Oireachtas Joint and Select Committees
Wednesday, 29 April 2026
Joint Oireachtas Committee on Health
Radiation Oncology Capacity: Discussion
2:00 am
Pádraig Rice (Cork South-Central, Social Democrats)
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Apologies have been received from Senator Ryan who is on maternity leave.
I remind members of the constitutional requirement that members must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to partake when they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precinct will be asked to leave the meeting. In this regard, I ask any members partaking on Teams that, prior to making a contribution to the meeting, they confirm that they are on the grounds of the Leinster House complex.
Today the committee will consider radiation oncology capacity in our public system and the need for investment and the replacement of critical infrastructure. This issue has been on the committee's agenda for some time, in particular the need for a rolling radiation therapy machine replacement programme. This is something I have raised directly with the Minister for Health on numerous occasions. At the moment, we have an ad hoc system of replacement for radiation therapy machines, with machines far exceeding their sell-by date before being replaced. This is despite the fact that the need to replace these machines is entirely predictable. This is by no means a fringe issue. Radiation therapy is a cornerstone of modern cancer treatment. It is simply not good enough that some machines are almost 20 years old when the international internationally accepted lifespan is ten years. It is an unacceptable situation that is fuelling the outsourcing of public patients to the private sector at huge cost. This is an issue that needs to be addressed urgently.
To assist the committee, I welcome Professor Aisling Barry, chair of radiation oncology at UCC, who is accompanied by Professor John Armstrong, consultant radiation oncologist; Professor Gerry Hanna, Marie Curie chair of clinical oncology in TCD; Olivia Brereton, radiotherapist; Professor Brendan McLean, professor of medical physics; and from the Irish Cancer Society, Stephen Dempsey, director of advocacy and communications, and Edel Shovlin, chief operating officer.
On privilege, witnesses are reminding of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that may be regarded as damaging the good name of a person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue your remarks. It is imperative that they comply with any such direction. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to him or her identifiable.
To commence today's proceeding, I invite Professor Barry to make her opening remarks.
Professor Aisling Barry:
Táimid fíorbhuíoch as an gcuireadh teacht anseo inniu thar ceann Chumann Radíochta Ailse na hÉireann chun an dúshlán atá amach romhainn maidir le trealamh radaíochta ailse a phlé leis an gcoiste. We are very grateful for the invitation to the Irish Society of Radiation Oncology to discuss the current challenges we have in Ireland regarding radiotherapy equipment. I am grateful to the witnesses that have come with us today. I also acknowledge the rest of the advocacy group and our public and patient representatives who were unable to join us today.
We are here to ask for proactive planning for radiotherapy machine replacement via a structured national replacement programme to ensure safe access, modern radiotherapy, and to ensure regional equity, world-class cancer treatment and the best outcomes for patients.
The ask is not for more money or more staff. It is simply to develop a national pathway with national oversight and accountability with rolling funding to replace our machines.
Radiotherapy in Ireland has a long history, dating back over 100 years, with direct links to the Nobel prize winner and mother of radium Marie Curie. As a specialty, we strive to deliver the highest quality, data-driven and compassionate care for our patients. It is an essential element of curative treatment for many types of localised cancers and is also effective in alleviating the symptoms of many patients with locally advanced or metastatic disease. Our modern infrastructure and landscape have evolved significantly, with the advent of increasingly sophisticated computerisation, technology, artificial intelligence and automated tools, revolutionising how we deliver patient-centred care today.
Current evidence indicates that up to 50% of patients with a cancer diagnosis will require radiotherapy during their illness, and that radiotherapy is responsible for 40% of cure rates, either as the main treatment or in combination with other cancer directed therapies. Our rates of utilisation in Ireland are increasing year on year. For example, in Cork we have seen a 17.8% rise in patients receiving radiotherapy from last year. Thanks to modern radiotherapy machines and world-class clinical expertise that exist in Ireland, patients with, for example, early stage lung cancers can be cured with radiotherapy without having to have surgery. Failure to deliver modern radiotherapy compromises patient outcomes, reducing cure rates.
Radiotherapy is delivered by machines called linear accelerators or LINAC machines. These machines are complex technologies and require expertise in the maintenance and delivery of treatment, which is why we have such a big team with us here today. The recommended lifespan of a machine, by organisations such as the International Atomic Energy Agency, is ten to 12 years. In Ireland's public system there are 23 LINAC machines, 14 in Dublin, of which 90% are beyond the ten-year lifespan. Furthermore, all five machines in Cork will be due for replacement in three to five years. This is over 80% of the Irish fleet requiring immediate or imminent replacement, with little to no proactive planning to do so. As any technology and machinery age, reliability, efficiency and precision lessen. It is no less for LINAC machines. Over time, breakdowns occur more frequently, requiring higher levels of maintenance, parts need to be replaced and programmes take longer to update and are no longer compatible with modern operating systems. Just because these machines can be kept active and working hard, they are not capable of delivering modern radiotherapy techniques.
Most poignantly, all these consequences of ageing machines negatively impact the patient directly, resulting in increased anxiety of missed treatments, delayed treatments, longer treatments, financial toxicity, knock-on impact of patients missing start of treatment targets, pressure on staffing and the requirement of outsourcing to other public or private centres, to name but a few. Furthermore, despite Government investment over the past 15 years to combat regional inequity, regional inequity is once again at the forefront with the current replacement issues in Dublin. By the time Dublin completes its equipment replacement phase, estimated to be 2031, LINAC machines in Cork will have again exceeded their lifespan, with Galway a mere two years away. This perpetuates a rolling inequity, leaving patients’ access to modern radiotherapy technology dependent on geography rather than clinical need.
It is also important to note that radiotherapy is the most economically efficient of any cancer treatment. Yet, when machines break down or can no longer deliver, outsourcing is required as seen in recent publicly available figures. Managed replacement is without doubt more cost-effective than replacement due to age and machine breakdown. I would like to read an excerpt from a letter written by Aoife, our patient representative on the advocacy committee who wrote last month to the Minister for Health and An Taoiseach:
... despite the incredible people caring for me, there was one factor that caused unnecessary stress and disruption during my treatment. The radiotherapy machine being used was old and unreliable. Of my 25 radiation sessions, six were delayed because the LINAC machine in Unit 7 repeatedly broke down. I later found out that Unit 7 is one of the oldest in Ireland now in operation for the past 18 years ... Unscheduled interruptions create anxiety about the effectiveness of therapy ... This is in addition to the practical realities: last-minute childcare arrangements, rushed travel, and the physical discomfort of elongated waiting times...
Aoife correctly points out that for some cancers significant data demonstrates delays in starting treatment influences outcomes negatively overall and delays during radiotherapy, specifically in rapidly growing cancers, deprive patients a chance of cure. We should not accept this.
We know that every time we place a LINAC machine into the system, it will need to be replaced at ten to 12 years in the future. Other countries know this too, and to mitigate massive replacement schedules at one time, like what is happening in Dublin, they have introduced, with Government support, rolling replacement programmes. These programs require accountability, foresight, planning and investment, but they work. In Canada, Cancer Care Ontario, CCO, have developed guiding principles for the radiation oncology specific capital strategy, which include keeping pace with advancing technology to improve delivery of care and minimising costs through centralised planning and procurement processes. This is now a Canada-wide strategy where radiation replacement grant allocation adequately funds the replacement of current equipment and ensures the investment process accommodates innovation. Northern Ireland, Scotland, Australia, New Zealand and the Netherlands all have recognised this need for proactive planning. Some have developed cyclical government-led plans for machine replacement, while some have entered public-private partnerships to deliver capital upgrades.
Regardless of the system employed, the structure ensures predictability and co-ordinated investment in radiotherapy infrastructure. We envision such a program akin to what was described in section 8.4.2 of the current national cancer strategy; "a rolling plan of capital investment will be required to ensure that high quality facilities are available for patients". We envisage that this programme would provide ring-fenced annual capital funding to replace two to four LINACs per year on an infinite ten-year rolling cycle.
In 2003, the then Minister for Health, who is our current Taoiseach, Deputy Micheál Martin, asked an expert group to undertake an assessment need in relation to radiotherapy services. This was led by the late Professor Donal Hollywood and Professor John Armstrong, who sits with us today. They described in their summary: "The national solution ... [should] importantly be configured in a way that provides maximum opportunity to address the anticipated and unrecognised elements of future radiation therapy provision." Further radiotherapy provision continues to be our mantra. With a structured national linear accelerator replacement program, access to modern, safe radiotherapy in Ireland will be determined by clinical need. This will ensure equity of access regardless of geographical postcode.
Finally, I would like to give the last word to Aoife, our patient representative from the letter she most eloquently wrote:
Today I am thankfully back working full-time and living life again. But there is no day where I forget about cancer. Every time I shower or change clothes, I see the four permanent tattoos placed on my body to guide the radiation treatment. Those tattoos are daily reminders of the experience. With newer radiotherapy machines, I believe these permanent markings I have to live with would not have been necessary ... Patients facing the most vulnerable moment of their lives deserve the best technology available, not equipment that risks breakdowns, treatment disruption and potentially avoidable long-term side effects. Cancer treatment is already one of the hardest journeys a person can face. We should not be making it harder by asking patients and clinicians to rely on machines that have passed their optimal lifespan.
Pádraig Rice (Cork South-Central, Social Democrats)
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I thank Professor Barry. I now invite Mr. Dempsey to make his opening remarks on behalf of the Irish Cancer Society.
Mr. Steve Dempsey:
I thank the committee for inviting us here today to discuss radiation oncology capacity in the public hospital system and the need for investment in the renewal and expansion of infrastructure. Issues around funding cancer care are always life and death. All too often, they are also highly complex in nature. When it comes to radiation oncology, however, this is not the case. The issues in this area are entirely predictable, as we have heard, and can be resolved with dedicated resources and a budget to support a structured national replacement programme of radiotherapy machines. A national replacement programme is an investment that will work hard for the health service. Up-to-date radiation therapy machines can treat thousands of people, over thousands of sessions, curing thousands of cancers.
Some 44,000 people in Ireland are diagnosed with cancer each year, and that number is set to grow. Radiation therapy contributes to a cure rate in 40% of cancer patients. However, 1,440 of us will not start radiation therapy within the recommended time frame. Without a plan to replace radiotherapy machines, this number is set to grow too. Day in and day out, the ICS hears from members of the public about difficulties accessing cancer tests and treatments in appropriate time frames. We have heard from a cancer patients, due to start radiation therapy, who are waiting longer than four months post-surgery on start date; and still with no appointment in sight.
For those who do get an appointment, the society has heard reports of machines breaking down. This means longer time waiting in hospitals, patients moving from one machine onto another and knock-on delays for another person hoping to start radiation therapy. We also hear that many patients face a postcode lottery, as machines around the country age and are not replaced as they become outdated. The result is that our current system causes unnecessary anxiety for cancer patients as they navigate an uncertain path through the healthcare system. Instead of predictability, they have uncertainty. Instead of dependable access, they have delays.
The current system also undermines hard-working staff, who show up to work every day to deliver quality care to cancer patients, but who are let down by inefficiencies in capital investment and workforce planning.
Given that the problems facing radiation therapy services are entirely predictable, the Government could solve them by establishing a national radiation therapy equipment replacement programme, with the oversight of the NCCP. This would ensure that new machines are installed every ten years and are adequately staffed. As we have heard, this is in the national cancer strategy, which committed to implement a national programme of equipment refreshment and replacement for a sustainable and ongoing approach to replace and refresh radiation therapy equipment by 2026. A similar but less specific commitment is also in the current programme for Government, which promised to invest in infrastructure to meet the national cancer strategy treatment times.
Ms Edel Shovlin:
As we have heard, a national radiation therapy equipment replacement programme is standard practice in other countries. I have overseen such replacement programmes overseas and understand the predictable nature of these programmes and the capital expenditure required for a successful replacement programme. It is not only an investment in a functioning health system, but also an investment in the outcomes of Irish cancer patients. State-of-the-art machinery has a real patient impact, from reducing discomfort, to removing the need for those permanent tattoos, which as we heard, are a constant reminder of their cancer treatment, to the delivery of precision treatment that has fewer side effects for patients and in faster session times. The recommended lifespan of a linear accelerator is ten years. Some 35% of our LINAC fleet exceeds that lifespan significantly, with some machines in service for 18 years. This in itself can mean significant annual maintenance costs as a result of age.
Finally and more generally, the Irish Cancer Society would also like to state that a lack of forward planning in the area of radiation oncology is indicative of a lack of forward planning across the cancer spectrum. We would once again like to remind the committee of the need for multi-annual funding for our current national cancer strategy, which although in its final year still needs adequate funding. As we have heard from our clinical colleagues, going forward it is critical that ring-fenced, multi-annual funding be baked into the next national cancer strategy and that appropriate infrastructure investment is made and associated staffing levels are maintained so that lives can be saved.
Pádraig Rice (Cork South-Central, Social Democrats)
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I thank the witnesses. We now move to questions from members. We have an agreed rota. They will get eight minutes each for questions and answers. We will take a five-minute break about halfway through and then we will continue. Members who are not members of the committee will be then at the end of the list and will be invited to speak at that point. Our first slot is for Fianna Fáil and Deputy Martin Daly.
Martin Daly (Roscommon-Galway, Fianna Fail)
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I thank Professor Barry and her colleagues and Mr. Dempsey. It is simply incredible that for such a critical form of treatment for cancer that the committee is being told it is not a question of money but rather a matter of planning and having an ongoing rolling procurement programme, which is a predictable model. Is that right? Some of the machines are so old, they break down regularly. How much does a new machine cost, approximately?
Martin Daly (Roscommon-Galway, Fianna Fail)
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If a machine breaks down, how much does it cost? How much would a part, for example, cost to replace in a machine that is 18 years old?
Martin Daly (Roscommon-Galway, Fianna Fail)
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There must be a ballpark figure.
Martin Daly (Roscommon-Galway, Fianna Fail)
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So that is €300,000.
Martin Daly (Roscommon-Galway, Fianna Fail)
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In an 18-year-old machine, are the comparable machines in nearby jurisdictions where parts can be sourced for them or does the HSE have to go further afield for them?
Martin Daly (Roscommon-Galway, Fianna Fail)
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If there are no similar machines in the UK or the European Union, where does someone have to go for parts like that?
Martin Daly (Roscommon-Galway, Fianna Fail)
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On average, how long does it take to put a machine right if it breaks down?
Martin Daly (Roscommon-Galway, Fianna Fail)
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On average.
Martin Daly (Roscommon-Galway, Fianna Fail)
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What happens when there are booked patients with cancer who have already had a delayed access to treatment?
Professor Gerry Hanna:
The challenge is that the machines do not break down in a predictable manner. That is the big problem and, as Professor McClean alluded to, it can be a variable time frame to get that part in and get the machine fixed. It could happen first thing in the morning and a machine is fully booked with patients. The machine has to be offloaded, those patients have to be redistributed and we have to cancel other, less urgent patients. There is this massive urgency inside the department day in and day out to re-sort these patients and make sure the patients whose treatment are time critical get treated that day.
Martin Daly (Roscommon-Galway, Fianna Fail)
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Where do the patients for Professor Hanna's unit travel from?
Professor Gerry Hanna:
They could be travelling from anywhere from Donegal to Waterford. I am mainly based at St. Luke's network in St. James's. We treat lung cancer patients all the way from Waterford to Donegal, so they could be travelling some distances for those treatments, and that can be delayed by several hours. We then have to try to get the staff to stay behind. This is an impact. I know it sounds very minor, but we have challenges recruiting and retaining staff. That is a really big issue for us, and there is a morale issue too. For people with families, if I say we cannot finish at 6 p.m. or 7 p.m. and we have to stay until 8 p.m. or 9 p.m. that is a huge impact on them, let alone the tremendous impact to the patients. As the committee heard from the letter Professor Barry read out, it is awful for patients, who are anxious to begin with. If someone is coming for their first treatment and the machine suddenly breaks down, their confidence in that system is smashed to pieces.
Martin Daly (Roscommon-Galway, Fianna Fail)
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Someone coming from Donegal may have flown down and expected to go back on an afternoon flight.
Martin Daly (Roscommon-Galway, Fianna Fail)
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What happens to them?
Martin Daly (Roscommon-Galway, Fianna Fail)
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It is a huge problem and this is all about the patient, by the way. There is huge anxiety for those patients. They have had delayed access to treatment and now they have arrived at a centre where a machine has broken down. We have heard it could take from a day to a week to have the machine fixed. There are other patients waiting for treatment on the other machines.
Professor Gerry Hanna:
Imagine trying to reassort this out day in and day out. We are really keen to deliver the most efficient timely service but it is impossible to do that if we are constantly reassorting these patients at short notice in an unpredictable manner. If there is a storm at Dublin Airport, it takes days for it to get back on track, and we are exactly the same as that. The flights get delayed and our patients all get reassorted in that way and it is very disruptive and it takes a long while to catch up. We are doing our very best to cope with that but at a great cost and it is not just those reassortments. In St. James's the machine that delivers our stereotactic programme is 15 years old. It delivers accurate treatment, but it breaks down very frequently. A treatment might take 20 or 30 minutes when it is working really well, but if the machine is constantly breaking down and tripping, that could take an hour. That poor patient is stuck on the bed for an hour rather than 20 minutes and it is not necessarily very comfortable. There is a knock-on effect that they are running late by 40 minutes. These minor things all add up to delays in the system, but huge patient impact. I cannot overstate how distressing it is for them.
Martin Daly (Roscommon-Galway, Fianna Fail)
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On average, how many treatments would be required for someone with lung cancer?
Professor Gerry Hanna:
For lung cancer, it can be as short as three treatments with our stereotactic programme, but they are very long treatments, often of 45 minutes. Some of our head and neck cancer treatments take up to 35 treatments over seven weeks, and some of our prostate treatments are seven and a half weeks with 37 treatments.
Martin Daly (Roscommon-Galway, Fianna Fail)
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There can be someone coming from Donegal or somewhere else at a distance, for 33 or 35 treatments, ending up in a situation where they arrive where there is not treatment available, they may have to be admitted sent home or rescheduled. This is a huge problem.
Martin Daly (Roscommon-Galway, Fianna Fail)
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I know.
Martin Daly (Roscommon-Galway, Fianna Fail)
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The messages need to be simple and clear. Access affects outcomes, and access is a problem. Reliability affects outcomes, because if people are being put off and their treatments are not being conducted in a cyclical manner the way they are planned, that also affects outcomes.
Professor Gerry Hanna:
It could affect outcomes. We work very hard to mitigate that, but it is at a huge cost. Our worry is that while we have never had a complete breakdown, we are very at risk. For example, our Beaumont centre has four machines and if all four broke down tomorrow, we would be in difficulty and they are breaking down so regularly that this will happen within the next year. It is only a matter of time before that happens.
Martin Daly (Roscommon-Galway, Fianna Fail)
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The precision of newer machines is important as well in terms of outcomes. Can someone make a comment about that?
Professor John Armstrong:
I thank the Deputy for that. He is absolutely right. The disruption is, of course, very important and there is a huge human cost but the real thing is the precision of machinery. Very old machines are less precise. In the case of a throat cancer, if we want to radiate a cancer sitting in the voice box and if it is a very old machine, the beam has to be opened wider and that means there are more collateral short-term and long-term side effects that the patient lives with for the rest of their life. A more precise machine allows us to focus the beam in more and to improve what we call the therapeutic ratio - the balance between benefit and damage. That is what we lack when all our machines are old. They are all going to be replaced some time in the future and we will get ten new machines all together. We do not have the capacity-----
Martin Daly (Roscommon-Galway, Fianna Fail)
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I asked a parliamentary question on the floor of the Dáil. I take the Minister at her word. She must have been briefed by her officials either in the Department or the HSE. None of that is congruous with the witnesses' statements today and I think it is a big ask of the Minister to put this right.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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I thank our guests. It is really wonderful to have them here. I have to be honest in that I am actually quite terrified by what they have said. My constituency is Longford-Westmeath. What I hear about time and again is the travel cost, the fuel cost - the actual cost of being sick with cancer. That has people so anxious and really frightened that they are not going to be able to meet the appointment they so desperately need. Then to hear from the witnesses' side that even if they did make it, there is a chance, maybe low or maybe medium, that the appointment would not even go ahead, I cannot imagine the level of anxiety a patient with cancer goes through with that pressure. Then there is taking time off work, childcare and whatever else.
Professor Barry said something that really struck me. It was a quote from Aoife of being deprived of a chance of care. If there is one thing that needs to come out of this committee today, it is that. Because of a system that is broken, because of a lack of a plan and of foresight and because of machines not being upgraded, a person could be deprived of a chance of care. Professor Hanna spoke of the confidence of patients being affected and of having to make a decision where a machine breaks down, with somebody whose treatment may be less urgent than the next person perhaps being moved or so that somebody whose appointment had to be cancelled could be slotted in. Surely we run the very real risk of a patient whose cancer today may be less urgent actually becoming urgent because they are not getting those appointments on time.
Professor John Armstrong:
There are obvious cancers where the data is very clear, such as cervix and throat cancers, where these tumours grow quickly. We have really clear evidence that delays lead to decreased outcomes, less survival and lower chance of cure. It is harder to demonstrate that in other cancers but the probability is that it is also true. You cannot indefinitely prolong a course of treatment for breast or prostate cancer, for instance. The Deputy is probably right.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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I am really struggling to get my mind around this. We are not a poor country, far from it. When 1,400 people do not start radiation on time, it is not acceptable that we have ended up in this situation.
Professor Gerry Hanna:
We now have the oldest radiotherapy fleet in Europe. That is a national disgrace. I know that is a strong word but it really is. It is very sad to say that. We do not accept this in other forms of medicine, such as drug therapy or diagnostics, but somehow we have let this slip in radiotherapy. We are being asked to work with the equivalent of Windows 95 rather than the most up-to-date equipment. We would not expect any of our colleagues to work with those software systems but that is what we are doing day in, day out. We are treating our most vulnerable patients, including children, in these older machines. It is a disgrace and it needs to be urgently addressed. We have a really easy solution. The money is already there. We have to pay it any way. It is about creating a programme that delivers on time. Also, beyond the rolling replacement we are asking for today, it is really about getting our St. Luke's replacement under way as soon as possible because we urgently need it.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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The witnesses have been very vocal on this issue for the past number of years. Why has this been allowed to happen? I am not asking them to point the finger at somebody, although they should please feel free if they want to.
Professor Gerry Hanna:
It is very hard to get to the bottom of it. One challenge is that in our procurement systems, we are paralysed by the fear of getting it wrong. We have probably over-complicated the procurement system in that way. We need to have a more efficient procurement system or do it a different way. There is a good chance, if we do it in a structured, planned way that will deliver, that it will probably also be more cost-effective, as we have heard. That is a benefit. We have an inherent duty to get the most cost-effective treatment for the public purse, so why would we not seek to do this with how we structure what we do? In fairness to colleagues in procurement and other parts of the HSE, the bureaucracy they deal with now is so much more than it was. It is very difficult to get around that. We need some way to streamline our processes of procurement so that they are actually effective and deliver for us and for patients across Ireland - for our communities.
Professor Aisling Barry:
If I can add to that, the biggest part of this is that there is no accountability. There is nobody accountable for the replacement of any of these machines. The only way this happens or that we get the machines to the point where somebody will decide to spend money on them is by starting with a business case in the hospital. I counted the steps. There are at least eight steps to get through, which takes a long time, to get somebody to say "Okay, we will do this." There is no accountability. It bothers me that we cannot find a very simple solution for someone to be accountable for these. There are 23 machines. It is not that many.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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That actually makes an awful lot of sense. We know the life span of these machines is ten years. That is not a complicated system to be able to manage. One of the machines is 18 years old, which is almost double its life span.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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Given the level of breakdowns that exist, what happens if Beaumont's four machines go down?
Ms Olivia Brereton:
I am clinical radiation therapist. From a clinical perspective, when a machine goes down, it has a massive impact on the patient who is currently set up on the treatment machine, on all the other patients in the waiting room and on the staff. I will just focus on the patient on the bed. That patient has had to be set up for the radiation therapy treatment. They need to go into a specific position. That can involve using a mask for immobilisation of the head. It can also involve bladder preparation. For some treatments, patients need to have a certain volume in their bladder, so their anatomy matches their plan, basically. If the machine breaks, that patient first has to be told there is a problem with the machine. That is an initial worry. For somebody who is nervous in a mask, for example, we want to minimise the amount of time these patients have to spend in that position on the bed. We need to take the patient off the bed. We have to go through the whole process of setting that patient up again on another machine. The patient has undergone the process twice. They have also potentially received a small extra dose of radiation to ensure they are in the right position. Hopefully then we find a space on another machine and we can give them their treatment. There are patients who struggle-----
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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I am sorry. I have one eye on the clock here. I am coming to the end of my time.
Ms Olivia Brereton:
I will just say that patients do struggle with moving machine. I also want to make a point about patients. Certain patients are anxious and may require more medication, relaxants, to go through the treatment. People with special needs are in a really difficult position. If you have found a window where you can treat that patient, you may lose that window and the patient may not be able to have access to treatment for that day.
Colm Burke (Cork North-Central, Fine Gael)
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I thank all the witnesses for coming here this morning and for their presentations as well as for the work they are doing in this whole area. In the presentation, it was outlined that there was a 17.8% increase in radiation therapy treatment in Cork. Would this be reflective of what is happening around the country, that the demand is growing because of increasing population?
Have we similar positions in all the other units around the country?
Professor John Armstrong:
Nationally we have a chronic problem with underutilisation of radiation therapy. A lot of that comes down, again, to the precision of the machinery, that is, the fundamental ability to direct the radiation where you want to point it as opposed to where you do not want to point it. That affects clinical outcomes and decision-making in a multidisciplinary team environment. If you have a liver tumour, for instance, and you have access to the latest machinery, you can tackle that tumour with radiotherapy as opposed to having a different type of intervention. If the radiotherapy machines in a region are not up to speed for that and do not have the necessary technology to do that, then that patient ends up with a different kind of treatment and therefore radiation is underutilised.
Colm Burke (Cork North-Central, Fine Gael)
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The question I am really focusing on is the increase in the number requiring radiation therapy. What is the average increase per annum in the number of people looking for treatment? Have we a growth rate of 5% or 10% per annum?
Colm Burke (Cork North-Central, Fine Gael)
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There is gong to be growth and Professor Barry said there was a 17.8% increase in the level of treatment in Cork but are we planning for that growth? Even if we talk about replacing the machines-----
Professor Gerry Hanna:
Partly we are. Inside the St. Luke's network, in our linear replacement plan, which again is not yet signed-off or gone to tender, even though it is urgent, we have a plan to expand the Beaumont centre by an extra two LINACs to reflect the increase in growth but also the changing population demographics in the northern corridor and northern region. There are plans for that and we try to match that. We have very good modelling, which Professor McClean might want to speak about.
Colm Burke (Cork North-Central, Fine Gael)
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One of the issues that concerns me is something like 90% of patients require treatment within 15 days but one in five is not starting their treatment programme within that timeframe. Is that going to stay like that for the next 12 months to two years, unless equipment is replaced immediately?
Professor Brendan McClean:
We have modelled this. We have modelled the demand based on the national cancer registry data and the projected data of the expected number of patients. We are tracking along that model and we see there is a need in St. Luke's to go from 14 LINACs to 17 LINACs to cope with the increased demand over the next five years.
Colm Burke (Cork North-Central, Fine Gael)
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Is there any plan from the witnesses, the Department and the HSE to deal with the budgeting for where that extra equipment is needed?
Professor Brendan McClean:
Yes. We have a plan in place. The tender for the building of the new Beaumont centre just went out last week. The additional three LINACs that are required in the network are going to form, as I understand it, part of the same procurement process as the replacement programme. It is important we have the same equipment across the three centres of the St. Luke's network. That is planned.
Colm Burke (Cork North-Central, Fine Gael)
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When we did the national strategy for 2017 to 2026 there was a clear commitment, I think under recommendation 22, that there would be a rolling replacement of equipment. How come that was not implemented?
Colm Burke (Cork North-Central, Fine Gael)
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If you have a national strategy, surely there is a reference group to go back to in order to make sure the boxes are being ticked each year regarding targets like having patients seen within the 15 days and whether the equipment is up to date. Surely there is a process for dealing with that directly with the HSE and the Department.
Mr. Steve Dempsey:
I do not believe the KPIs for last year have been published yet, so transparency around data is an issue. The broader point we make from the Irish Cancer Society perspective is the national cancer strategy has not got ring-fenced funding and has not got certainty. Every year they go into the budgetary process wondering if they are going to get funding to deliver against the plan. There are two issues, which are transparency and then funding.
Colm Burke (Cork North-Central, Fine Gael)
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What about getting all the experts together to set out a clear programme over the next five years? There is no point in doing it over the next ten years. It needs to be done over five years. Have any proposals been sent in to the Department or the HSE or have there been any discussions on that over the past 12 months?
Professor John Armstrong:
The national cancer strategy is out of date. We do not have a new one. That committee should be formed and we should have a new national cancer strategy. We have a national cancer control programme and the logical thing to do is to empower it, as opposed to HSE estates, with this rolling replacement programme because HSE estates has not delivered the goods and we need to say that very clearly. When we bring this up at the level of the Dáil, we are told how things work, how things should work and the process that is going on but it is not functional. That is not a good enough response anymore and we need a new system.
Colm Burke (Cork North-Central, Fine Gael)
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However, the budget this year is €27.4 billion. Surely we should be able to identify where equipment needs to be replaced. If the witnesses say one in five is not receiving treatment within the 15-day time period, then there is a problem. Surely we should be able to get the message to both the HSE and the Department that the reason this is arising is we do not have the equipment.
Professor Aisling Barry:
One of the challenges has been that we focus on annual capital funding as opposed to forward funding, and that is what we really need here. We need to know annually we are going to spend X million on replacing two machines and just have it there constantly. At the moment we have to go begging every year and if you miss that cycle, then you are waiting another year to get into the next annual budget. It is just about trying to streamline that process a bit more.
Professor Gerry Hanna:
I was clinical director for oncology in Belfast before I came to this role and in that example in Northern Ireland we had an annual budget that clearly funded the replacement in a proactive manner. No machine in Belfast is over 11 years old and has not been for the past 25 years. That is just to give an example of a comparator just up the road in Belfast. Those are things I did not see and I was quite aghast when I came here to see the age of the machines. It is about having, as Professor Barry said, rolling replacement. That is managed. It has grown a little bit. We look to see what the need is. There is a whole place for that management. The ask is of the Minister for Health. We really need her to instruct the HSE to get this done and to get the tender out for the St. Luke's replacement. Those are the two very simple asks going into this meeting.
Professor Aisling Barry:
There is a narrative coming out that there is a replacement programme in place. There is not a national replacement programme in place. The replacement programme that is being referred to in the parliamentary questions that have come back is solely looking at Dublin, so we cannot say there is a replacement programme in place.
Colm Burke (Cork North-Central, Fine Gael)
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One of the presentations made here by the Department of Health was about the eight areas around the country where targets were being reached. There was criticism of one target and I argued the reason that was not reached was the equipment issue but also the lack of radiation therapists. Has the issue with radiation therapists been resolved in each of the areas at this stage?
Professor Gerry Hanna:
It is being resolved and there has been an increase in the number of training places and supports around it. It takes a little bit of time but it is not the key issue, which is the LINACs. We are solving the radiation therapist bit but also looking at the medical staff, the physics staff and all the other bits we need.
Pádraig Rice (Cork South-Central, Social Democrats)
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I have a number of questions. I start by thanking everybody who works in cancer services for all their work, their commitment and working in what are not ideal conditions from what we are hearing about the equipment. I commend everybody on their work. What we are hearing about how old the machines is really worrying. There is not a replacement programme in place even though it is entirely predictable. These machines have a set lifespan and there should be a rolling replacement programme. There are issues with staff shortages. We speak to people who struggle to get jobs sometimes and there are issues there. There is then the huge outsourcing of services to the private sector at a cost of €28 million last year. There is cyclical running down of these services when we could instead have invested that money into the public services, built them up, ensured we had the staff in place and delivered a world-class service. It is really concerning. As was said, there are real impacts for people in the form of delayed treatment, appointments being missed and even the length of treatment being longer here than elsewhere because the machines are older and that takes more of the doctors' and consultants' time. Then there is just the cost of repair and of not bulk-buying the machines. There would be cost savings there in the long term.
The calls the witnesses have made this morning are common sense. It would make perfect sense to have a replacement programme in place, for that to be entirely predictable, to invest in the public system and not spend the money on outsourcing. I have a few questions about the number of machines. There are 23 public radiation therapy machines across the country, is that right?
Pádraig Rice (Cork South-Central, Social Democrats)
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Of the 14 in Dublin, 12 are beyond their ten-year life span. Is that correct?
Pádraig Rice (Cork South-Central, Social Democrats)
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They are all more than ten years old.
Pádraig Rice (Cork South-Central, Social Democrats)
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Twelve are over 15 years old. They are well beyond the ten-year life span. Where the machines have reached end of life, is it the case that they are so old manufacturers will not support them?
Professor Brendan McClean:
There are two levels the manufacturer will respond to. One is end of support and the other is end of life. Eight LINACs are beyond end of support. It will provide a service and get parts as best it can. Four of our LINACs are beyond end of life. It is simply not possible to get parts although there might be some lying around. Likewise, the expertise within the company to repair LINACs of that age is extremely limited.
Pádraig Rice (Cork South-Central, Social Democrats)
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What happens if there is a major crash in one beyond the end of life or end of support?
Professor Brendan McClean:
That is the problem, especially with the ones that are end of life. It is very difficult to get them back up and running. We have an in-house engineering and physics team and a service agreement with the companies but once they get to this age, the companies are very wary about providing an ongoing service. They are loading the premium on that service. They are now actively considering stopping that service. That will be a problem, in that if a major part goes that we cannot get access to, then that machine is out of action.
Pádraig Rice (Cork South-Central, Social Democrats)
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These machines are so old they cannot even be supported or serviced. It is a real concern.
Professor Gerry Hanna:
It is increasingly difficult to get parts. We had to go to Egypt to try to get a part recently. That is how tricky it is. We are not getting them from other European countries. We are having to go to Middle Eastern countries to try to find these parts. That is where we are at.
Pádraig Rice (Cork South-Central, Social Democrats)
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Concerning the 14 machines that need to be replaced in St. Luke's, how regular are the breakdowns?
Professor Brendan McClean:
Last year we did some numbers. We had 1,500 events of downtime across the network amounting to a total of about 1,700 hours of unplanned downtime. That is not planned downtime when we plan and schedule maintenance; it is unplanned. It is the disruptive time we find very difficult to cope with. That is 1,700 hours across our network only.
Pádraig Rice (Cork South-Central, Social Democrats)
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It is nearly a daily experience.
Professor Gerry Hanna:
That is what we record. We do not record every incident because we are just too busy. The example I gave of the patient lying in the machine and the machine tripping but they were able to get the treatment done would not count as a breakdown in Professor's McClean's statistics but it adds another 40 minutes to the day. Even beyond the extraordinary figures we just heard, there is another impact beyond that again.
Pádraig Rice (Cork South-Central, Social Democrats)
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All of this is lost clinical time which is very expensive as well. Does the number of machines used have to be limited at any one time to mitigate these regular breakdowns?
Pádraig Rice (Cork South-Central, Social Democrats)
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One machine is saved because the witnesses know some of the others will break down. We are not getting the full capacity of these very expensive machines just to prepare for the breakdowns.
Pádraig Rice (Cork South-Central, Social Democrats)
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What is the estimated of the loss?
Professor John Armstrong:
There is an additional cost. The fact that all of this happens limits our ability to take part in state-of-the-art clinical trials where we define what the future is. We want future therapy for Irish patients today not in ten years' time. We do our best to participate in these trials but it limits our ability because our machines are too old fashioned for modern trials.
Professor Gerry Hanna:
In lung cancer treatment there is stereotactic radiotherapy. We can usually do it in five or eight treatments but we could do it in one treatment if we had the right imaging equipment. That is efficiency. It would be cost saving. It is an example of where replacing these machines is good for patients and good for the system as well.
Pádraig Rice (Cork South-Central, Social Democrats)
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I am quite concerned about the amount of money spent on outsourcing. It was €28 million last year and €120 million since 2020. Are the ageing machines one reason for that level of outsourcing?
Professor Aisling Barry:
The publicly available outsourcing figures are complicated. We have private agreements with centres in Limerick and Waterford. They are long-standing. They are not going anywhere. That accounts for quite a large proportion. We do not have centres in Limerick or Waterford so public patients are treated in those private centres.
Pádraig Rice (Cork South-Central, Social Democrats)
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Should we have a public centre in Limerick instead of relying on private providers?
Professor John Armstrong:
It is a very old argument. The point is that at present patients in Waterford and Limerick are accessing state-of-the-art machinery in state-of-the-art centres regardless of whether they are public or private. Access is entirely equitable for public and private patients. They are very well served. The machinery in those centres is better than what we have in St. Luke's.
Pádraig Rice (Cork South-Central, Social Democrats)
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It is not in line with the stated health policy of a universal public system.
Pádraig Rice (Cork South-Central, Social Democrats)
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I call Deputy Sherlock.
Marie Sherlock (Dublin Central, Labour)
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I thank all of the witnesses for being here today. I find myself gobsmacked that we are even having this conversation. We have the oldest radiotherapy fleet in Europe even though we are the wealthiest county in terms of our public finances - or our public finances are certainly in the healthiest position - yet there is no national plan for replacement. Someone spoke earlier about the dishwasher if you were running a restaurant. In any organisation, there is a plan for depreciation and maintenance but there is no plan for the workhorse of our cancer services, radiation therapy, which is outrageous. There is an element of striking terror into people this morning. While we have incredible staff working in our cancer services, our older machines are less precise than should be the case. That is a damning indictment of our services. That is no reflection on the witnesses but if we have older machines and they are less precise, in this day and age it is unacceptable. Then there is all the upset caused by delays and the backlog for the witnesses. With all the talk of productivity in our acute hospital system in particular over the past 12 months, that we are still having this Groundhog Day conversation about relatively small sums of money is astounding. I looked at the HSE capital plan this morning. I only went back to 2023. In 2023 there was commitment in the HSE capital plan for the refreshment and replacement programme for St. Luke's, St. James's and Beaumont. It was design, build, equip and maintain. It is the exact same reference in the 2024 HSE capital plan and in the 2025 one. The witnesses know all this but I am saying it for the record. It is the same again in the HSE capital plan this year. It is copy and paste every year.
The witnesses spoke about the business cases. Will Professor McClean tell us when they first started putting in the business cases, particularly for the four LINACs in St. Luke's which were put in in 2008? When did the first business case for their replacement go in?
Marie Sherlock (Dublin Central, Labour)
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In 2020. Okay. We are six years on now. I was told in response to a parliamentary question just before Christmas that the procurement process would commence in quarter 1 of 2026. Has it commenced?
Marie Sherlock (Dublin Central, Labour)
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Okay, so the HSE capital plan for 2027 would probably still be a copy-and-paste job of all the preceding years.
The witnesses made a point about the very elaborate procurement processes at Beaumont Hospital. I was told on 1 October 2025 that the tender process will commence in the coming months. Has that process commenced for the new radiation oncology building in Beaumont?
Marie Sherlock (Dublin Central, Labour)
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Okay. I understand that when equipment has to be replaced, there are works to the physical infrastructure of the building as well. Professor McClean might talk through that disruption a little bit. The reason I ask this is when I talk to hospital chief executives, they talk about having to repurpose wards. They come up with all sorts of weird and wonderful ways of managing to put patients into another place temporarily for a week or two while they manage to repurpose spaces for their need. What kind of disruption is involved in having to put a new machine in? I am sorry that I am even asking this question. It sounds so basic but we need to understand because we are all in shock that we are still having this conversation about these machines.
Professor Brendan McClean:
In our two new centres - they are not new but newer centres - in Beaumont and the St. James's site, we built the bunkers to future-proof them to a certain extent. The rooms themselves just need refurbishment rather than a rebuild. A linear accelerator is quite a difficult piece of apparatus to take out and put a new one in. Typically, taking them out is easy because they are scrap - it takes a week or so - but it takes a couple of months to install and commission a new machine and bring it into clinical service.
Marie Sherlock (Dublin Central, Labour)
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I presume there is a plan in place to relocate activities when the machines are being replaced. What is the contingency?
Professor Gerry Hanna:
It is a very challenging thing to replace linear accelerators in terms of workflows. When you take the machine out, there is no immediate replacement. The system extends the day. We will extend the day and may even treat into weekends. You are going beyond routine hours in order to cope. If you think about it, we have got 14 machines to do all at once in St. Luke's. It is not just about the displacement of treatment; it is also about what Professor McClean's team in medical physics have to do to accurately commission the machine. As we need these machines to be highly accurate, a lot of work must be done to make sure that what we have accepted from the company treats patients very accurately. That is a huge amount of work. To do that over 14 machines in a couple of years will be really challenging. We will have to think about how we staff and run that. It is not going to be a very easy task.
That is why this planned programme is so important. If we do not do this to plan, we will have a massive tsunami of work to do over the next couple of years, let alone cope with the breaking down of machines, the extended days etc. It is not just about putting a machine in a room and turning it on; there is a lot of impact on the service around that. I wanted to highlight that bit.
Professor John Armstrong:
On the process of commissioning, when we get these new machines it is one thing to commission them to operate in the way we are used to operating but these new machines have new technologies and new capabilities. We have not had one of those new machines in ten years so we do not have the day-to-day expertise to get the most out of our machines. We will be under huge pressure to get people onto these machines and get them on. If we do not succeed, we will not end up commissioning the extra capabilities of these machines that can make a huge difference to patient outcome.
Marie Sherlock (Dublin Central, Labour)
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In regard to staffing, that is a question of being able to get the most out of the machines whenever they are in place. My understanding is that there has not been the same push with regard to radiation therapists and the training of those as there has been in other areas. I would like to hear about that.
I am conscious of my time but I have a second question. If I understand correctly, there are 25 LINAC machines-----
Marie Sherlock (Dublin Central, Labour)
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There are 23 of them across the country. Sorry about my sums. How many are on standby for when there is a breakdown? One was referenced earlier. Is there more than one or just one? Just one. I thank the witnesses. They might address the staffing question please.
Marie Sherlock (Dublin Central, Labour)
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Yes.
Marie Sherlock (Dublin Central, Labour)
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Okay. Could someone speak to the radiation therapist training piece?
Professor Gerry Hanna:
Those numbers have increased and we are grateful for that increased provision. There is also increased provision of clinical tutors. We are not there yet but it is a really good step in the right direction. It will take a number of years before they come on line and we still have challenges around staffing of radiation therapists, particularly around retention. I mention retention because that bit about the workforce impact day in, day out causes radiation therapists to be lost out of our public system to other sectors.
Marie Sherlock (Dublin Central, Labour)
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I thank the witnesses.
Pádraig Rice (Cork South-Central, Social Democrats)
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I thank the Deputy. I suggest that we take a quick break now. Is that agreed? Agreed.
Pádraig Rice (Cork South-Central, Social Democrats)
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We will continue the committee's consideration of the issues related to the adequacy of radiation oncology capacity in the public health system and the need for investment in the renewal and expansion of that infrastructure.
Teresa Costello (Fianna Fail)
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I thank the witnesses for coming before the committee. I had breast cancer 13 years ago and am the owner of some of tattoos. The tattoos do not bother me once I am above ground. I have a few questions.
I understand that when someone is going through treatment and an appointment is cancelled it has a significantly negative impact on their psychological health because they are ready and prepared to go in. I do not need to tell the witnesses that one has to be arranged in a machine. It is great to get in and get the appointment over with. During my treatment my biggest worry was missing an appointment because I wanted to be out the other side. I wanted to get my treatment and live my life.
What is going on with the procurement department? Photocopiers are replaced seamlessly. If a photocopier comes to the end of its life, it is replaced. I worked in procurement and understand the responsibility involved. I would love to speak to a member of the procurement team to find out the barriers those involved face and their plan. Do they have a schedule or monitor what machines are available? Do they monitor what stage of life the machines are at? Procurement teams are obviously negotiating maintenance and so on.
I would like more information on how procurement operates. The purchase of high-cost items requires due diligence. We are awash with money. If things are bought that should not be bought, we would be the first to be held to account. How many machines are currently out of order? How many machines are needed compared to how many we have? Is there a minimum quality standard under which machines must operate? Are our machines being validated, audited and monitored to make sure they meet the criteria? Does this come under ISO classification? Who is responsible for this?
I ask the witnesses to explain the difference in performance between an 18-year-old machine and a new one in terms of precision and effectiveness. The phone I had 18 years ago does not do the job my current phone does. As a cancer survivor and somebody who is very passionate about cancer care, in particular, I am disgusted to think that businesses replace photocopiers when they expire due to age but life-saving machines are creeping along at 18 years of age. I imagine that finding parts for them is a nightmare. It is not good enough. I also query the quality of the parts being found. Is it the case that parts are left over and we are scrambling to stick something into machines to keep them working? I am frustrated by this.
I am the Fianna Fáil spokesperson for health in the Seanad. I take it very seriously. I take everything I have heard here today very seriously. I am very interested in procurement side of things.
Ms Olivia Brereton:
I will make a quick comment. When I started working in 2010, St. Luke's centre in Rathgar had a type of technology that was cutting edge at the time and we were able to utilise that for our patients. Galway did not get that technology until 2023. We have to learn from that. We need to determine where procurement is going wrong, where the gaps are and what we are missing.
Professor Gerry Hanna:
We are delighted Senator Costello is with us today. That is brilliant. It is great news. In terms of quality, I want to reassure the committee and public that we deliver safe radiotherapy. We have a brilliant physics team that quality assures our equipment. We have a brilliant radiation therapy team which does world-class planning. We do our utmost to make sure that every treatment is safe.
There are some treatments we cannot deliver that would be ever so slightly better or might be more time efficient that might have lesser side effects.
Teresa Costello (Fianna Fail)
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I know there is a new radiotherapy gap. I went 26 days and it could be delivered in one session.
Professor Gerry Hanna:
That is right. It is that type of thing where we can do something with one treatment, for example. For instance, I mentioned doing stereotactic radiation. At the moment it takes us 45 minutes per treatment session while in a newer machine it can be done in ten minutes. It is that type of efficiency. As Professor Armstrong has said, that has probably some impacts on comfort but also accuracy in the end.
Teresa Costello (Fianna Fail)
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Efficiency equals cost savings as well.
Professor Gerry Hanna:
Absolutely. On parts, the Senator is right, we are really struggling with the old machines. I will give an example of a part from Egypt. It is mind-boggling to be honest. That part is really carefully quality assured. That is time that our physics team are taken away from routine tasks. They have to quality assure and that goes into the impact of our efficiency, timing and what we can deliver in the end as a service.
Professor Aisling Barry:
If I may address two of the Senator's comments on procurement, that has to be a question to the Department of Health and the HSE directly. There is no accountability. It goes back to my previous comment. There is no name that we can say “This is the person”. We have no idea who that person is. It absolutely needs to be figured out. The knock-on impact of that is that Dublin is going through all this at the moment; Cork and Galway are going to be a disaster. Cork needs all its machines replaced in the next four years. That is not going to happen when Dublin has 17 machines that need to be replaced now. I do not know how the procurement people are going to figure that out.
On performance, we are already seeing the regional inequity of that. As Ms Brereton mentioned earlier, we have already seen that over the past 20 years and now it is happening all over again. Cork has state-of-the-art machines. We can do so much with our machines. Dublin does not have the same abilities for certain treatments.
Teresa Costello (Fianna Fail)
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I run a support group for girls affected by breast cancer so I put a question to the private group asking how many people had had their radiotherapy appointment cancelled. A few have told me that their machine was out of operation twice. That annoys me because I know what it takes and I know the impact. I fear metastatic cancer. We are in a very sticky place here and we have a job to do of asking some very serious questions on this. How many machines have the witnesses got and how many do they need?
Professor Brendan McClean:
In St. Luke’s we have 14 LINACs. We predicted we needed 17 by this stage. That is exactly what we do need. The number of treatments that we are treating would require 17. Therefore it is the 14, plus the expanded Beaumont site. The Beaumont site is being expanded with six rooms that are capable of holding these but we are putting three machines in. We need 17 now.
Teresa Costello (Fianna Fail)
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I am sorry to cut across Professor McClean but I am on the clock. I am assuming there is a supplier relationship management between the providers of these machines and the procurement department. With my procurement hat I would think that people are being alerted that it is time to upgrade, there is a new machine on track and if they have a 18-year-old machine, this will cause problems. Are the witnesses aware of that kind of operation?
Teresa Costello (Fianna Fail)
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Okay. I thank Professor Barry.
Pádraig Rice (Cork South-Central, Social Democrats)
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We will move next to Fine Gael and Deputy Roche.
Peter Roche (Galway East, Fine Gael)
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The witnesses are very welcome. It is a pleasure having them here. The story they have brought to us today is kind of worrying. Earlier, I felt as if I had a puncture on the motorway with the bad news about the state of the services. I was really taken aback when Professor Hanna said we have the oldest fleet in Europe. I know I am repeating things that were said earlier. That is really worrying. In the west north-west we do not have a PET scanner and were reminded at a meeting here last year that we would have to wait until 2030 to have same. I asked questions at that time about what the witnesses just mentioned and I received departmental responses - and I will read out some of that – that are at complete variance with the story that is emanating here. If what I was given that day by means of a response was a way to fob me off, I would say shame on them. I was specifically asking a question around the fact the four LINAC machines in UHG, that is, Galway university hospital, are operational for 40% of the time only. If you have a machine operating at 40% of the time, would that give a lifespan of 20 years? That is a loaded question. It is confusing to me. On the use of the LINAC machine, I was told by the official:
I will deal with the use of the LINAC machine. We have an investment programme of anywhere between €16 million and €20 million a year to replenish and refurbish our equipment.
Another official told me, "On the radiation oncology, in terms of capacity, we have five public radiotherapy treatment departments and a total of 22 LINACs” with four in Galway. The witnesses today have said it is 23. She told me “The LINACs in Cork and Galway are new but require regular scheduled maintenance and quality assurance checks.” It is not ten years ago that we had that committee meeting. It was five or six months ago. Somebody blatantly told me, and this committee, that the LINAC machines in Galway and Cork were new and the witnesses today are telling me they have two years of lifespan left.
Professor Aisling Barry:
The ones in Cork went in in 2019 or between 2019 and 2020. I think the youngest LINAC in Cork is five-and-a-half-years old and the oldest is six-and-a-half. Looking at this replacement of ten to 12 years, we are three-and-a-half-years to four-and-a-half-years away from all of them all needing to be replaced. The machines in Galway are three years old now so their replacement is seven years away. I do not know but whatever the Department’s definition of "new" is, I would not really call the Cork ones new.
Peter Roche (Galway East, Fine Gael)
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As I mentioned earlier, the officials acknowledged they were operational for one reason or another, whether staffing or otherwise, for 40% of the time. I am trying to get my head around whether they would be due to be replaced in that ten years if they are only operational 10% or 40% of the time and they are 60% of the time lying idle, notwithstanding the demand there is for such machinery.
Professor John Armstrong:
Making them out of date is not just a question of how much use they get. It is the service contracts and the fact that you will not be able to replace the parts after a certain time. It also means you are dealing with an asset which is depreciating in terms of financial value and in what it can deliver to patients.
Peter Roche (Galway East, Fine Gael)
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One thing that struck me was the witnesses mentioning that the now Taoiseach and then Minister for Health engaged with them and had what was called the national solution. That is 23 years ago. Was anything promised or planned then get rolled out or did it stop far short of what was required in cancer treatment?
Professor John Armstrong:
The simple answer is it was rolled out but it simply has not kept pace with the growth in demand. We have a national cancer control programme, which was initially quite strongly empowered to make the changes necessary to improve cancer services such as, for instance the centring of surgery in centres of excellence and that was very successful. The national cancer control programme had a budget. It still has one but it does not have the power or the degree of budget and the budgetary discretion that it once had so I ask myself what it is achieving when it is there without the necessary power and funding to make decisions and do things. I would love to see this procurement process come in under the national cancer control programme. They are the experts. They are there and employed – they have a job and they know what to do.
We have all the relevant expertise on that NCCP. They should be empowered to do this.
Professor Gerry Hanna:
There is a plan from 2002. It was very successfully delivered particularly in the first 15 years with the establishment of the St. James's and Beaumont centres and the co-ordination of strategy across the country. It was a brilliantly delivered plan to begin with but we seem to have lost our way somehow as a health service in the last ten years in delivering that procurement and planning ahead. We have an urgent issue with radiotherapy but I suspect it is a much wider issue across the health service that we need to somehow get back on track to delivering really good national plans. We have the plans but we just do not choose to implement them.
Peter Roche (Galway East, Fine Gael)
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I get a sense from the contributions that we are doing a lot of firefighting as opposed to positively reacting to demands. In response to an earlier question, Professor Barry suggested that there was no accountability; that someone needs to take account of what is required and nobody is doing that. That is stark for what should be a world-class system and service for cancer treatment, rather than passing the buck, which is how I perceived the situation according to the response. Ultimately, who is responsible?
Professor John Armstrong:
When we have raised these issues and when our representatives have raised it in the Dáil, we have heard a reiteration of the process whereby they are trying to procure things and it is not working. We just get a rehash of a non-functioning system. Ultimately, this comes down to the leadership in the Department of Health and the leadership in the HSE and, particularly, within HSE estates.
Mr. Steve Dempsey:
We heard the intended plan for the last budget was that a letter of determination went out from the Department to the REOs, who would decide how the budget was spent and how capital expenditure projects were going to be treated. The idea of subsidiarity was there such that the REOs would understand where the need was best in their areas. The question the Irish Cancer Society has is what that means for national programmes? The NCCP, as we have heard, was previously empowered, it had a budget and was able to roll out national programmes. Now, with this new approach with the REOs, it is unclear where the NCCP sits in relation to that and what its role is specifically in national projects like what we are talking about here and what is required.
Peter Roche (Galway East, Fine Gael)
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There is nothing I would wish for more than for these professionals to be sitting opposite Department officials to get a better handle on where we are at and get a fix that is going to be future-proofed rather than having mixed messaging coming from the Department.
Pádraig Rice (Cork South-Central, Social Democrats)
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Absolutely. Senator Maria Byrne is next.
Maria Byrne (Fine Gael)
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I apologise for not being here. I was at the disability committee earlier but I have read the opening statements. I thank the witnesses for coming here today to discuss this important issue. I apologise if my questions were already asked.
In terms of the shortage of radiotherapists and posts, how many posts are currently vacant and are any going to be filled? There are 40 places between Trinity College and UCC each year. Is that enough?
Ms Olivia Brereton:
According to current staffing levels we do not have a huge deficit of staff. However, we must bear in mind that the model used in staffing dates back to 2003 and the time of the Hollywood report. The actual staffing model does not really reflect the way a radiotherapy department works in delivering modern radiotherapy. Trinity has increased its intake. I thank Deputy Colm Burke for his work in that area. We have had an increase in our practice tutors and from next September, Trinity will increase its intake of students. However, it will take four years for the knock-on effect of that to be felt within our system. While on paper our staffing levels look good, we do actually have roles and patient services we are delivering now that we were not involved in when the staffing model was devised. I would be cautious around staffing levels.
Professor Gerry Hanna:
The Department has rolled out a new advanced practitioner role in relation to therapy. This role has been a standard role in other healthcare systems for the past 15 or 20 years. It is brilliant the Department has invested in it. It is a trial and a pilot, so it is not by standard. It is only five posts across our three public systems. However, it is something that would really need to grow. That role is also about improving the quality of care, improving the survivorship and increasing the efficiency so it is less reliant on doctors being every place and making it easier to take on some of the roles that medics would do. There is a very big efficiency to be had in those roles in particular.
Maria Byrne (Fine Gael)
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That is great. My understanding is that between 75% and 80% of machines currently in use need to be replaced. That is quite a high figure. Are there plans currently to replace some of them? Is it going to be outsourcing? Where I am based, in Limerick, it is outsourced. It is with the private hospitals. While there are not huge reports of people missing appointments in Limerick, in Dublin and other places like Galway and Cork there are many reports of people missing appointments because of machines breaking down. Could witnesses comment on that?
Professor Gerry Hanna:
In terms of the current status, as we heard, the machines in Galway and Cork are just over halfway through their lifecycle and would be due to be replaced in around four or five years. We need to plan for that. There are no plans for that. In the St. Luke's system, our 14 LINACs have to be increased to 17 LINACs We have been working towards a tender process in the last number of years, as my colleague Professor McLean said, since 2020. As yet, the tender for the replacement of the machines has not been issued and it is really urgently needed because we are at real risk of a crisis breakdown where we could lose several machines together and could not deliver adequate cancer care to patients in the Dublin area.
Maria Byrne (Fine Gael)
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In terms of the outsourcing to private hospitals, is there much of that across the country? I know there is in certain areas but I do not know how it is everywhere.
Professor Aisling Barry:
We briefly touched on this earlier. Limerick is an example, as is Waterford, of pre-existing relationships. It is interesting how the Senator mentioned she had not really heard many stories of the machine breaking down in Limerick compared with what she might have heard from other places around the country. That might be telling that these are privately run centres that actually run. For us in Cork, a lot of our outsourcing was down to staff shortages and challenges with that. That has really come along significantly and we have not had to outsource any patients in recent months. Unfortunately, Dublin is in a different position due to the various challenges they have specifically related to the machines and patients do need to be outsourced. That will be a challenge as the replacement comes through because these machines take quite some time to replace. People will probably have to be outsourced at some stage.
Professor John Armstrong:
That may get worse in terms of us not having the capacity in St. Luke's to treat the absolute numbers but also the particular technologies that allow us to deliver innovative treatments that are really important to people. We are outsourcing a significant portion of them to the private centres at present.
Maria Byrne (Fine Gael)
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On the public hospitals and people missing appointments because of machines breaking down, what is the rough percentage of that on a weekly basis? It it high?
Professor Aisling Barry:
It is not people missing appointments but rather there are delays in the appointments. So much goes into the mitigation of people actually missing appointments or treatments. Extended days are run or people are moved. A lot of extra things are put in place to ensure people do not actually miss appointments. It is more down to machine breakdowns. Professor Hanna talked about some of the figures earlier.
Professor Gerry Hanna:
We do not physically record how many people miss or delay appointments because that is a lot of granularity to record. Professor McClean mentioned earlier that in St. Luke's, we actually lost about 1,700 hours of time due to unplanned emergency breakdowns. That is 1,700 hours of shifted appointments.
Maria Byrne (Fine Gael)
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The most frightening thing is that there is no plan in place in terms of future planning. Some of the machines need to be replaced and others in four, five or six years.
It is about having a national plan. Have there been discussions with the Department about a plan being put in place? I know the witnesses made a recommendation, but has there been any communication?
Professor Gerry Hanna:
The national cancer control programme has a team that has been really supportive and that is really trying to make this work. Where we seem to have a barrier is with HSE estates. I do not know the detail - and others may want to comment - but we seem to be stuck at that point, namely getting the final tenders and line of sight going.
Professor Brendan McClean:
We have a plan. We know what we need. We are working with HSE estates to do that. The number of barriers in place to try to reach the procurement and tender process seem to be delaying the whole thing. Again, we have been doing this for the past five or six years.
Ms Edel Shovlin:
As indicated in the opening statements, we are in a really predictable predicament. There is a playbook, and other countries do this really well. Professor Barry gave examples in that regard. It is extremely unfortunate that this is the position we are in, considering that how we solve this problem is so predictable. The plans are there, but we just do not have the funding to execute them.
Maria Byrne (Fine Gael)
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I apologise if I missed this earlier, but, looking at other countries, what is the best model that we should look to follow?
Professor Gerry Hanna:
National procurement run by the HSE that actually involves professionals, patients and stakeholders and that predicts, bulk buys and includes a competitive tender process. A national programme is right.
Pádraig Rice (Cork South-Central, Social Democrats)
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On the point of public versus private, we can have a public system that works as well as, if not better than, a private system, if invested in, supported and resourced. That needs to be made clear.
I welcome Deputy Boyd Barrett. He is not a regular member of our committee. I thank him for waiting until the end to come in.
Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I am not a member of the committee, but it was very educational to hear everything that our contributors said. I thank them for their contributions and for the work the do. I thank all of them for what they did for me and for what they are doing for so many thousands of people, year in, year out, in providing life-saving treatment. I repeat my thanks to Professor Sinead Brennan, my radiation oncologist, and Dr. Cliona Grant, who did the chemotherapy. I know we are talking about radiation oncology today. I thank Professor Conrad Timon, who did the surgery for me. It is almost a year to the day since I started my treatment in St. Luke's. One thing comes up which the witnesses might say something about in order to dramatise the importance of what they are saying. I and many others are alive today because of linear accelerators and the people who operate them, prepare the plans and provide all the ancillary supports at St. Luke's and at all the other locations at which cancer services are delivered across the country.
I will not say who it was, but one very sobering thing was said to me in St. James's very early on when I got the diagnosis that I had throat cancer. It was to the effect that you get one pass at this treatment for throat cancer. They were confident that they could do it, but that there was only one pass at it. Will the witnesses elaborate on the precision of the machines, which strikes me as pretty important for whether it is successful, and how significant the collateral damage of the treatment is, which I am still feeling the effects of? They did a very good job in my case, and I am very grateful, but I am also conscious that the precision makes a big difference in the context of what is an extremely difficult treatment. I recall when I was first strapped into that thing with the mask on. There were days when there were delays and breakdowns. What was already difficult became a lot more difficult. I could see it for the staff and people having to be hooshed around. There were days when everything was working and everything was nice and calm. It was difficult and still pretty hard going, to put it mildly, but at least I was going through a difficult thing in a relatively calm and organised way. There were other days when the machines broke down and the place was packed with people who had to be sent away and told to come back at a later date. People were giving them lifts in and there were people travelling from other parts of the country. I just thought that people really do not need that.
I want to say how important what the witnesses said is. Will they talk a bit about the importance of the precision? Will they also comment on getting the new machines that they need, the proper replacement programme and the procurement tenders, and why that is so important for the patients and staff?
Professor Gerry Hanna:
First of all, Richard, it is brilliant that you are here. It is fantastic. You could not have said it better.
These machines weigh a couple of tonnes. They move in 360° rotations. They can scan patients and deliver treatment at energies of up to 18 million volts. They are really spectacular and cost-effective. They cost a couple of million euro each, but they will run for ten years and be used to treat thousands of patients. One could not ask for a better economic model. The big thing with radiotherapy is that, generally, you get to preserve the organ you treat. If you treat with surgery, it has to be taken out and is gone. This is a really worthwhile thing to do. We know from our clinical trials that precision has to involve millimetre accuracy. We are at risk of not delivering that if we do not keep up to date. What is happening with radiotherapy is that we used to treat with old, big fields that treated a lot of the body with a lot of toxicity. Radiotherapy has got a lot less toxic, thankfully. We are not there yet, but we are improving all the time. It is about reducing the fields to exactly where the cancer is and shaping that million-volt beam around the cancer to make sure it is exactly where we need it to be. That is where we need the best equipment, to give Irish patients the best chance, that one shot that the Deputy mentioned.
Professor John Armstrong:
As Professor Hanna said, it is about making sure that we do not miss. If we take the case in point, of a throat cancer, the things we do in our head and neck are the things that define us as humans. We see, talk, swallow, and taste. When you try to tackle a cancer in that area, there is a danger to those vital functions. With the newer machines, the ones that we want but that we do not have, we will be ever-more precise in how we design and deliver the treatment. Right now, we make sure that we do not miss the tumour, but we radiate pieces of people that do not need to be radiated. We do not want that anymore. We want to cut down the side effects and improve quality of life.
Ms Olivia Brereton:
As a clinical radiation therapist, I see techniques coming through where, with some of the newer technology, you can utilise the pictures that we have taken for your treatment. If there are changes in your body, we can use those pictures to slightly adapt the treatment. We cannot do that with the older systems.
Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I thank Ms Brereton's team. It is difficult being strapped into those machines. They used to play songs for me.
Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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When it was delayed, the difference in 15 or 20 minutes strapped to that thing, with it moving around-----
Ms Olivia Brereton:
It is wonderful to see you here today, Richard. For people to have to do that twice is unnecessary and makes things so much more difficult. Everybody is different, and different people cope with it in different ways. Some people can cope with delays and can wait. Other people cannot and stress about the people waiting for them outside and about collecting kids. A whole mix comes into the patient experience. Obviously, I cannot speak from the perspective of the patient, but just from observations and the reports that people generously feed back to us about how they are coping and whether they are coping.
Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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The witnesses are great. They do not need the stress, and nor do the patients, about those machines breaking down. It happened frequently. I think my machine was slightly better, but it happened with me too.
Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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In the initial statement, Professor Armstrong raised the need for future planning as far back as 2003, so we are talking about an unbelievable and disgraceful period of 23 years. For 23 years, he has been asking the Government to future plan the replacement of the treatment necessary to save people's lives with radiotherapy but has still not got what he needs.
Pádraig Rice (Cork South-Central, Social Democrats)
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I thank the witnesses. It is important that their voices are heard here in the context of representing the many patients who have had similar experiences.
Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I thank the witnesses for giving me a lot of information about all of this.
Tom Clonan (Independent)
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Before I start, I wish to apologise. I sit on the Joint Committee on Disability Matters, which is also sitting at the moment. I was here for the quorum this morning but had to leave. I am so sorry for that.
I have two questions, and I apologise if they have already been addressed. I have a friend who is a radiographer. I shared with that person the list of witnesses attending today. Every person on the list should be embarrassed by how highly this person spoke of them, so I thank them for their advocacy and for the work they do. Deputy Boyd Barrett and I have had chats about the journey he has been on. I would want people like the witnesses standing at the end of my bed holding the chart.
It is shocking to think that after 23 years of advocacy, a proper rotation of that equipment is still not in place. One of the concerns highlighted to me related to the workforce I refer to the fact that we have very few people in this area and that the age profile is quite young. People tend not to stay in it, and it is difficult to attract people. My question is particularly directed at the witnesses who hold academic posts. I am told that is a four-year course and that there are summer placements. Many of these students cannot work during the summer to help finance their journey through college. They cannot do a J1. Could something be done there to address that?
For other specialties such as nursing, students get a bursary in one or two of the years. Radiographers do not get that . This is also a challenge, particularly for students on placements who are trying to support themselves but who cannot avail of part-time work. I could be completely wrong about this.
There is something called the care to drive initiative. Is this confined to the public system? Because of some of the infrastructural and machine deficits, many people are being treated by private providers by way of that referral. That is very expensive. It was pointed out to me that a lot of the people in that situation would benefit from the care to drive scheme. Could it be expanded to include that cohort?
Ms Olivia Brereton:
There is a huge burden on students. The core requirement is for 1,000 hours of clinical practice, which we all accept is the relevant amount of time. There are radiotherapy centres in Galway, Cork and Dublin so in order to access those placements, students from Dublin have to go to Cork. With the accommodation crisis at the moment, it is exceedingly difficult for students to even find somewhere to stay if they need to travel to a distant placement. The financial burden on students and their families is another factor. Trinity College tells us that students from Dublin often attend university in Dublin and that it is very hard for it to recruit from other parts of the country because of the situation with accommodation. People just cannot afford accommodation in Dublin, and having to double up on that for clinical placements makes it inaccessible for a lot of people.
Professor Aisling Barry:
There are two courses in the country. There is a four-year course in Trinity College and a two-year master's course in Cork. The two-year Master's course is a full-time course with no summer break, which is really difficult with the 1,000 core hours. The numbers within UCC and Trinity College are increasing, so increasing numbers of students are coming out.
Professor Gerry Hanna:
The Senator asked about the age demographic. We have a relatively young workforce, which is very typical of a public system that has not had career progression. They are brilliant professionals who do an excellent job day in and day out. Their attention to detail is fantastic, so they are very sought after by other sectors and industries so there is a leaching out because that skill set is highly appreciated. We need to advance the advanced practitioner roles we mentioned earlier and ensure that as they grow older, they have career progression and jobs to which they can aspire. It will not be for everybody, but we need that if we want to retain those high-performing radiation therapists in our public sector.
Professor Aisling Barry:
This goes back to machine replacement. If we are working in centres that are using machines that are old, we are not going to keep people. They will go elsewhere where they get the brand spanking new machines so they can do what they learned in college. One of the reasons I came back to Cork is because it had a new centre. I would not have come back if it had 18-year-old machines. I might pass the question about care to drive to the witnesses from the Irish Cancer Society.
Ms Edel Shovlin:
The Travel2Care scheme we have provides access to private centres that provide public care to patients who access the care to drive scheme. The Irish Cancer Society has a new strategy for its general transport overview that has been signed off by its board this year and part of that will involve expansion of the service into other areas.
Tom Clonan (Independent)
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I must apologise because I have to go up to the Seanad for the Order of Business. My mother and one of my sisters passed away from cancer. I cannot speak highly enough about the care they got from the oncology teams in St. James's Hospital and all the supports they were given - not just medical supports but also psychological supports. It made a very difficult journey bearable for everybody. I cannot overstate that so I thank the witnesses, including those from the Irish Cancer Society, for all the work they do.
Michael Cahill (Kerry, Fianna Fail)
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The new oncology and haematology unit in University Hospital Kerry, UHK, has been in the pipeline for a while. Last year, over 5,000 patients were treated in UHK. The numbers in that regard are rising. In excess of €1.5 million has been raised by a local organisation. Patients from Kerry are travelling to Cork, Limerick and Dublin for treatment. I ask that the new unit be expedited. Councillor Mikey Sheehy, who is a both colleague of mine on Kerry County Council and a cancer survivor, has been a tremendous advocate for this project over many years since it was initiated. Could I get an update on that? It is hugely important to us in Kerry. As we know, one in two people is being diagnosed with cancer today. It is hugely important that we get this project over the line, funded and opened as soon as possible. If I could get an update, that would be great.
Professor Gerry Hanna:
Generally, we obviously want cancer care to be done as close to home as possible for patients.
The Deputy is absolutely right, in that there is nothing worse than the journey. Where journeys have to be made for specialist treatments, we want that to be supported. The care to drive scheme is one example of that where it is made as easy as possible. Some treatments can be delivered at home. Some forms of chemotherapy can actually be physically delivered in the home or close to home. The challenge with radiation oncology is that we have these very big, immovable machines. There are not even like CT scanners, which can be put on a truck. These cannot be physically moved. There is also a smaller workforce. Making sure that there is enough of a workforce to be sustainable and retainable is difficult. There is a minimum size. I have worked in other countries where there has been a fragmentation of services, with very small services dotted everywhere. There is a balance between trying to do this close to home, which is really important, and making sure that we have a sustainable service. That is a challenge.
When thinking about the country, we in the national cancer control programme radiotherapy group very carefully consider where linear accelerators should be distributed so that they service the population as best we can. It would be brilliant if we could deliver it more locally to home but at the moment there is probably a cut point where we cannot put it everywhere. That is a balance. We should be doing a lot of the follow-up visits, the scans, and the chemotherapy around that closer to home. I do not know about the Kerry situation but that would speak to what the Deputy says.
Michael Cahill (Kerry, Fianna Fail)
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Perhaps afterwards when the witnesses get the information, they could forward the report.
Pádraig Rice (Cork South-Central, Social Democrats)
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When we have the HSE and the Department of Health in, we could follow up with them on it directly. Does Deputy Burke wish to come in with an additional question?
Colm Burke (Cork North-Central, Fine Gael)
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One of the things coming across this morning is the total disconnect between the people who are working on the front line and the people who control the getting of new equipment. What is the process? I presume it is different between the HSE hospitals and the voluntary hospitals, but there must be a process when a hospital wants to get new equipment. It appears that there is a huge disconnect there. How is that dealt with? We have now reconfigured the HSE again. Do we have further challenges now because of this reconfiguration? The whole message coming from here this morning is that there is a huge disconnect. How do we resolve that issue?
Professor Aisling Barry:
To give an example of what it looks like to get to that point, our team first builds a business case. We then put it forward to the local estates section. It then goes to the CEO and then the REO. After that, it goes to HSE estates and then HSE capital expenditure and the Department of Health. They are all the different steps it has to get through. We are looking to get rid of those first five steps and have somebody right in the centre to say what needs replacement.
There is some disconnect at the moment in terms of the regional and national components of this. Mr. Dempsey referenced this earlier on. The region is now being encouraged to divide up the budget, but I am not sure that is reflected in our experience in radiotherapy. The regions still feel that this is a national capital expenditure. There is a bit of a disconnect that probably needs to be hashed out a bit more. That is my experience.
Colm Burke (Cork North-Central, Fine Gael)
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Obviously, we need to set up the structure to make sure that happens.
Professor John Armstrong:
We have a structure but we need to give it the power to do something. We have the NCCP. We have HSE estates. We need to get over the bureaucracy and make decisions.
Pádraig Rice (Cork South-Central, Social Democrats)
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I have an additional question for the Irish Cancer Society. One of the key problems we are seeing across the health service more generally is a lack of multi-annual funding. We saw that with the cancer strategy not having funding and here today we have heard that we do not have the funding in place to plan for services, for example, a replacement programme. Has the Irish Cancer Society had engagement with the Minister on the need for multi-annual funding for the national cancer strategy or the health service more generally?
Mr. Steve Dempsey:
Yes. The Minister indicated previously that she was interested in finding a way to support the need for multi-annual funding. Obviously, it is difficult because there is voted expenditure. Members of the committee know that better than us. That is the tension but there has to be a mechanism found whereby we can plan for the future outside of annual cycles of funding, which can change depending on the political ramifications at any given time.
Pádraig Rice (Cork South-Central, Social Democrats)
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The funding and the strategy more broadly are key issues that we will hopefully return to.
Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I think I understand on the one hand but, on the other, I am still struggling to understand how this has not been sorted out. I do not agree with it, but I can understand the Government penny-pinching on current expenditure but I do not understand it on capital expenditure. The Government says it is a different type of expenditure. We have lots of money for capital expenditure. There is no cost in doing what the witnesses are speaking about. In fact, there might even be a saving in what is being proposed, namely, a multi-annual, planned, replacement programme. It makes me wonder why there is any blockage to this at all. Is there anything more we can say or the witnesses can tell us about where we have to put the pressure on? Is it with the Minister? Is it with the Department? I raised this when I came back to the Dáil and I kind of got reassuring noises from the Minister about how the Government was going to take this seriously and look at it. I am struggling to understand why something that seems to be a no-brainer still is not happening.
Professor Aisling Barry:
We have spoken to many people. Professor Armstrong and I have done many meetings. We have been here and Professor Hanna has been here before. It seems to me that the decision has to come from whoever is at the top, be that An Taoiseach or the Department of Health. It has to come from there. I cannot see it happening in any other department based on our conversations.
Professor Gerry Hanna:
Either An Taoiseach or the Minister of Health needs to instruct the HSE to get this done. Perfection is the enemy of progress. In this State, there seems to be a disabling bureaucracy that is not saving us money and is now costing us money.
Pádraig Rice (Cork South-Central, Social Democrats)
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Hearing from members from across the different parties, there seems to be consensus on this that it is something that needs to be done. In the first instance, I propose that we write to the Minister outlining what happened today and put the request that a decision be made and this matter be progressed. We will have a follow-up session more broadly on the cancer strategy and feed into that. We will continue this engagement and the work on the matter. We might take that action out of today's meeting and, individually, we will continue to advocate for this as well to ensure that the decision makers make the correct decision on this. The evidence presented is compelling.
I thank Professor Barry, her team and her colleagues from the Irish Cancer Society for today, for all of their engagement and advocacy, and for sharing their expertise and time. It is greatly appreciated. This has been an ongoing issue for many years and they have dedicated a lot of time and effort to it.