Dáil debates

Wednesday, 12 March 2008

12:00 pm

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

That Dáil Éireann:

welcomes the publication of reports into events relating to breast cancer services at the Midlands Regional Hospital, Portlaoise;

supports the action being taken by the Minister for Health and Children, and the board and management of the HSE, to ensure that patients' interests come first in the future management of all such reviews and serious adverse incidents;

reiterates its support for the National Cancer Control Programme to ensure equitable access to high quality cancer services for patients throughout the country;

expresses its appreciation for the leadership and work of clinicians, nurses and staff in delivering improved levels of care for cancer patients under the Cancer Control Programme;

welcomes the improvements in survival rates and supports the Cancer Control Programme which will deliver further improvements; and

commends the early progress made by Professor Keane since his appointment in late 2007 on the improvement in symptomatic breast cancer services.

I am pleased to have the opportunity in this House to discuss the four reports into the events that happened in Portlaoise hospitals between 2003 and 2007. Last Thursday, we had an opportunity at the Joint Committee on Health and Children to have a discussion with Deputies, the day after those reports were published. A week later, a debate can be better informed because Deputies will have had an opportunity to study those reports and to reflect on them.

At the outset I want to reiterate the apology I expressed in this House when these matters first came into the public domain last autumn. I extend that apology to all of the women who were caused upset and anxiety as a result of the necessary review of mammograms in the period from 2003 to 2007. In all, there were over 3,000 women involved. Subsequently more than 600 ultrasounds were also reviewed. Thankfully, in regard to the ultrasounds, no new cancers were diagnosed. Clearly the biggest apology has to go to the nine women whose diagnosis was delayed as a result of an initial misdiagnosis. Eight of those were in Portlaoise hospital and one was in St. Vincent's Hospital in Dublin.

If there is anything we have learned from what happened in Portlaoise, it must commit us all to ensuring we put in place in Ireland the best possible cancer service that this country can provide for cancer patients, whether from Portlaoise, Donegal or Cork. In regard to the findings of the report, the clinical report is clear that nine cancers were misdiagnosed. As a result those women had their treatments delayed. Some of that misdiagnosis happened when the health boards were in place and some of it happened following the establishment of the HSE. All of those clinical errors were errors of doctors and not errors of management. We must remember that.

If we are to minimise the capacity for doctors to make errors, particularly in regard to breast cancer, where there are 250 different publications worldwide, we must have specialist doctors working in teams in major centres where there are large volumes of patients. That is the finding not just in Ireland, as a result of the expertise we put together, but it is also the advice from countries around the world. Until relatively recently we had in Ireland more than 30 different hospitals performing breast surgery. Only four out of every 100 surgeons were doing more than 50 procedures per year. Three out of every ten women had their surgery performed by surgeons who did really low volumes of activity. Perhaps I will get an opportunity to speak about that in a while.

In summer 2005, a few months after I became Minister for Health and Children, I put together a group, chaired by Professor Niall O'Higgins, who is recognised as one of the leading experts, not only in Ireland but internationally, on breast cancer. He chaired a group at my request to advise me on what guidelines and standards need to be put in place to deal with symptomatic breast cancer. He reported and I took that report to the Government, which endorsed it. The findings of the report were that no hospital should perform breast surgery unless it was dealing with a volume of 150 cases per year. Notwithstanding that this was during the run-in to the election, when many felt it was not a wise time to publish and endorse these standards because of the consequences for so many hospitals, we endorsed them and published them in the spring of last year in the presence of the HSE and HIQA.

From that point on, it became a question of how quickly we could implement the standards. Since then, 16 hospitals have ceased breast surgery and a further seven will cease breast surgery this year. Although the cancer control plan in respect of breast cancer was to be implemented over a two-year period, Professor Keane told me that he expects it to be at least 90% implemented by the end of this year. Such is the speed at which patients are demanding that they be treated in specialist centres. As a result of the publicity and awareness surrounding Portlaoise, many patients are better informed. There is strong advice coming from patients groups such as the Irish Cancer Society, Europa Donna and others in respect of safety and quality. Volume equals quality, and this is not to do with the skills of individual doctors. It is only with high volumes that one can get specialist doctors to work in centres.

There is much debate about letters. I reiterate that politicians, Ministers, clinicians and officials have a responsibility to redouble our efforts to make sure the appropriate cancer care is established in Ireland. In the past, that did not happen because of medical opposition not political opposition, which was the beginning of something not happening. Professor Keane has acknowledged, and I have seen, that there is major clinical buy-in to the new cancer control plan and terrific clinical leadership, as evidenced by the announcement from Mayo General Hospital, Castlebar yesterday. Dr. Barry, a highly skilled breast surgeon, has agreed to move to Galway to carry out breast surgery. He is in discussions with Professor Keane in respect of those arrangements. That is a major positive, putting the patients first.

When the decision was made to designate Portlaoise as the breast cancer centre for the midlands, cancer care was to be spread across three sites — Portlaoise, Mullingar and Tullamore. If there is a small population and one spreads the cancer resources of clinical expertise across three sites, one will never get the outcomes one expects even in 2002.

Mr. Naughten has issued a copy of a letter he says he sent to my predecessor at the end of April 2002. To be fair to officials in the Department of Health and Children, all letters sent to the Minister are electronically recorded in the Minister's office and in the Department. There is no record of the letter there, nor at the health board office, which would be normal practice. I am not suggesting that the letter was not sent but there is no record of it. Mr. Naughten gave a copy of the letter to Ann Doherty when she was carrying out the report. Subsequent to the letter, some €500,000 was allocated by my predecessor in that year, 2002. That letter was sent during the election campaign leading up to the election on 17 May 2002. Following his reappointment as Minister for Health and Children, Deputy Martin allocated €500,000 to cancer services in the midlands and sanctioned the appointment of three clinicians, a surgeon, a radiologist and a pathologist, who were to have specialist interest in breast cancer and who were to work in a multidisciplinary team with triple assessment. That was the condition on which the appointments were sanctioned. Much emphasis has been placed on letters. It is not the case that no action took place or that there were no resources.

Photo of Charles FlanaganCharles Flanagan (Laois-Offaly, Fine Gael)
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When were the jobs advertised?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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Deputy Flanagan may remember that in that era it was a matter for Comhairle na nOspidéal, which was dominated by consultants, to proceed with the appointment of clinicians. The jobs were advertised in 2004.

Photo of Charles FlanaganCharles Flanagan (Laois-Offaly, Fine Gael)
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Two years on.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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It became impossible to get anyone with specialist breast radiology skills.

Photo of Charles FlanaganCharles Flanagan (Laois-Offaly, Fine Gael)
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Not in 2002, it was not even advertised.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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A radiologist was appointed in 2005. That doctor did not have a specialist interest in breast treatment and when the appointment of such a person was sought it was impossible. These clinicians are scarce globally. It is extraordinarily difficult to get clinicians with specialist expertise.

Photo of Charles FlanaganCharles Flanagan (Laois-Offaly, Fine Gael)
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The Minister ran it into the ground.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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It is particularly difficult to get them in hospitals with small volumes of activity. In 2005 and 2006 the volume of activity in Portlaoise was very low, as it is in many other hospitals.

Photo of Olwyn EnrightOlwyn Enright (Laois-Offaly, Fine Gael)
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The Minister was still promising the facility in 2005.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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There were 42 cases a year in Portlaoise in 2006.

Photo of Charles FlanaganCharles Flanagan (Laois-Offaly, Fine Gael)
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What was it in 2002?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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In 2005, it was 51 cases. In 2002 it was somewhere in the 60s. As screening began, it declined because the screening programme is attached to clinical care, unlike other countries, so that where breast cancer is picked up the woman is treated at the centre. In this case it would have been St. Vincent's Hospital in Dublin.

I reiterate that we cannot undo the past but must learn from it. We never investigated these matters in the past. The Dr. Neary episode continued for 25 years, even though there were people working with him. Thankfully, in the end midwives, specifically someone who came from outside this jurisdiction, blew the whistle. People knew for a 25-year period that something wrong was happening there. If we had audit and data we would have seen that what was happening in the maternity unit at Our Lady of Lourdes Hospital was completely different from what was happening elsewhere by a margin of 20 times. When issues came to light, matters were not investigated. We are now in a new era with many investigations, difficult and unpalatable as they are.

To revert to Deputy Flanagan's question, there were 46 cases in 2002.

These investigations are challenging for those who work in the health system and they are challenging for patients. It is also challenging in respect of confidence in the health system but if we have no standards we can improve nothing. If we do not have determination to implement the standards, we do not improve matters. If it was not for the director of nursing, who was concerned about over-diagnosis, as Mr. Fitzgerald stated, we would not have picked up on these nine errors. If the director of nursing did not get in touch with the HSE last August and express concern at over-diagnosis or false positives, we still would not know what is happening in Portlaoise. We owe her a great deal of gratitude. The HSE put the doctor on administrative leave, which is normal practice, and carried out a review and investigation. We know the outcome of the clinical review.

The second matter is the management of the issue. I was concerned, particularly after information was given at the meeting of the Oireachtas Joint Committee on Health and Children on the ultrasound review. I asked the board of the HSE, which is appointed by and accountable to me, to examine what happened and see what lessons have been learned. Clearly, there were serious failings of management, communication and governance in respect of how Portlaoise was handled. The most important matter with regard to these findings is that we discovered what happened. Accountability is about getting the facts, identifying what must be done to address failings and implementing the steps taken to address the failings. The serious issues identified must be put right and it is my responsibility to ensure the board of the HSE puts them right. I have asked the Chairman of the HSE to ensure that happens in regard to incidents of this kind; we know there will be more incidents of this kind because there will always be clinical error. We can only minimise it when we have groups of doctors working together in teams in large centres. When incidents and errors occur we must have protocols that are patient-centred and we must ensure patients come first. I want to give a guarantee that when errors of this kind arise, patients will be contacted directly and not hear about it through the media or the political system. I have asked the HSE to consult patient groups, many of which wish to be involved, when drawing up the protocol. I want one person in charge to ensure the protocol is implemented. We see from the Fitzgerald report that a plethora of people involved in the one incident leads to confusion, mismanagement and serious governance and communication issues. I want to ensure the board of the HSE through its risk assessment committee oversees this.

I have many more comments to make, but if there is any lesson we must all learn, it is that we must rapidly ensure that we implement the new cancer plan around the eight specialist centres. They are not centres of excellence — as every health setting should be a centre of excellence — they are specialist centres. Above all else, we must learn from what occurs in respect of children's cancer. As it is centrally organised at Our Lady's Children's Hospital, Crumlin — although many of the treatments are delivered in 16 places — we exceed the best performers in Europe and the United States. That proves that appropriately organised care in cancer delivers a good outcome for patients. This debate concerns patients, putting them first and investing necessary resources in the eight centres to have them fully operational as quickly as possible.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I move amendment No. 2:

To delete all words after "Dáil Éireann" and substitute the following:

"—expresses its serious concern at the findings of recent reports into breast cancer services at the Midlands Hospital Portlaoise;

regrets the deep distress caused by these failures to many patients and women in the midlands;

concludes that the reports demonstrate serious failures in the management of the HSE and in the delivery of essential health services;

notes that these failures arise directly from decisions made by the current Minister for Health and Children, Mary Harney, T.D. and her predecessor, the former Minister for Health and Children Micheál Martin, T.D.;

is alarmed that the Minister for Health and Children Mary Harney and all other members of the Government continue to express confidence in the current structures and management of the HSE;

calls on the Government to reform the HSE so that within 3 months:

the service puts the patient at the centre of all its activities;

every HSE employee has total clarity about their roles and responsibilities;

decision making on services is devolved to regional and local level to the greatest extent possible;

the bureaucracy at HSE headquarters is reduced; and

HSE accountability to the Oireachtas is dramatically improved."

The Minister is correct in that this debate concerns women and patients, particularly the women of Portlaoise and their families who have been treated so badly by our health service and have suffered so appallingly. This debate takes place in an effort to bring political accountability to the House for the defective health systems that failed us and over which the Minister presided. While the errors were clinical, they occurred because the system did not put in place appropriately qualified personnel. As the Minister stated, the radiologist appointed was not one with a special interest in mammography and no specialist pathologist was put in place.

I note in the Minister's speech the emphasis on centres closing rather than centres of excellence developing. I am sure people will take a message from this. A deficit of approximately €360 million in the HSE and a struggle to perform with today's services while maintaining last year's do not augur well. I would like to believe the Minister, but the record prevents that. Like her, we want to ensure that every effort is made to prevent such a catastrophe from recurring so that no patient or family will need to experience a similar situation.

Discussing the establishment of the HSE in November 2004, the Minister stated: "It is a once-in-a-generation event... our generation's chance to put patients first in the design of the management of health services". She continued: "We badly need clarity of roles and accountability — political responsibility for the Minister and management responsibility for the management... that will make a real difference to the quality of health services provided for our people". Does this sound familiar? If anything, the reports published last week prove that patients are not put first. Despite the Minister's lip-service to the contrary, the HSE management is anything but effective. The ethos of administration, as pointed out by Professor Niamh Brennan in her report, is clear, but there is no management ethos and people are still unclear about their roles and responsibilities three years since the HSE's establishment. This is incredible. Any CEO or head of such an organisation would have been shown the door, as stated by senior businessmen. If political accountability is to mean anything, the Minister must accept responsibility for the failures of her creation, the crass, uncaring way these women were treated and for her inaction and that of her Department.

The Minister referred to Dr. Naughton's letter but, until last week, the Minister denied its existence and her Department knew nothing about it. However, it was sent to the Minister's predecessor in 2002. In it, Dr. Naughton highlighted his serious concerns about cancer services in Portlaoise and brought to the attention of the then Minister, Deputy Martin, the lack of progress made in cancer services in the region since Portlaoise became a designated centre for cancer care in the midlands under the Government's watch in 2001 and the publication of the O'Higgins recommendations on symptomatic breast disease in 2000. The Minister and her colleague presided over this issue. Portlaoise was a designated centre of excellence, but it was not funded appropriately. Notwithstanding the inability to find the letter and the implication that it never reached the Department, it is interesting that action was taken on it. This is extraordinary logic.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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No, I did not state that. I stated that the Midland Health Board made an application at the same time.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I heard what the Minister stated.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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In June, the Midland Health Board applied for three posts, which were funded. That is what occurred.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Does the Minister still maintain that the Department did not get the letter?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I am telling the House that there is no record of it. When the Deputy raised this matter previously, I told him to show me the record if there was one. I am telling the Deputy the truth. I invite him to examine the electronic recording of correspondence. I would be very happy——

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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In that case, the Minister will be able to confirm that no acknowledgement of the letter is on file.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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That is a fact. I did not go through the files, but I want to tell the truth as I understand and know it to be fair to the officials who deal with these matters.

Photo of Charles FlanaganCharles Flanagan (Laois-Offaly, Fine Gael)
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Nothing occurred.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Dr. Naughton made the then Minister aware that despite the allocation of funding, none of the necessary specialist personnel were in place or had been advertised for, including surgeons, radiologists and pathologists. Dr. Naughton wrote that life would be much easier for him if he walked away because, at least in that case, patients would need to go elsewhere to get a service they deserved and could rely on. Unlike the current Minister, he realised people were being misled as to the nature of the service, believing it to be the best available as a designated centre, but this was not the case because staffing had not been put in place. By that time, Dr. Naughton had written approximately seven letters highlighting his frustration and despair with cancer services in Portlaoise. However, nothing occurred or changed and no one took any notice. For this reason, we face this situation today.

The Minister was oblivious to this letter when I raised the matter with her on 21 November. When a freedom of information request was made, the letter could not be found. I want to know why. We need an inquiry into this matter, as our democracy demands it. How many other files in this Department or others are incomplete? We need to get to the root of the matter. History reveals that, when similar issues occurred previously in the Department of Justice, Equality and Law Reform, a major investigation took place immediately and was reported on within four weeks.

This is not the first time we have been denied information. On 6 November 2007, the Taoiseach misled the House on when the Minister, Deputy Harney, was first notified of the difficulties with breast cancer services in Portlaoise. While he claimed that it was in August 2007, we know that a letter was sent in July 2005. In it, the consultant told the Minister that radiological services were being provided by people who had no expertise and that women were having or might have unnecessary surgery because of a lack of decision making. What was the Minster's response? She did not even read the letter. Instead, she passed the buck to the HSE, which passed it to the network manager, who passed it to the hospital manager, who interviewed the consultant. The Minister stated that appropriate action was taken, that is, a senior clinician spoke with the clinician in question. However, appropriate action would have been to put in place the specialist in mammography, a pathologist and a clinical team leader. It was not done and I do not accept the Minister's contention.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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The Deputy knows the HSE advertised the position, but could not get the person.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I know why. I was——

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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The Deputy should put all of the facts on the record.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I hope this time will not be taken from me.

Photo of Seán ArdaghSeán Ardagh (Dublin South Central, Fianna Fail)
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It will be.

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

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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The Minister has told people that it is difficult to get the staff in question on a global basis. I will explain why people will not go to the hospital in Portlaoise or elsewhere, namely, the word on the grapevine in medical circles is that such hospitals have no future and that the careers of those who go there will not progress. I wonder who put this word out there.

Photo of Charles FlanaganCharles Flanagan (Laois-Offaly, Fine Gael)
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The Government ran it into the ground.

Photo of John MoloneyJohn Moloney (Laois-Offaly, Fianna Fail)
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We did not. The court case did that.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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No further action was taken and the patient has not been put at the centre of the health service. Furthermore, the Minister misled me at last week's meeting of the Joint Committee on Health and Children. She stated: "Professor Keane has also agreed with the Irish College of General Practitioners on a new method of referring patients for breast diagnosis". However, this is not so, as no such agreement is in place. Why does the Minister seek to mislead the House again? Waterford, which is supposed to have a centre of excellence, awaits funding despite promises from the Minister and the Taoiseach. I am deeply concerned by Professor Drumm's assertion that transport costs are to be cut. How will this affect transport to our centres of excellence?

The Minister's reform of the health service through the establishment of the HSE was supposed to put patients first. How often have we heard this? It was supposed to increase efficiency, transparency and accountability, and make a real difference to the quality of health services delivered to the people. These were the Minister's words, not mine and these are her failures.

The Fitzgerald report catalogues the systemic failures in the HSE's response to the Portlaoise cancer crisis. I reiterate that although a former Ombudsman has stated one cannot blame Ministers for every tittle-tattle, one certainly can do so when there is system failure and they should be held accountable. Members must remember that this body, with its systemic failings, oversees the spending of more than €12 billion of taxpayers' money.

The Fitzgerald report found a "fundamental weakness in the management and governance of this process from the outset, because there was no authoritative co-ordination and management role established for the review process as a whole". It reported that communication throughout the period was inconsistent and sometimes contradictory, that too many were involved from different levels and areas within the HSE who were unclear about their roles and responsibilities and that they had differing understandings of what was going on.

Overall, the report found a lack of urgency on the part of the HSE prior to the meeting of the Oireachtas Joint Committee on Health and Children on 22 November, when it announced that 97 women reviewed under the ultrasound process needed to be recalled. It commented that had the same urgency been shown before November as was shown subsequently, much of those patients' pain and suffering would have been avoided. Unfortunately, the Minister was unaware of the ultrasound review, which demonstrates clearly communication difficulties. Unfortunately, this is what one has come to expect, namely, a detached and disinterested Minister for Health and Children who is unaware of what is going on.

It was not until the aftermath of the joint committee meeting and the subsequent media furore that emergency clinics were set up to examine the women in question. Had this issue not been flagged at the Joint Committee on Health and Children, it is questionable whether these clinics would have been set up in the first place. As I have noted, the Fitzgerald report concluded that had the same level of urgency that was shown subsequently, when the Minister's neck was on the line, been shown beforehand, a different situation would obtain today.

The Minister cannot continue to avoid responsibility. The reports published last week demonstrate the falsity of her claim that she presides over a health system that puts patients first. Instead of attributing responsibility to any individuals, the reports refer to systemic failures. However, one must ask who put the system in place? Who designed and built the HSE? Who decided on its staffing structure? The Minister presided over it all. She must accept responsibility for her creation and ignoring the warnings about a bureaucratic bulge in the HSE, in which there is no shortage of managers but a serious shortage of anyone who takes responsibility. The Minister must take responsibility for the lack of urgency shown from August to November.

A health service is needed that is not about bloating bureaucracy and ineffective management structures but is about patient values and how people are cherished. A health service is needed that prioritises patient safety, as one has learned time and again that the current structure does not protect patients. A health service is needed that is accessible, provides high quality care when needed and does not waste the resources available to it. Accountability and transparency are required in order that one always can answer the questions: who made the decision? Why did they make it? How much did it cost and, most importantly, what impact did it have on patient care?

A full independent inquiry must be carried out by the Health Information and Quality Authority, the terms of reference of which would allow for examination of all matters from 2000 to 2008, including the roles of successive Ministers for Health and Children, the Department of Health and Children, the HSE and the health boards. Above all, a Minister who will listen is needed. I refer to a Minister who recognises the failings of her creation, in whom the people can trust and who recognises that tomorrow's plans are not today's achievements.

The Minister has lost trust. The HSE is a low trust organisation. There is a disconnection between those on the front line who are struggling to deliver efficient and reliable services and those who are part of a centralised and controlling bureaucracy. The HSE has prioritised its bloating bureaucracy over patient care and failed test after test.

Yesterday, Tuesday, 11 March 2008, 390 patients lay on trolleys in accident and emergency departments. Despite a promise in 2002 to extend eligibility to a full medical card to an additional 200,000 people, only 29% of the population have a medical card today, compared to ten years ago in 1998, when 32% of the population were entitled to a full medical card. Moreover, one hears of the catastrophic effects on children suspected of having autism being obliged to wait for up to two years for initial assessment. This constitutes two years out of the three-year window that can make all the difference to such a child's future. Although this is brain awareness week, people with brain injuries are obliged to wait up to two years to see a specialist, even though the first two to four weeks after diagnosis are crucial.

I refer to the disgraceful situation in St. Ita's Hospital, in which 23 women lie in an open ward with 3 ft between beds. The 23 women share a shower with the ceiling coming down, a bathroom and three toilets. Although this is 2008, they have no privacy when getting dressed. What does the Minister do in response to their request? Having planned for a new psychiatric unit at Beaumont Hospital in 2004 and having put it out to tender in 2005, she now has plonked her private co-located hospital on the site. How is that for putting patients first? Moreover, cystic fibrosis sufferers must wait for their isolation rooms and the waiting list issue goes on and on. Some of my patients are obliged to wait. One lady, thankfully, is having her operation today. However, although it should have been performed two weeks ago, it was cancelled repeatedly. She has a large tumour and I wish her well.

This is the Minister's health service and her responsibility. Her greatest achievement is a centralised bureaucracy that does not work or deliver patient care. I have noted that this debate takes place for the women of Portlaoise and their families who have suffered appallingly because of the failures of the Minister and the HSE. However, it constitutes poor recompense to the nine women wrongly diagnosed as not having breast cancer, as well as the dozens of women whose potentially life-saving treatment was delayed because of the failures of the Minister's system. The women of Portlaoise are the victims of this atrocity. They paid a high price for the decisions made and not made by the Government and carry a heavy burden for the failings of the system. These failures arise directly from decisions made by the Minister and her predecessor, Deputy Micheál Martin.

When will the Minister listen and accept that some reform of the HSE is required to restore credibility and trust in the system? When will she accept that tomorrow's plans are not today's achievements and that promises of excellence tomorrow are no substitute for service today? The remedies are clear. The HSE must put patient care at the centre of all its activities, all its employees must have total clarity about their roles and responsibilities, HSE decision-making on services must be devolved to regional and local level to the greatest extent possible, bureaucracy at HSE headquarters must be reduced and the HSE's accountability to the Oireachtas must be dramatically improved. These constitute five simple steps to restore some credibility to the HSE which is a failed and deeply flawed entity.

On behalf of the people, I demand that the Minister cease making empty promises and take real action as suggested to give the people the health service they deserve and for which they have paid so dearly. I commend the amendment to the House.

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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I would like to move the Labour Party amendment to the Government motion.

Deputies:

The Deputy cannot move the amendment as Deputy Reilly has moved an amendment which the House is discussing.

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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I will speak to the amendment and the Minister. Sadly, since publication of the three reports last week, nothing I have heard today or from the Government gives me great confidence that anything will change greatly or that the Minister is not presiding over a health system in which similar incidents to those that happened in Portlaoise could be happening or may happen in the future. I state this with sadness because when I heard her apology which I welcomed, I thought there would be genuine learning from the experience of what had transpired at Portlaoise. However, I cannot discern any evidence that this has happened. Each section of the Government motion starts with phrases such as "welcomes the publication", "supports the actions", "reiterates its support", "expresses its appreciation for", "welcomes the improvements" and "commends the early progress". This does not suggest the Government is learning anything from the debacle that took place at Portlaoise or the appalling act done to the nine women who received an incorrect diagnosis and, therefore, did not have early detection of their cancer. It is as though the ranks are closing again. Nothing will be learned and we will continue as before.

Sadly, I do not have confidence that we will see real changes in cancer services by the time Professor Keane returns to Canada or, on the broader issue, any real change to the way the HSE operates or the Minister runs the health services. One of the victims of the health services, Rebecca O'Malley, stated there was no culture of learning among the Department, the Minister or the HSE. Unfortunately, that is the situation we have to face but I hope today's debate will be positive in terms of giving rise to some sort of culture of learning. However, while I also hope the Minister will genuinely attempt to introduce reform, she will have to take responsibility if she is to be successful.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I ask the Deputy to quote correctly from the long article by Rebecca O'Malley published over the weekend.

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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My reference was not to that article but to comments she made on the news. I had a pen in my hand and recorded her comments in writing.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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She wrote an extensive article which I suggest the Deputy reads.

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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I am not referring to her article.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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It would be fairer to her.

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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I am referring to her appearance on television last week which I watched with a pen in my hand. I wrote down her comments on the lack of a culture of learning. From what I have heard today, I believe she is right. This motion pays lip-service to patients' interests, stating they will come first "in the future management of all such reviews and serious adverse incidents". However, patients need change that will ensure mistakes will not be made in the first place so that we do not need reviews of serious adverse incidents. None of the reports published thus far addresses the problems that caused the clinical errors. The Minister has repeatedly noted that the reasons for the misdiagnoses were clinical errors. However while I accept that a small percentage of clinical errors are unavoidable, the reason six times the normal percentage occurred in Portlaoise was because the system was wrong. The experts were not available because the appointments were not made. The issues raised by Peter Naughton in his letters to the former Minister, Deputy Martin, the current Minister and others in the HSE were not addressed. It was nobody's job——

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

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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I am not incorrect.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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They are not the facts.

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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Where are the experts in mammography, the triple assessments or the multidisciplinary teams?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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Does the Deputy know how many times the HSE advertised for an expert?

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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Where are the multidisciplinary teams? Whose job was it to ensure they were established or to close the unit otherwise?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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That is what we are doing.

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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How many years later and how many misdiagnoses have been made in the meantime?

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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We did not even have standards until last year.

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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We have standards now.

Photo of Alan ShatterAlan Shatter (Dublin South, Fine Gael)
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The Minister was in Government for 11 years.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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The parties opposite did not support them either.

Photo of Alan ShatterAlan Shatter (Dublin South, Fine Gael)
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The Government is entirely responsible.

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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Portlaoise was a designated centre.

Photo of Charles FlanaganCharles Flanagan (Laois-Offaly, Fine Gael)
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The Government did nothing for four years subsequent to the designation.

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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It is my time not Fine Gael's.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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You were too busy going to court.

Photo of Alan ShatterAlan Shatter (Dublin South, Fine Gael)
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The Minister for Health and Children came from Fianna Fáil or the Progressive Democrats for 11 years.

Photo of John MoloneyJohn Moloney (Laois-Offaly, Fianna Fail)
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That is the reality for Deputy Flanagan; going to court.

Photo of Alan ShatterAlan Shatter (Dublin South, Fine Gael)
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The Government presided over this debacle.

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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I presume I will be given some of Fine Gael's time later.

Photo of Seán ArdaghSeán Ardagh (Dublin South Central, Fianna Fail)
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I ask Deputy O'Sullivan to address the Chair.

Photo of Jan O'SullivanJan O'Sullivan (Limerick East, Labour)
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I am trying to address the Chair but the Minister is not listening to me. She is listening to other people in the House.

When Portlaoise was designated as a centre for cancer, an expert with mammography experience and interest, triple assessment and multiple disciplinary teams were supposed to be in place. None of these was put in place and nobody has taken responsibility for this debacle. Somebody must have had the responsibility of ensuring these factors were in place in the aftermath of Peter Naughton's letter in which he raised the issue with various people. Deputy Flanagan stated that the post was not even advertised at the time but, even if it could not be filled through one advertisement, the HSE should have continued to work on the issue until it was resolved. It is not acceptable to say the HSE advertised but could not find the appropriate person.

When Professor Keane goes home, will these centres have what they require? There is no evidence in the responses of the Government and the HSE to the crisis in Portlaoise to suggest we will have a different system. When the Minister established the HSE in November 2004, she stated that she would retain clear accountability for our health services. It is clear, however, that she handed accountability to the HSE. She also claimed that the HSE would be an integrated and accountable organisation which would offer value for money and a simpler governance structure but it has none of these qualities. That is how the Minister established the organisation. She guillotined debate in the Dáil in 2004 in order to establish it in January 2005 and, in effect, she stuck Professor Drumm and his team on top of the existing structure of the health boards. Nobody knows who is responsible and the entire structure is centralised. Any decision-making capacity that existed at local level was returned to the centre. The reports, and Ann Doherty's in particular, clearly identify this. Dr. Doherty's report describes the various kinds of managers employed by the HSE, such as the network manager, the general manager, the manager for strategic planning, the hospital manager and the risk manager, all of whom were reporting in different directions. Some did not even know to whom they were supposed to report. I do not see evidence of actions being taken to prevent those circumstances recurring in various places. The Minister might address that issue in her reply given the reports in this week's newspapers that the Government was considering a return to some kind of regional structure for the HSE. Apparently, however, it decided not to make that change. The Minister has to do something about the structures. Speaking to the Joint Committee on Health and Children last week, she stated that the issue concerned patients. If she does not reform the system and structures, patients will suffer but she does not appear to accept that point.

She claims that Professor Keane is ahead of his schedule and will have 90% of his work completed by the end of this year. Where are the resources to achieve that aim? I do not see evidence of resources being invested. Deputy Reilly referred to Waterford hospital, which is extremely concerned about having the resources it needs to be a centre of excellence. I concur with these concerns because no commitment seems to have been made on giving them the necessary resources. Limerick is also a designated centre. One of my constituents wrote that, as a VHI member, she is not eligible for breast screening before July or August 2008. If she was a public patient, her wait would be much longer. She was told that because Ennis and Barrington's hospitals have stopped screening, the regional hospital is dealing with the work of three hospitals with one machine and the same number of staff. She was originally told in October 2007 that she would be screened in January 2008 but the waiting time has been extended by at least eight months and possibly much longer. I received a telephone call from somebody else who told me she was waiting in Limerick with approximately 30 other people. The environment in Limerick is stressed and the clinical director has indicated that he needs more resources in order to respond appropriately. I do not see evidence that Waterford and Limerick will be given the resources they require to provide the service they have to give to patients.

Issues do not arise solely in respect of breast cancer. Figures on waiting times for colonoscopies were published recently. The longest wait for public patients was 18 months, and nine months in my own area. The waiting times vary across the country. Colonoscopies are tests which determine whether somebody has bowel cancer. We were supposed to learn from the Susie Long case in respect of which apologies were given and apparently genuine concern expressed about the fact that she did not get a diagnosis or early treatment because she was a public patient. She died after waiting ten months but others are clearly waiting 18 months for colonoscopies their GPs have recommended. We have to get real in terms of resources and ensuring people get the assessments they need in an appropriate timeframe if we are to reduce the fatality statistics in Ireland.

This week I received a letter from Europa Donna which stated that since 2000 Ireland's mortality rate for women with breast cancer has been 15% higher than the European average and referred to the national quality assurance standards for symptomatic breast diseases. It refers to concerns, including the concerns of Professor Niall O'Higgins, who advises it, as to what is required in the designated centres with regard to prioritising the timetable. Europa Donna also expresses serious concern that there is a litany of best practice deficits that need to be resolved through the provision of resources for the specialist centres.

The Minister talks as if everything will be perfect by the end of 2009, which it will not be. I do not care whether the Minister calls them centres of excellence or otherwise, but we will not have appropriate centres unless they are given appropriate resources and unless the structures are such that when a gap in the resources is noticed, as a gap was noticed by Professor Peter Naughton, there is a way in which the clinical experts can have their voices heard. I did not hear anything in what the Minister said to suggest this will happen.

On the outstanding reports we have not received, including the report on the Rebecca O'Malley case and the reports in regard to diagnostic services at Galway and Cork, until we get all of those reports into the open and we find exactly what the adequacies of the system are, we cannot fully put it right. I urge the Minister to ensure that the rest of those reports are published as soon as possible so we can address the issues raised in them.

We are dealing with the health of the nation. We have put a great deal of our money into this — I acknowledge that spending has increased in recent years. However, there is a sense that nobody is in charge of the service, that it is dysfunctional and that a huge amount of money and goodwill is wasted in a system that is frustrating those who want to deliver care. The Minister needs to address this. She needs to take the HSE by the neck and take responsibility for it. She needs to do what she should have done before she set it up in the first place. She should set up very clear chains of command so that people know exactly what they are responsible for, and have the authority to make decisions where they are needed.

I take phone calls and receive e-mails every day from people who work in the health system, as I am sure other Members do. These people have a wonderful work ethic and want to do their best for their patients, whether they be doctors, nurses, other medical staff or others working in the health service. Since the establishment of the HSE, however, their level of frustration has grown enormously. I know the Government backbenchers agree with me because they are in touch with what is happening on the ground.

The Minister must admit something is wrong before she can put it right. It is not enough to focus narrowly on what she hopes Professor Keane will achieve because that is only a small part of the picture. That will not bring about the root and branch systematic changes needed in this country if we are to avoid a repeat of what happened at Portlaoise. I urge the Minister to do the big job that is required, not take the small steps. She should open her mind to what is wrong with the system and not hide behind the derisory Government motion before the House, which is closed to everything we should have learned from the Portlaoise situation and everything we will learn from the other reports due.

This debate must achieve a radical change in the HSE and in particular in the thinking of the Minister in her stewardship. There is an urgent need, for the country's sake, for the Minister for Health and Children to take charge of her brief.

Photo of Mary WhiteMary White (Carlow-Kilkenny, Green Party)
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I wish to share time with Deputies Michael McGrath and Charlie O'Connor.

Photo of Seán ArdaghSeán Ardagh (Dublin South Central, Fianna Fail)
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Is that agreed? Agreed.

Photo of Mary WhiteMary White (Carlow-Kilkenny, Green Party)
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I am glad these reports regarding the breast cancer services at the Midland Regional Hospital have come into the public domain. I hope one positive thing to emanate from the reports is that the Minister and the HSE will know exactly where the problems lay. I am only sorry this lesson will be learned at the expense of women whose lives were turned upside down by the mismanagement and misdiagnosis at the Midland Regional Hospital.

Since I became a Deputy last June, I have been surprised at how much mud-slinging and how many demands for heads I have heard in this House in debates relating to the health service. To make political capital out of the tragedies of other people is unhelpful. The tone of this debate should be like that during a recent debate on autism, when the Opposition thought it was too serious an issue to get politically personal. Opposition Members should do the same in this case to advance confidence in the service, improve the systems and ensure what happened never happens again.

Photo of Alan ShatterAlan Shatter (Dublin South, Fine Gael)
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Has the Deputy heard of the concept of political accountability for total incompetence?

Photo of Mary WhiteMary White (Carlow-Kilkenny, Green Party)
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I only have three minutes to speak so I want to make good use of it.

Photo of Seán ArdaghSeán Ardagh (Dublin South Central, Fianna Fail)
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There is very little time, Deputy Shatter. I ask Deputy White to continue.

Photo of Mary WhiteMary White (Carlow-Kilkenny, Green Party)
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We need to acknowledge the report's findings of "systemic weaknesses in governance, management and communications" within the system in the Midland Regional Hospital.

Many Deputies have quoted Europa Donna Ireland, some with a negative aspect. I want to concentrate on the positive. It has claimed rightly that a priority is to consolidate the eight designated centres of excellence in assessing the logistical arrangements for multidisciplinary teams and other staff, of which good communications must be a part, filtering down through the system. Clear communications and clarity of responsibility is essential.

Another recommendation of that report is worth noting, namely, the establishment of a national IT system capable of analysing and auditing the clinical activity and related administration and management across the eight specialist centres to assure best practice, which would be an essential feature of the early warning systems to minimise the risk of errors. I heartily endorse this recommendation.

There is a good Latin saying, carpe diem — seize the day. Let us seize this day. Progress has been made. Professor Keane has commenced his work well. Centralised centres for diagnosis are the way forward and the national cancer control programme will mean centralised, focused diagnostic centres with treatment counselling and therapies available at the nearest possible location to the patient.

To end on an optimistic note — we must be optimistic if we are to achieve change — there is goodwill. The staff of the HSE, of whom I know many, are good-spirited, hard-working and courageous. Let us not destroy that goodwill by casting sweeping aspersions on the entire system. There must be increased transparency in communication between the various strands of cancer care and administration — we all know this. Let the lessons be learned. The litmus test is that the women who have contacted me since this sorry episode tell me they believe wholeheartedly in the cancer control programme. What they do not believe in, however, are the gaps, omissions and failures. These must be eradicated to ensure women's confidence in the service at an intensely vulnerable time of their lives.

1:00 pm

Photo of Michael McGrathMichael McGrath (Cork South Central, Fianna Fail)
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I welcome the opportunity to speak on this important issue. The problems which arose in the delivery of breast cancer services at the Midland Regional Hospital in Portlaoise are proof, if we needed it, that our approach to cancer care must change, and quickly. Having read the reports, the essential message is that we cannot achieve anywhere near the highest standards in breast cancer care if we spread resources across a multiplicity of hospitals throughout the country. The same holds true for all other forms of cancer.

The three reports that have been published make the case in a compelling manner for the full implementation of the national cancer control programme. The clinical standards at Portlaoise, which resulted in a higher than normal delayed diagnosis of breast cancer, are unacceptable. I extend my best wishes to the nine women directly affected.

If we are to be honest, this situation may be replicated in other non-centre of excellence hospitals delivering cancer services throughout the country. For this reason, I strongly support the implementation of the national cancer control programme and the transfer of all major cancer treatment to eight designated centres of excellence which provide treatment for all forms of cancer involving diagnostic, surgical, medical and radiation oncology services.

In Professor Tom Keane, the interim director of the national cancer control programme, we have a leading expert in his field and an Irishman who has excelled in the provision of cancer care services in British Columbia. He is ably qualified and well positioned to deliver the programme we seek.

The eight centres of excellence will gain public support. Patients are voting with their feet and are voluntarily going to the eight centres. If it comes down to a choice between attending a hospital which is convenient but where clinical standards are not in keeping with best practice or attending a hospital which is inconvenient but where the best patient outcome is assured, people will travel to the centre of excellence for the highest standard of cancer care. The expert group chaired by Professor Niall O'Higgins recommended a minimum throughput of 150 new cases per year in order to maintain the highest standards of breast cancer care. Are we to shred that report for the sake of political expediency? If we ignore the evidence which is so clear, we will put patients' lives at risk and sow the seeds of further problems and give rise to further examples of what happened at Portlaoise. Areas with centres of excellence must have a minimum population of 500,000 to have the required volumes to maintain the highest standards. There is intense competition for top clinical professionals across the globe. We must focus our resources on these centres. Systemic therapy services, including oncology and chemotherapy, will continue to be delivered locally. That point appears to have been lost. People believe they will receive no cancer services in their local hospital. This is simply not true.

The HSE cannot be beyond criticism. The systemic weaknesses of governance, management and communication referred to in the Fitzgerald report are very serious and must be addressed immediately by the HSE which must move to a new level of performance. The clinical issues will be dealt with by the cancer programme and the introduction of the centres of excellence, but the management issues must be dealt with by the HSE. This is an organisation with a budget of €15 billion this year and we must have confidence that it is in a position to deliver the quality of health service we deserve.

Politicians on all sides of the House have a role to play in restoring confidence in cancer care. Nothing will be served by seeking a head on a plate. We should not play politics with this most important issue. Politicians in all parties must state clearly their full support for the implementation of the national cancer control programme. This support must be unequivocal. As the Minister indicated, there is no point in looking back. This is about the future and putting a proper system and service in place.

Photo of Charlie O'ConnorCharlie O'Connor (Dublin South West, Fianna Fail)
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I welcome the opportunity to make a very brief contribution to what I consider to be a most important debate. Other colleagues have made their points and colleagues opposite are entitled to make their political points. I have no real difficulty with that but we should all try to support the Minister in so far as we can. I do so strongly. This is about human suffering and the need to change the system. The Minister has shown a desire and commitment to do precisely this.

When I was a very small child in the inner city, one of the first things I learned about was cancer because it affected my family deeply. I often wondered over those 50 odd years why more progress had not been made in cancer treatment and services. I have no problem with the concept of centres of excellence and will not be parochial in terms of my constituency in this debate except to say the Minister is aware that there is a strong case to be made in respect of cancer care services at Tallaght Hospital. This debate will continue.

I am serious about this issue and support what the Minister is trying to achieve. Tallaght is the third largest population centre in the country. The hospital in Tallaght which is ten years old this year treated 1,500 new cancers in 2006. There is no question but that as someone who lives in the community, I am entitled to make the case on behalf of people listening to this debate who wonder what is the situation.

The work of the Oireachtas Joint Committee on Health and Children has been particularly important in this regard. All of its members, sometimes in a non-political way, have contributed to the debate under the competent chairmanship of Deputy Moloney. We should continue to do so, as it is where the real work can be done. Here in the Dáil Chamber Members make their points but the real work can be done at committee level. I hope this issue stays on the agenda after today.

Photo of Dan NevilleDan Neville (Limerick West, Fine Gael)
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I wish to share time with Deputies Shatter and Perry.

Photo of Seán ArdaghSeán Ardagh (Dublin South Central, Fianna Fail)
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Is that agreed? Agreed.

Photo of Dan NevilleDan Neville (Limerick West, Fine Gael)
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I welcome the opportunity to contribute to this debate. Mr. Fitzgerald found that there was a fundamental weakness in management and governance of the process from the outset. What concerns me is that people are now beginning to feel a lack of confidence in the Health Service Executive. This has been developing for some time in the Houses of the Oireachtas, mainly due to a lack of communication. It was also evident with the Minister at a previous meeting of the Oireachtas Joint Committee on Health and Children. She stated: "Regarding Dr. Naughton's letter to the then Minister, Deputy Martin, when Deputy Reilly asked me about it, I asked the Department to carry out an investigation and it was unable to find any letter sent by Dr. Naughton to my predecessor." A note was then passed to the Minister who informed us: "I have just received a note from Ann Doherty who says she did receive a letter as part of her inquiry." If there is no communication between the Minister——

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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I will clarify. She received that letter last December, not——

Photo of Seán ArdaghSeán Ardagh (Dublin South Central, Fianna Fail)
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I will allow the Minister to clarify.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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There is still no record.

Photo of Dan NevilleDan Neville (Limerick West, Fine Gael)
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I am talking about what took place at the Oireachtas committee meeting last week. There was a similar situation during the previous meeting on cancer services. There is concern at the lack of accountability to Members of the Oireachtas in regard to the delivery of health services, let alone cancer services. It now appears that not even you are informed. I asked a simple question locally——

Photo of Seán ArdaghSeán Ardagh (Dublin South Central, Fianna Fail)
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Deputy Neville should speak through the Chair. I wish to avoid dialogue between the Deputy and the Minister.

Photo of Dan NevilleDan Neville (Limerick West, Fine Gael)
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I am sorry. I asked a simple question two weeks ago of the parliamentary affairs division about the dialysis unit in Limerick city but it has not come back to me. I asked Professor Drumm about the matter last week and he said he would write to me but he did not do so. The whole communications system is breaking down and there is misrepresentation.

Last October I inquired whether funds for mental health services had been diverted to other service areas and, if so, what measures would be taken to protect them. I received a reply in which I was informed that €51 million had been allocated in 2006 and 2007 for the development of mental health services in line with A Vision for Change. I took it that €51 million was spent in those two years but the Irish Mental Health Coalition found out through a freedom of information request in January that 57% of the developments funded in 2006 had been put in place at an annual cost of €17 million out of the figure of €25 million and that 40% or €10 million of the funding provided in 2007 had been made available. It was stated: "The balance of the funding from 2006 and 2007 was time delayed to address core deficiencies in existing mental health services thus ensuring that the HSE meets its obligations to deliver services within the vote." I was not informed of this when I asked a straight question about the diversion of funds through the Health Service Executive. The assistant national director wrote to me but did not inform me that that had happened. This detail only came to light through a freedom of information request.

The Minister is responsible for the expenditure of €15 billion of taxpayer's money. There must be accountability at all levels for its expenditure. The Minister must hold the Health Service Executive accountable for what has happened and account to the Houses of the Oireachtas. Failure to do so amounts to a failure of accountability, which is inherent in our system. The Minister must re-examine the relationship between the Health Service Executive and public representatives, the Health Service Executive and the Minister and the Minister and the Houses of the Oireachtas.

Photo of Alan ShatterAlan Shatter (Dublin South, Fine Gael)
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The reports which have been published are a damning indictment, not just of the HSE, on which the Minister wishes us to focus, but also of the Minister's incumbency in the Department of Health and Children. What we have is a damning indictment of 11 years of Fianna Fáil-Progressive Democrats government and a total incapacity on the part of a succession of Ministers for Health and Children to deliver the health service to which we are entitled and, in particular, the national cancer strategy.

We should not lose sight of the reality that the national cancer strategy was published in November 1996. Over a period of 11 years successive Fianna Fáil-Progressive Democrats Governments, Fianna Fáil Ministers for Health and Children and now a Progressive Democrats Minister for Health and Children have failed abysmally to implement the strategy. The problems at Portlaoise would not have occurred had it been properly implemented. In 2001 the Department of Health and Children issued a letter of determination to the Midland Health Board which provided an allocation for the development of a specialist breast unit in Portlaoise. Throughout 2000 to 2005 the regional director for cancer services advised the then Midland Health Board that the ideal situation would be to centralise cancer services in one unit to avoid fragmentation. The O'Doherty report records that acute hospital services in the HSE midland area were described to her review group as a single hospital on three sites. The O'Doherty report expressly states that this was at variance with the national cancer strategy. In 2007 what happened in the former Midland Health Board area, as still in place under the flag of the HSE, was at variance with what was recommended in the national cancer strategy 11 years earlier. The review group confirmed the inappropriateness of this in that it led to problems in recruitment and fragmentation of services. The Minister has described the difficulty of recruiting clinicians for the Midland Regional Hospital at Portlaoise. The difficulty derived from the reality that the Government abysmally failed to implement the national cancer strategy published by then Minister for Health, Deputy Noonan, in the coalition Government that was in place in 1996.

Photo of John MoloneyJohn Moloney (Laois-Offaly, Fianna Fail)
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Exactly.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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Deputy Shatter's colleagues took us to court.

Photo of Alan ShatterAlan Shatter (Dublin South, Fine Gael)
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This Minister is politically responsible for that. We have heard much about the difficulties of governance regarding the HSE. The O'Doherty report refers to systemic problems of governance, management and communication. Those systemic problems are not confined to the HSE. Systemic problems of governance, communication, administration and management apply specifically to the Department of Health and Children. A lack of accountability and a failure to accept responsibility for the running of that Department attaches to the Minister. The O'Doherty report is interesting in this context. The focus of the media and this House has been on the HSE and its well-known inadequacies. However, this report highlights the Department's inadequacies. We were told it came as a surprise to the Minister to discover on 22 November 2007 that a review of ultrasound was taking place. If that was a surprise it confirms that her Department is seriously dysfunctional and that she is not in charge of her Department and does not know what is going on within it. The O'Doherty report confirms that it was communicated to her Department on 30 August that an ultrasound review was taking place and that on a subsequent occasion, I think on 6 November, her Department was so told.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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Deputy Shatter is being very selective. Mr. John Fitzgerald said 21 November.

Photo of Alan ShatterAlan Shatter (Dublin South, Fine Gael)
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On 21 November her Department was so told. So on three occasions before 22 November the Minister and her Department were advised of what was happening with ultrasound.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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Deputy Shatter is misrepresenting the facts.

Photo of Alan ShatterAlan Shatter (Dublin South, Fine Gael)
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She did not know about it and did nothing about it. Her Department was so dysfunctional that it came as a surprise to her that an ultrasound review was announced in the hospital review that took place before the health committee.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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Deputy Shatter is misrepresenting Mr. Fitzgerald's remarks.

Photo of Alan ShatterAlan Shatter (Dublin South, Fine Gael)
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The Minister is not in control of her Department and there should be an inquiry into how her Department dealt with these issues. I stand by the Constitution, which provides for ministerial responsibility and accountability, which this Minister consistently seeks to avoid for the appalling state of our health service.

Photo of Mary HarneyMary Harney (Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
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Does Deputy Shatter support the plan now?

Photo of John PerryJohn Perry (Sligo-North Leitrim, Fine Gael)
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Following on from the Portlaoise reports we have the Minister and the HSE using the Portlaoise events to push their propaganda that the answer is the eight-centre model of cancer care. The Portlaoise reports do nothing to further the argument for the proposed model. If the science behind Professor Niall O'Higgins's report was rigorously applied, there would be just one breast cancer facility in Dublin. Let us end the farce that the proposed eight-centre model is the only valid model for cancer care in our country.

Last November, the Royal College of Physicians of Ireland expressed concern that it is not intended to have any comprehensive cancer service north of a line from Galway to Dublin. The proposed removal of cancer care services from the midlands and Border counties runs totally counter to all the Government's talk of seeing the region as having an important cross-Border dimension. Speaking at the all-island economy conference in Dublin last week, the Minister for Foreign Affairs said mainstreaming North-South co-operation is a central part of Government policy. I again call on the Minister to explore the provision of cancer care services from Sligo General Hospital to patients from County Fermanagh. This is very important and the Minister said she would return to me on it. Will she tell this House the up-to-date position on the joint North-South feasibility study on the potential for future co-operation in health care?

Last week I received a copy of the results of a cancer care survey carried out by senior medical staff at Sligo General Hospital. This paper is available within the HSE. It clearly demonstrates that the outcomes for Sligo patients are identical or superior to those achieved in the United States. This is real, scientific evidence that Sligo General Hospital is already a centre of excellence. Again I challenge the Minister to respond clearly to this paper. The decision to close cancer care at Sligo General Hospital is political, not based exclusively on science. The decision ignores the cancer care needs of the population north of the line from Galway to Dublin. This is not acceptable. This is the most critical constituency issue in the last few decades. The voters of Sligo-Leitrim will not forget if it happens. I am totally dismayed by the Minister of State at the Department of Health and Children, Deputy Devins. I will not let the voters forget it either. North of a line from Galway to Dublin there is no service while there are four centres in Dublin. If the Minister is talking about eight centres of excellence why is there not a regional spread with one of the centres covering the border and midlands region? It is essential.

Photo of Seán FlemingSeán Fleming (Laois-Offaly, Fianna Fail)
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I wish to share time with Deputy Chris Andrews. I came here to talk on the health debate. Listening to the pure, naked politics, I have not heard a health debate in the last few minutes. It was about votes and holding political threats over people.

Photo of John PerryJohn Perry (Sligo-North Leitrim, Fine Gael)
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Deputy Fleming should come to Sligo.

Photo of Seán FlemingSeán Fleming (Laois-Offaly, Fianna Fail)
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I would like to move on to the topic in question. We are here because of the difficulties that arose in the Midland Regional Hospital in Portlaoise and the delayed diagnosis for nine patients. We should never lose sight of the fact that every debate on the health services is about patients, not politicians. The delayed diagnosis has caused serious health problems for those involved and the Oireachtas should do everything in its power to ensure those people and their families are personally supported in every way possible, both medically and emotionally.

We must put our hands up. This is no different from what happened with Dr. Michael Neary in Our Lady of Lourdes Hospital, Drogheda. These people were appallingly treated by the health services of this country. We can blame the Government, the former health boards, the HSE or whoever, but ultimate political responsibility stops here with the Minister for Health and Children, Deputy Harney and I admire her. I have heard and seen her on television in recent days accepting political responsibility for the health services. People ask where the buck stops and she firmly says, and has said in recent times, the buck stops on her desk. That is as it should be and we see it here today. At no stage does she try to shirk her responsibilities. If there is a request from the patients or families I hope she would meet them and if anything can be done regarding compensation, I hope that will be done for the victims concerned. The health service's duty of care was breached and the people suffered ill health effects as a result.

When it is all over and we have our different reports we can go through the different aspects of them at length, but reports count for nothing if we do not learn the lessons. We are learning the lessons and the Minister and the HSE are learning the lessons. That is the most important matter. We had a brief resumé of how this came about. Former Minister for Health, Deputy Noonan, published a national cancer strategy in 1996. That proposed a specialist cancer centre in the midland region. The then Midland Health Board sought approval from the Department of Health to appoint three additional consultants for that centre. Those posts were never filled. It was held up on Comhairle na nOspidéal and different situations like that. In hindsight we all know the reform of the health delivery service in Ireland was long overdue. I support one unified structure for the whole country. People in Sligo and Portlaoise are entitled to the same treatment as the people in Dublin. I do not want to be pigeonholed in a unit in the midlands nor do I want others to be pigeonholed in a unit in the west of Ireland when there is Rolls Royce treatment available in Dublin. I support one structure for this. Some Deputies talked about going back to the old system in some form, but that is mischievous and is not good for the delivery of health services. There are 4.5 million people here and one health service can give us a unified structure.

We have a new national cancer control programme under Professor Tom Keane. We have eight specialist centres and I do not want to hear the term "centre of excellence". That implies that if people are not at a centre of excellence, they get a bad service in their hospital. I do not know where these phrases come from. They are specialist centres for cancer care and are not the only centres of excellence. Every hospital should be excellent in the work it does.

There has been a fundamental change. The move away from the national cancer strategy announced in 1996 means that the 12 regional centres have now been reduced to eight. Places like the midlands will not have a centre, but the people of the midlands will be better served under the new arrangements. If we have to travel to Dublin we will do so. The issue is not the convenience of visitors, but the delivery of the best care for the patient who needs treatment.

Many people played politics with Portlaoise over the years. I will be generous and say that most people acted in good faith. They might have been misguided, but I hope they were not malicious in what they were doing. People are playing politics with health in this House today. I thought that by taking the politics away from the health boards and establishing the HSE, we would take the party-political bickering out of the system, but we seem to be getting that in the House today. That is a retrograde step. We should talk about health.

I have listened to Professor Brendan Drumm at the Committee of Public Accounts on several occasions and I have the height of regard for him. The man has immense knowledge and ability. It is a mammoth task to manage 120,000 people. Nobody will ever get it 100% right, but he has the authority. However, the Minister, the Department of Health and Children and the Secretary General are possibly one step removed from the delivery of services, as Professor Drumm is the Accounting Officer. It would be better if the Accounting Officer was directly in the Department reporting to the Minister, rather than reporting to a board which in turn reports to her Department. That puts an extra layer on things and diminishes the level of good communication. We have seen on occasion that there has not been good communication from the HSE, but that body must then communicate to the Department officials, who in turn report to the Minister. I feel sorry for her sometimes because she does not have all the information in front of her when most of the documentation lies with the HSE. We need to streamline communication from the chief executive of the HSE directly to the Minister, as she is politically accountable. She is happy and courageous enough to be accountable and she is to be supported in that.

The main job of this House is to recognise the mistakes made, look after the patients as best we can, learn the lessons and move on to the new cancer control programme under Professor Keane. Through Professor Drumm and the Minister, we should try to deliver the best health service possible from now on.

Photo of Chris AndrewsChris Andrews (Dublin South East, Fianna Fail)
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I thank Deputy Fleming for allowing me to share time. The implementation of the cancer control strategy is the major priority for this Government, as it is for every member of Fianna Fáil. The overriding objective of the strategy is to deliver high quality, fully integrated, multi-disciplinary cancer care at a national level. Cancer patients deserve nothing less.

Like every other Member of this House, I have had experience of the health services. Most of my experience has been good and I speak highly of the people working on the front line with whom we come into contact. There is no sense that people in the Government are somehow detached from the reality of the health service. People are well aware of the difficulties facing the Minister and the management of the HSE. Professor Drumm is extremely capable and is the right man for the job. Anytime he has come before committees of this House, he has acquitted himself exceptionally well. He has certainly shown that he has a very comprehensive knowledge of his brief.

The reorganisation of cancer services is at the heart of the strategy and it is imperative that the decisions of the HSE on the designated cancer centres are implemented without delay. However, when I hear people like Deputy Perry and go back to my own constituency, I am aware that it is so political. Some Deputies are just looking towards the next election and that is not the way forward. If we are serious in bringing about change, we must bite the bullet sometimes. Deputy Perry's actions would show that we are not willing to do anything and that we want to put our short-term political interests first. We must have a perspective on this.

The implementation of the managed cancer control networks will necessitate a tapering of the additional capacity at the cancer centres. That will be in tandem with the sequential withdrawal of services from other locations. One of the most significant strategic issues facing cancer services is the variation in survival rates in Ireland. We have relatively poor cancer survival rates for many common cancers when compared with other European countries. This can be attributed in part to the fragmentation of cancer surgery services whereby too many hospitals and consultants are involved in the provision of treatment for cancer services. The national cancer control strategy provides a clear framework through which this can be addressed and which will lead to improvements in survival.

This is all about getting the right care for the right person in the right place at the right time. I recently had a knee operation at the sports clinic in Santry. The consultant that operated is experienced. He sees that type of case regularly every week and that has to be the way we deal with our cancer.

Photo of Olwyn EnrightOlwyn Enright (Laois-Offaly, Fine Gael)
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They only do one of those per week in the midlands.

Photo of Chris AndrewsChris Andrews (Dublin South East, Fianna Fail)
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The Deputy does not even know what kind of operation I underwent.

Photo of Olwyn EnrightOlwyn Enright (Laois-Offaly, Fine Gael)
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The Deputy said it was on his knee.

Photo of Chris AndrewsChris Andrews (Dublin South East, Fianna Fail)
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What kind of operation was it?

Photo of Olwyn EnrightOlwyn Enright (Laois-Offaly, Fine Gael)
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A knee operation.

Photo of Chris AndrewsChris Andrews (Dublin South East, Fianna Fail)
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There are many kinds of knee operations. That was a glib comment.

Photo of Olwyn EnrightOlwyn Enright (Laois-Offaly, Fine Gael)
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It was an orthopaedic operation.

Photo of Chris AndrewsChris Andrews (Dublin South East, Fianna Fail)
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The Deputy does not know what she is talking about. What kind of operation did I undergo? The Deputy is not qualified to talk about medical expertise.

Photo of Olwyn EnrightOlwyn Enright (Laois-Offaly, Fine Gael)
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There is one hip or knee operation carried out per week there.

Photo of Seán ArdaghSeán Ardagh (Dublin South Central, Fianna Fail)
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Please stick to priority items.

Photo of Chris AndrewsChris Andrews (Dublin South East, Fianna Fail)
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Patients enjoy a 20% improvement in survival if they are treated in specialist centres. The consultants must have a throughput and an expertise in those particular operations.

St. Luke's Hospital is in Rathgar and a decision has been made to transfer services to St. James's Hospital. I support that decision because it will be good for cancer control. We must make those decisions and I support the transfer of services, although I do not support the decision to close the hospital down, as it offers an opportunity for a community health care facility.

Photo of John PerryJohn Perry (Sligo-North Leitrim, Fine Gael)
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I see the Deputy is getting local and political as well.

Photo of Chris AndrewsChris Andrews (Dublin South East, Fianna Fail)
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I support the transfer of services. I could go along with the rest of the sheep.

Photo of John PerryJohn Perry (Sligo-North Leitrim, Fine Gael)
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If the Deputy was in Sligo he would be very political as well.

Deputies:

This is out of order. I call on Deputy Andrews to move the adjournment of the debate.

Debate adjourned.

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