Willie Penrose (Longford-Westmeath, Labour)

I am not a doctor and I am not here to argue for a centre for the midlands, even though Professor O'Higgins said clearly that we had the critical mass to have such a centre. I acknowledge that the Minister of State, Deputy John Maloney, has faced up to considerable pressure and adapted to a situation that was to his political disadvantage. Nonetheless, he faced up to it in a fair manner and I acknowledge that here tonight.

The Census of Population 2006 shows clearly that the choice of cancer centres of excellence bears little relation either to geography or the population structure of Ireland. That is the problem I have — I am not arguing about the midlands but addressing the motion about the north west, Sligo and that area.

There is no centre north of a line from Galway to Dublin, leaving ten northern counties and about 18% of the population a considerable distance from such a centre. That is a considerable proportion of the population and I wonder why there has to be four centres in Dublin. It is grand for me because I can avail of the good road from Mullingar. However, for someone in a remote rural area who must first navigate boreens before getting to a tertiary road, then hopefully hitting a secondary road before gaining access to a primary route, it is extremely difficult. Those are the people I am concerned about. It is all right for many of us who can get from A to B. It might solve many of the problems if a proper air ambulance service was introduced. It is no use having one, just piddling around here and there. We need such a service across the country for all health services.

I want to know how such a strange result could have come about because it does not arise from the basic philosophy for health care in Ireland set out with admirable clarity in the national health strategy in 2001:

Access to health care should be fair. The system must respond to people's needs rather than have access dependent on geographical location or ability to pay.

Would the ten northern counties believe they have fair access to the specialised services in terms of geographical location? In terms of the genesis of the problem, two major reports provided the groundwork for the decision on cancer centres, the Hanly and Hollywood reports. The Hanly report was officially about medical staffing and how to ensure compliance with an EU directive for junior doctors. However, it spread out like an amoeba and went into other areas such as medical education and training, organisation and location of acute hospital services, ambulance services, etc. Many of these issues were only covered in a superficial manner, especially the decision that there should be only one major hospital in each region. Accident and emergency, as well as other services, should be centralised in this hospital while other hospitals would become 9 a.m. to 5 p.m. five-day a week care centres. The Hanly report states on page 68 that, ultimately, there should not be a requirement for an on-site medical presence overnight or at weekends.

The most amazing thing about this influential report is that it did not take demographics or geography into account. I am not a medic and I am not here to politicise the issue — I would say this if the Labour Party was in Government — but it does not make sense to plan for a medical reorganisation of hospital services without knowing where people live in Ireland. I was criticised widely for proposing to reduce the number of accident and emergency departments and so on. However, a TCD research group found that the percentage of those in the country able to reach an accident and emergency department within an hour would fall from 82% to 72% and increase from 44% to 47% in the west and north west of the country.

It is surprising that Hanly ignored the 2002 report by Comhairle na nOspidéal, the statutory body advising the Minister on the organisation and operation of hospital services, which showed in detailed analysis that Ireland needed all its 38 accident and emergency units to provide adequate and timely care for the victims of major accidents, heart attacks and so on. Its main argument was about the "golden hour", which all the doctors here know about — seriously ill patients have a much better chance of survival if initial treatment and stabilisation is given within the first hour of an emergency. The most recent international research on accident and emergency services, published in 2007, confirms very strongly the principle of the "golden hour".

The Hollywood report on radiology services was much more research based, but still has serious flaws in its analysis and conclusions. It put great emphasis on the decision to centralise radiology services in Dublin and Cork, with another centre already agreed for Galway. That obviously affected the recent choice of multidisciplinary cancer centres of excellence — that is its origin. The objective was to ultimately balance the potential conflicting aspirations of bringing the service to the patient or the patient to the service. The authors set out two models of care, the hub and spoke, where diagnosis and major care is given in the large centralised hospital, with more routine care given under supervision in a small hospital close to the patient's home. It recommends the centralisation of all radiology services, with just three centres for the whole country. It gives three major arguments for deciding on centralisation for Ireland and all of them are deeply flawed.

The hub and spoke model is used successfully in Scandinavian countries where there is a low density of population. However, it was argued in this report that Ireland's population density is much like that in the UK or the Netherlands, which use centralisation and, therefore, centralisation would be more appropriate for Ireland. That is so stupid that I cannot believe it was included. Norway had 14 residents per kilometre in 2005 and a population of 4.6 million, while Sweden had 20 residents per kilometre and a population of 9 million and Denmark had 126 per kilometre for its population of 5.4 million. Iceland has 3 residents per kilometre, with a population of 296,000, while Ireland has 59 residents per kilometre for a population of 4.2 million. The UK has 245 residents per kilometre and a population of 60 million, while the Netherlands the 389 residents per kilometre and a population of 16.3 million. In terms of residents per sq. km and total population, Ireland is much more like the Scandinavian countries than the UK or the Netherlands. That is fact. With respect to the Minister of State, Deputy Barry Andrews, it has been a great mistake for Ireland to slavishly follow UK medical trends over the years, especially in terms of hospital structures, catchment areas, etc., when in so many ways Ireland is so unlike Britain.

I will not even talk about the fact that the Hollywood report relied on a postal survey of the attitudes of cancer patients. Do not draw me out on that one. Some 2,500 patients were treated in St. Luke's Hospital and more than 700 were treated in Cork. When one has a postal survey, what does one get? A majority of the survey's findings should have come from Dublin, because that is where 3.5 times the cancer population was treated. I will not even comment.

However, the authors of the report expressed concern that if there were satellite centres to give treatment closer to where people actually lived, the medical personnel in these centres would feel very isolated. If they feel lonesome, they can avail of mobile phones.

The hub and spoke system requires very close networking between the major centre and its satellites, with much direct contact among all staff to maintain standards and discuss patients. It would be much more reasonable to ask a few fit and healthy medical personnel to travel occasionally to the central unit or the satellite units in order to prevent feelings of isolation instead of forcing thousands of seriously ill patients to travel long distances every day for weeks on end, as in the centralisation model.

In my view, those major reports which provided the groundwork for the decision on the new cancer centres both suffer from many significant shortcomings — I have only pointed out some of them. Chief of these is the total lack of interest in, or perhaps lack of knowledge of, Ireland's unique demographic structure.

I will conclude with two major points about the multicentre cancer centres of excellence — it is inappropriate to term them centres of excellence because it implies that all other hospitals and institutions lack excellence. Excellent services can be found in many hospitals, large and small, throughout the country. It is unfair to suggest that excellence in cancer care is only available in a handful of hospitals in the southern part of Ireland. The correct term, as referred to by the Minister, is multidisciplinary centres. The objective, which everyone should support, is that the primary diagnosis and treatment planning for all cancers should take place in a centre where there are experts in radiology who are familiar with the many diagnostic tools necessary for investigating cancer. Experienced cancer surgeons should work together to provide all the necessary preliminary investigations to define both the problem and the best treatment.

As the Minister said, no one should complain about travelling a distance on a number of occasions to have the benefit of a multidisciplinary team working on his or her cancer problems. However, it is important to ensure that the poorer members of society, the elderly, disabled and those who are isolated, have adequate State support to enable them visit the multidisciplinary centre without inordinate difficulty or financial loss.

The big issue in respect of the fact that the cancer centres are not new is that existing hospitals have been asked to take on the additional burden of new and expanded cancer services although these centres, in common with those of the entire acute hospital sector, have fewer beds per 1,000 citizens than in most other developed countries. There are 2.8 per 1,000 while the OECD average is 3.9 per 1,000.

The provision of public health care, of which I am very proud, boils down to a choice. For 26 years, our capital investment in health care was only 63% of the EU average; need we say more?

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