Dáil debates

Wednesday, 7 November 2007

Cancer Services: Statements (Resumed).

 

3:00 pm

Photo of Olwyn EnrightOlwyn Enright (Laois-Offaly, Fine Gael)
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I wish to share time with Deputy Joe McHugh.

It was a mistake that shouldn't have happened even once. And now I can't believe that here has been yet another botched cancer test in our health system.

These are not my words but those of Rebecca O'Malley, which were published on 8 August 2007. I wonder how she feels today knowing that it is no longer one mistake or two but several mistakes in several hospitals affecting several women. One could be put down to human error; at this point, crises seem endemic in our system. When one reads her words and meetsthose affected by the latest scandal in my constituency, it brings it home that these are real women with real families who placed their trust in the health system and were let down andfailed utterly. This is the central point and nothing we do in the future will change this reality for them.

Due to a failure by the Government to get any sort of handle on the health service, 3,026 women who had been through the Portlaoise centre in a four-year period had to wait by a ticking clock while a review was carried out. Now eight women have received the worst possible news, six more must get further checks and 13 still await confirmation while the clock is still ticking. Early diagnosis was stolen from these women.

I reiterate a clear fact in this case. This Government chose the Midlands Regional Hospital in Portlaoise as a designated centre for breast cancer care for the midlands area in 2000. However, the follow-through on this designation, in terms of adequately funding that supposed commitment, providing the most up-to-date equipment for a designated centre and ensuring enough staff were available to take mammograms, read results and check them, never happened.

In October 2005, the Minister for Health and Children personally made a commitment at a press conference in Emo that the cancer unit would be up and running within the next 12 months, with interviews taking place to find staff. It is easy to make a designation and the Government did that but then it effectively walked away. What confidence can we have that its attitude to the newest forms of designation, the centres of excellence, will be any different?

The Minister outlined today that she first became aware of problems at the Midlands Regional Hospital in July 2005 when she was told that the radiological service was being provided by people who had no expertise. Yet, apart from passing the issue around for examination, nothing seemed to change. There seems to be some contradiction which I ask the Minister to clarify in respect of her speech. She said the hospital had one permanent consultant appointed in June 2004. She then said that in the summer of 2005, breast radiology services were being provided by two locum radiologists. What happened to the permanent one appointed in June 2004? One permanent post was then filled in August 2005.

I am also concerned by the delay between advertising posts, holding interviews and making job offers and the fact that the person offered the position is allowed such a long period of time in which to turn it down. I ask the Minister to respond to this point and to address the question of why it is so difficult to recruit staff to the Midlands Regional Hospital. Thousands of people are moving into the area. People are commuting from there to Dublin and elsewhere, yet it seems to have been a particular problem to get staff for the hospital there, which is a reflection on the entire issue.

What response was given to the radiology department when it expressed concern about the age of the mammography machine and advised that a digital machine was needed? The HSE said a routine inspection on 18 May indicated that the machine was satisfactory. We are told that it was operating correctly. However, the complaint was not about it operating incorrectly. It was about it not being up to the job and the need for a digital system, rather than a film system. Was any inspection carried out in the intervening five months? They were warned, in black and white, about the possibility of delayed or wrong diagnoses. How much clearer did it need to be? Did this, together with the earlier warning to the Minister, not at least spark any little ember of concern or suggestion that maybe we need to look a little bit closer at this issue? I do not know whether the machine was at fault but it is clear that staff had legitimate concerns.

Professor Drumm's job is to implement the policy laid down by the Government, or so we were told when he was appointed. He blamed this crisis on "an inherited fragmented system of care". It is time to get a grip on the facts. Practically the only difference is that the actual health boards were abolished. At the time the health boards in the midlands were dominated by Fianna Fáil. As far as I can see, since the creation of the HSE, the same people are in the same jobs but with fancier titles, in mostly the same places, being presided over by the same Government. Nothing has changed.

Some people have questioned the commitment of Fine Gael to centres of excellence. I make no apologies for raising questions. Deputy Enda Kenny read out a letter where the Minister, Deputy Micheál Martin, then Minister for Health and Children, clearly outlined what the Government committed to Portlaoise on designating it as the midlands centre for breast care. Key components of that promise were reneged upon. The Government did not honour its promise to the women of Laois-Offaly so for me to accept, on blind faith, these new commitments by the same Government without question would be a total failure on my part to represent the women and men who put me here to hold this Government to account. The Minister must show me where the money will come from to build these centres, prove that she has the right numbers of qualified staff ready, show me where those women who need examination and treatment in the meantime will go, prove that this will not further delay them getting appointments, give me start and end dates for each centre and prove to me that transport will be provided. If she does, there will be no buts.

I was sickened listening to the Taoiseach reply to questions today. He seems to take umbrage at answering questions on this issue. He has attempted to wave the problem away. According to him, he gave the HSE the money and it is up to the HSE to decide what to do with it. That will not help these women who have had a dangerous disease fester in their bodies after being told they were not sick. He told the House that the Government is "doing a top class job for those women". He stated: "While I feel sorry for people and I will work might and main to try to improve the position, I reject the position whereby Deputy Gilmore can come into the House and castigate a health service which we put in place and which is a good one." What frightens me is that he is so far out of touch with reality that he believes it and does not realise it is not a good idea. I have seen many failures of accountability in this House but today has taken it to a new level and a new low.

I accept that the Minister has apologised but the system is not working. It failed the women of the midlands, women in Cork, Susie Long and Rebecca O'Malley. How many more names will be on the list before someone in government has the courage to realise that there is more to the job of government than making announcements, that it is about follow through, responsibility and accountability above all?

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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I thank the Minister for meeting one of the representative campaign groups yesterday, Co-operating for Cancer Care NorthWest, and her ongoing communication with another group, Donegal Action Cancer Care. I listened to the remarks of my colleague, Deputy Niall Blaney, who stated that this should not be a politicised issue. We sing from the same hymn sheet with regard to equal access and best practice patient care. The only effort at politicising this debate comes from the Fianna Fáil Party, which has attempted to spin the fault for this problem onto the desk of the Minister for Health and Children, Deputy Harney. No one person can achieve the radical overhaul of a system on his or her own.

We must call everyone to account, particularly the Taoiseach. A few weeks ago, on the Order of Business, he stated that he was listening to what the people are saying on the street. Obviously he listened but did he hear? The ongoing debate is vociferous and those involved in campaign groups seeking proper cancer care provision are those with cancer. They have been through the mill and are talking sense; they not just being parochial by seeking a centre in their backyard.

Naturally I am being parochial in referring to the north west but the Minister is open to the idea of a satellite radiotherapy centre accessible to the public, as desired by those on both sides of the Border. She will meet with Minister for Health, Mr. Michael McGimpsey, next week. There is no reference to this in the Hollywood report but I plead with the Minister to maintain her openness to this idea. She should also demonstrate her commitment to Letterkenny General Hospital. Three weeks ago she indicated that Letterkenny would be the site of an outreach cancer service provider. Letterkenny must be a pivotal centre for the area as far as Sligo and Altnagelvin Hospital.

People are debating this matter but they do not have access to transparent information. I tabled a question to the Minister last week about communication with private developers in Letterkenny about a private hospital. I was delighted to receive a response because that usually presents problems. The Minister replied that she had met them but would delegate responsibility to the HSE to continue communication. It is important that the Minister remains focussed because she has an important role to play.

The debate on co-location and private versus public requires information. I ask the Minister to keep us informed on what is happening in Letterkenny with regard to private hospital development.

4:00 pm

Photo of Seán FlemingSeán Fleming (Laois-Offaly, Fianna Fail)
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As a representative of Laois-Offaly, it is with a heavy heart that I speak on this matter. The past week has been a sad time for us. The women affected as a result of the misdiagnosis are our friends, family, relations and neighbours. Some seven patients who were given the all clear have been diagnosed with cancer. Some six women live in fear for their lives. Although there is overall political responsibility, the debate must be patient centred rather than an exercise in political point scoring. We must speak more about the patient than politics. Those who are suffering from cancer live in fear of it, which causes stress, which in turn causes cancer. It is a vicious circle. The sooner the six women are put out of the fear they suffer at present, the better.

The three most important aspects of health services are the patient, the patient and the patient. I thank the Tánaiste for being honourable and courageous in issuing an apology to those who have suffered as a result of late diagnosis. I hope the treatment will not be too late, that they will make a full recovery and receive counselling. There is an additional trauma to carry. Every cancer patient considers what would have happened if it had been detected earlier. These people have this doubt proved positive.

The Minister for Health and Children, Deputy Mary Harney, was very good to the patients of Dr. Michael Neary in Louth. She learned lessons in that process, as we all did. The humanity she displayed at that time is present now. I can understand the families telling us where to go with our apologies. They are suffering and are right to be angry. I understand that people vent their anger at those elected to run the country, who are ultimately responsible for delivering health services. We must accept that there are good times and difficult times in politics and we must endure the latter as well as enjoy the former.

I am sickened by the use of the hackneyed phrase "centre of excellence" in this debate. Each health facility should be a centre of excellence. If one's local GP cannot provide an excellent service, he or she should not be in business. The concept that there can be eight centres of excellence and that every other facility is somehow operating to a lower standard is wrong. The phrase "centre of excellence", which should be banned from the medical lexicon, demonstrates the hierarchical approach taken by those who use it, namely, that what is done in the main centres is better than what is done at smaller centres. As a result, those who work in the former look down on their counterparts in the latter. I address my comments in this regard to the medical profession because phrases such as that to which I refer emanate from medical reports — they are not invented by members of the public. If one attends one's dentist, one expects to be provided with an excellent service. We expect the same level of service provision from the entire health service and not just from the eight regional centres.

Members of the medical profession have been at odds with one another on this issue. As the Minister stated, in 2001 Professor Niall O'Higgins, who was involved in the overall national service, suggested that the midland region should have one centre of excellence and that this should be based, for geographical reasons, in Tullamore. Not long after and having discussed the matter, the then Midland Health Board decided to locate the breast service in Portlaoise and other services in Tullamore. In recent times Professor Drumm scrapped the entire approach and essentially stated that there should be no such centre whatever in the midlands. Tullamore was subsequently removed from the list of the centres of excellence.

I represent County Laois, which is situated not much more than one hour's journey from Dublin. If a better and more comprehensive service can be availed of in Dublin, patients will travel to the capital. Most of the complaints I receive about cases where people are obliged to travel long distances to avail of hospital treatment involve the difficulties, particularly those relating to parking, experienced by families and friends trying to visit these individuals. It is only on occasion that a patient will complain and this is usually in circumstances where he or she is obliged to attend for regular blood tests or check-up. People would be happy to have their treatment in Dublin and if they are obliged to have some of their follow-up treatment here, well and good. I accept that families, relations and friends have been discommoded and have dominated the debate relating to transport and access. If these individuals asked their relatives or friends suffering from cancer how they felt, their opinion would change.

We cannot flinch. Professor Brendan Drumm has been charged with delivering the service. He employs his staff and has been running the service for a number of years. In addition, the HSE has been in place for some time and responsibility lies with Professor Drumm. I will put it as mildly as possible by saying that he made a sad choice in the words he used when blaming members of the public and patients for causing this problem. The responsibility lies with Professor Drumm and the staff are his. The Taoiseach stated that a systems error was not involved. I can only take that to mean that there was human error somewhere along the line. If that is what the report shows, then we must accept it. One cannot blame the public for mistakes made by one's staff.

I praise the consultant and other staff at Portlaoise hospital who highlighted the problems that came to light. They did their best, within the structures of the HSE, to ensure that information was passed up the line.

I am pleased that the recovery or survival rates relating to breast cancer improved from 73% to 78% between 1994 and the early years of this decade. I would like to see a breakdown of these survival rates on a hospital-by-hospital basis because I want to be sure that the rates at the new centres of excellence will be much higher than those which obtain in the facilities that are being closed. I am not pleading for a local service, I am seeking the best service to be provided for all. Location is not the issue. Perhaps information in this regard is already available. However, I have never seen it. If it is available, I would like to be directed to where I can obtain it.

I am not in favour of the provision of overall national statistics. It must be remembered that hospitals such as that in Portlaoise contributed to the improvement in breast cancer survival rates during the period in question. It is not fair to scapegoat Portlaoise on foot of human error. There are many dedicated staff in Portlaoise hospital and some of them are extremely upset about this matter. There is much good activity taking place in the context of the maternity, paediatric and psychiatric services on offer at the hospital. This matter will be a blow to the morale of everyone involved in the health service and the sooner the cloud hanging over Portlaoise hospital is lifted the better.

I wish to follow up on the point raised by Deputy Enright, namely, why the post of a third consultant radiologist at the hospital, which was advertised in July 2005, has not been filled. Perhaps it is difficult to recruit staff to some of the smaller hospitals because they do not offer the same range of training and promotional prospects or the opportunity to deal with as varied a caseload as bigger hospitals. Those issues will have to be addressed, not only in the context of cancer services but also in respect of the appointment of further consultants. If we progress matters relating to the new consultants' contract and move towards a consultant-led service, perhaps there will be more consultants working in our smaller hospitals. I am not saying that Portlaoise is a poor hospital but it does not compare to some of its larger counterparts.

Funding was provided a number of years ago in respect of investment in breast cancer services in the region. I suspect that more money has been spent on the PPARS system than on cancer services in Portlaoise hospital. Staff in the midland region are included under the 40% of staff in the PPARS system. I understand that it cost €158 million to put the system in place in respect of those staff. I am an accountant but I will not break down this figure because I am fearful of the answer I will obtain. However, I reiterate my suspicion that more money has been spent on PPARS than on breast cancer services at Portlaoise hospital. Perhaps information relating to this matter could be provided at some stage.

Debates of this nature are no good unless lessons are learned. It is in that context that the Minister will do well. We are undergoing a difficult and traumatic period of change as regards the delivery of health services. The Minister will have the support of Deputies in respect of this matter. I do not want Deputies to fly the flag on behalf of their local areas just for the sake of doing so. We want people in the midlands to receive a service that is similar to that received by everyone else. Results tend to be better on the east coast. I do not know why but perhaps it is that there are better facilities in the Dublin region. I would also like to see figures in this regard.

I hope all the women who were diagnosed with breast cancer make a full recovery.

Photo of Joan BurtonJoan Burton (Dublin West, Labour)
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At 8.30 a.m. tomorrow, an event on the calendar of the Dáil, which has been eagerly awaited since the general election, will take place. The event in question is one of the meetings — there are usually two per year — involving Members of the Oireachtas and Professor Drumm, the head of the HSE. Professor Drumm is expected to appear and give most Members the only glimpse they will probably get of the supremo of the health service. It will be a hot ticket. The meeting takes place in the private dining room and if it is similar to previous gatherings, there will be standing room only. People of all parties, ranks and distinctions from the Dáil and Seanad will crowd in to try to obtain some answers from the man for whom Members on all sides have much goodwill, particularly in the context of our hopes that some improvements will be brought about as a result of the allocation to his organisation of €15 billion.

As on previous occasions, I am sure Professor Drumm will be accompanied by some of his top advisers. I do not know if the Minister or the Ministers of State will be present. Certain members of the Government attended previous meetings and, like Opposition Members, they did so to ask questions. Even though they have privileged access to the notes from Departments to Members on the backbenches and Front Benches on the Government side of the House, they could not make sense of what was happening. The Minister must bear in mind that because of the crucial significance of the health service to everybody in this country, nobody on the Opposition has anything except a desperate hope and longing that some of what the Minister set out to do will improve the lives and chances of the men, women and children who use our health services.

I hope when the professor shows up in the morning with his top team at the top table they will have answers for us. On previous occasions they lectured us on what we as politicians lack in our attitudes and where we have not reformed robustly enough our mental approach to this issue. The professor outlines scenarios such as centres of excellence. We are all rational people. Nobody has a difficulty with the concept of a centre of excellence. However, we have a difficulty with the concept of a centre of excellence that will not exist until after 2009. In the meantime, what will happen to the poor little people who need excellence? Why, if one pays €50 to go to one's GP, is one not entitled to a sense of excellence? Everything we hear from the new structure is that mañana, next year and the year after we will have a health system with public confidence.

I examined closely comments made about the health system during recent weeks. The Taoiseach quibbled in his comments and replies to the leader of the Labour Party this morning when Deputy Gilmore mentioned four eminent people on the doctor consultant side of the health services who pointed out difficulties. At a conference yesterday, Professor Neligan stated the HSE chief and the Minister "have alienated all the caring professions, all the nurses, all the doctors, so it will be very hard to get dialogue and co-operation going again."

This is a disastrous indictment of the health service. I know from having worked as a Minister of State, and the Minister has enough experience to know, that the culture of the public services is very different from that of private industry and private business. If the workers in the health service, such as doctors, consultants, nurses and paramedics, do not acknowledge, recognise and look to the political and executive leadership, that leadership is in an extremely difficult situation.

The crisis in the health service is not simply down to the drive to modernisation and change, which is always difficult in any institution. Even politicians find changing constituency difficult. Change is not easy to manage. However, it is an incredible indictment that the people most proud of their contribution to the health services and who are well paid for it now indicate the system has large elements of chaos, shambles and lack of accountability.

Today, at the beginning of her contribution, the Minister was kind enough to make a full apology to the women and families involved. This is important and is a mark that the Minister, if not the Taoiseach, is prepared to accept some level of responsibility for what has happened, however detached.

I want to discuss the debate that took place in this House on creating the Health Service Executive. I recall the Minister and politicians in the Government parties arguing for key features to be built into the system. The new structures were to have a fundamental lack of democratic accountability because it was deemed by many of the interests in the old health board system, not least the civil servants and perhaps the Minister, that politicians at local level interfered too much.

I assume the Minister was the architect of the critical transfer of functions from the Minister for Health and Children to the chief executive of the new body, effectively reducing severely the role and accountability of the Department of Health and Children and the Minister. The manifestation of this is most alive to politicians through the public affairs division of the HSE. As far as I can see, it now occupies the entirety of space in Stewart's Hospital. Six or seven months later it answers queries which at times are so unreferenced that one can no longer work out what exactly they were about.

I defy anyone to understand the fuzzy management structure of the HSE. Earlier this week, Fintan O'Toole wrote in The Irish Times about the review done by the review body on higher remuneration where Professor Drumm, with Ministers, judges and the Garda Commissioner, received significant increases in their wages above benchmarking and the level of inflation. However, the review body on higher remuneration withheld similar increases to the second tier of managers in the HSE because it could not work out what they did. The reporting lines and the definition of their jobs were not clear. It could recognise that people work hard and to the best of their ability but without purpose in the context of an overall coherent plan. This middle level of managers grew by 37%, from 521 to 713, between late 2005 and June 2007. Most Dáil Members who attend a Health Service Executive function meet managers who are traumatised.

With regard to BreastCheck, the present position is difficult for women. They are damned if they go for a mammogram because of the major uncertainty — everyone who has had a mammogram has a doubt in the back of her mind about whether the results are as indicated — and they are also damned if they do not go because they are holding back. At present, the sense of trauma is such that women do not know what to do. Why go and be tested by a service that is so poor that perhaps it is better not to have it done? As Deputy Fleming stated, the people involved could save themselves endless stress. The system is in chaos and is a disgrace, but I thank the Minister for her apology.

Photo of Mary O'RourkeMary O'Rourke (Longford-Westmeath, Fianna Fail)
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I came in to do as Deputy Burton did, to thank the Minister for her apology to the House this morning and to the women who feel so let down by what has happened in the health service. It is also to the credit of the Deputies who agreed so readily that we are having this full debate. We are constantly told the Dáil does not reflect what is in ferment in the country but the state of the health service, particularly breast cancer services, has the country in ferment at present. While running an errand to Brown Thomas during Priority Questions, 11 women stopped me between here and Grafton Street to describe what had happened to their relatives and neighbours and all had awful tales to tell. I admit, however, that we also meet people at our clinics who have had positive experiences of treatment for maladies other than cancer. No doubt a great deal of good service is also provided.

I am astonished Professor Drumm actually said that people marching caused the misdiagnoses. We have a constitutional right to assemble and march. We do not live in a State which forbids us to attend an assembly. I understand the connection he was trying to make but it was surprising that he said it so baldly and badly.

Photo of Charles FlanaganCharles Flanagan (Laois-Offaly, Fine Gael)
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He was also factually incorrect about marches in County Laois.

Photo of Mary O'RourkeMary O'Rourke (Longford-Westmeath, Fianna Fail)
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There were no marches in 1999 in County Laois. It was jarring that a person of his calibre and status would seek to denigrate a woman in her moment of need. Lest people think I do not want to face him tomorrow, I have already sent my apology because I must attend another engagement. I telephoned his office but, of course, I spoke to seven different people and do not know who eventually received my message.

Photo of Joan BurtonJoan Burton (Dublin West, Labour)
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That is typical.

Photo of Mary O'RourkeMary O'Rourke (Longford-Westmeath, Fianna Fail)
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I have no vested interest in this issue because even though Athlone is bursting at the seams, it lacks a hospital. We have an excellent care service which treats older people with dignity and love but we have no hospital. Centres of excellence make sense but the transition must be charted from what we have now to the point at which the centres are established. People will otherwise be left in a vacuum, unsure of whether they should continue to attend their local services or wait until the magnificent centres of excellence appear out of the gloaming to the wonder of us all.

I recall being told in the 1980s that mental hospitals should leave their Victorian settings so that people could live in private houses with care assistants. The mental health system eased itself in that direction but it took a long time to do so. In the meantime, the mental hospitals remained open for those who were not ready to move to private homes. The centres of excellence, about which we feel guilty if we are not supportive, are somewhat of a mirage. It is as if one is in a desert and constantly sees a great city.

I am in despair about the health services in Ireland. Thankfully, I have not yet had personal cause to experience them, although members of my family who have passed away were beautifully treated in the Mater Hospital. I do not know how the Minister can continue because there are always dragons in her path which must be slain. She has made a good effort at slaying them but fresh dragons keep emerging. Will Nirvana or Hy Brasil ever appear? Will we ever see the promised land in health? I do not think so, regardless of how much admonishment we receive from Professor Drumm or the Minister, although hers is given kindly.

Deputy Burton spoke about how the HSE makes us feel when we receive correspondence from it. By the time we receive the letters, weeks have passed and we have forgotten the query and must tune into the issue once again. I received a letter which began by asking me if I realised that I had complained about a care home for troubled adolescents. Of course I was aware it was a care home but that did not explain why the young inhabitants were not being properly minded. I was made out to be unfeeling because I dared to bring it to the attention of the HSE that the young people were running wild in the town. The letter was astonishing in its implications.

We need to see exactly where the centres of excellence will be located. I am puzzled because Professor O'Higgins outlined 12 centres of excellence but there are now eight. We know where the remaining eight are to be located but I would be happier if I knew what happened to the missing four. What pitch has been made in respect of the finance for the centres, given that they will be hugely expensive? Have we made allowances for that in our financial forecasts? The hospitals which are currently providing good care should continue their operations. We cannot suddenly send everybody down the road to centres of excellence without allowing for the phasing outof the centres where services are currently provided.

I wish the Minister well but there are so many dragons in her path that I do not know whether she will have sufficient swords to slay them. It is depressing that the dawn is always supposed to be brighter if we deal with the consultants or mollify this or that group when the dawn never arrives. The health services remain in the doldrums despite all the positive stories which appear to give hope to people. The HSE has become a giant which cannot come to grips with its many parts. The Minister must preside over it because I do not agree that all responsibility should lie with Professor Drumm. We will now have another person like Professor Drumm, the czar for cancer, and all the problems will be heaped upon him. I wish Professor Tom Keane well and hope he has a kindlier manner, a better way of approaching people and an appreciation of the enormous worry all this has caused. I wonder how women who have had mammograms sleep at night. If they sleep, their first thought when they wake up must be "Oh my God, am I due, am I one of the people who is going to be called out or will I have to go again? Is that what my fate will be?"

Photo of Charles FlanaganCharles Flanagan (Laois-Offaly, Fine Gael)
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I wish to share time with Deputy Kieran O'Donnell.

I call on the Minister for Health and Children to ensure that the Portlaoise inquiry is independent because what is happening is not sufficient. An appalling wrong has been perpetrated on the women of the midlands and their concerns and welfare must remain paramount throughout this debate.

Seeking answers as to why some mammography screenings failed at the Midland Regional Hospital is not about identifying a scapegoat but about finding out what went wrong, why it went wrong and taking lessons from this appalling situation to ensure that nothing like this will happen again. Professor Drumm's recent outburst, blaming the people and scapegoating professionals and health care workers is unbecoming of a man of his position. To blame the public is to miss the point. People and health care professionals are not trying to hamper progress. All they want is a decent health service. The HSE has been critical of people for not accepting the rationalisation of local hospitals in exchange for so-called centres of excellence that are not in place. In such circumstances, who would not object to the removal of services? The responsibility to deliver health care services to the taxpayers of Ireland lies with the HSE, an agency that is funded entirely at the taxpayers' expense.

In 2002, the Minister for Health and Children, Deputy Micheál Martin, designated the hospital in Portlaoise as a centre of excellence for symptomatic breast diseases in the midlands. The cynicism of the Government in making that decision has only now been revealed to the public. It has become clear that the funding to meet that commitment never materialised. It turned out to be an empty gesture with appalling consequences.

The recent situation in Portlaoise has captivated the attention of many people because we are all well aware that the situation there is not unique. It is not the only hospital in the State that has no system for the independent auditing of mammograms. In a majority of hospitals, quality control and maintaining adequate standards have become serious issues due to the absence of a commitment to appropriate funding by the Government and the failure of the Minister and the HSE to engage constructively with radiologists. The chain of responsibility for what happened in Portlaoise goes right to the top. In the past seven years the former Midland Health Board, the HSE and, ultimately, the Department of Health and Children were responsible for budgets and staffing. Fundamental questions must be addressed about the impact of decisions taken at senior management level at the coalface.

I have a number of specific questions for the Minister for Health and Children which I will put to her now in order that her officials will have the opportunity to seek some answers before she responds to this debate.

Contrary to best practice, why was the sole radiologist frequently responsible for interpreting mammograms in Portlaoise on her own? Who sanctioned that situation? Is the internal inquiry focusing on the work of one person or of all those working in the radiology department at the hospital? What of X-rays other than mammograms carried out by radiologists, having regard to the fact that mammograms only comprise some of the work of radiologists? What of the qualifications, academic and professional, experience and accreditation of those attached to the X-ray unit in Portlaoise? What are the terms of reference of the inquiry under way?

It is on the record that the radiology department formally wrote to the hospital warning of the "potential of misdiagnosis" and "delayed diagnosis of tumours", but it appears that no action was taken by management. Why was the letter not acted upon? Where is the response to it? What action was taken? When was the letter received by the HSE in Tullamore? What action was taken by the HSE following receipt of the letter? Will the report detail the many pleas for resources from consultants, public representatives — I listened to Deputy Seán Fleming and agreed with most of what he said — and the public?

Concerns about chronic under-resourcing at the Midland Regional Hospital were expressed on a regular basis and early warnings were ignored. True to form, we have waited for a crisis before taking action. The gross bureaucracy and labyrinthine structures of the HSE which undermine our services have been highlighted yet again by what has happened in Portlaoise. Vital letters went nowhere and no one was willing to take responsibility. We know that a consultant surgeon wrote directly to the Minister for Health and Children in July 2005 informing her, in fairly strong terms, as she disclosed to the House this morning, of his concerns about the situation in Portlaoise hospital and raising specific issues of a type that are now central to the current debacle. It is astounding that the Minister was informed more than two and a half years ago that "radiological services at Portlaoise are being provided by people with no expertise in this area". While the Minister referred the letter down the line, the failure to follow through and adopt a position of leadership and interest in this matter has shown that the Department of Health and Children-HSE model simply does not work.

I fully agree with the concept of centres of excellence which are accessible and well equipped. However, as Deputy Fleming pointed out, a centre of excellence means different things to different people. A centre of excellence means proper hospital management and delivery of a service. I urge the Minister for Health and Children to set up her centres of excellence and then convince the people that they are a superior option. Without an accessible, physical, functioning centre of excellence providing appropriate cancer services, no one will support the removal of cancer services from regional hospitals.

The Government has promised the centres will be in place by the end of 2009, but what will happen in the interim? St. Vincent's hospital is designated to deal with people who would ordinarily attend Portlaoise hospital. How will St. Vincent's hospital, which is already one of the busiest hospitals in the country, cope with an influx of new patients from the midlands? Is there adequate capacity, beds, staff and day care facilities in St. Vincent's hospital? Only this morning a woman detained me on the telephone for more than 15 minutes telling me about her experience in St. Vincent's hospital on Monday. She was left walking around Dublin for most of the afternoon, having left St. Vincent's hospital and missed her train home. She had no acknowledgement from the Health Service Executive and no assistance by way of transport.

The modus operandi of the Department of Health and Children and the HSE in recent years has been to shift the entire blame for anything that goes wrong on to somebody else. In this instance there has been an attempt by senior management in the former Midland Health Board, now the HSE, and the Department of Health and Children to lay the blame at the door of the radiography unit in Portlaoise hospital, but that is not the full picture. What has happened in Portlaoise is the inevitable result of consistent neglect in respect of funding and neglect by those with decision-making capacity in the HSE, the Department of Health and Children and the former Midland Health Board. They chose to look the other way when those at the coalface in the hospital attempted to draw their attention to the problems.

As Deputy Fleming said, there are many diligent and committed people working in the Midland Regional Hospital, and I agree with him, but an internal inquiry is neither sufficient nor appropriate at this time. A narrowly focused internal inquiry on one person is unlikely to uncover the complex chain of events that has led to the current crisis in the radiography unit at the hospital. It is essential that a broad-ranging, independent inquiry is established so that what exactly went wrong and why can be made abundantly clear. Without such clarity we will not be able to ensure that such failures will not take place again.

There is real anxiety, concern and fear on the part of women and their families, not just in the midlands but far beyond. Recent events have sparked a crisis in public confidence in our health care system. The first step to be taken in addressing these fears is to establish a transparent inquiry in Portlaoise that will answer the people's questions. Hiding behind an internal review will only erode public confidence further. The Minister owes it to the women of Portlaoise who, with their families, must remain the primary focus in this debate.

Photo of Kieran O'DonnellKieran O'Donnell (Limerick East, Fine Gael)
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The Government has known since 2001 that centres of excellence for breast cancer should have been established. That is more than six years ago. Why has it taken so long to establish them? In terms of the centres of excellence, Professor Keane will be in place at the end of this month. Will the Minister put the resources in place to make absolutely certain that Professor Keane can move with efficiency to establish the centres of excellence immediately? Otherwise there is a danger that this will drag on.

The Minister for Health and Children is responsible for all health services. Under the Health Act 2004, the Minister is responsible for Government policy while the HSE is only responsible for its implementation. The Minister appointed the board of directors of the HSE and Professor Brendan Drumm but, ultimately, she dictates policy. I wish to take up a point mentioned by Deputy Mary O'Rourke. The powers in the HSE are vested in the board. It can decide how much power to give Professor Drumm but, ultimately, it is answerable to the Minister and the Taoiseach. It was not good enough for the Taoiseach to come into the House this morning and say that neither he nor the Minister are responsible for what the HSE does. They are the HSE's boss and should be calling the shots.

I refer to issues I would like addressed, in particular Barringtons Hospital. The issue in Barringtons Hospital arose on 6 August. Why has it taken over two and a half months for the inquiry to be fully set up? The team has not been put in place. When will it be put in place and when will the report be produced? The end of the year was mentioned but we are entitled to know the date. The women of the mid-west are entitled to know as are the women in the Portlaoise area who my colleague, Deputy Charles Flanagan, mentioned.

I would like the issue of mammograms addressed. This morning the Taoiseach mentioned there would not be a double reading in hospitals with 500 or fewer readings per year. That is not good enough. The Minister is responsible for giving an assurance to women that they will get a proper reading. It should be Government policy that double readings take place. There may have been some confusion this morning. The Minister spoke about triple assessments and double readings in the same sentence. They are two totally different things. A double reading is two radiologists reading a mammogram twice. The situation arose in the hospital in Portlaoise because there was only one radiologist.

I would like double readings to take place and digital machines to be put into all the existing hospitals so that double readings by radiologists can take place. The Minister needs to give an assurance to the people in the interim until the centres of excellence are established, which should happen immediately.

Photo of Beverley FlynnBeverley Flynn (Mayo, Independent)
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I welcome the opportunity to speak on this important issue. On 1 November, not realising what happened in Portlaoise, I tabled a motion asking that Government time be allocated to a discussion on the national cancer strategy because it is a huge issue in my area. What happened to the women in Portlaoise is dreadful and one's heart would go out to them and their families. It is hard to even begin to imagine what they are going through. It is a terrible situation which I hope is not repeated anywhere else. Our sympathy goes to those women.

Some 7,000 people marched through the streets of Castlebar and 2,000 people marched in Galway. Instead of criticising them, we should commend them. In the past we have spoken about satisfaction ratings. The Minister mentioned the satisfaction of the majority of people who go through the health system and the fact so many of them are satisfied. Some 7,000 people walked through the streets of Castlebar to show their confidence in their local health service. They are people who have been through the system, who have had surgery, who have survived and who are telling the world what a wonderful system exists. We should not knock these people — we should applaud them for doing so because of the confidence it demonstrates in what is, in many ways, an excellent health service.

Will the outcome of the HIQA audit due to take place in April next year in any way alter the national cancer strategy as outlined? If it cannot have any impact on the strategy, why is the audit taking place in the first instance? I refer to the eight centres of excellence. It has been highlighted that the country can only justify eight centres of excellence with a population of 500,000 per centre. I understand that but what I cannot understand is the location of those eight centres and why not one of those centres is located north of the Galway-Dublin line. Even if there is one centre of excellence per 500,000 of population, there could be a greater geographical spread throughout the country. It is completely unjustified that four of those centres would be based in Dublin.

What will Professor Tom Keane's role be when comes to Ireland? Will it be purely the implementation of the national cancer strategy and the decisions which have already been made or will he be able to recommend changes based on the outcome of the HIQA review next April?

Why is it acceptable to have a satellite in Letterkenny as part of the centre of excellence in Galway modelled on Mayo General Hospital when we are closing the services in Mayo and in Sligo? I do not believe it is about geography or social or economic groupings; it is about women getting the best possible outcome and an excellent service. If we can justify the location of a satellite in Letterkenny, then surely if similar excellence is being provided in Mayo General Hospital and in Sligo, that should also be acceptable.

There was much talk today about Portlaoise and the fact it was a designated breast centre. Mayo General Hospital, which has operated a breast clinic since 2000, has one consultant surgeon who specialises in breast surgery and who will carry out 80 procedures this year. We have three radiologists, all of whom are trained in breast ultrasound and two of whom are trained in breast ultrasound biopsies. Each mammogram is read twice. We have two pathologists, both of whom are trained and are specialists in breast pathology. We have a medical oncologist from Galway who does two sessions per week. He sits in on all the conferences on every new cancer case which occurs in Mayo General Hospital. We have excellence. I make this point not only because it is my local hospital, although the cynics might say it is. As a woman, I would not recommend to the people of my county a substandard service. However, it appears they are getting a far better service than that in Portlaoise where there is only one radiologist reading mammograms. It is also quite obvious given the waiting times. In Mayo, if one has an urgent referral, one can be seen within a week. If one has an early referral, one is seen within six weeks. A definite diagnosis is given to an urgent referral within two weeks of being seen. This is the service to which the people of Mayo have become used and in which the women of Mayo have expressed confidence. If something is working, why are we changing it? Are we changing it for change sake?

The Minister quoted some very interesting statistics. She mentioned that the survival rate from breast cancer has improved from 72.9% to 78.2%. How do those figures break down between the various hospitals carrying out breast surgery? Mayo General Hospital has contributed to the improvement in those services. Are those statistics available? How can we close a service with which the people are satisfied and in respect of which 7,000 people were prepared to march on the streets to demonstrate their satisfaction if we do not have statistics telling us that service is inferior? If I have to go back to my constituents to explain to them that the service is inferior and if the Minister has statistics to back that up, I will discuss that with them because I do not want them to get an inferior service.

We should wait until April when HIQA carries out is review. I am confident, as are the consultants and staff of Mayo General Hospital, that they will come through that review with flying colours. If they do, will the Minister amend her national cancer strategy and agree with a managed cancer network in the west taking into consideration Mayo General Hospital, Sligo and Letterkenny as part of a managed network?

Two years ago the Minister recommended that the Oireachtas Committee on Health and Children visit Sloan-Kettering, the finest cancer hospital in the world. We took the Minister up on that and in May 2006, we visited Sloan-Kettering where we met Dr. Thomas Fahey who is head of the international breast centre there. I spoke to him today specifically about the networking arrangement which currently operates in New York. Sloan-Kettering has been held up as the finest cancer hospital in America and we are holding it up as a shining example. It has satellites around the periphery of the city in which diagnostic, chemotherapy, radiotherapy and day surgery take place.

I discussed with him the arrangements we have in this country, specifically in my local hospital, Mayo General Hospital, and he said it is very significant that 80 surgeries take place every year. Professor Niall O'Higgins said in his report that if a consultant is doing more than 50 and less than 100 surgeries, he or she is deemed to be proficient in his or her area. Like all women in County Mayo, I am confident that Dr. Kevin Barry, who is the consultant surgeon in Mayo General Hospital, has the requisite proficiency. Having seen media reports of women who say they do not think they can have confidence in their local hospitals anymore, I assure the House that 7,000 people in County Mayo have confidence in Mayo General Hospital. As their public representative, charged with coming to Dublin to express their interests in the Dáil, how can I tell them that the service in Mayo is not good enough and will close? I ask the Minister, in the interests of excellence, to retain a cancer management network in the west. Such a network will provide for the best possible outcomes for the people of the region.

Photo of Mary WhiteMary White (Carlow-Kilkenny, Green Party)
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I speak from the heart today in the aftermath of recent tragic events. A number of women have been given false positives on foot of mammograms and it is possible that many more women may endure the dreadful experience of a recall. Having had a mammogram at Carlow hospital a few weeks ago, I cannot begin to imagine what those women are going through. When I was waiting for my X-ray, I spoke to women from Carlow and the surrounding districts — friends, neighbours and women I did not know — and we had in common that we were delighted to be getting an opportunity to avail of BreastCheck. Some of us were nervous and others were nonchalant, but all of us were anxious about the outcome. The service I received was superb. After we had our mammograms, we were asked to wait to ensure that the process had been undertaken correctly — that the X-ray had been taken properly, for example — before we were allowed to go home. We all waited for over three weeks before we were delighted to learn we had been pronounced fit and well. It is almost impossible to imagine what it would feel like to be recalled for a further check after a period of anxiety, stress and, to put it mildly, plain terror at the prospect of bad news.

It is easy to take part in the blame game, to score political points, to make accusations and to blind each other with statistics and figures. The only thing that matters now is that we get the service right. We all want specialist centres with multiple checking. If we are sick, we want to get better. We all want the best for our loved ones. People are entitled to expect the best and to have it. The people's servants have to get it right.

The national cancer control programme is comprehensive. The ideas underpinning the proposed structure of cancer centres throughout the country are good. People tend to overlook the fact that good services can only be provided if experts are recruited to a certain place. The designation of eight cancer centres, all of which will meet certain criteria for eligibility, should ensure that consultants and experts are incentivised to work throughout the country. I urge the Minister, Deputy Harney, to get Professor Tom Keane to start the process of establishing the eight centres of excellence as soon as he takes up his post, the week after next.

The roll-out of BreastCheck is continuing throughout the country. More than 63,000 women were screened last year. I urge the Minister to ensure that this service is rolled out across the country quickly. Rather than calling for political heads to roll, we should think of the women whose lives have been traumatised by the recent errors.

Photo of Charles FlanaganCharles Flanagan (Laois-Offaly, Fine Gael)
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Nobody is calling for heads to roll.

Photo of Paul KehoePaul Kehoe (Wexford, Fine Gael)
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If Deputy White was on this side of the House, she would be saying something different.

Photo of Mary WhiteMary White (Carlow-Kilkenny, Green Party)
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We need to get on with the task of ensuring——

Photo of Paul KehoePaul Kehoe (Wexford, Fine Gael)
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It is sickening.

Photo of Ciarán CuffeCiarán Cuffe (Dún Laoghaire, Green Party)
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I ask Deputy Kehoe to allow Deputy White to conclude.

Photo of Paul KehoePaul Kehoe (Wexford, Fine Gael)
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Who is to blame for the recent errors?

Photo of Mary WhiteMary White (Carlow-Kilkenny, Green Party)
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We should get on with the task of ensuring that such scenarios do not happen again.

Photo of Deirdre CluneDeirdre Clune (Cork South Central, Fine Gael)
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I would like to share time with Deputies Terence Flanagan and Kehoe.

Photo of Ciarán CuffeCiarán Cuffe (Dún Laoghaire, Green Party)
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Is that agreed? Agreed.

Photo of Deirdre CluneDeirdre Clune (Cork South Central, Fine Gael)
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The House is discussing the serious issue that has arisen in Portlaoise. Many Deputies received an education when this shocking news became known. Seven women who had been given the all-clear in Portlaoise have now been told that there was a misdiagnosis and that they have breast cancer. These revelations have rocked public confidence in the health system. Women throughout the country who have had mammograms on foot of recommendations from their general practitioners must be questioning the accuracy of the diagnoses they were given. I listened with interest to the statement made by the Minister, who will respond to questions later in this debate. We look forward to the production of the full report by Dr. Ann O'Doherty of St. Vincent's University Hospital. I hope her review will be concluded next week.

The Minister, the Taoiseach and various other representatives of the Government have told us that centres of excellence are needed if we are to solve this problem. I accept that these centres will bring some benefits. I spoke to Professor Niall O'Higgins in 2001, which is six years ago, and the report that was adopted by the Government at that time has not yet been implemented. The Minister said that the centres of excellence will be in place by the end of 2009. Many people question whether it can be done within 14 months, especially when Professor Niall O'Higgins's report has not been implemented since it was published in 2001. How can we make such progress within a short period of time?

Many people are worried about the mammograms they had in the past or might have in the future. Are the existing services adequate? Can we have confidence in the system? We have heard a great deal of information about double readings of mammograms and triple diagnosis. Many Deputies and members of the public understand the various technicalities and nuances in this regard. People will ask questions about the service that is available locally, the service they have availed of in the past and may avail of in the future. Family members will have similar questions. This crisis affects not just the women involved, but also their children, partners, mothers and fathers. The news of cancer in a family member rocks everybody in the family and sets them back. They consider how they will deal with the illness and wonder whether the outcome will be positive. We all hope there will be positive outcomes in these instances.

We are familiar with statistics which indicate that dedicated centres of excellence can and will reduce mortality rates by 20%, which is good. There is a crisis of confidence in the system, however. It will be difficult to instil confidence in people so they believe that the centres of excellence proposed by the Minister, Deputy Harney, and Professor Drumm will guarantee an adequate diagnostic service, as well as treatment if it is needed. That is the challenge being faced by the Minister and it is time for her to face up to it. She develops policy and Professor Drumm implements it. The policy is not working at present, however. We do not have the standards of excellence that are required at present. We are supposed to wait for the Minister's centres of excellence to be established at the end of 2009. I appeal to the Minister to give people confidence in the interim. We need an open and transparent system. We need to know exactly what types of services are on offer throughout the country for those who might have to avail of them.

5:00 pm

Photo of Terence FlanaganTerence Flanagan (Dublin North East, Fine Gael)
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I welcome the opportunity to contribute to this debate. I welcome the Minister's statement that it is important that the misdiagnosis of women with breast cancer should not happen at any hospital again. Like most people in this House and on this island, I was shocked and angry to learn that eight women who had been given the all-clear after getting mammograms at the Midland Regional Hospital, Portlaoise, have now been identified as having breast cancer. The health service has failed these women and their families, who placed their trust in it, but they have been badly let down. Nothing we do or say will change the reality for these eight women. Neither will it change the facts for those six women who require further checks nor for the 13 who await further test results. It is certain the Minister for Health and Children, Deputy Harney and the Fianna Fáil Government must take political responsibility for the shambles that is the health service. The buck rests with the Minister and the Government who have collective responsibility for the health service.

The Minister stated on "Prime Time" last night that there had been an inspection of the mammography equipment in the hospital early last year yet her Department is aware that this machine was 15 years old, that radiation equipment in general has a lifespan of ten years and that this machine should have been replaced five years previously. Half of the total number of 52 hospitals have equipment older than 15 years and this is completely unacceptable. What plans has the Minister made to replace these machines?

My party and I are looking for the Minister to immediately issue a memorandum to all HSE staff advising them that the double reading of mammograms is to become standard practice in all hospitals from now on. The Government needs to invest in digital scanners immediately in order that double reading can take place in another centre if two radiologists are not available to read the scan. The women of Ireland cannot wait for the Minister's centres of excellence; they have been waiting since 2001. Six years in total is a long time to wait.

Centres of excellence need to be established immediately in order that the women of Ireland can have some hope and faith in our system which has been allowed to fail under what the Government has established. Today there has been a further revelation about a misdiagnosis in Cork and we already know about the fiasco in Barrington's. Who knows what other cases may be out there which will be made public soon?

What women want and demand is a health service which will deliver the best service and the best result in order that people can trust it and rely upon its integrity. This should be a service that delivers the best result for women and will make an early diagnosis of problems.

I hope the Minister will take on board the constructive criticism given by all Deputies and that there will be an immediate roll-out of the centres of excellence which are badly needed.

Photo of Paul KehoePaul Kehoe (Wexford, Fine Gael)
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I will offer one minute of my time to Deputy McGinley.

I compliment the Minister on apologising to the people of Portlaoise because it takes political backbone to apologise. On too many occasions, Ministers have been afraid to apologise and I thank her for making that apology.

It is a sad day for the women of County Offaly and for the women of Ireland when statements on this subject are being made in the Dáil today. Deputy Terence Flanagan called for an independent inquiry to be carried out on Portlaoise hospital. I second his request so that we can ascertain who was at fault because someone must have been at fault in this case. It is disappointing to hear the HSE and Professor Drumm not taking the blame because they have to bear a part of the blame. I ask the Minister to do all that is possible to correct what has happened.

Voluntary fund-raising for cancer services takes place all over the country and every day Members are asked for their support in fund-raising for cancer services. The Government should match the funding raised by people putting their hands deep into their pockets who would like to see their tax moneys being spent on cancer services.

Photo of Dinny McGinleyDinny McGinley (Donegal South West, Fine Gael)
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I acknowledge that the Minister and Minister of State yesterday met a deputation from County Donegal representing those who are very concerned about the level of cancer services in our county and in the north west in general. As an Opposition Deputy, I appreciate that I was also present at the meeting and I appreciate the guarantees given by the Minister to the deputation that services in Letterkenny will be maintained for the time being. The big problem in the north west and in the area north of a line from Dublin to Galway is the absence of a radiotherapy service. We are dependent on Northern Ireland. While I welcome any access we are given to those services in Northern Ireland, it is not the answer to our problems in the north west and in County Donegal in so far as radiotherapy is concerned. It is not acceptable that half of the country which is north of the line from Dublin to Galway is a barren desert in radiotherapy terms.

Photo of Séamus KirkSéamus Kirk (Louth, Fianna Fail)
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The Deputy has taken some liberties with time.

Photo of Dinny McGinleyDinny McGinley (Donegal South West, Fine Gael)
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I ask the Minister and my constituency colleague, the Minister of State, to take another serious look at this issue. I am aware of ongoing negotiations with Northern Ireland but I ask them to expedite those negotiations and let the people know that they will be looked after.

Photo of John MoloneyJohn Moloney (Laois-Offaly, Fianna Fail)
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I wish to share my time with Deputy McDaid.

I extend my sympathies to the women affected and to their families. County Laois Deputies are more acutely aware of the effects on the families and we know some of the families involved.

The Government and the Minister have properly extended the time allowed for these statements today. I compliment the Minister on her immediate apology to the families because this takes considerable backbone.

I have been aware of this debate in the midlands for the best part of ten years. We were one of the first places to discuss the idea of lead centres for cancer care. I refer to the National Cancer Forum and to Professor Jim Fennelly who chaired that forum. I welcome the proposal for eight centres of excellence which is the way forward. However, I hope the Minister will, in her usual forthright manner, explain to this House and to the public how those centres are to be funded. It is essential that confidence is restored by explaining how these centres are to be funded and staffed. People who depend on more localised services must be reassured that services will be continued up and until the centres of excellence are established.

I was a member of a health board during the 1990s, in particular from 1997 onwards. The midlands health board became a very divided health board. Everyone came to the table with the belief that they were proposing and providing the best level of cancer care within their own counties to cover the whole region. The health board region contained three acute hospitals, in Portlaoise, Mullingar and Tullamore. It was a divisive issue when it came to the selection of the lead hospital.

When the eight centres of excellence are delivered it will be important that all the medical staff within those centres will be singing the same tune and believing in what is being delivered. Unless they have a belief in the service, we will not persuade the public to buy into it. I speak as one with experience who grappled with the issue in the midlands.

I supported the location of the lead centre in Tullamore against the wishes of my own county. The impression was that I had let my county down, let down my people. I took the independent medical advice of the cancer forum. I would dread to see the same fate visited on any Member of this House who might support a hospital in some other county. If we are to set up these centres, we must be able to first assure the public, the medical people and the politicians that these centres can work and will deliver the service required in a centre of excellence.

I do not want to come back to the Portlaoise issue specifically but it is important that every report is seen to be independent in an effort to restore confidence within this hospital. It is important to recognise that the staff in the hospital are under pressure. This report must be published as quickly as possible and be seen to be independent.

I believe in the Minister's commitment. I have no time for questions on her ability to run the Department. I fully believe she can do so and is committed to and has the determination to do so. The appointment of Dr. Keane should at long last provide the level of service that is required. I hope that as we move on and as the report is published that we will have learned from the divisions of the past. The first step in securing confidence in such centres must be securing the support of the medical staff, otherwise there will be the same level of division that, unfortunately, has halted progress in the midland region in recent years. When summing up I appeal to the Minister to clarify when the centres will be up and running and how they will be funded.

Photo of Jim McDaidJim McDaid (Donegal North East, Fianna Fail)
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While this debate has mostly revolved around the tragic consequences that have occurred in the midlands I wish to make two points to the Minister, one of national importance and the other of more local importance.

Of all the drugs, technology, and the Star Wars-type equipment available in the medical field, which mother nature and science has thrown up to us, only one substance is known to prevent cancer. There is a vaccine against what is known as the human papilloma virus. While there are a number of strains of this particular virus, Nos. 16 and 18 have been shown to be responsible for 75% to 80% of all cervical cancer in women. Some 180 women per year are diagnosed with cervical cancer, 70 to 75 of them will die. It generally happens during the prime of a woman's life, in her child bearing years, mostly when she has a young family, yet this vaccine which has been available since 2006 is the only product that prevents cancer. Ireland is only one of two countries in Europe, the other being the Netherlands, that has not made this vaccine available. For example, in Greece it is mandatory for all 12 year-old girls to have this vaccine. It is available in all other countries in Europe. While screening is wonderful when we have it, cervical cancer remains the second largest killer of women outside breast cancer in the 15 to 44 age group. If this vaccine was to be made available through the GMS it would ensure that females of the appropriate age would be able to avail of this potentially life saving treatment free of charge. While I am aware the cervical screening programme is to be rolled out next year, if it is not on the GMS list and does not receive approval from the Minister, it could mean that in the interim period a significant number of females could benefit from the vaccine.

Where is this vaccine? It is with the National Immunisation Advisory Committee. The NIAC is studying the cost effectiveness of this vaccine. Every other country in Europe has done a cost effective study on this vaccine, including the UK. How many more cost effective studies do we need? By the time the NIAC allows it to go on to the market it will probably take another year between negotiations and the tender process. In effect a vaccine which has been available since 2006 and known to be safe will still not have been rolled out in this country and whatever number of women will not have benefited. I ask the Minister to take that point into consideration as it concerns cancer and cancer treatment in general.

The other programme is a local one. While I agree with centres of excellence, cancer treatment has three stages of management. First, it involves the diagnosis which is either through mammography, radiology or biopsy. The second part involves surgery, where required. The third stage, which is what has happened in the north west, is a radiation oncology prescription which is required by these women for ten weeks after surgery. It is a ten minute procedure every day of the week generally for ten weeks. The women of County Donegal have to travel and book into bed and breakfast accommodation from Sunday to Friday. They are away from their families at a potentially terrible time in their lives. It is this radiation oncology that I hope will be provided in the north west whether through the private or the public sector. I do not mind which, nor do my patients, so long as it is provided.

If the private sector builds a hospital which is on the plans, and of which the Minister is aware, I ask her to ensure it receives every assistance to expedite this project because that third stage of the management of cancer, radiation oncology, is the part that is getting to the people of the north west. If one looks at the map one will see centres in Belfast, Dublin, Waterford, Cork and Galway while the north west is naked. The reason for this is that the north west does not have the population. Derry city is the fourth largest city in the country. Donegal has the seventh largest population with 140,000 to 150,000 people. I am trying to work out where the figures come from. While I would dearly like to have a centre of excellence will the Minister please ensure that at least the oncology part is made available and that no obstacle is put in its way whether it comes through the public or the private sector?

Photo of Liz McManusLiz McManus (Wicklow, Labour)
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I welcome the fact that we have an extended debate. It is such an important matter that Members wish to contribute. The one thing we know about breast cancer — it is a lesson we are given continually — is that the earlier it is diagnosed the better chance there is for survival. As others have said, today as we speak in this House, there are women we need to think of who are sitting in their kitchens, at their workplace, having to grapple with a terrible and unnecessary anxiety and suffering. They did the right thing. They underwent the necessary test to find out whether they had cancer. Their trust in the health service was understandable. Any one of us advised to go for a test when there was a chance of cancer would have done what they did. Even in the best of circumstances it is a stressful experience. In the instance of the women we are talking about, their betrayal and anguish is unimaginable. The terrible truth is they are not alone. It is not just in the area of misdiagnosis that injustice is being done to sick patients.

I was rather taken aback to receive correspondence today about a patient who was diagnosed through BreastCheck. She said she got very good quality care from BreastCheck and within a week was able to have surgery for the cancer. After surgery I understand that best medical practice in a case such as this is that one would have radiation treatment within six weeks. In the case of this particular patient she was shocked to find that when she sought an appointment for radiation treatment at St. Luke's Hospital a date 26 weeks later was given to her. When she said she had private health insurance that transformed her access to getting the treatment the following week. Seven days later she started radiation in a private hospital.

Dr. Crown is right. We have an apartheid system in our health service. It is there because the Government refuses to address it and it is getting worse because the Minister for Health and Children promotes inequality with the expansion of private care at the cost of public care. She has overseen the closure of public facilities, cutbacks and a staff freeze in the public sector that is now causing serious delays in many hospitals. Meanwhile, she is featherbedding the private hospital sector with generous tax breaks and offers of public lands. To be fair to the Minister, she certainly took the hit on her policies at the last general election, while the Taoiseach continues to deflect any responsibility on to doctors, health workers, patients, administrators, public representatives, community activists and in any direction except towards himself. This is a political matter and it is the responsibility of a government to ensure standards in and access to health care. This is why this morning's response by the Taoiseach when he was asked questions on the issue was despicable. I like others want to acknowledge that the Minister for Health and Children has chosen the correct route in offering an apology to those who have suffered so much.

The Minister for Health and Children was informed on 29 August about the problems at Portlaoise hospital. In her speech she made an interesting point that the person taking the lead role in alerting the authorities about the problems was a director of nursing. There is a parallel. In the case of the Dr. Neary scandal where patients were in effect mutilated and nobody shouted "Stop", it was a young midwife who eventually blew the whistle and bravely stood outside the herd in order to ensure the matter came to an end. In this incident it is a director of nursing, which surely tells us something. Why do we need to depend on the courageous director of nursing or the courageous nurse to alert us to what is going on in our hospitals?

That information came to the Minister on 29 August and it is now 7 November and we still do not know what has happened. We know there is a crisis of confidence not just in cancer services in Portlaoise, but also generally. It requires a political response and leadership, but we have got neither. It also raises again the importance of establishing a patient safety authority with statutory powers to oversee and investigate hospital services in order that standards are met and patients are protected. If we had that authority now, expertise would be building up to ensure a swift response when something went wrong — inevitably things go wrong no matter how perfect the system. We need an authority with power to ensure that information is garnered speedily and action taken. Such an authority should have an ongoing oversight role. HIQA is simply not capable of providing that role.

We need to know what standards prevail at any centre carrying out tests. We need an overall look back at mammograms. We have a curious anomaly in that there is double assessment in the cases of mammograms carried out by BreastCheck. While the vast majority of people who turn up at BreastCheck are perfectly healthy, systems are in place to ensure double-checking of any testing it carries out. However, in incidents such as in these ones in Portlaoise where people had indications and symptoms in some cases, no such safeguard was in place. It only came to light because of concerns being expressed at a high level of false positives — not false negatives. In effect, the problem was discovered by accident.

We need to ensure services are of good quality in existing centres. We all want to move to the model of centres of excellence. Let us get rid of that canard — that is what we want as is generally understood. However, it seems that only people on this side of the House appreciate the length of time it will take to reach that new model. In the meantime there is a need to treat patients properly in the system we have. It is not a question of just closing down units, which would just overload the system. A 26-week delay in accessing radiation therapy in St. Luke's Hospital represents a red light telling us we cannot simply close down small units and rely on existing infrastructure to take the additional demand.

I wish Professor Keane well — he has a hard job ahead of him. However, the appointment of one individual is not enough in itself. Resources, planning, staffing and strategic thinking are all required. We also need a debate about the matter. We need to consult and bring people with us in order that there is general understanding about what is required and what is being done. While time is of the essence, it will still take considerable time to construct the new model. In the meantime, public trust in our cancer care services needs to be rebuilt. Resources need to be dedicated to the establishment of centres of excellence. Funding needs to be ring-fenced and real commitment needs to be shown by the Government that has done so little in the past seven years while patients have been put at risk. I agree with the Deputies from the north west that we need to know what will happen in that region, which is in a very isolated position under the new plans. While it is difficult enough at the moment, provision must be made for them under the new plan.

Returning to the bigger picture, ending apartheid in our health service is essentially a political challenge. The Government and its predecessor have been intent on deepening the divide rather than bridging it. Susie Long, while she was alive, was proof of the inequity of our two-tier health service. We know that other women are waiting in line today because they happen to be public patients and not private patients. Unfortunately, we will get more evidence unless the issue is addressed. We need a response fitting to the problems encountered. It is more in hope than in anticipation that I ask for this action. Ultimately, we need to remember the anguish of women who were impacted by what happened in Portlaoise hospital. We must ensure that nobody goes through a similar ordeal.

Photo of Paul GogartyPaul Gogarty (Dublin Mid West, Green Party)
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I wish to share time with Deputy Conlon.

Photo of Ciarán CuffeCiarán Cuffe (Dún Laoghaire, Green Party)
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Is that agreed? Agreed.

Photo of Paul GogartyPaul Gogarty (Dublin Mid West, Green Party)
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I express my sympathy to the families concerned in Portlaoise and Cork. I note the Minister's timely and prompt apology and her commitment to ensure that every possible action will be taken to ensure that errors like this do not happen again in cancer care services. I would like to make a few suggestions in this regard. I note the Taoiseach this morning pointed out that triple assessment only takes place when a diagnosis of cancer or pre-cancer has been made. Even from a cost efficiency point of view, would it not make sense for the file, having been examined by a radiologist, to be sent to a backup group of radiologists dedicated to checking files as a matter of course? They do not need to be in the same location and it could be done on a central basis. A copy of the screening could be sent to such a national location for a mandatory double check of all diagnosis. As the Minister said it is not necessarily the machines that are at fault. In some cases it is human error. Double-checking would seem to represent good practice even if the checking is not taking place alongside the local radiologist.

I do not have a problem with the roll-out of centres of excellence. I acknowledge that for cost efficiency and to ensure standard treatment we need centres of excellence. However, for low-level cancer screening we should decentralise when possible. The most vulnerable, the elderly, low-income families and those on social welfare do not necessarily have the means to travel long distances. They have to take buses, taxis or trains and stay overnight, often at considerable expense. They suffer most from the centralisation of services that should not always be centralised.

I tabled a parliamentary question recently about the smear testing of Traveller women in my constituency. The service which was provided for them in conjunction with Ballyfermot and Tallaght Well Woman centres managed to increase the number attending for smear tests until 90% of eligible women were screened. However, this free service ceased two years ago and, as a result, the number of Traveller women accessing the service has decreased substantially. That is an example of how lack of proximity can lead to longer term problems which will impose a cost on health services exponentially far in excess of the cost of a smear test.

The HSE does not emphasise prevention enough in dealing with cancer in the context of diet, exercise and physical education and schools, which are cross-departmental issues. A person who does not smoke and has a healthy diet is less likely to contract cancer. While no scientific analysis has been carried out in my constituency, there is anecdotal evidence that where pylons and telephone masts coincide in communities such as those located beside Ronanstown Garda station, the number contracting brain tumours increases. The HSE should carry out a cluster survey and compare the findings with those of a survey conducted in a community that does not have pylons and telephone masts to establish whether this is the case and, if so, what can be done about it.

Deputy McDaid mentioned the issue of human papilloma virus and cervical cancer screening. Care must be taken with the vaccine. For example, I have raised with the Minister the issue surrounding one medication, Deprovera, which can thin the lining of mucus and lead to an increase in STIs, even though health warnings in this regard are not carefully written on the label. A debate on whether vaccination should take place is needed, as happened in the United Kingdom. At the very least, a full and frank debate should take place, perhaps at the Joint Committee on Health and Children, because if deaths are prevented, all the better. Prevention is better than cure. Abstinence is the best way to prevent cervical cancer. This should be followed up by educating people about safe sex practices and screening. That could all be done in local communities at a lower cost than treating someone who needs a high level of cancer care.

Photo of Margaret ConlonMargaret Conlon (Cavan-Monaghan, Fianna Fail)
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I welcome the opportunity to contribute to the debate. Since 1996, approximately €1 billion has been invested in cancer services nationally. Progress has been made and in government we are determined to make further progress. We must build on all aspects of cancer care and control until our cancer services are at world class standard. We are making patient safety and quality outcomes the drivers of all decisions on cancer care, which patient confidence demands. This programme of investment in cancer care will be pursued relentlessly, which is why I welcome the Minister's unreserved apology to the women affected by misdiagnosis. My thoughts are with them and their families at this very difficult time in their lives. I call for the speedy conclusion of the inquiry and compilation of the report, which is the least they deserve.

We must strive at all times to ensure patients have confidence in all medical services. As a new Deputy, I seek cross-party support to deliver a world class health system in practice, not in theory. I do not want a system where money is wasted due to duplication of services and personnel. We cannot let our own local parish politics block the deliverance of concentrated areas of expertise, all of which would ultimately benefit the patient who must be at the centre of all our health service goals. Location must not replace quality of service.

It is only fair to those working hard in cancer care to record the improvements they have made and continue to make. It is important that patients should have reasons for hope and optimism about cancer care, despite the events of the past few days. We have achieved the key goal of the 1996 national cancer strategy, to reduce the death rate from cancer in the under 65 year age group by 15%. This was achieved three years ahead of target. In 1997 no cancer screening programme was in place anywhere in the State. This year the roll-out of BreastCheck to the south and west will begin and a cervical screening programme will commence later in the year. BreastCheck is available in 15 counties, which is a success, but we must drive this superb project forward. A total of 60,000 women were screened by BreastCheck in 2005, a 19% increase on the figure for 2004. It is expected that more than 70,000 women will be screened this year.

I welcome Professor Tom Keane's appointment as the new cancer control director. He will have key goals to deliver during his two-year term to provide the level of service cancer patients deserve. Cancer is a word that strikes fear in the hearts and minds of everyone and, having had personal family experience in this regard, I agree our health care system must seek to allay those fears. I would want a top class service for myself and my family in which I would have complete confidence if I found myself in that position. I agree with the proposal for centres of excellence, as it is necessary for positive outcomes for patients that surgeons are regularly dealing with a critical mass of cases, which should ensure a higher success rate and constant upskilling on their part. Patients deserve this and we, in this House, must deliver it.

We must move from the notion of my backyard politics. I tuned into Olivia O'Leary yesterday evening on "Drivetime". She referred to people who say "I agree with the principle of centres of excellence but..."; "I am favour of centres of excellence but...", or "I welcome the concept of centres of excellence but...". We cannot talk out of both sides of our mouths. It must be ensured resources will not be spread too widely or thinly because if that happens, everyone will lose. I concur 100% with Olivia O'Leary that there must be no more "buts" and that the patient must always come first.

Photo of Fergus O'DowdFergus O'Dowd (Louth, Fine Gael)
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I hope there will be action when the debate concludes because the country needs an open, accountable and transparent health service because of the lack of transparency, openness and, most of all, accountability on the part of the Government. An apology does not go far enough. While I welcome it, it does not change the fact that the Government has given responsibility for the health service to a body which is not accountable. A HSE delegation led by Professor Drumm will be present in the Oireachtas Members' restaurant tomorrow. No one from the media will be present and there will be no accountability to the House regarding what happens.

I refer to the HSE north east area from where cancer services are being transferred. Deputy Conlon is correct that people are concerned about this, as they were told the services would be moved. Professor Kearney, the medical oncologist in the hospital in Drogheda, and his staff who service the north east have done fantastic work but he is leaving and we have not been told why. The people are protesting but have not yet marched. They want facts, leadership, accountability and transparency. They want the truth but they are not getting it from the Government.

Everyone agrees about the need for centres of excellence but I wonder what will happen in Drogheda and the north east. In a letter I received from Tony O'Brien, chief executive officer of the HSE north east, dated 26 October, he stated, "It is hoped to achieve a 60% transition to these centres by the end of 2008 and a 90% transition by the end of 2009. However, no services will be transferred from a location until the intended receiving location has the appropriate capacity to provide appropriate care". The problem is that the people with cancer do not know what is happening. The HSE cannot tell them what is happening. Their consultant oncologist has resigned and the Minister has very kindly apologised for all the mess she has got us into. It is not good enough and it is not acceptable. This Government fails on the basic issues of accountability and transparency. The concern in the north east is that the service there is going to go in the next three years. What is to replace it? Where is the service to come from? What about the people from Cavan and Monaghan, who now have further distances to travel? Where is the Minister's initiative as regards cross-Border services? What is she and the Government doing about linking in hospitals in the North of Ireland with the population living along the Border to provide these services?

The Minister's apology is not acceptable to the people faced with the dark future they now have because of the mess she has made of the health service. The only honourable position for her is to resign forthwith.

Photo of John O'MahonyJohn O'Mahony (Mayo, Fine Gael)
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I welcome the opportunity to contribute to this debate on cancer services. I sympathise with all the women in the midlands and their families who are going though unbearable trauma as they face the agony of being rescreened and await the results. The Minister and the Government introduced the new cancer strategy and centres of excellence with great fanfare a couple of months ago. It was as if everything was going to be top class and the term "world class" was being talked about. Nothing could be further from the truth. We have seen one scare after another, with no one taking the blame but many dishing it out.

Alongside these crises we see the cancer services in my constituency, Mayo, which were developed to the excellent standards other centres aspire to, being withdrawn under the new proposals. When my party leader raised this matter a couple of weeks ago, he was accused of scaremongering, yet neither the Minister nor the HSE has contradicted his assertions in this regard, except to dispute the timescale. Mayo General Hospital is currently providing a top quality specialised treatment service, and this should continue within the proposed new structure as a managed cancer network, like the Mayo Clinic model in the United States. The Mayo Clinic is the parent centre and the surrounding hospitals provide high quality audited oncological practices, working through protocols for patient care decided at multidisciplinary meetings.

The people of County Mayo have the utmost confidence in the services being provided by the excellent team led by Mr. Kevin Barry and Mr. Ronan Waldron in Mayo General Hospital. The consultants and their team have meticulously built up this centre of excellence during the years. They work in co-operation with Galway and will do so into the future, but they passionately want to retain the services in Mayo. Dr. Brendan Drumm praised the services when he visited the hospital earlier this year. An audit of Mayo General Hospital is scheduled for next April, but the problem is that some of the services may be gone by the time it reports. Here is something that is in place, which does not demand any extra cost in terms of new resources, which fits into the proposed centre of excellence model, as proposed, and has the support of the people. Will the Government and the Minister not take the easy decision and keep these services in Mayo? Up to 10,000 people marched in Castlebar last Sunday week and I have no doubt, if there is not a positive answer from the Minister and the Government in the weeks to come, there will be many more than 10,000 outside the gates of Leinster House.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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Like other speakers, I acknowledge the trauma, anxiety, terror and hurt being experienced by those women who were either diagnosed late or misdiagnosed as regards cancer in the past year or so. I listened with interest to the speeches of the Minister and the Taoiseach this morning and am appalled at the manner in which some of these issues have virtually been dismissed.

It is enormously traumatic for any woman who has a concern about potential cancer. The first thing she thinks about is early diagnosis and availing of the services as quickly as possible. There is considerable mystery about centres of excellence. This is not rocket science, according to my information. Modern technology has leant itself extensively to the medical area in general. Therefore, it is possible now for an early, first-class and accurate diagnosis to be given in several small areas in close proximity to each other. I cannot for the life of me understand how there was no cross-checking of results. This morning the Taoiseach informed the House that only in very particular circumstances was there cross-checking. This cannot be right. I cannot understand why this is happening.

What is going on as regards the appointment of people to the positions they hold? Surely, it must be possible to identify the people who are suitable in the first place and ensure they are capable of carrying out the work they propose to do. It has to be possible that if the Department, the chief executive or the Minister is informed that certain technology is outdated and not functioning properly, someone should recognise that this is a serious matter. Something must be done about it immediately, with no postponement to another day.

The last point I want to make is about something with which I strongly disagree. There is now a notion abroad that this particular tragic issue is about to be used as a vehicle for bringing this about the closure of a whole series of hospitals and health centres throughout the country. I urge the Minister not to take that route, because it would be a serious mistake. This has happened before. I have seen this throughout my entire time in public life, namely, issues of this nature used as vehicles to achieve a particular target. I urge the Minister not to go there, and I shall tell her why.

Deputy Jim McDaid made an interesting intervention when he made reference to the fact that in these cases women can very often be away from home in bed and breakfasts and so on. I listened to a woman recently on radio who set out the way she felt when she left home and booked into a bed and breakfast. She described the loneliness of being left alone and the impersonal nature of the situation in which she found herself. There is one way of dealing with this. Centres of excellence will not deal with it. They will give an excellent service, but as the Minister knows, they do not provide the quality of service required unless they have the committed people required to do so. They will not provide the personal service and as Deputy O'Mahony has indicated, there are people throughout this country who have become reliant on the services in their local areas. They know the people concerned, they depend upon them and I ask the Minister to be very slow to remove them from the arena.

Photo of Noel DempseyNoel Dempsey (Minister, Department of Transport; Meath West, Fianna Fail)
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I start by acknowledging the apology that the Minister proffered in the House this morning to all the women concerned in this. It was typical of the Minister and also typical of her to respond so quickly and to be accountable to the House as regards this particular matter. There is no excusing the pain and fear which has been visited on the women concerned, who were given the all clear when in fact they had breast cancer. That pain and fear, as many Deputies have said, should not have happened. Every Member of the House would wish to join the Minister, I am sure, in the apology to each of those patients, while knowing that it would not make the women concerned feel any less miserable or vulnerable.

It should not have happened. We have to find out precisely what happened. Again, the Minister is taking a course of action in that regard by setting up the ministerial inquiry. We must have an eminent and uninvolved person to lead the inquiry, who can probe the issue without fear or favour and provide clarity as regards why it happened. The reason I have come to the House tonight to intervene in this debate is to express my support for the Minister for Health and Children in her constant determination to try to drive through a vast conglomeration of fixed positions and vested interests in order to give people the world class health service to which they are entitled. The Minister is correct that what happened in the Health Service Executive could continue to happen unless we get our act together. We have the relevant information, reports, buildings, personnel and Minister to ensure we do get it together, but the problem is that we very often allow reports to be used for political point scoring. In this regard, I am not just referring to party-political point scoring.

A general problem in the health service, rather than in the field of cancer care in particular, is that we allow the very existence of buildings to shape our thinking and delay our actions when doing the right thing. A great health service is not about reports or buildings but about services and people, as Members on all sides have stated. Unless we decide to have the best possible service, we will never move beyond our current position.

We have a fixation on having a hospital building in every county. Such buildings are undoubtedly staffed by committed experts who are serving their patients in so many ways. Members of the public who enter these buildings as inpatients or outpatients are overwhelmingly satisfied with what happens therein, as is proven by objective research, but the issue we now face is not one of preserving each of these buildings as they currently operate. We cannot allow the presence of a building to dictate how we pursue the excellence of service to sick people, to which every participant in this debate subscribes. However, this has happened and it has dogged and delayed progress in this vital area of Irish life. The problem in Portlaoise is just one result of playing politics with the lives of people.

We all know all politics is local and that is why politicians of every hue — I am not exempt — stick our flags down for our local county or town. We do so from the best of motives and quite rightly believe it is best for the local economy and employment but quite wrongly believe it is best for the health of our local constituents. In many cases, it is not. All health service is not local and its direction should not be decided by someone from another time who put bricks and mortar in one location. I hope that, on foot of this debate, the concept of excellence of service will permeate all our thinking. Localism should not feature in debates on health and we should not play politics with health issues. I hope this debate will lead to a better focus on real issues in the health service.

Photo of Jimmy DevinsJimmy Devins (Minister of State, Department of Health and Children; Minister of State, Department of Education and Science; Minister of State, Department of Enterprise, Trade and Employment; Sligo-North Leitrim, Fianna Fail)
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As Minister of State at the Department of Health and Children, I commiserate with the women in Laois who are suffering at this horrendous time. I echo the apologies that my colleague the Minister, Deputy Mary Harney, made in the House this morning.

Hearing the news that one has cancer is always very difficult. It raises many emotions, which can include shock, anxiety, sadness and uncertainty. I can only imagine the torment and anguish that the women in question are experiencing and I am distressed that a situation like this has occurred. It is a traumatic turn of events for these poor women and their families. I, like the other Members, hope they make a full recovery.

I concur with the statements of the chief executive of the Health Service Executive, Professor Brendan Drumm, who described the misdiagnosis of the women who went for breast cancer scans as "appalling". It is imperative that such incidents not be allowed to recur. This issue is far more important than party politics and I am sure the partisan political points made by some politicians in this House on this issue ring very hollow for the women in Laois and their families.

I will outline briefly some facts to the House. Since the implementation of the first national cancer strategy in 1997, approximately €1 billion has been invested in cancer services nationally. Over 100 additional consultants and 360 additional clinical nurse specialists have been appointed in key areas of cancer care. The Estimates for 2007 include additional Revenue funding of €20.5 million for cancer control, that is, for screening, acute services and research. Patients in Ireland are benefiting from the development of a clinical trials network nationally. Between 2002 and 2008, the Health Research Board will have invested more than €21 million to support this initiative.

The policy of the Department and Health Service Executive is to implement A Strategy for Cancer Control in Ireland 2006, which was prepared by the National Cancer Forum. Investment in cancer control will be based on the reform programme now being implemented by the Health Service Executive. The programme is to provide the necessary governance, integration and leadership to create the essential framework for cancer control.

It is essential that the national cancer control programme be delivered and I am particularly keen to see stepped, practical and demonstrable early progress in this regard. This is a real opportunity for cancer control to be a key driver in the overall health reform programme.

I welcome the appointment of Professor Tom Keane as interim cancer control director. I understand he will report directly to Professor Drumm and will be set key deliverables during his 24-month term of office. He has an excellent record of delivering on cancer control services in British Columbia in Canada. I am hopeful he will make a difference when he starts his job in the next couple of weeks. He has the full support of the Minister, myself and the other Ministers of State in the Department of Health and Children.

I am fully behind the idea of centres of excellence. It is vital, in light of what happened in Portlaoise, that women in this country receive the best care to the highest international standards.

In my area in County Sligo, there has been much public debate about the future of cancer services. I am very pleased the Health Service Executive has responded to my request that Professor Keane visit Sligo General Hospital to view at first hand the services available therein. This will certainly educate him on the range of facilities and expertise available. I would like representatives of the Health Information and Quality Authority to visit Sligo General Hospital and carry out a full audit of its cancer surgery services. I know from my visits to the hospital that the surgeons, nurses and staff, whom I have met, share my wish that their work be independently audited so the women in the north west can be assured the services they are receiving are of the highest international standard.

Photo of Dan NevilleDan Neville (Limerick West, Fine Gael)
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I wish to share time with Deputy Bannon.

Photo of Ciarán CuffeCiarán Cuffe (Dún Laoghaire, Green Party)
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Is that agreed? Agreed.

Photo of Dan NevilleDan Neville (Limerick West, Fine Gael)
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I, too, sympathise with and offer my condolences to the women in question, who are deeply traumatised. It is a personal tragedy for them and their families and has had an inexcusable effect on their quality of life and well-being. They are suffering from mental anguish over the roll-out of cancer treatment from which they should not have to suffer in this day and age. Unfortunately, trust and confidence in the health system are disappearing very fast. I urge the Minister to ensure that the problem be addressed.

The changing of the old system by the Government to form the Health Service Executive is now regarded by many as disastrous. Many of us objected very strongly to the change and our view has been vindicated. There is now a great reduction in the morale of health service providers. This is serious because, as morale decreases, the system will be further damaged and the quality of services will be reduced significantly. I urge the Minister to address this as quickly as possible.

6:00 pm

Photo of James BannonJames Bannon (Longford-Westmeath, Fine Gael)
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Today in the House the Minister spoke immortal words: "Today is a day for patients first". This is a most extraordinary statement by any Minister for Health and Children. Has she just woken up to the responsibilities of her portfolio? Has she discovered only today that it is all about patients, including the ill, dying and vulnerable? She had years to work it out but failed to do so and people are dying. A very serious situation has arisen. People have a right to life, as the Minister should recognise. It is a very sad day for Ireland, given what has happened in Portlaoise. I sympathise with the people concerned.

The loss of the breast cancer treatment centre in Tullamore was a huge blow for the midlands. Owing to the poor quality of rural transport services in the midlands, causing undue hardship for vulnerable patients, extremely ill women in counties Longford and Westmeath and elsewhere in the midlands will now be forced to travel to Dublin or Galway with no designated transport services on which to rely. One young cancer patient in my own county of Longford has been waiting over four years to recoup travelling expenses of €1,000. Such expenditure on taxis is beyond the reach of many patients desperately seeking to access hospital services. Once again, the Government has shown total disregard for the midlands. History is repeating itself over and over again. Counties Longford and Westmeath have been waiting over 12 years for the completion of phase 2B of Mullingar Hospital. How many lives must be lost before the Government recognises health care needs in the midlands? How long more will we have to wait for the Government to bring openness and fairness to its dealings with the sick and vulnerable?

In an ever-repeated formula, with a familiarity that almost defies belief, to all intents and purposes, services are being centralised in Dublin. Those not lucky enough to live within the Pale are expected to travel at their own expense to avail of basic medical entitlements. As Deputy Durkan said, the loneliness experienced by many is dreadful. I have met people who had to come to Dublin and stay overnight in bed and breakfast accommodation. It is a dreadful experience for anyone traumatised by a serious illness.

As a former member of the Midland Health Board which covered the Midland Regional Hospital in Portlaoise, on many occaions I raised issues in respect of service delivery, yet we are now being told by the Taoiseach that there was no systems failure involved in the misdiagnosis of breast cancer patients at the hospital. This is another Government-induced health risk for people in the midlands, whatever way the Minister wants to spin it. There has been considerable spin by the Government which we have witnessed in every Department, none more so than the Department of Health and Children.

Photo of John O'DonoghueJohn O'Donoghue (Ceann Comhairle; Kerry South, Ceann Comhairle)
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I am now moving to the question and answer session which will proceed in the same way as Question Time. I remind the House that, in accordance with established practice which has fallen by the wayside in recent years, Members should keep their supplementary questions brief and concise. There is no need for lengthy preambles and prologues. The reason we had statements was precisely that we did not want lengthy statements during the question and answer session. The objective of the exercise is to elicit information. If Members impart information instead of seeking it, the objective will clearly have been defeated. If Members co-operate in this way, I am sure everyone will have an opportunity to ask a question or questions and may even be called upon more than once. If Members do not proceed in that way, obviously, the procedure will fail, as has often happened.

Photo of John PerryJohn Perry (Sligo-North Leitrim, Fine Gael)
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I am seeking clarification from the Minister, as I did not speak previously on this matter. Section 7 of the national cancer control strategy, dated September 2007, deals with the configuration of primary cancer surgery centres. It is stated on page 13 that about 2,000 breast cancers are managed surgically in the public hospital system in Ireland. Given the proposed number of 150 new cases per centre, this equates to 13 or 14 cancer care centres. The report then makes the assumption that BreastCheck will reduce the number of new cases requiring surgery by 33% to 50%. On this basis, the number of recommended centres will be eight. I have a problem with this assumed reduction. With the vagueness of the projected timescale, I do not see a sufficiently strong data foundation on which to build a national strategy.

In addition, it is stated on page 18 of A Strategy for Cancer Control in Ireland, published in 2006, that the number of new cases is projected to reach 28,000 by 2020. This is more than double the figure of 13,888 produced in 2000. How can the Minister justify only having eight cancer centres when about 2,000 breast cancer surgical procedures are performed each year? She is assuming that this number will drop by up to 50% and has totally ignored the projected significant increase. The science is flawed.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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Obviously, the evidence is evolving all the time. When Professor O'Higgins produced his report in 2000, the advice was that a centre should deal with 100 new cases. By 2007, this figure had moved to at least 150 cases a year. What is being said is that the number should be at least 150 cases and 50 per surgeon. A number of other criteria are involved. For example, in the case of staffing, reference is made to the need to have two breast surgeons, two radiologists with relevant experience, pathologists and so on. A range of criteria are outlined on page 6 of the report.

The persons who chose the centres were experts. They included individuals representing patients' groups such as Europa Donna and the Irish Cancer Society. Of the 26 people involved in the National Cancer Forum, over half were clinicians, most of whom were at consultant level with expertise in cancer care. They made the recommendations. They were not chosen politically, in the Department of Health and Children or by the HSE. They were chosen on the advice of an expert group which included representatives of the Irish Cancer Society, Europa Donna and other patient groups. It is important to remember this point, given what was said in the debate earlier.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Will the Minister answer the questions I put to her during that debate? Must I reiterate them?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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The Deputy asked me a large number of questions.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I did.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I do not know if the format permits me to answer all of them.

Photo of John O'DonoghueJohn O'Donoghue (Ceann Comhairle; Kerry South, Ceann Comhairle)
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Which question would Deputy Reilly like the Minister to reply to?

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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There are a couple of particular questions.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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If the Ceann Comhairle is flexible, I will be happy to answer all of them, if Deputy Reilly wishes to put them again.

Photo of John O'DonoghueJohn O'Donoghue (Ceann Comhairle; Kerry South, Ceann Comhairle)
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Every Member must have an opportunity to ask a question. As we only have until 7 p.m., I ask Deputy Reilly to pick out the priority questions, if he can.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Obviously, the big question is funding. Has the amount been assessed or quantified? Is it ring-fenced for cancer care? Surely the Minister for Finance can find funds for a digital scanner in his own constituency. A digital scanner costs €400,000. An analogue scanner costs €250,000. As I have heard what the Ceann Comhairle said, I will not make statements. However, I will say the HSE overspent by €4.5 million on IT. This wasted sum could have been used to buy 11 digital scanners to safeguard patients.

During the course of her speech the Minister pointed out that concerns had been raised about the quality of radiology in the hospital in question in 2005 and that two positions had been advertised and filled, one by a locum. I asked her whether the locum in question was the individual who had been providing locum cover in 2005 when the original concerns were expressed. Furthermore, I am told that the doctors on the original interview panel raised concerns about the fact that the person being interviewed was never included in the relevant specialist register, a prerequisite for a consultant post, and that they also had concerns about her experience of reading mammograms but that their concerns were overruled by the other members on the board. If that is true, it is a very serious matter which I ask the Minister to investigate and report back to the House.

The other big question to which everybody wants an answer is when the new cancer service will begin. Will it commence in 2009, 2010, 2011 or 2015? We are very confused and hearing conflicting opinions from both the Minister and Professor Drumm. It is difficult to understand how one day Professor Drumm will say it will commence in 2015 and the next, 2009. Will the Minister explain to the House what has changed? Has she abandoned public private partnership as a process which would delay it? Will she confirm that the Taoiseach's statement this morning, that triple assessment only applies in cases of cancer, is wrong?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I will respond first to the last question. Triple assessment applies where cancer is suspected or diagnosed. The point the Taoiseach made was that in the seven cases in question the radiologist gave the women concerned the all clear. Therefore, the triple assessment did not apply.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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With respect, this was a symptomatic breast unit and the women concerned had symptoms such as a lump. Surely they received a clinical assessment.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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That is the serious question, that the radiologist in question gave the all clear. I wish to clarify that one consultant radiologist is on administrative leave but the inquiry does not concern only the work of that person. There are two consultant radiologists. There were two locums during that period.

The interview was held by the Public Appointments Commission and I understand there were a number of radiologists on the interview panel, perhaps two. A recommendation was made; the job was offered and the person who was a locum got the job, for which there was only one applicant. There was a subsequent advertisement for another post and the person who was offered the job declined to take it. The radiology unit had two consultant radiologists and two locums during the period. The two locums have probably moved on in the intervening period.

Regarding the scanner, the same scans were read by three consultants in Dublin. The three did not read each one — they divided 3,000 between them. They made a diagnosis of cancer based on the mammogram taken in Portlaoise. It is preferable to have the most modern machinery. Digital mammography was not as developed as digital radiology. Some years ago, when digital radiology was introduced, the advice was not to introduce it for mammography because it was evolving very quickly. I spoke to a practitioner last night who told me that Ireland had made the transition to digital mammography faster than the United Kingdom. When Portlaoise hospital was asked for its capital priorities, its priority was the CT scanner, not a mammogram machine.

Photo of Leo VaradkarLeo Varadkar (Dublin West, Fine Gael)
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Your son or your daughter.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Hobson's choice.

Photo of Olwyn EnrightOlwyn Enright (Laois-Offaly, Fine Gael)
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They needed both.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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We will see what the report reveals. Three radiologists attached to the BreastCheck service in Dublin read the same mammograms and diagnosed cancer. That is not to say we do not need the most modern equipment but it is separate to the diagnosis issues in this case.

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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What will the Minister do to restore trust in the cancer testing system? I listened to the Minister of State at the Department of Health and Children, Deputy Devins, who invited HIQA to audit cancer services in Sligo. Has the Minister asked HIQA or the HSE to audit all services that test for cancer and specifically breast cancer given what has happened in Portlaoise? In this way the public could be assured in terms of equipment, the qualifications of those working there and the variation of expertise required to provide a safe service. There is a crisis of confidence.

What is the plan to maintain safe services as we move to where the Minister wants us to be? I refer to Deputy Reilly's question which has not been answered. Have resources been audited? What extra resources are needed? Is there any information to assure us that resources are available for the centres of excellence? The Minister expects most to come from existing resources but I do not believe there is enough in them. We need information on what is available, what is required and the timescale involved. The chain of command seems to be that Professor Keane will report to Professor Drumm. I assume he will be more distant from being held accountable by us, the public representatives.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I apologise to Deputy Reilly for not answering the question on resources. The National Hospitals Office is undertaking an audit of existing resources, examining each hospital and isolating the money spent on cancer care. The intention is that Professor Keane will control the budget. That is how it worked in British Columbia and the only way it would work here. Professor Keane will come here on secondment from the British Columbia Cancer Agency, from which we have purchased his services because we were impressed with the service which is viewed as a world leader. The region has approximately 4.3 million people, peripheral issues similar to ours and Professor Keane is Irish educated. He was successful in British Columbia and we availed of the agency's offer to help. There was no global advertisement to find a cancer guru. The arrangement is for two years and one of his tasks will be to appoint a successor. He will have a deputy director and staff from oncology, radiology and other specialties.

The audit is under way. A lot of money will come from redirecting resources, as happened in Canada and elsewhere. In 1996 Northern Ireland began to reduce the number of places where breast surgery took place from 19 to five and the number of surgeons from 50 to 19. Over 70 surgeons perform breast surgery in Ireland, even though we only need approximately 20-25. In places such as Tallaght or Blanchardstown where world experts work we envisage the experts moving to the centres. If one has expertise in cancer care, one will want to work in the designated centres.

Regarding a guarantee of safety, HIQA is the patient safety agency. Its task is to enforce and monitor the application of standards and advise me on them across a range of areas, including breast cancer. It is an independent statutory body, separate from the HSE, which provides health services. When the Commission on Patient Safety and Quality Assurance reports, we can apply the same standards to the private sector as we apply to the public sector. We have already written to the insurers and independent hospitals regarding standards. We do not have the legal wherewithal to enforce them until the commission reports.

We have closed down 13 places. The centre in Roscommon, with which Deputy Naughten is familiar, closed 18 months ago. There was a major buy-in clinically and in the wider community because people knew it was the right thing to do. Patient advocacy groups such as the Irish Cancer Society and Europa Donna and women at the Marie Keating Foundation event which many of us attended two weeks ago told us that they did not care where the centre was, they wished to go to the best place. There is a considerable buy-in, by women in particular. That is not to underestimate the difficulties of transport which are being addressed.

Some 2,000 of women contract breast cancer, the vast majority of whom receive a speedy, expert service according to all the research. Survival rates have increased from 72% to 78%. A 6% increase over a five or six year period is extremely significant. Ten years ago only one in four women who contracted breast cancer had their operations performed by surgeons who carried out at least 50 procedures each year. Now, three out of four women have their surgery performed by such surgeons. I want to reach the stage where 100% of women — this is why the service can only be provided in larger centres — will have their breast surgery performed by surgeons who carry out at least 50 procedures each year. All the evidence shows that outcomes and survival rates improve when surgeons with this level of experience carry out procedures.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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What does the Minister propose to do to bring to a satisfactory standard the current inadequate regulation of radiological equipment in hospitals? Why have the HSE and the Department of Health and Children failed to provide for the replacement of old equipment in the various radiation units in our hospitals? How does the Minister respond to the charge that patients have been denied access to proper screening because the HSE and the Department will not spend the money required on new equipment?

Will the Minister clarify her intentions in respect of the roll-out of cancer care services in the north west, particularly County Donegal? Is it her intention to see located in the county a satellite unit which will serve the north west and have a cross-Border dimension to its remit? What is her intention regarding the north-east region which comprises counties Cavan, Monaghan, Louth and Meath, and the adjacent area comprising County Fermanagh, south Tyrone and south Armagh? The journey to Dublin is prohibitive for many in west Cavan and north Monaghan. The journey to Belfast is equally prohibitive for those who live in the area across the Border to which I refer. I refer, in particular, to sick cancer patients in this regard.

I wish to recap the questions I posed in my earlier contribution. The Minister has already made reference to Tallaght Hospital in the replies she has given. However, I highlighted the concern in respect of Tallaght Hospital from May to September this year. The uncertainty must be cleared up. What is the Minister's position on cancer services at Tallaght Hospital?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I will start with the Deputy's final question because Tallaght Hospital is situated in my constituency. Tallaght Hospital lost the children's hospital and is not one of the designated cancer centres. There are world class experts working at the hospital and a huge volume of their activity revolves around cancer care. I refer to people such as Professor Conlon, Dr. Geraghty, an expert breast surgeon, Mr. McDermott, etc. I was due to meet these individuals at 6 p.m. but that meeting had to be postponed as a result of this debate. I hope they will work at one of the other designated centres in the Dublin area. Tallaght and St. James's are teaching hospitals for Trinity College. They have very close working relationships on which I hope they can build.

With regard to the north west, Letterkenny, as a result of peripherality and geographical issues, was the only exception on critical mass in terms of numbers. Essentially, it will be a satellite unit of the centre in Galway. It will not be a stand-alone facility. The facility will operate in Letterkenny once it meets quality assurance criteria. No one in Letterkenny or County Donegal in general would want to be treated in a hospital which did not live up to the highest standards as far as quality is concerned. We have, therefore, made an exception for reasons of geography and peripherality.

We originally purchased some radiotherapy services from Belfast City Hospital. Patients from County Donegal have been using that service for the past year. However, the take-up is small and the numbers involved are not huge. At a recent meeting Northern Ireland's Minister for Health, Social Services and Public Safety, Mr. McGimpsey, and I engaged in a very good discussion on the possible provision of a facility at Altnagelvin. The Northern Ireland authorities have not yet made a formal decision but Mr. McGimpsey was extremely positive in respect of it. We would, in turn, be positive in supporting such a development because the necessary critical mass would be created in a cross-Border catchment area to justify the establishment of a state-of-the-art radiotherapy facility as a satellite of the centre in Belfast. I made it clear to Mr. McGimpsey, as I did to the group I met yesterday, that the Government would strongly support a cross-Border initiative of that nature, either financially — in the context of the capital equipment aspect — or by procuring services on behalf of patients. We await further developments in this regard.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Will it be located in either Letterkenny or Altnagelvin?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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Northern Ireland requires an additional centre to meet its capacity and the authorities there are examining the position in that regard. While a formal decision has not been made — it is not my place to announce decisions on behalf of the authorities north of the Border — I understand that part of Northern Ireland which would suit patients from County Donegal is under consideration. I further understand that clinicians and patients and the groups which represent them in County Donegal would be supportive of the establishment of a facility at Altnagelvin. The intention is that Beaumont Hospital on Dublin's north side will be the centre of excellence for the north east.

Many Deputies made the point that every health facility should be a centre of excellence. I agree with them in that regard. However, what we are discussing are centres of excellence for surgery. We have a centre of excellence at Our Lady's Hospital for Sick Children, Crumlin, where treatment for every child with cancer is either planned or provided. In many cases, chemotherapy and follow-up treatment is delivered in 15 other hospitals. However, cancer treatment for children is the one area in which we compare really well with America and other European countries. We are top of the class in terms of our performance in this area. I am of the view and the expert advice I receive suggests that we are at the top because we have not, even though we can deliver treatment on a regional basis, fragmented the expertise available.

The position in regard to the eight regional centres will be similar. What we are discussing is the carrying out of surgery in those centres. Most patients who require radiotherapy, diagnostics, chemotherapy or oncology services will be provided with them in satellite centres which will be linked to the centres of excellence. It is not envisaged that everyone who needs a mammogram will be obliged to travel to a centre. The idea is that in some instances mammograms will be able to be carried out in a satellite facility and then analysed at one of the centres by means of modern technology. It is not the case that all services are being moved to the centres. The idea is that surgery will be provided at the centres and that other services, provided it is safe to do so, will be available at satellite facilities.

When he arrives, Professor Keane wants to talk to clinicians, nurses, doctors and others throughout the country. He wants professionals and others to buy in to rolling out the new service. He has set a 60% target for next year — he believes he can realise this — and a 90% target to be achieved by the end of 2009. These targets are ambitious and I wish Professor Keane who has my full support well in reaching them.

On the standards relating to radiation equipment, there are issues with the relevant statutory instrument. I am not an expert in this area. However, those at the HSE with the relevant expertise are involved in discussions in respect of this matter. The machinery is inspected on an ongoing basis by the Radiological Protection Institute. The facility at Portlaoise was inspected last May and received a clean bill of health. I am not sure what is the frequency of such inspections. This morning I heard Dr. O'Keeffe refer to the need to set standards. I have been discussing that matter with my officials. However, I have been in the House all day and have not had an opportunity to be briefed on it. I am aware that discussions are taking place at a technical level among the HSE and other parties.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Why will the Government not spend money to replace aging equipment?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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If one of my predecessors, Deputy Noonan, had stood here in 1996 and stated that in ten years we would be spending four times more on health, that there would be 45,000 additional people working in the system and that there would be an extra 110 consultants working in the area of cancer care, nobody would have believed it was possible. If people did believe it, they would have stated it would be fantastic. We have invested a great deal of money but there is always a need for more because there are competing demands. It is not always possible to have the most modern equipment because there are 52 acute hospitals and we have a massive hospital infrastructure. It is a question of priorities and balance. Demand might be for expensive equipment such as CT scanners, MRI scanners, PET scanners or new beds, refurbishments, new facilities or new hospitals. We will spend approximately €600 million on capital investment this year and the figure will be similar during the coming years. Radiotherapy facilities alone will cost approximately €500 million. Money for this is in the national development plan as is money for the national children's hospital which will cost a couple of hundred million euro. It is not that we do not want to spend the money but that there are competing demands on the money and it is a question of deciding priorities each year for each hospital as we allocate resources.

Photo of Olwyn EnrightOlwyn Enright (Laois-Offaly, Fine Gael)
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I know the Minister has not received the report yet. Will she confirm that all the information she and the Taoiseach have to date has been made available to the House? Will she outline in more detail than she did in her speech what actions the Health Service Executive took and what further contact she had with it following the communication in July 2005 from Mr. Naughten? She mentioned it was brought to the attention of Professor Hollywood and discussions took place on the issue. What action was taken? Was the letter of 5 July brought to the Minister's attention at that time? Where are women from the midlands to go for detection and investigation until the centres are established? Does the system have capacity to take these extra women to other hospitals without adding to delays? Will they experience delays in receiving appointments?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I made all of the information at my disposal available to the House in my statement. I asked Professor Drumm to provide me with a report as soon as possible on the circumstances which led to the decision at the end of August to suspend the mammography service. In my comments today I paid tribute in particular to the director of nursing. She wrote the letter to the HSE on 15 August expressing her concerns about ten false positives. She felt this was of sufficient concern to bring it to the authorities and it was as a result of her correspondence that the service was suspended. We owe her a great deal of gratitude because instead of seven we might have had ten, 12 or 15 cases. She was terrific.

The correspondence handled by the Department in the summer of 2005 included communication with the National Hospitals Office and Dr. Hollywood because at that point he was still the clinical director. After this a radiologist was appointed. One of the complaints made was about the lack of a full-time radiologist and the position was advertised and a person was recruited and appointed in the autumn of that year. A pathologist was appointed in Mullingar to also cover Portlaoise. I await a report from the HSE to see what other issues arose.

As I understand it, there were ongoing discussions between Dr. Hollywood as the clinical director for cancer and the management and clinicians at Portlaoise hospital. We were never aware at official level in the Department or, to the best of my knowledge, in the HSE that issues arose over particular mammograms until 15 August.

Photo of Olwyn EnrightOlwyn Enright (Laois-Offaly, Fine Gael)
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Were people who did not have expertise as pointed out by Mr. Naughten removed from the service in 2005?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I do not believe anybody was removed. An appointment was made. Locums were in place. I did not speak to Mr. Naughten about this although I met him in September at the opening of the hospital which I believe Deputy Enright attended when he was supportive of the new centres of excellence even though Portlaoise lost out.

The complaint was that the service was being run with locums. A radiologist was subsequently appointed. I acknowledge the radiologist was one of the locums but the person was not appointed by me or by a political process. The person was appointed by the Public Appointments Commission under rules laid down by Comhairle na nOispidéal.

The new medical council legislation strengthens the role of the Medical Council with regard to specialist registrars and competence assurance. When the Act becomes effective doctors must fulfil competence assurance measures to remain as a specialist registrar. It will be a reassurance to patients when it is fully operational.

Photo of Olwyn EnrightOlwyn Enright (Laois-Offaly, Fine Gael)
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Where will the women go now?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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They will go to St. Vincent's Hospital. The mammography service has been suspended and will not be restored pending the outcome of Dr. O'Doherty's investigation which we will have at the end of the month.

Photo of Leo VaradkarLeo Varadkar (Dublin West, Fine Gael)
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I acknowledge the willingness of the Minister to come to the House and answer questions in free format. If other Ministers were prepared to do so on important issues such as this we would have a stronger Parliament and democracy and perhaps a better Government.

I understood the role of the Radiological Protection Institute was to assess whether machines were dangerous in terms of their emissions and not their efficacy. Will the Minister clarify this? Did all of the women affected have symptomatic breast disease in that they went to their doctors with a lump or were they breast screening cases? Breast screening cases would raise a different argument. As a doctor I would be surprised to hear that in places triple assessment is not the norm for people who have lumps. I did not know this and it amazes me.

The phrase "centres of excellence" is a PR term. Let us be honest, we are not discussing centres of excellence we are discussing centres of adequacy and it is not what we have. The decision to have four centres in Dublin seems strange. Clearly, it has to do with university politics and I am disappointed the Minister did not take on the universities in the same way she did over the children's hospital and state they cannot all have a centre of excellence. Perhaps we should have had one or two in Dublin which would have been real centres of excellence like Sloan-Kettering. If hospitals in the north east or midlands come together and agree on one regional hospital is it open to consideration that at a later stage those new hospitals could become centres of excellence?

It will still be the case that women will have breast cancer diagnosed in smaller or district hospitals. Very often, when a person is in with a complaint such as a heart attack or pneumonia they are examined properly for the first time and a lump is detected. Is it envisaged that patients admitted with other conditions would be sent to a centre of excellence for triple assessment? It is important that it will still be possible to do mammography and biopsy on site as it is common for someone to come in with a different complaint and have a breast lump noticed during admission. Has this been considered?

Photo of Dara CallearyDara Calleary (Mayo, Fianna Fail)
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Given all that happened this week will the Minister consider providing extra resources to HIQA to bring forward the audit and complete it as soon as possible as a way of restoring full confidence in the service? I agree with the Minister's wish and aim that every woman would have a surgeon who does at least 50 procedures. Does it make sense to close a service completing 80 procedures in a year and transfer it to a so-called "centre of excellence"?

Apart from the people around the table, what was taken into account when the proposed eight centres were selected? Were locations measured against criteria and were other locations considered? When will the medical, clinical and ancillary facilities such as car parking be in place? Will satellite services such as mammography be consultant-led and what will be the process for their management? Will Professor Keane have a role in oncology transport, particularly to bring people who do not have access to cars and public transport to a centre in a fair way?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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We spend a considerable amount of money on transport, with €20 million spent on taxis alone last year. Yesterday, when I spoke with a group from County Donegal I made the point that €100,000 is spent on radiation transport from Donegal. The HSE has put together a group chaired by Mr. McClintock from the ambulance service to examine transport issues. It includes people from other public services. We need transport for reasons other than health and synergy could be achieved with other public services in developing a more modern and responsive transport system, particularly for those who live farthest away from the centres.

The HIQA data for 2006 indicate a figure of 43 in Mayo, 57 in Sligo and 42 in Portlaoise. I am not questioning anybody because I am not an expert in this matter and was not involved when the experts chose the centres in consultation with patient groups such as the Irish Cancer Society. However, while I have seen references to a figure of 80 since the announcement of the centres, this has not been confirmed by any data available to me or the HSE. HIQA will do a baseline study and Professor Keane is coming here. The number of operations carried out by individual surgeons is one of the factors which must be considered. The number of new cases presenting to the unit is also relevant because it is not a matter of one person working alone. The recommendation is that two breast surgeons should work alongside two radiologists with relevant expertise. Deputy O'Reilly will also be aware that not all radiologists are experts in needle biopsies, an essential capacity for breast radiology. As well as these experts, pathologists with relevant knowledge are needed. It is not just a matter of having one breast surgeon with a high volume of cases.

More resources will be allocated to HIQA which was established on a statutory basis in May and is already making its mark. It does not want to be solely an inquiry agency, although it commenced its operations by being involved in two inquiries. It is essentially a standards setting and enforcement agency and will have a major impact on health services. As is the case elsewhere, health services in Ireland will increasingly be driven by quality and standards. When we have the data, everybody will sign up to the standards.

Professor Keane will start in two weeks time. He will consult widely and have responsibility for controlling and allocating the budget for cancer services. We will be migrating some work out of the centres of excellence, or the cancer centres for those who do not like the word "excellence", to the hospitals from which cancer services are being withdrawn. Half of the surgical patients and 30% of the medical patients from the north east are treated in Dublin hospitals but many could be treated in regional hospitals. The intention is to transfer activity and ensure safety in regional units.

Deputy Varadkar is correct about the Radiological Protection Institute of Ireland and radiation safety. I am not sure who tested the machinery last May, but I do not think it was investigated from that perspective. I will revert to the Deputy with the information.

All of the cases were symptomatic, none arose from screening. Presumably, people were referred by their general practitioner because they had symptoms.

Photo of Leo VaradkarLeo Varadkar (Dublin West, Fine Gael)
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Is it the case in the midlands when somebody presents to a general practitioner with a lump on the breast, that a triple assessment is not the norm?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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The Midland Health Board was given €7.8 million since 2001 for implementation of the O'Higgins guidelines. I do not know where that money went but surgeons, pathologists and radiologists have been employed.

Photo of Charles FlanaganCharles Flanagan (Laois-Offaly, Fine Gael)
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Another inquiry.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I do not know whether these specialists sat down on a weekly basis to discuss cancer cases, as was recommended. The issue pertaining to the seven women in question was they had been given the all-clear. They were told everything was fine and to go home. Ten women who were identified as having cancer had no such ailment. They were probably subjected to a triple assessment.

Photo of Leo VaradkarLeo Varadkar (Dublin West, Fine Gael)
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Was cancer excluded solely on the basis of the mammography?

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

Photo of Leo VaradkarLeo Varadkar (Dublin West, Fine Gael)
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There was a lump but the mammography was negative.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I do not know whether there was a lump because I am not a clinical expert. Irrespective of the reason, they were sent to the hospital. Clearly, they had some symptoms, presumably including a lump, and were given the all clear. Reference was made earlier to eight women, one of whom had a second mammography carried out in St. Vincent's Hospital after cancer was confirmed. I believe she spoke to the media.

I am advised that the national and British guidelines and the O'Higgins's recommendations advise that radiologists should be reporting 1,000 cases per year. If a radiologists reports 500 cases, he or she should get a second opinion because he or she probably does not possess the requisite level of skill. Nobody recommends two radiologists.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Except for BreastCheck.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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Yes, because symptomatic cases are supposed to be easier to identify than screening an entire population. A second radiologist is recommended internationally in those instances because it is more difficult to diagnose cancer among an entire population when the people coming for screening have no symptoms. I am not a clinician and do not draw up the guidelines. They are developed by clinical experts in the field of radiology.

Photo of Charles FlanaganCharles Flanagan (Laois-Offaly, Fine Gael)
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Given that we would not be having this debate if it was not for the Portlaoise inquiry, the Minister will forgive me if I narrow my questioning to that issue. Will she outline the terms of reference of the inquiry? It was announced in September as a look back at the work of one person but has since become an inquiry.

Having regard to the fact that we now know more than one person is involved, the question of machinery is all the more important. Given that the mammography work was done by one person, a case can be made for examining other work undertaken in terms of X-rays and scans not involving mammograms. In view of the manner in which this unfortunate news is becoming public, there is a compelling case for making the inquiry independent. As with the issue which arose for the Department of Transport last week, it is not satisfactory for the HSE to be involved at the inquiry stage. I ask the Minister to accept that the issue is much wider than the work of one consultant during a certain period. We need to consider all the questions raised this afternoon.

In regard to the people who must leave the midlands for treatment in other areas, I ask that they be provided with medical cards. Capacity problems in St. Vincent's Hospital which have already arisen this week must be addressed in the period between now and the establishment of the new service rather than some stage in the future.

Photo of Denis NaughtenDenis Naughten (Roscommon-South Leitrim, Fine Gael)
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With regard to screening in the west, can the Minister explain why BreastCheck has refused to provide any details in respect of the number of women who already have been screened or will be screened by the mobile unit at the county hospital in Roscommon? Is the unit turning into a political ornament rather than a facility to screen women?

In respect of women in my constituency of Roscommon-Leitrim who have to pay for private screening, why is this not being independently monitored? When will such scrutiny commence?

On the issue of equipment, transport and value for money, when will we see up-to-date equipment in hospitals? Does the Minister think it acceptable that last month a taxi had to bring test results from the county hospital in Roscommon to Beaumont Hospital because the basic technology was not available to transmit the information? Does this represent value for money?

When will the cervical cancer screening programme be in place? Will women in the west once again be left behind in that regard?

Photo of Beverley FlynnBeverley Flynn (Mayo, Independent)
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I wish to correct something. When the Minister spoke earlier, she mentioned that her figures indicated that in 2006 in Mayo General Hospital there were 43 new cancer cases. The National Cancer Registry states there were 70 new cases in that year in County Mayo, 66 of which were treated at Mayo General Hospital. The figure for 2005, according to the registry, was 63 new cases. It is important that the statistical information is correct to ensure the wrong impression is not given. I also wish to point out that triple assessment is available to all new patients under the age of 35 years with a lump on the breast——

Photo of John O'DonoghueJohn O'Donoghue (Ceann Comhairle; Kerry South, Ceann Comhairle)
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Statements cannot be made at this point. I have explained that Deputies must put questions to the Minister.

Photo of Beverley FlynnBeverley Flynn (Mayo, Independent)
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I have two questions for her. In her speech she referred to the survival rates for women with breast cancer. Does she have a breakdown of the figures, hospital by hospital? Is the statistical information available and, if so, will she make it available to us?

My second question relates to the forthcoming appointment of Professor Keane. The Minister mentioned that he will be responsible for the budget but will there be any flexibility in his role? Will he implement the national cancer strategy as currently outlined or, after the HIQA review, will there be flexibility built into his role, whereby he can change the strategy if the review indicates that it is advisable to do so?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I did not respond to one of the questions posed by Deputy Varadkar. The universities had nothing to do with the selection of the centres. I know the Deputy has a particular interest in Blanchardstown where many of my friends feel this was the case.

In response to Deputy Flynn, there are no National Cancer Registry data for 2006. My advice is that the data are not available. Our data, the HIPE data which hospitals must submit every year, indicate that there were 43 new cases but I am happy to examine whatever data are available.

The job of Professor Keane will be to implement the strategy. He does not wish to be, nor was he, involved in the selection of the centres. Clearly, his job, the centres having been identified, will be to make it happen. One of his first tasks will be to appoint a team to assist him. He will not be a one-man outfit. He will have a deputy director and a number of key clinicians to help him in the task. He is very keen, in particular, to ensure a buy-in and will come to very flexible arrangements to make this happen as quickly as possible.

On the issue of cervical screening, we allocated some money this year to the national screening programme to begin preparations for a cervical screening programme. It will be rolled out yesterday.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Is that Freudian?

Photo of Olwyn EnrightOlwyn Enright (Laois-Offaly, Fine Gael)
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Wishful thinking.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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My apologies, next year.

Photo of Denis NaughtenDenis Naughten (Roscommon-South Leitrim, Fine Gael)
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We understand. The Minister has had a long day.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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As I understand it, it will not be done in the same way as BreastCheck.

I apologise to Deputy Reilly for calling him Deputy O'Reilly. My very efficient press officer sent me a note saying "I think you said O." If I did, I apologise.

As I understand it, the screening service will be inviting expressions of interest from those who have the capacity to take smears. We must then deal with the issue of the laboratories. Deputy Reilly has made the point previously about the lack of accreditation here. These are the issues being addressed. I hope the Minister for Finance, when he announces the budget in a few weeks, will be in a position to announce additional funding for the screening programme to make it happen early next year. That is the plan to which we are all working.

On the issue of privately funded facilities, anyone can build and open a hospital in Ireland. Clearly, medical practitioners and nurses who work in them have to be registered but the situation is unsatisfactory. We have established a commission, chaired by Dr. Madden, which is due to report next summer. Among the issues Dr. Madden has been asked to address are those of accreditation and licensing. In the meantime we have written to the Independent Hospitals Association and health insurers in Ireland to advise them of the new standards and to ask them to implement them. As Minister for Health and Children, I am concerned about patients, whether they are in public or private facilities. They must be my main concern.

On the issue of basic technology, there is no justification for what Deputy Naughten described. To be fair, the technology in the health system is not adequate. That is a fact and because of the PPARS debacle, technology got a bad name. I do not know the facts of the case mentioned by the Deputy but it does not make sense to send essential data by taxi when it can be read electronically. Nowadays one can transmit data on a mobile phone across the world in a matter of seconds. Many countries have outsourced the reading of X-rays and so on. Modern technology makes many things possible. It has the capacity to end peripherality in the health system. We want to see modern technology used for the development of health services.

Photo of Beverley FlynnBeverley Flynn (Mayo, Independent)
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That is why networking works. That is why in the Sloan Kettering centre they can do day surgery, diagnostics, chemotherapy, radiotherapy——

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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The jury is still out on what will happen in the other hospitals in terms of diagnostics. Obviously, with regard to medical areas such as chemotherapy and radiation oncology, we have designated facilities.

My strong preference and that of the Government is to make as many things happen as close as possible to where people live, provided they can be quality assured. That is the only rule. Nothing else——

Photo of Beverley FlynnBeverley Flynn (Mayo, Independent)
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Will the Minister build that into the terms of reference?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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If it can happen, my door is open.

Photo of Beverley FlynnBeverley Flynn (Mayo, Independent)
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Fair enough.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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That is what the experts advise. Perhaps in a couple of years there will be new advice. I know that when Professor O'Higgins advised in 2001, he recommended 12 or 13 centres. By 2007, that figure had gone down because the evidence evolving suggests that rather than 100 new breast cases each year, a hospital should have 150. The evidence is changing all of the time. The challenge for us is to make sure our cancer strategy can keep pace with the changes in order to guarantee quality for patients.

Photo of John O'DonoghueJohn O'Donoghue (Ceann Comhairle; Kerry South, Ceann Comhairle)
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I call Deputy McHugh who will be followed by Deputy Crawford. We will then have to finish the debate.

Photo of Charles FlanaganCharles Flanagan (Laois-Offaly, Fine Gael)
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The Minister forgot to make reference to my questions.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I beg the Deputy's pardon.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Will the Minister answer my question about the public private partnership and funding——

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

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Will there be double reading of scans?

Photo of John O'DonoghueJohn O'Donoghue (Ceann Comhairle; Kerry South, Ceann Comhairle)
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If Deputy McHugh will give way, I will certainly allow that question but I cannot oblige the Minister to answer any question.

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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I just have one brief question for the Minister.

Photo of John O'DonoghueJohn O'Donoghue (Ceann Comhairle; Kerry South, Ceann Comhairle)
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The Minister is being very comprehensive. In the light of that, I cannot do any more.

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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In the light of the commitment to establish Letterkenny as an outreach unit of the centre in Galway; the Minister's statement that she is examining, with Mr. Michael McGimpsey, the possibility of a radiotherapy unit being established in Derry and the fact that she met private developers recently regarding a proposal for a private hospital, what commitment can she give to the people of County Donegal that the services at Letterkenny General Hospital will not be downgraded? These three units will be based within a 20 mile radius of Letterkenny. Is the proposed accident and emergency unit for Letterkenny General Hospital still part of the Minister's plan?

Photo of John O'DonoghueJohn O'Donoghue (Ceann Comhairle; Kerry South, Ceann Comhairle)
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Deputy Crawford is giving way to Deputy Reilly.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I simply reiterate the question I asked, namely, has the Minister abandoned the public private partnership process? Is that why we are now in a position to deliver the services in 2009 as opposed to 2015, as suggested by Professor Brendan Drumm? It is a specific question to which I would like a yes or no answer.

Second, will we have double reading of mammograms to protect patients from human error, regardless of what international practice may be? I discussed this issue with a professor of radiology today and he could not tell me why it was not done in symptomatic cases which clearly are very serious when it was done in the case of BreastCheck.

Triple assessment means that a patient is examined, has a mammogram and a biopsy which is checked by a pathologist. Otherwise one cannot diagnose or rule out cancer.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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The public private partnership process has not been abandoned but it is the case that through the traditional route we will have four extra machines at Beaumont Hospital and St. James' Hospital to deal with capacity issues between now and 2009 or 2010. However, we are talking about large sums of money. Deputy Reilly mentioned the Whitfield Clinic this morning but who provides the money is not the issue. The issue is safety and safe patient care. I am a fan of the HSE procuring services once they can be provided safely.

On the issue of double reading, I understand 15,000 mammograms are conducted every year, excluding the breast screening service, which is an incredible figure. I am not certain, for example, that if two people were reading in Portlaoise, it would have made any difference.

I forgot to answer Deputy Flanagan. I can provide him with the terms of reference. The HSE engaged Dr. Ann O'Doherty who is not an employee of the HSE but an employee of the independent organisation BreastCheck to carry out a review. She is an international expert and is involved with the breast screening programme in the United Kingdom. The last thing one could accuse her of is not being independent. All clinicians value their autonomy and independence. She has been asked to look over the mammograms, ultrasounds and anything else that is relevant, including the machinery, and to write a report. When we see her report, we will see what follow up action is necessary.

Photo of John O'DonoghueJohn O'Donoghue (Ceann Comhairle; Kerry South, Ceann Comhairle)
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My apologies to Deputies O'Donnell, English, Deenihan and Bannon. Unfortunately, we did not reach their questions because the time had expired.