Dáil debates

Wednesday, 7 November 2007

Cancer Services: Statements (Resumed)


12:00 pm

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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In her speech, the Minister for Health and Children stated: "One person applied for the post, the doctor who had been a locum beforehand, was offered the position, and took it up on 1 November 2005." Is this the same locum about whose expertise the surgeon had concerns? The Minister might answer this later.

I accept totally the Minister's statement that the same pictures taken by the mammography machine were presented to other experts to be read. This raises two points. Regardless of whether international guidelines are concerned, the case demonstrates clearly that it would be wise to accept a guideline stipulating that two radiologists read each mammogram. With modern technology and digital imaging, this can be done from a remote location anywhere in Ireland irrespective of where the mammogram is taken. However, having said that, it is crucial to remember that Portlaoise Hospital was designated as the breast care centre for the midlands, as announced by the Minister's predecessor and committed to by the Government. The commitment amounts to an old machine that the Government would not replace. What does this say about the resourcing of and commitment to a service? It beggars belief.

The Minister stated the surgeon raised the issues in question because of false positives rather than false negatives. Nobody is disputing this but the point is that, having put somebody on administrative leave, the Minister's answer to this crisis and the people of the midlands is to close down the service rather than employ another competent radiologist to resume it. It is all very well talking about centres of excellence but the modus operandi of the Government seems to be one of saying, "Live horse and you will get hay". One cannot expect those with a breast lump, who need a mammogram tomorrow, to wait for a centre of excellence that will be created some time in the hazy future.

Over recent months we have seen the harsh reality of the consequences of the Government's neglect and mismanagement of the health service. Regardless of what the Minister said, women all over Ireland have suffered as a result of bad equipment and poor practice where an individual professional is left isolated while reading mammograms. Best practice should involve reassuring people that human error will be reduced to a minimum by the system.

The problem is not isolated in one centre in Portlaoise because the horror story is repeated in Limerick, Cork and Galway. On Monday we heard of yet another tragic case in which a women who had previously been given the all-clear for breast cancer has now been diagnosed as having the disease. We therefore know for sure that a total of eight women have been misdiagnosed at Portlaoise Hospital. A further 19 women from the midlands have yet to find out whether they have also been diagnosed incorrectly. It is tremendously difficult to even begin to understand how these women and their families and friends feel today. Being diagnosed with cancer at any stage is an enormously distressing and frightening experience for them and the consequences of late diagnosis can be devastating. I hope and pray this will not be the case but we know that all the evidence shows that the longer one delays a diagnosis, the more likely the outcome will be negative rather than positive.

Last May, the diagnosis of Rebecca O'Malley was delayed for 14 months because of an error made in Cork. In August, a woman from County Tipperary had two separate tests taken at Barringtons Hospital. On both occasions, the samples were sent to University College Hospital, Galway, and were given the all-clear, yet, when her own doctor had the results rechecked in Cork, it was revealed she had the disease. We learned recently that the Department of Health and Children was aware of specific concerns at Barringtons Hospital as long ago as January 2006, yet it failed to take action for 19 months. Rather than taking action, it allowed questionable practices to continue. How many women's lives were put at risk during this period and how long did it take for the HSE's midland area to act on the information on the state of its machine sent to it by the radiologists, who requested a modern digital machine?

By the Minister's own admission, through the Taoiseach, it was stated the normal life of these machines is ten or 11 years. Many of those in use are older. If the Government is truly committed to health care and centres of excellence, there must be ring-fenced funding and we must know where it is coming from. It is not good enough to say a reorganisation of the health budget will achieve this. Frankly, I do not believe the Minister in this regard, nor does anybody else at this stage.

The Minister's credibility is on the line because there were cutbacks in spite of her saying on the national airwaves that their would be none. The list in this regard grows longer and includes Sligo, Galway and Beaumont hospitals, the National Rehabilitation Hospital, home care packages for the disabled and home care for the elderly. The Minister opened a theatre in Louth County Hospital with great fanfare in April, just before the election. It remains closed because the doors of the two theatres, which cost €5 million, do not work.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I did not open a theatre; I launched a CT scanner.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Perhaps it was not a theatre but that does not take from the fact that there was major investment in two theatres that cannot be used because the doors do not operate. It is like an episode from "Keystone Cops".

The Minister then told us that cutbacks were being made but that they would not affect patient care. However, they clearly have affected it. Patients' procedures right across the country have been cancelled. Surgery has been cancelled in Beaumont Hospital and Our Lady's Hospital in Navan and we are told surgery has also been cancelled in Tallaght Hospital, although this has not yet been confirmed.

How much more must go before we open our eyes? The people on the ground do not need to open their eyes because they see surgeries for them and their loved ones being postponed and cancelled. I know of a lady in the south east who had a brain tumour removed several years and who was booked into Beaumont Hospital three or four weeks ago. The couple have seven children and her husband took three weeks off to mind them while she went up to Beaumont because, given her symptoms, it is likely that there has been a recurrence of her problem. She is having fainting fits at home and badly needs to be seen. She was told there was no bed for her on the day before she was due to go in.

I rang the surgeon about this and asked him whether he could look after this lady. His words to me were "my choice is between this lady who shouldn't have to wait but who can and a man who is unconscious or somebody else who's got an intracranial bleed". This is 21st century Ireland, supposedly the second wealthiest country in the OECD, and this is reality of our health service. The Minister talked about facts. These are facts which affect real people; they are not figures in the ether.

We already mentioned the Midland Regional Hospital in Portlaoise, which was designated in a report by Professor Niall O'Higgins as a centre for the treatment of breast disease in the midlands, but which has been starved of resources. We have seen the consequences and so, sadly, have the women of the midlands. We saw the cancer specialist in another designated centre in Cork resign in frustration three years ago because there was not even a cancer ward at the hospital. When we begin to look at commitments and promises for action and we have this sort of history to back it up, I am afraid it does not give any of us any faith or confidence in the Minister's ability to deliver.

There are so many examples of broken promises in respect of health that the list seems endless. What seems to be the spin that the Minister and the HSE are broadcasting to the good people of Ireland is that "we will build you centres of excellence some time in the future but in the meantime, we're taking away your existing service". This is the reality for people on the ground. Where will the people of the midlands go to now for their breast cancer services? Where will the people in Ennis, whose mammography unit was closed down, go? They are supposed to go to Galway, which has been designated as a centre of excellence, yet a letter from the medical board there states that the cutbacks mean there will be more patients on trolleys, less beds available in the hospital and the breast cancer service may have to be reduced from a five to a three-day service. This is our centre of excellence. The Minister can see that words are cheap but real action is a bit more difficult. The people on the ground in the west and south east are seeing for themselves the result of the mismanagement of our health service.

I was told that yesterday on the radio an individual from the HSE referred to Cancer Care Alliance as being one of the groups who, with their protests, delayed the implementation of these centres of excellence. This is the group that, through public protests in 2004, triggered the release of funds for BreastCheck around the country, a programme which still remains to be rolled out.

While we are dealing with the issue of credibility, I will refer to cervical cancer screening. The Minister told this House some weeks ago that this would be rolled out in January 2008. It is now the middle of November. Christmas will intervene so there are not even six weeks left to that point. Can we really believe this is going to happen when there is only one accredited laboratory in the country and the HSE's commitment has been not to resource further laboratories and build up facilities and resources, but to ignore them and outsource to the US? Furthermore, as far as I know, no arrangements have been made with those who must administer the smear tests — family planning clinics and GPs. Credibility is becoming a serious issue here and everywhere we look we see very little to give us hope that theMinister's credibility is something she can stand over.

The scenario of "live horse and eat hay", which involves telling people that they can have everything they want tomorrow but that we will take away what they have today, cannot go on. It can no longer be tolerated by people who have paid their taxes and who expect a health service that delivers safe, efficient, reliable and timely care. What is required is to put in place digital scanners which will allow for cross checking of scans by a second expert either locally or at a second centre down the line, for example, as I mentioned earlier, in Dublin, Cork or Galway. This is common practice in the world now and in the Whitfield Hospital in Waterford where scans are read remotely by a leading world expert. Distance is no object with current technology. We need to think outside the box.

I return to what the Minister said a few minutes ago. A report in today's edition of The Irish Times says that the BreastCheck service double reads mammograms for safety. However, the Minister and the HSE say that double reading is not a requirement at symptomatic breast disease centres. The logic defeats me. Somebody has a lump, it is symptomatic and she is worried. Her mammogram will only be read by one person but in the screening service for the country, it would be read by two people. The Minister had better correct that because it is wrong and is putting patients at risk. We have seen how it has put patients at risk.

I do not want to blame any single professional. The Minister's inquiry will show up the truth of the matter at the end of the day but the bottom line remains that the risk of human error must be reduced in a system by cross referencing and cross checking. That is what the airline industry, which has the best safety record of all, does. It will tell one straight up that if different people are making the same mistakes, it is the system that is wrong, rather than the individual. The Minister can try to hang out the Midlands Regional Hospital in Portlaoise as the bad place for cancer services but the reality is that the problem is found in Galway, Cork and Limerick and nothing has been done about it.

I will now discuss a matter which was mentioned earlier in the House by the Taoiseach and echoed by the Minister, which is that triple assessment does not take place unless the cancer is diagnosed.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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Or suspected.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Bunkum. If one has a breast lump, one needs a mammogram, a clinical examination and a biopsy unless one has a past history and they can see clearly that it is not cancer. One cannot determine that with a mammogram alone. It needs clinical examination. That is the triple assessment. It does not involve three people reading a mammogram. It involves the pathologist looking at the histopathology from the biopsy, the surgeon who has examined one and taken the biopsy and the radiologist who has read the mammogram. I do not know from where the Taoiseach or the Minister get their information and I do not expect them to be doctors. However, I do expect the people who advise them and who are paid handsome salaries for it to advise them appropriately. This practice is current in some hospitals. I concede that it is not being done in all of them but it should be. If we are really concerned with delivering excellence in care, excellence is what we should be after, not second best.

Is the Minister really interested in it or is it a case of continuing to close down the public services of today while promising nirvana tomorrow — a tomorrow that never comes? She rushes around the country opening private facilities. We have had a long debate here in the past over the airways——

Photo of Seán ArdaghSeán Ardagh (Dublin South Central, Fianna Fail)
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Deputy Reilly's time has concluded.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I will be very brief. I will make this valid point.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I do not think I have opened any private hospitals.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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The Minister has certainly been seen at some of them.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I have been in them but I have not opened them.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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If we are interested in excellence, can the Minister tell me how many breast cancer surgeries have taken place in the Beacon Consultants Clinic, the Blackrock Clinic, the Hermitage Clinic or the Galway Clinic? Is she concerned about the low numbers of surgeries being carried out there when she talks about the public service? It seems that this is an example of spin or smoke and mirrors to allow the Minister to close down public services while she promotes the private area of health. The big question for this country must be that if we have a free secondary care service — free hospitals for everyone in the country — why have 53% of the population chosen to take out health insurance which many of them cannot afford? It is because they have lost faith in the ability of the public service to deliver in a timely fashion. With these recent events, they are losing faith in the actual medical delivery as well. This is a terrible thing to say after all the years during which people could, at least, trust that if they could get into hospital, access the service and get a diagnosis, it would be the right diagnosis.

I call on the Minister to take control of the health service and to instruct the HSE to replace this outdated equipment with digital scanners with immediate effect. People cannot wait for the Minister's nirvana of centres of excellence. We all support the concept but we deeply suspect whether they will ever happen because the Minister has not ring-fenced funding for them. The women of Ireland cannot wait for her centres of excellence. I know there is no culture of resignation in the Minister's Government but I ask her to take responsibility and act now before more women and men are put at risk.

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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I acknowledge the Minister's apology in the Chamber to the women who were affected so appallingly. I agree that it is a day to put patients first. The problem with the Minister's speech and the Taoiseach's response to Deputies Kenny and Gilmore is that there is no evidence of the Government taking responsibility as opposed to apologising and examining what happened.

There is no evidence that the Government is making the necessary links between the events that have eroded confidence in the service. Listening to the airwaves over the past few days and from the phone calls to Members recently, there is a genuine crisis of confidence in diagnosis, particularly with regard to breast disease. Women are wondering if their local facility will be the next on the list. This morning we heard about concerns in Cork University Hospital. I do not know if these concerns are justified. People have lost confidence and the only people who can restore confidence are those who are charged with responsibility for policy and resources in the health services, namely, the Government, particularly the Minister for Health and Children. I have not heard that this responsibility is being taken on. Instead of trying to find a way to restore confidence, the Taoiseach was defensive in the argument, particularly with my party leader.

The issues in Portlaoise are not isolated. The Minister has outlined the events in so far as she knows but we cannot isolate it from what Susie Long and Rebecca O'Malley have said to us, the Barrington's Hospital affair and testing in University College Hospital Galway. All are connected and together they have eroded confidence. One cannot deal with situations in isolation.There is a suggestion that those in opposition are opposed to the centres of excellence, but we have fully supported the concept and will continue to do so. They will not be established for some time to come. We do not know what resources are available, nor the timescale.

In the meantime, we see a rundown of services, as was the case in Portlaoise, based on what I have heard so far. Someone brought attention to the age of the equipment in the hospital. The issue was first raised by someone in Portlaoise on 5 July 2005. The Department responded but it was not adequate, otherwise what happened would not have happened. On behalf of the people, Members cannot be satisfied with the answers we are getting. We must know how and when resources will be available to the centres of excellence. Otherwise, Members are not doing their job of being responsible to the people who elected. We must ensure they can have confidence in the system to the extent that if someone finds a lump in her breast tomorrow, there must be a service that tests properly and provides an accurate result and timely treatment in an appropriate setting.

I am not just making this up, nor is it merely what the Opposition is stating. People throughout the country, including highly respected medical people such as Dr. Maurice Nelligan and Dr. John Crown, believe this. Some are not going public but are concerned, as the Minister knows. One cannot respond by saying that these people have a political agenda. Those in the medical services do not speak with a political agenda. We support what is said to us.

The series of failures of the health services to deliver safe, reliable and timely diagnosis and treatment to cancer sufferers, culminating in the fiasco at Portlaoise hospital, has caused enormous trauma and suffering to the women concerned and their families. Furthermore, there is now no public confidence in the system and that is a national crisis that must be addressed. I can only imagine how it must feel to have symptoms of breast cancer; to go through the testing process and the anxious wait for results; then to experience the relief of being given the all clear only to find out months later that the whole thing was an awful mistake and that one must go through the whole experience all over again. In addition, as one of the unfortunate ones facing a diagnosis of cancer, a patient would be doing so having lost those vital weeks when early treatment could have improved the likely outcome and recovery. Eight women in the midlands have gone through this awful trauma and others still do not know their fate. Women all over the country are wondering if their hospital will be the next one in the news. Already this morning there are suggestions in the media that Cork University Hospital is recalling a number of patients.

I am disturbed at the blame transferred to the public and patients who are campaigning. How is the patient who is referred for testing to know how many experts are judging the case, if the testing equipment is up to scratch, if the images the experts are examining are clear enough to read or if the resources have been provided for a hospital such as Portlaoise? The public must trust the system when people are sick or fear they are sick. I call on the Minister for Health and Children to take responsibility to restore people's trust. She cannot devolve responsibility to anyone else, such as the CEO of the HSE. We cannot continue to lurch from crisis to crisis and see the spectacle of everyone involved apportioning blame but taking no responsibility for doing something about it. How do we get from the current situation to the concept of centres of excellence? I accept the Minister's point that we should already have centres of excellence in Ireland. The O'Higgins report in 2001 recommended centres of excellence. People working in the so-called centres of excellence are not satisfied with the resources provided.

Professor Gupta, who does excellent work, publicly stated that his unit is not adequately resourced to address the needs of the region in a timely fashion. As I do not wish to cause fear, I must state that the centre is doing excellent work but it does not have adequate resources. People choose to have mammographies in private hospitals because they are done quicker. We know that private facilities do not have the necessary throughput or the triple assessment to which Deputy Reilly referred. People choose private health insurance because of the wait in the public system. We must provide resources for the centres.

Brave women like Rebecca O'Malley and Susie Long went public on their personal pain because they wanted to make a difference and bring about change. The responses I have heard from those who are charged with running the country and running the health services give me no hope that they have been listened to. The Minister provided an account of the situation at Portlaoise but questions remain. We must know what was going on, why only one person read mammographies and why those read for a second time gave a different result. Clearly there was concern about what was happening, which was not in accordance with best practice or the original intention in setting up that centre.

A specialist radiographer stated on radio this morning that national standards had been under discussion since 2002. One of the implications of what he said is that such standards have not been adopted because of the serious cost implications involved. If that is the case, then the situation is extraordinarily serious. We must have national standards and also standards relating to laboratories and quality assurance. If such standards do not already exist, they must be put in place as quickly as possible.

We must go beyond simply carrying out a thorough investigation of what went wrong and why at Portlaoise. We must be informed as to what will be done, when it will be done and how it will be resourced and funded.

The term "centre of excellence" sounds very good and reassuring but this particular emperor has no clothes. How are we supposed to believe that what is envisaged will happen, particularly in light of the track record to date? Centres of excellence were proposed by Professor O'Higgins in 2001. We debated this matter with the Minister a couple of weeks ago when she announced the plans but she did not provide any information regarding how the centres will be established, not to mention indicating when they will be in place and fully operational. If people who are being asked to give up their local services were informed of the latter, they could at least believe that something better will be established to take their place.

I wish to add to what Deputy Reilly said in respect of patients in various parts of the country who do not know what lies ahead for them. People in Clare have been informed that they will be obliged to travel to Galway for treatment but a reduction in services has taken place there. How will these individuals be accommodated? I was also contacted by the Cancer Care Alliance, whose members are extremely disturbed by the fact that they were considered to have obstructed a process of moving towards establishing centres of excellence. The alliance has been campaigning strenuously and successfully in respect of Waterford and Limerick regarding centres of excellence, radiotherapy treatment, etc. The Minister must address this matter because the organisation in question is of the view that it has been wronged.

Instead of obtaining the information we need, we are faced with a situation where high expectations have been placed on Dr. Keane, who is returning to Ireland from British Columbia, to resolve this matter. Members of the public require far more information. We, their representatives in Parliament, cannot accept that responsibility for this matter will be given to one person, expert though he may be, with no commitment of resources. If we accept this, we will be informed, when we raise questions in the years ahead, that the Minister and the HSE are not responsible. Responsibility has been shifted to a gentleman, Dr. Keane, whom I have never met. That is not good enough. We must know, before responsibility is transferred, how the Minister proposes to resource and fund the centres of excellence.

The Minister must provide a commitment today in respect of resources. I do not believe that the centres can be established in the way she outlined on last night's "Prime Time", namely, through a redistribution of existing resources. What are those resources and have they been audited? Can staff be transferred? What are the building requirements? The Minister stated that fewer than 56 procedures are being undertaken at the 13 locations that are being closed. Surely this does not indicate that there is a significant level of resources available to be transferred from those hospitals. I imagine that many of the surgeons involved are doing other work and cannot simply be transferred.

We do not know the answers to any of the questions I have posed. We are aware, however, from the information provided by the radiologist who spoke on radio this morning, that national standards do not exist. Such standards must be put in place as a matter of urgency.

The Minister must engage with us in dealing with these matters. It is her responsibility to restore trust. It is not enough to say that an expert will come here from British Columbia and resolve everything. I lived in British Columbia for one year and I am aware that it has a completely different population distribution to Ireland. When I was there, it also had a much more advanced health service than that which existed in Ireland at the time. One cannot simply transfer what may have worked there to a totally different and very complex system here. Before the centres come into being, we must be informed as to how their establishment is going to be achieved.

We are not going to let Deputy Harney off the hook regarding her responsibilities as Minister for Health and Children. This is not about placing blame, it is about taking responsibility. Unless credible answers are supplied in respect of the questions raised by Rebecca O'Malley, Susie Long, the women from the midlands, the professionals who work in the health service and Members who will contribute to this debate on behalf of those who elected them, this issue will remain on the Dáil agenda.

In the question and answer session to take place at the conclusion of this debate, I hope the Minister will address the question of resourcing and indicate how we will put in place the system she is proposing. That system is merely a concept at present and we do not know how it is going to come into being. People, particularly those who have been campaigning for cancer services, are not willing to accept something that is just a concept; they want to know exactly how the system will be put in place. We will not allow the Minister to wash her hands of the matter. We want to know exactly how the system will be established.

1:00 pm

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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People throughout the country have been appalled at the plight of the women who were given the all clear after breast cancer screening but who have now been diagnosed with cancer. Many more women may well be affected. Our sympathy and solidarity goes out to all of them.

It is scandalous that so many women should have been let down so badly. A total of 3,000 mammograms have been reviewed in the Midland Regional Hospital in Portlaoise alone. The same may be required in other hospitals. There are now conflicting claims regarding what lies at the root of the mammography scandal at Portlaoise. There is an urgent need for a thorough investigation. Any investigation must be open and transparent.

Thousands of women must feel betrayed and bewildered as they listen to the conflicting claims. Neither the Health Service Executive nor the Minister can shirk their responsibility for this situation. The HSE is directly responsible for public hospital services and it has a duty to ensure that proper standards are maintained. It is disgraceful for the HSE's chief executive, Professor Brendan Drumm, to try to shift the blame for this situation onto the people of Portlaoise and the midlands because, like those in other regions, they opposed any threatened downgrading and loss of services at their hospital.

The claims of the Minister and Professor Drumm in respect of the mammography scandal have been totally undermined by the letter revealed yesterday. The letter to management at the Midland Regional Hospital, Portlaoise, dated 13 December 2006, from the radiology department advised that to deliver the highest standard of patient care an imaging system that could produce mammograms of the best possible diagnostic quality was required. The correspondence expressed concern regarding the age of the mammography machine and advised that a digital system was needed instead of the film system, which at times was affected by dirt from the dark room environment.

This morning, another radiologist, David O'Keeffe of Galway, stated that there is inadequate regulation of radiological equipment in our hospitals. He pointed out that it has been recognised since 2002 that standards were required but that there had been no agreement in respect of them. Most damningly, he claimed that agreement is still being delayed as a result of the reluctance of the HSE and the Department of Health and Children to replace old equipment. I want to hear the Minister's response to Dr. O'Keeffe's remarks. If his claim is true, it is a great scandal in itself. Are patients being denied proper screening because the Government and HSE will not spend the required money on new equipment?

So much for the claim made by the Minister for Health and Children that the problem in Portlaoise arises from the absence of centres of excellence. So much for Professor Drumm's disgraceful attempt to blame the people of Portlaoise and the midlands for this scandal. One can only gasp with astonishment at the Minister's statement in response to this crisis. I remind her that she stated, "It has happened because of our failure in the past to put in place centres of excellence, which could never have happened under the old health board regime". The Minister referred to "our failure" as if it were the failure of Irish society as a whole. However, she and the Taoiseach have been in Government continuously for over a decade. They have had at their disposal resources undreamed of by any previous Administration. Those resources are the fruit of the most prosperous era in the history of the Irish economy. Yet the Minister has presided over failing, chaotic and inequitable health services. She failed to meet the needs of the people at national, regional and local levels. She promised us a world-class health service but we have a two-tiered, disorganised, disjointed and ailing health service, and the Government's so-called solution is privatisation.

I totally refute the gross misrepresentation by the Minister and the HSE chief when they claim that people are opposed to centres of excellence. I have not heard anyone speaking in opposition to such centres or heard anyone say that there should be centres of excellence for cancer at every hospital in the country. What has been said and rightly so is that properly resourced existing cancer services cannot and must not be taken away in the absence of centres of excellence, which is what the Government and the HSE are trying to do.

Consider the debacle over the provision of radiotherapy, a key component in centres of excellence. The Minister wanted these provided by public private partnership. A report to the HSE stated this process would take until 2015. We then heard a series of conflicting statements from the Minister and Professor Drumm, with the HSE chief stating that the public system can provide the radiotherapy facilities — agreement with him at last. We heard conflicting dates for the provision of centres of excellence, including 2009, 2011 and 2015. The need for these centres was clearly established and officially identified in the millennium year.

The Minister for Health and Children, Deputy Harney, and Professor Drumm castigated local campaigners, but I applaud these people. A year ago, I stood on a platform with Co-Operating for Cancer Care North West in County Donegal. It demanded a cross-Border centre of excellence for cancer care in the north west which had been completely left out of the Government's plan. It rightly pointed out that Donegal people could not be expected to rely on a tentative arrangement with already hard-pressed services in Belfast.

Yesterday, the group met the Minister for Health and Children and, as is reported in The Irish Times and other print media today, it was positive afterwards that progress would be made on delivering such a centre in the north west. I hope this is the case and that the Minister will clarify that in certain terms in her closing address today. This emphasises very strongly the need for local and national campaigns to vindicate the health care rights of communities. It is only because of the heroic efforts of people such as Noelle Duddy and those campaigners in the north west that the prospect of siting such a facility in the north west, it is hoped in Donegal, will be realised. The Minister should state clearly exactly what she intends.

The Minister's plan for the location of centres of excellence with radiotherapy only in Dublin, Waterford, Cork and Galway is not sufficient. It leaves the northern half of the country very badly served. I have repeatedly stated and I repeat again that nobody seeks these facilities at every crossroads. We seek regional coverage and not discrimination based on where one lives. I urge the Minister to proceed with the centre in the north west and to re-examine the gap in the HSE north-east region and in the adjacent areas north of the Border. As a representative of the people of Cavan and Monaghan I state that we, and the people of Louth and Meath, need a similar cross-Border solution to that proposed for the north west.

This latest crisis over mammography exposes the overall lack of coherent policy and planning by Government and the gross mismanagement at HSE level. Hospitals such as Portlaoise have out-dated equipment while in hospitals such as Dundalk the HSE has allowed the new CT scanner to lie idle for months. This CT scanner was unveiled by the Minister in the period immediately before the general election. Where is the coherence and good management that we were promised in the brave new world of the HSE heralded by the Minister on the floor of the Chamber?

The crisis in mammography is mirrored in the situation with cervical screening. The Well Woman organisation expressed concern over the ongoing outsourcing of smear tests to the United States for analysis and at the absence of clear information as to what cytology laboratories will be used to underpin the national cervical screening programme from January 2008. The outsourcing of cervical smear tests for analysis to private laboratories in the USA could lead to inconsistencies in the interpretation of results by Irish doctors, which could have ramifications for women with abnormal smears.

Before any roll-out of the national cervical screening programme, the Well Woman organisation is anxious to have the following questions on smear analysis answered and I urge the Minister to do so as part of her response today. If United States laboratories are used who will take responsibility In Ireland for making judgment calls in borderline cases? Will that person be a suitably qualified and experienced cytologist?

Well Woman takes more than 9,500 cervical smears each year. In the key age group of women aged 25 to 40, it estimates that 8% of these patients will need to be referred to the hospital system for further investigation and colposcopy. It points out that the colposcopy service in Dublin is patchy. The service in Tallaght hospital operates efficiently with acceptable waiting times whereas the north side of Dublin is extremely poorly served, with entirely unacceptable delays before women with potentially significant cervical pathology can be seen.

This pressure on the north side was made worse recently by the ending of colposcopy services in Beaumont Hospital, putting added pressure on the colposcopy clinics offered in the Rotunda and the Mater hospitals, which have not increased their capacity sufficiently to meet this extra demand on services. Well Woman perceives a greater need for colposcopy services in areas of social and economic deprivation, as can be illustrated by statistics from Well Woman's Coolock clinic. I ask the Minister to take note of all that detail, which is hugely important. That information proves a significantly higher rate of referral for GMS patients as opposed to private patients, including those who live in the same geographic area.

Well Woman informs us that to date it is unaware of any communication from the national cervical screening service to primary care doctors over details of the service contract, payment to smear takers, reporting requirements, compilation of the population register, start date, how women will be contacted and so on. Well Woman believes that at this stage, this makes the quoted roll-out date of January 2008 unrealistic. I ask the Minister to address that problem also. All this is very worrying and must be addressed as a matter of urgency if we are to avoid a repeat of the mammography scandal in cervical cancer screening.

I also ask the Minister to address the issue of cancer services in Tallaght hospital. I am told the hospital features in a referral guide issued by the HSE in May 2007 as a hospital for patients to be referred to from general practice. The document is called General Practitioners Cancer Referral Guides and was issued after extensive consultation by the regional oncology director of the HSE. The hospital is trying to ascertain the position — the Minister should note this — as it was part of the regional cancer plan in May and was removed from the plan in September. What is the position? Why, as we advance towards mid-November, does the administration in that hospital not know the full detail of same?

The current crisis in mammography is being used by the Minister and the HSE to justify their drive to over-centralise our hospital services and downgrade local hospitals. That is a disgrace and is the opposite of what is needed. The women concerned need answers as to what went wrong. Women need these services to work and be seen to work. Our whole population needs comprehensive cancer care provided in the public health care system and available to all based on need, regardless of their ability to pay or geographic location. I have made that point repeatedly and make it again to the Minister because I do not believe it can be raised with her often enough. There can be no discrimination. We want a service that is equitably delivered and accessible by all.

I listened with much interest to Deputy Ó Caoláin's contribution regarding cancer services in the north west. His comments were slightly tinged with hypocrisy given that former Northern Ireland Executive Minister for Health, Social Services and Public Safety, Bairbre de Brún, MEP, decided to divert health services in the Six Counties to Belfast. I do not think she was wearing her all-island hat on the day she made that decision. Thankfully, the Government is addressing that issue.

I pay tribute to the two cancer lobby groups in County Donegal. Only one group formerly existed but a split since occurred. I do not know if political personnel were responsible for the split but others may tell the full story and County Donegal now has two good lobby groups.

Following consultation with Government Deputies, the Minister is working with her counterpart in Northern Ireland to ensure that the north west, that is the area west of the River Bann and County Donegal, receives the radiotherapy therapy service it deserves. The Minister and her counterpart in Northern Ireland are making progress in that regard and I look forward to a good outcome.

The new Oireachtas Joint Committee on Health and Children, of which I am a member, met yesterday. Members on all sides adopted a proactive approach to the committee's work. We do not want to be a "yes" type committee or meet groups of all persuasions for the sake of holding meetings. We intend to make a real input into the provision of health care in this country and help achieve the world class service which the Minister is striving to put in place. I have every confidence that she will be successful.

In recent days, Portlaoise hospital has been the subject of extensive debate in this House. The Chairman of the Oireachtas committee, Deputy Moloney, made me aware of several facts in that regard which I wish to share with Deputies. In 1996, the then Minister for Health, Deputy Noonan, introduced a plan similar to the current proposals for centres of excellence. He intended to move services from Portlaoise to Tullamore hospital, for which he had the backing of Deputy Moloney but was opposed by his party. After political persuasion by his rainbow coalition colleagues, he changed his decision. Deputy Moloney nearly lost his seat as a result but his stance has since been proven correct because when this Government came to power in 1997 it took responsibility for dealing with that fiasco and has been working on it since then.

A number of references have been made to the hospital equipment used by the consultant radiologist. That equipment was quality checked in May. I am sure any faults of which people are aware will be set out in Dr. Ann Doherty's report when it is published at the end of this month.

I look forward to Professor Keane taking up his new job of rolling out the cancer centres of excellence. The fiasco in Portlaoise highlights the need for such centres. It is somewhat hypocritical that Deputies opposite call for better quality services when they will not take the crunch when it comes to providing cancer services in hospitals. They all want the services to be delivered in their own backyards, which is not logical. It is mere political opportunism to run around the country calling on party colleagues to organise rallies and it does not help to put in place any of the Minister's proposals.

I look forward to the establishment of the new centres of excellence and I am particularly pleased that the Minister has included Letterkenny General Hospital as an outreach facility because we face significant geographical problems in County Donegal. The Minister has recognised that we are much further from Galway and Dublin than the people of counties Sligo and Mayo. Even though services are now being provided in Letterkenny, people in parts of the county are probably further from Letterkenny hospital than the remotest parts of counties Mayo and Sligo are from Galway.

We should all get real about this issue and have the common sense to stop using it as a political football. Let us treat these proposals with the respect they deserve. I look forward to the establishment of the new centres of excellence, Professor Keane taking up his new role and ensuring this fiasco is not repeated.

Photo of Enda KennyEnda Kenny (Leader of the Opposition; Opposition Spokesperson on Northern Ireland; Mayo, Fine Gael)
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For the information of the Minister, I stayed for this debate because I have to go to Brussels this evening, which means I will not be present when she takes questions. I welcome this debate on cancer services and hope it will result in her being able to answer the questions raised by Deputies.

Women are not fools and they are not going to attend a service they consider to be substandard or which does not offer the best chances of survival. However, the issue is not confined to women because every woman is a daughter, sister, wife or girlfriend of somebody else. It also affects men in that sense.

I have been pilloried in regard to the extent of my acceptance of centres of excellence. While I support the concept of such centres, competing forces are at play and clarity and decisiveness of agenda are needed. The Department of Health and Children has been removed from the mainstream on the issue and is only now re-emerging.

The HSE is a creature of Government, set up by the Government to implement Government policy. However, when the HSE was set up it abandoned the Hanly report — a report to which my party objected — and pursued its own initiative, giving the impression that the HSE is a creator of policy. It seems, arising from the very unfortunate case in Portlaoise, that there is now a new rush to create the aforementioned centres of excellence. Obviously they should be put in place as expeditiously as possible but the Portlaoise situation is being used as an example of why we need the centres of excellence. However, the very legitimate question remains as to what people, and women in particular, are to do in the meantime.

According to the latest update on the Portlaoise case, the consultant radiologist whose practice gave rise to the review remains on administrative leave. When the Taoiseach spoke here this morning he said that the radiologists in Dublin examined the same images as those examined by the radiologist in Portlaoise and found seven cases of misdiagnosis. I do not care what international best practice is, we can improve on it, either by having digital mammography, as referred to by Deputy James Reilly, or a second radiologist reading the images. If, in the case of Portlaoise — regardless of bad imaging or dirt in the machine — two radiologists had read the mammograms and if there was any instance of concern, doubt or a belief that something was present, the seven cases would not have got through the screening process. That is the kind of standard of integrity and professionalism that women need. They need to have a demonstrable belief that the service they are getting is as good as can be obtained anywhere else. It is not about 75% of people, as the Taoiseach said this morning, getting a very high standard of service. It should be about 100% of people getting the very best service possible to give them the best opportunity to survive. I understand that six more cases of the 19 under review have been confirmed as positive for cancer. That speaks for itself.

The creation of the HSE has brought about an over-managed, over-manned and, in some cases, over-paid system. Now we have Professor Keane coming here from British Colombia on a two-year contract to implement the new cancer services strategy for breast cancer. That is a very difficult schedule for him. In the 13 cases where services were closed down, there was a very low incidence of activity and that was, unquestionably, the right thing to do. However, when the Health Information and Quality Authority carries out its audit of performance next spring, what will be the position in the case of a hospital, for example, Tralee General Hospital, that measures up to the standards of excellence now, where there is triple assessment, a full multidisciplinary team and where 100% of cases are assessed, discussed and given the highest standard of treatment possible? If a hospital achieves the standards set out in the National Quality Assurance Standards for Symptomatic Breast Disease Services, what will be the impact of the HIQA audit of performance, assuming the hospital measures up in everything except volume, because it cannot have the volume required by the standards when it is not serving a population of 300,000? If, on every other level, a hospital measures up to the standards set, will that have any impact or will the fact that the Government has already made a decision to develop only eight centres of excellence be the overriding factor?

I know my own constituency best and have had intensive involvement with the consultants, radiologists and surgeons at Mayo General Hospital. The O'Higgins report was based on the movement of surgical services to centres of excellence but it is not the surgical element of the service which has failed here, but the diagnostic element, whether it was undertaken in Cork, Galway or Portlaoise. That is a cause of serious concern.

The HSE announced details of its cancer programme on 26 September where it outlined the various services to be provided. It referred specifically to the outreach activity which is proposed for Letterkenny. The presentation states that outreach activity "if undertaken, should be incorporated in a rigorous process and outcome audit as though the activity took place at Galway to ensure that the provision of such an outreach service does not serve to place patients availing of it at any disadvantage compared with patients treated in Galway". I accept that; this is as it should be. It is precisely the reason that, in Mayo General Hospital, seven years ago agreement was reached with the professionals in Galway that the Mayo hospital would be an outreach centre monitored and supervised by, and working in co-operation with, Galway University College Hospital.

In the intervening years, my analysis of the Mayo service indicates that it measures up to the standards set out by the HSE, with the exception of not being able to achieve a volume of 150 new cases per year because the population base does not allow it. The consultant surgeon at Mayo General Hospital, Mr. Barry, has already carried out 80 procedures this year, based on a population of 100,000. The facilities at the hospital are excellent. A questionnaire was sent to Mayo General Hospital recently. The following questions and answers are of interest:

Is there a breast multi disciplinary team meeting held in your hospital? Answer: Yes.

What percentage of new patients with breast cancer are discussed at the mdt meeting? Answer: 100%

What percentage of new, benign, patients are discussed? Answer: Between 10% and 20%

Who attends at the multi disciplinary team conference? Answer: The consultant breast surgeon, the consultant pathologist, three consultant radiologists, the consultant medical oncologist, the clinical nurse specialist, the oncology liaison nurse, the oncology nurse, five NCHDs and five female surgical ward nurses.

All of the aforementioned people attend when every case of new cancer is discovered, assessed and discussed at the hospital. That happens in consultation with the professionals in Galway, who have a very strong liaison with Mayo General Hospital. Yet, the centre at Mayo is to be closed down. If a hospital has reached the required standards already, why should the excellence that has been achieved be stood down? That is why 10,000 people took to the streets and not, as Deputy Niall Blaney argued, because of political opportunism. It is because they believe in the service they have and do not want it taken away. If somebody from the HSE, Professor Keane, or some other expert told me that the service currently provided in Mayo is inferior, inadequate and life threatening to women — the colon and rectal cancer services will also go, once the breast service is moved — that would be fine, but the hospital has already achieved the high standards set by the HSE. Women voluntarily took to the streets because of their belief in the service, which is closely related to Galway and was deliberately set up thus so that a situation like the one in Portlaoise could not arise, where an inferior service is delivered. High standards are employed and there is clarity of agenda and decisiveness. That is what we need on a country-wide basis.

I ask the Minister for Health and Children to address this matter in her reply, although I will not be in the House to hear her. The HSE proposes to set up an outreach centre in Letterkenny based on the model successfully operating for the past seven years between University College Hospital, Galway and Mayo General Hospital. In these cases, where the rates of survival and standards of assessment, diagnosis and treatment measure up, I see no reason to take that away in the context of setting up of the centres of excellence the Minister proposes.

I mentioned six more cases being confirmed in Cork. They have been confirmed as needing further assessment.

Photo of Dara CallearyDara Calleary (Mayo, Fianna Fail)
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We all welcome the new strategy and the centres of excellence. It is unfortunate this debate is happening in the context of the occurrences in Portlaoise and possibly in Cork. I join other Members in expressing my hope that those occurrences will not be repeated and I send my best wishes to the women involved.

Like Deputy Kenny, I know only too well the services on offer at Mayo General Hospital but would rather not have had to in the past number of years. All cancer services currently available in Mayo General Hospital are delivered in conjunction and in association with Galway, which is a proposed centre of excellence. This is done as part of a formal network arrangement which was brokered by the Department of Health and Children in 2000. Indeed, the arrangement in place was so successful that it is being used as the model in this new cancer strategy for the outreach arrangements in Letterkenny.

The arrangement means that all cancer cases referred to Mayo General Hospital are considered in conjunction with the teams at UCHG. There are formal consultations on a daily basis and there is a weekly multidisciplinary team, MDT, meeting held on site in Castlebar involving oncologists from Galway, surgeons, radiologists, nurses and other staff in Castlebar. Each case referred in that week to Mayo General Hospital is discussed and the appropriate treatments are agreed and undertaken in Castlebar.

This arrangement and the manner in which it has developed over the past seven years is delivering positive outcomes on a daily basis to cancer sufferers in the west. No cancer sufferer who has used that facility in the past number of years is currently disadvantaged or was mistreated because of its location.

This year over 80 breast surgeries will be carried out at Mayo General Hospital. In the context of the population of Mayo, that is quite a substantial number. All breast surgeries in Mayo General Hospital are done by one surgeon and another surgeon takes care of colon surgeries. Both Dr. Kevin Barry and Dr. Ronan Waldron are highly qualified excellent surgeons in international demand at conferences because of their work and their work on the network. If both surgeons are to transfer to the new centre of excellence in Galway, they will each perform fewer surgeries annually thus reducing their individual exposure to each treatment.

In addition to the surgeries, 2,000 mammograms and 1,500 colonoscopies will be completed at Mayo General Hospital this year. There is a policy in Mayo General Hospital of double reading of these examinations to ensure accuracy. We have five consultant radiographers in Mayo General Hospital, three of whom have specific training and education in breast treatment. They can provide a diagnosis within 24 hours if required and that is an absolute weapon in the fight against cancer. One can see why we passionately believe we already have a centre of excellence in Mayo General Hospital delivering positive outcomes on a daily and weekly basis to the highest possible standards. We look forward to the HIQA audit next spring which will confirm our feeling on that. I welcome the Minister's remarks that the existing services are excellent because there was annoyance in Mayo General Hospital that because centres of excellence were being created, there was an implication the services currently on offer were not good.

The new proposals will mean breast surgery, colorectal surgery, mammograms and colorectal examinations will be withdrawn from the hospital and transferred to Galway. Post operative treatment, such as chemotherapy etc., may no longer be consultant supervised. It is fair to expect that the staff involved in the delivery of services in Mayo General Hospital will leave the hospital in pursuit of their chosen specialties. Patients will have to travel from all around Mayo to Galway for surgery which is currently available in Castlebar under very high standards and conditions, as I have outlined. For many, a trip to Galway can be a five-hour one.

I wish to give the House an idea of what is actually involved. A constituent wrote to me in regard to her treatment at Castlebar and her subsequent treatment in Galway. She said:

The treatment in Castlebar was dealt with by Mr. Barry and his team in an extremely friendly and efficient manner. Having it in such a central location meant that my husband, family and friends were able to visit on a regular basis, which naturally made the whole experience far more bearable. This would not have been possible on anything like the same scale if my treatment had taken place [elsewhere] as maintaining a full-time job while travelling for the periods mentioned below would be completely untenable.

The radiotherapy I subsequently underwent in Galway was again performed to a very high standard. [We endorse the standards of care in Galway.] However, the daily return trip was an ordeal, to put it mildly. With city traffic to take into account, it was necessary to allow 5-6 hours per day for travelling, regardless of the time spent inside the hospital. This took place from three to five times per week for six weeks. If [this strategy] is followed, patients would have to undergo these travelling conditions for such common procedures as mammograms, as well as for the surgery involved in cancer cases. In my view, this would represent a major step backwards, impacting upon an extremely vulnerable group of people.

I endorse the views of that constituent in regard to the reduction of services under this proposal.

The model we have in Mayo General Hospital and the model proposed for Letterkenny on the back of it was originally backed on to, and was done in association with models in Scotland and in North America, in particular the US. The model which has evolved is an Irish solution to Irish conditions. We hear of international best practice and international excellence but given the conditions we have in terms of transport facilities or lack of them in terms of road infrastructure and otherwise, we must look at a very Irish condition. We do not have the highways they have in the United States to get people to centres.

I welcome the opportunity for questions and answers later and will ask a number of questions, if possible. The HIQA audit, which will be forthcoming next April, will add to the reputation of Mayo General Hospital and show that the services on offer are of an international standard and are delivering positive outcomes. What impact will that have on the national cancer strategy?

I query the method of selection of the eight current centres of excellence. I am particularly concerned that not one of those centres is located on a line north of Dublin to Galway. It does not make any sense that the eight centres of excellence are all located in one part of the country. Were the centres of excellence chosen by the membership of the national cancer forum, membership of which is drawn from centres of population or hospitals on that line? What role did the national cancer forum have in the selection of the eight centres of excellence?

I welcome the fact we are creating the position of director of the national cancer strategy and I wish Professor Keane every success. Was there an international competition for that position? Did recruitment for that position take place across the oncology community throughout the world? Was the vacancy made known around the world?

Will non-surgical treatments in the new cancer strategy, such as chemotherapy, be consultant supervised in a situation where the centres of excellence are established? When can we expect full details on what will be involved in these centres of excellence? Will there be extra buildings, facilities, beds and staff? It is very difficult to try to justify a centre of excellence and the selection of such a centre when one cannot even park one's car in University College Hospital Galway when going for treatment. It is well-known that there are not sufficient car parking spaces for patients and people visiting them. That is not to downgrade the treatment available in the hospital where the team performs to its very best. If one is a cancer sufferer going for chemotherapy, the least one can expect are basic facilities, such as easy access and being able to park one's car without having to drive around for 40 minutes to an hour, which we hear from patients on a daily basis.

We all agree with the centres of excellence. However, I disagree with my colleagues in that the protests last weekend were not political and people did not go out for the sake of protesting. There were 7,000 people all of whom had experience of, and daily dealings with, the services available. There were people who put their faith and their lives in the hands of the team at Mayo General Hospital, to whom many of them owe their lives.

Family members of mine have been through that hospital and cancer centre in the past ten years and I stand over the current level of treatment there. The centre works and delivers outcomes. If we are to use that model to expand the cancer service into the north west, it does not make any sense to lose what we have in Mayo General Hospital.

Sitting suspended at 1.30 p.m. and resumed at 2.30 p.m.