very important.

With regard to our funding, as the Senator knows, we had to cancel daffodil day at short notice last year, which was very challenging for us and also for our amazing volunteers, who look forward to doing it every year to raise funding for people affected by cancer in their community. However, it was also amazing for us to see the strength of the Irish Cancer Society community across Ireland, in that people came together and found new and interesting ways to raise money for us. While our income was down by €2 million last year, we were also buoyed up by the work people put into doing virtual events and how well daffodil day did this year. That means we have been able to restart some of the things we had to pause during Covid, although there is so much more that we need to do. There are a lot of strengths in the fact we are funded by the public and we get such enormous public support. It gives us a lot of independence. During the pandemic, we were able to innovate, change and introduce new services faster than some of our counterparts who work in the public health system because of that flexibility. However, we are always open to more State funding for some of our core services so we are able to pilot new things and support our medical colleagues in trying new things.

Martin Conway (Fine Gael)
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I have a follow-up question for Ms Power. Has the Irish Cancer Society had much engagement with NPHET and or has it made any submissions to NPHET? If it did make a submission, how responsive did it find NPHET?

Ms Averil Power:

I will let Ms Morrogh deal with that question because she manages that relationship.

Ms Rachel Morrogh:

It is a short answer. No, we have not made any submissions to NPHET. I know the national cancer control programme made a submission of a piece of briefing material to NPHET in January of this year just to update it on how cancer services were running at that time. However, we have not had any direct engagement with it.

Ms Averil Power:

NPHET has got a lot of criticism during the pandemic. From our point of view, we think our public health doctors have shown immense leadership and we are very grateful because people with cancer are one of the groups most vulnerable to the virus. We are very grateful for the leadership we have seen in calling for the strongest possible public health measures to protect people with cancer. I would also remind people that while the vaccination programme is proceeding at pace for the different age groups, there are many people in cohort 7 who have still not been vaccinated. As people start to relax and maybe assume that everybody who is vulnerable is protected, that is not yet the case for cohort 7. It is very important that we all keep up our vigilance in regard to protecting ourselves from the virus and protecting those at greatest risk.

Martin Conway (Fine Gael)
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Thank you. I appreciate that.

Dr. Clive Kilgallen:

I will pass over to Dr. McCauley to give a detailed answer in regard to HPV.

Everybody should understand that the biggest improvements in health care in our nation are clean water, proper housing, proper nutrition and vaccines.

Dr. Denis McCauley:

On the Senator's first question regarding the potential outcomes, I agree with the previous speaker in that it is too early to say. The figures indicate that 60% fewer bowel screening tests were done last year. That amounts to 75,000 tests. With a positivity rate of 6%, 450 positive cases were not captured. Of those, 10% would have cancer. There are probably 45 people with bowel cancer whose diagnosis is delayed for a year. Taking each of the other sectors into account, the figure goes up. It will be in the next few years that the outcome of delayed diagnosis will be known. It is too early to say now. That is why it is important that we accelerate forward.

With regard to the vaccinations, there are two points to be made. The vast majority in cohort 7 have had their first vaccine but not their second. With regard to the HPV vaccine, I agree there has been a delay requiring acceleration. The entire HPV programme has worked very well because it has been school-based. The educational part has been excellent. If there is a delay, we should consider reasons for proceeding in the way I describe. Historically, the vaccination was done in general practice but we realised it was better done in the schools. That is still the best model.

Martin Conway (Fine Gael)
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I thank all our guests for their comprehensive replies.

Annie Hoey (Labour)
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Ahead of this session, I spoke to some GPs to get their sense of, and thoughts on, how things are going. One of the people I spoke to gave me three sentences: Covid-19 has massively impacted our ability to diagnose cancer; Covid-19 has massively impacted our ability to treat cancer; and Covid-19 has impacted our ability to prevent cancer. It is not that the first two are okay, but we kind of understood them. What really struck me was the point that Covid-19 has impacted our ability to prevent cancer. Could anybody offer a commentary on that? Beyond diagnostics and delays, it is concerning that prevention, which is so important, has been affected.

I have only two questions. My second relates to how GP access to diagnostics is at sea. The Irish Cancer Society report alluded to this. The winter initiative was cancelled. That was supposed to provide free scans to GMS-eligible patients in private facilities. This sort of initiative has been revoked. Could anybody involved in this offer a commentary on it? The person I was talking to referred to the need for publicly funded access to radiology services and a possible need to decouple the public resource. We have got demand-soaked hospital settings. When cancer is properly diagnosed, it is very hard for community services to access hospital-monopolised diagnostics. Has anyone any thoughts on that? My question is based on the comments of some of the GPs to whom I have spoken.

Dr. Gabrielle Colleran:

Again, it all comes back to capacity and having enough staff and equipment and whether the service is provided in the hospitals or community diagnostic centres. My husband, a radiologist, works in an acute hospital with a community diagnostic centre that is very much integrated with primary care. It is all about the patients getting access when they need it, or as soon as possible. Our number of radiologists is among the lowest in Europe. We have huge issues with radiologists and radiographers. Therefore, it is about getting the staff and using them to meet patient need.

With regard to the issue of screening versus diagnostics, the burden of disease is greatest in the symptomatic population, as alluded to by Ms Power. Therefore, while we are very focused on screening and the importance of preventing cancer, to do the most good and preventing further harm, the symptomatic population has to be addressed first. For example, of the women with postmenopausal bleeding who are awaiting access to gynaecological outpatient facilities for further evaluation, one in ten will have cancer. That involves a huge burden of disease, so much more than among the screening population.

I probably sound like I am banging the same drum but we have the lowest number of consultants in Europe. It is a major issue for capacity when there are just not enough specialists. The answer is getting the specialists. The infrastructure is the next issue. There was a comment earlier about consultant surgeons with access to theatre only once per week. When people cannot use the skills they have, they have a choice between deskilling and leaving the system to work in another that allows them to use and keep their skills. It is about getting the capacity so patients will have access when they need it.

Dr. Denis McCauley:

On the Senator's question regarding prevention, Covid-19 has had a significant effect on pathways, be those pathways screening pathways or referral pathways, and on the ability to be assessed in a hospital and to be diagnosed, treated and followed up. These have all been affected.

To put it into numbers, while cancer is prevented through public health measures and so forth, screening is an important aspect. With regard to breast screening, reference was made to whether it is best below 50 or above 50. The three screening processes we have are evidence-based and work but last year they did not work as well as they should have. There were 70% fewer mammograms last year. There were 44% fewer smears and 60% fewer bowel screening tests were done. Prevention was impaired because of this. That is probably where the statement came from. It is a fact. There are probably cancers whose treatment has been delayed. In the short term, we must realise we have to accelerate the process so the affected cohort will be a once-off cohort and so the problem will not recur.

With regard to diagnostics, Covid-19 has in a perverse way afforded opportunities. For instance, within two weeks of the Covid crisis, we were not supposed to do online prescriptions for three years. We could do so within two weeks when the Covid crisis started. That was positive. Where radiology is concerned, the Covid crisis and malware problem have meant general practice has been allowed to have direct access to diagnostics. Unfortunately, I anticipate that this will be a short-term measure but it will be interesting to see what materialises. It enhances our ability to test a worried patient to determine whether he or she has cancer. It is part of a national cancer strategy. I hope it will be continued and that it will not just be a short-term force majeuremeasure.

Dr. Clive Kilgallen:

On preventing cancer and other diseases, the first objective of any healthcare system is to keep the healthy people healthy. That is the job of the public health doctors. We need a massive uplift in public health. Recently public health doctors have got new consultant status. That is a good sign. Again, a big uplift in respect of public health is going to be needed.

Annie Hoey (Labour)
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I am happy with that. I thank the witnesses.

Cathal Crowe (Clare, Fianna Fail)
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I confirm I am in Leinster House. I thank the witnesses. I was following the meeting remotely before coming to the office and I have been listening to the witnesses' statements. There are a few points I would like to put to them.

My first question is for Dr. Colleran. The level of diagnostic delay is worrying.

There are people who are sitting at home today, having breakfast, going to work and dropping the kids to school and who have cancer. They could have early stage cancer or their bodies could be riddled with it, unfortunately, and they may not be aware of it. Some of that is down to delays in cancer screening and some of it is caused by the fact that people have put off everything over the past 14 months, from seeking advice about toothaches, knee pain and everything in between.

I read in Dr. Colleran's opening statement that "More than 21,000 patients are now waiting longer than one year for essential hospital treatment". I wish to focus on the following. Does Dr. Colleran have any metrics on how long catch-up may take, assuming that in the midsummer period around 82% of the population will have received their first vaccine? We are getting to the herd immunity stage, which is a term I really do not like. We are getting close to that. Assuming there will be public confidence to re-engage and go back to healthcare, how long might this catch-up take, in Dr. Colleran's opinion?

Dr. Gabrielle Colleran:

It is very hard to put a concrete figure on it. Given the additional impact of the cyberattack, we will be doing recovery on follow-up of the cases that were being looked after during the cyberattack to make sure things were not missed with the lack of access to prior imaging and labs. There is a huge body of work around reconciling that to make sure we can stand over the care that was provided during that period.

In terms of capacity, it comes back to the staffing issue again. Many people have not taken their leave. They are exhausted after Covid. We just do not have enough staff. We need to get the specialists into post and they have to get access to the diagnostics and the theatre spaces to get through the backlog. We and our colleagues in the IMO and the ICGP have done quite a lot on public messaging and communications on the importance of going to your GP with symptoms. It is very understandable that people were nervous about engaging. However, we have been encouraging them not to sit on symptoms because we do not want the delayed diagnoses, which we know will happen. We need to keep up the public messaging on that and to keep encouraging people to present with symptoms so that we can investigate them.

Ultimately, it is about addressing the bottlenecks in our hospitals through having enough doctors to see people, enough radiographers to do CT and MRI scans, radiologists to read them, pathologists like Professor Landers and Dr. Kilgallen to read the specimens, and for everything to be going at full tilt. However, the reality is it is like fielding half a team against the All Blacks and being surprised we are not winning and getting through the backlog. We are running to stay still. We are like swans. We may look calm above the water but we are not, because we are constantly in crisis mode.

I must mention that in respect of burnout before the crisis, the figure among Irish consultants was 44% in 2018. That would compare with about one in three worldwide. That figure was at 77% in January. That was before the impact of the cyberattack. I have multiple colleagues who are off on sick leave due to the impact of the excessive workloads. Other colleagues are considering leaving the system. We do not just have an issue with recruitment, we also have an issue with retention. The knock-on impact of that for patients is a lack of slots and outpatient and diagnostic capacity. The critical issue is having the people power and having enough people on the team.

Cathal Crowe (Clare, Fianna Fail)
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I thank Dr. Colleran for her response. I take her point that it is about people power and having the personnel to deal with it. The same point has been made over many months by other colleagues of Dr. Colleran.

The next issue I wish to raise from the opening statements is-----

Seán Crowe (Dublin South West, Sinn Fein)
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Before I move, do Ms Morrogh and Professor Landers wish to contribute?

Cathal Crowe (Clare, Fianna Fail)
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We have limited time. I wish to ask my question, if that is okay. I do not mind who responds after that.

Seán Crowe (Dublin South West, Sinn Fein)
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It is up to the Deputy.

Cathal Crowe (Clare, Fianna Fail)
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In Ms. Power's opening statement, she noted, "We are in the Stone Age when it comes to collecting real-time information on cancer services." My question for Ms Power and the other representatives on the panel is this: do the cogs that were put in place during the Covid-19 pandemic have a purpose beyond the pandemic? I have seen the European Medicines Agency, EMA, the European Centre for Disease Prevention and Control, ECDC, the WHO, Médecins sans Frontières and international entities over and beyond our own HSE in Ireland that are all communicating. The cogs of the wheel are working together. Smart pharma is engaging directly with the HSE and briefing it. It seems all of the cogs have come together during the crisis. The pandemic has been like our Blitz. We are in war mode, as it were. It seems there is great cohesion and co-operation internationally on the issue. Should some of those cogs remain in place, at least domestically, after we have rolled out the mass vaccination programme? Should some of these big cogs that have been additions to our regular HSE capacity remain in place to achieve a heightened roll-out of the national cancer screening programme to get more people in, so that niggling pains are checked out, screened and we detect and treat more cancers? I ask members of the panel of witnesses to respond.

Ms Rachel Morrogh:

I might address the Deputy's first question and talk about the data issue. With regard to the diagnostic delays, we concur with everything Dr. Colleran said about needing to make sure the services are there once people initially seek that medical advice. The issue with the Covid-19 pandemic is they have not been taking that first step. They have not been going to their GPs. When we look at the number of cancers diagnosed in rapid access clinics last year, they are about 6% below where we would expect them to be. With the annual increase in cancer, which is around 4%, we are probably down around 10% in cancers diagnosed, as Ms Power outlined in her opening statement.

These are real people. When we see there are 800 fewer attendances at prostate cancer rapid access clinics and 300 fewer attendances at lung cancer rapid access clinics, as Dr. Colleran stated, they are people who are at home at the moment and who, out of genuine goodwill towards the healthcare professionals, do not want to burden them. We did ask the question in research. Respondents stated they did not want to take away from the Covid effort that healthcare workers have been so caught up with over the past year. Earlier in 2020, one in four people told us they would not have gone to seek healthcare, even though they may have needed it. That statistic is still one in six people. We last ran the research in May, so we know there are still issues that we, as a community, need to address and encourage people back into healthcare. That will have an impact on the number that Ms Power described in respect of missed cancers that have not been diagnosed yet.

The data that Ms Powers used are some of the only data we have. We do not have eyes on any of the other cancers, aside from those being diagnosed in the rapid access clinics. That leaves us in a really vulnerable position when we are talking about solutions. What is the actual problem? I do not know that anybody can provide the answer to that question. For example, we cannot have targeted solutions that are needed to get head and neck cancer patients into the system because we do not know about the diagnosis rates. That is extremely troubling.

With regard to data, there are things we can do, such as adopting the individual healthcare identifier. Things that have already been progressed need to be accelerated because we need those data to inform policy responses.

Professor Robert Landers:

I wish to draw together some of the strands of the discussion. I would like to make a request of the committee on behalf of the IHCA. I am sure I will be supported in this by the IMO and the Irish Cancer Society. The committee has heard from all of the witnesses today about the huge deficit in terms of resources, capacity, diagnostics, beds and staff. The IHCA has made a submission to the national development plan which is due to be launched in July. It is a critical plan for the future planning of healthcare infrastructure in the State. We have sought engagement and we have had none. I ask the committee to encourage those putting together the national development plan to include associations like the IHCA, the IMO and the Irish Cancer Society in their planning. What we need is joined-up thinking. There are too many silos and organisations doing their own thing. It all needs to be drawn together. I ask that we are involved in the planning. We are only too willing to help.

Seán Crowe (Dublin South West, Sinn Fein)
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Has Deputy Crowe finished his questions?

Cathal Crowe (Clare, Fianna Fail)
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Yes. I know not all of the witnesses had the chance to respond, but I sense great commonality in their responses this morning. We will take them on board.

Seán Crowe (Dublin South West, Sinn Fein)
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In response to Professor Landers's point, for anyone watching this morning, the lack of joined-up thinking comes across very strongly. In some areas, we have the equipment but we do not have the staff. We heard Dr. Kilgallen talk about having surgeons who only get a half day of surgery a week and the danger of people deskilling or leaving the health service.

From a personal position, I have had cancer twice. The positive message is there is life with cancer and life after it. That is the positive message people need to hear. When you are told you have cancer, it is not a pleasant or nice thing but, in many cases, it is not a death sentence.

How are people being told at the moment that they have cancer? The opening statement referenced the fact no one is there to your hand after treatment and so on. The big positive for me on the day I was told was my wife was with me when we heard that information. I am concerned that I have had a number of phone calls as part of my treatments since the Covid pandemic. I would be concerned if people were getting that information over the phone. Can anyone inform us, more so for people listening at home, how that information is told? Can someone give us an answer on that?

Dr. Clive Kilgallen:

In terms of cancer diagnosis and treatment, the good side is that never before have there been so many opportunities. There have been incredible recent advances in cancer diagnosis and treatment. If patients present, particularly if they present earlier, the more likely it is they can be cured and treated. This is new. There is a silver lining in all of this in that, between all of us, we have an opportunity to make changes.

I hear from our doctors on the wards during this Covid crisis that because patients are ill and in hospital, they do not have access to relatives. It is a communication problem in that clinicians, NCHDs and nurses are spending a lot of time texting, ringing and emailing relatives. That is extremely difficult. Of course, relatives at home may not be getting the full story. They are worried and anxious. The patients in hospital are anxious. This is one of the major things that has happened to staff on the ground who are trying to improve that. It has been very difficult.

Seán Crowe (Dublin South West, Sinn Fein)
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On that point, there are lessons we can learn post Covid. For instance, 40 people can get an invitation to see a consultant at 9.30 a.m. and another 40 in the afternoon. Maybe we can do things differently in that regard and make better use of consultants' time. The phone call idea for a consultation can work in many cases. It is probably not the same as meeting the consultant or doctor but it can help.

The other positive message is we hear about new drugs all the time. In yesterday's newspapers we read about a new drug discovered in Scotland. Again, life chances are increasing all the time with new treatment. The positive message needs to come across. I cannot get my head around the idea of people not attending their appointments. This happened pre-Covid as well. The number of people who did not turn up for BreastCheck was quite high. People were sent a bowel cancer test and did not use it because it was somehow uncomfortable or they did not like to do it. It is absolute nonsense because, at the end of the day, if this saves a life or the life of someone belonging to you, someone you love, you would take those tests.

On the one in six issue and the research on people who said they had difficulty attending doctor's referrals and so on, was some of this, again, down to mixed messaging? For instance, it was difficult to get in touch with a GP during the Covid pandemic. People were told to go to their GPs only for urgent cases and so on. Did some of that mixed messaging move through the population and people said they were not really that sick? Maybe that is something we need to concentrate on now. We will make a statement after today's meeting if people feel that is helpful. We will take up the issue of Irish consultants not being brought into the discussion on healthcare.

Is there anything else? One of my colleagues, Deputy Burke, wants to come back in. Specifically, is there anything else people want to make a point on? We are coming to the end of our session. What else can this committee do as part of its work, especially around the area of cancer? I am conscious some cases can be down to lifestyle, obesity, alcohol, diet and so on, which all have an impact on health and the growth of cancers. We also need to send out the message to people that we all have cancers in our body, but some are switched on and others switched off. However, it is not the death sentence some people seem to think it is. It is important we keep reiterating that. Does anyone else want to come in? I will then let Deputy Burke in.

Ms Averil Power:

I will pick up on the Chair's last point. I thank him for sharing his personal experience and reminding people that, increasingly, there is life after cancer. We are in a crisis, obviously, at the minute and it is right the committee is focusing on how we can address the Covid backlog and the cyberattack to get things back on track. However, it is also important to give people hope because there will be people watching this webcast who are going through cancer and need that hope. Things really have improved. Thirty years ago only three out of ten Irish people survived cancer; today six out of ten do. Many cancers, such as childhood blood cancers, that were almost always fatal in the past are now largely curable. Progress is being made every day, including with research we fund, to turn today's terminal cancers into tomorrow's treatable and survivable ones.

I urge that, in addition to addressing the current crisis and focusing on those short-term measures, we also get back to the long-term vision that it is absolutely within our grasp to end cancer deaths. The scale of medical and scientific progress made in recent decades is incredible. We have doubled the number of people surviving. If we see the same political and investment priority given to cancer research after the pandemic as we have seen for Covid, it is absolutely within our grasp as a global research and medical community to end cancer deaths in a generation and make sure people do not needlessly lose their lives to this terrible disease.

In addition to raising short-term issues, I urge the committee, through all the work the various Deputies and Senators do here influencing Government priorities in the recovery plan, to make sure we see those political and investment priorities for the national cancer strategy and cancer research so we can realise that ambition. If we look at how quickly we have developed not just one but many different Covid vaccines, when we make something a priority and we give experts such as those on this call and their colleagues globally the support and investment they need, we can do incredible things. This will make such a difference to people affected by cancer currently and in the future in every community in Ireland.

Dr. Gabrielle Colleran:

We have seen today the patient perspective and advocacy from the Irish Cancer Society, the professional clinical expertise from ourselves and the political leadership from members of the committee. What we need now, for the next step, is to have everybody available and working together to build forward better so we really deliver for patients. It would be wonderful if the revised national doctors training and planning, NDTP, coming out in July was discussed by the Committee on Health before then, so those of us involved in delivering and receiving the care could have an opportunity to help shape that. It is critical that is successful and has the capacity in terms of staffing and infrastructure to deal with the impact of the cyberattack, Covid and the lists that pre-existed so it works for patients.

To address the point about patients not attending appointments or taking up the opportunity for screening, it is very important that we centre the patient and the patient experience in that and not take a judgmental approach.

There are many reasons people struggle to engage with services or might be afraid of services. Travellers in Ireland have experienced a lot of systemic discrimination, as have other vulnerable groups, where their experience when they deal with the medical establishment has, historically, not been a positive one. There is a body of work around trust. We see this with the vaccination programme and vaccination hesitancy in certain groups, where we must take an inclusive health approach. We must also recognise that not everybody has the educational ability to interact with all of the public health measures. A person might have a reading age of 12, for example. Our colleagues, Dr. Clíona Ni Cheallaigh and Dr. Austin O' Carroll, do a lot of work in this area. It is important when people do not engage that we do not judge them for that, and that we are curious about the reasons behind it so that we adapt our service to meet them. Too often in the past we expected people to adapt to the service, but the HSE shaping our service for people's needs is where we need to go.

Deputy Durkan made a point about how much the health service costs and about it not being as good as it should be. When we surveyed patients' experience of the system our satisfaction ratings for care were up in the high 80s, at 84% or 96% in the last survey. I have worked in the best children's hospital in the world. Ireland has fantastic staff here who are second to none. Our issues are around capacity, not having enough staff and not having enough infrastructure. We have a population the size of the greater Manchester area. This is totally fixable. Covid showed us that when we have the politicians, the Department of Health, the HSE and the front-line staff working together with the public, we could change things. As my colleague, Dr. McCauley, pointed out, e-prescribing, which people have been working on for years, was transformed overnight when there was a will to work together. Our health service is fixable. We can go from the longest waiting lists in the EU to the shortest if we get everybody's shoulder to the wheel and working together. We just need to have that collaboration. It must be led from the front line, from the patients and the staff who are at the point of care.

Dr. Clive Kilgallen:

As a nation, we have come a long way in a year and half with this new disease. We are now in the situation where vaccines are being rolled out and hopefully in the next few months the vast majority of the population will be vaccinated and we can slowly get back to normal. One of the big things is the solidarity of all of us, doing what we are supposed to do, keeping our distance and wearing masks: all of those good things have paid off. There are people at home, however, who may have symptoms, who may be losing weight and be worried. People know their bodies. If there is something wrong, then I would say to them "Please, please do not be afraid". They should go to their GP. They will be looked after and will be cared for safely. This is the big message to get out to patients now.

Seán Crowe (Dublin South West, Sinn Fein)
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Two of my colleagues, Deputies Durkan and Colm Burke, are looking to come in but I am over time with the Covid regulations. Unfortunately, I will not be able to bring them in.

I thank everyone for their attendance. I am conscious that there is a cost factor with cancer and we really did not get into that today.

I thank all of our witnesses. This concludes the committee's business.