Brendan Ryan (Labour)

While he never had cancer and did not die from the condition, it lurked in the background. Much of the fear relates to the time before the development of the palliative care and hospice movements which facilitated the realisation, organisation and delivery of the capacity to provide people with palliative care. Before then, horrendous stories were heard regarding the conditions of people in the later stages of cancer. Mercifully, such cases are relatively rare, if they ever occur, and there is a capacity to provide people with a certain level of palliative care.

Dr. Sheila Cassidy became famous when she was imprisoned and tortured in Chile and now works as a palliative care consultant in south-east England. Anyone who has read some of her more recent writings on the lives of people in the final stages of various forms of cancer will have found them to be eye-opening, scary and extremely reassuring. They are reassuring because of the capacity to deliver a high quality of palliative care, as well as the extraordinary capacity of human beings to deal with life as it is, when obliged to so do.

A close member of my family has been through breast cancer and has survived well. I recall one time when simultaneously, three partners of male Members were being treated for breast cancer. It was a scary encounter with reality for all Members and may have obliged them to think about many matters from a different perspective.

Who could argue with the strategy? All agree it is a good strategy. However, I believe there are fundamental differences in respect of health care delivery between myself and the Minister of State and the Government. I do not agree with the Tánaiste's contention that enough is being spent on the health services. She is factually incorrect to state that Ireland spends as much as Germany or France. My own figures suggest that per capita, Ireland spends 25% less. Given the unique structure of the economy, indicators such as percentages of gross national product and gross domestic product are not great and may be ignored. However, the actual cash value is a good indicator. Senator Browne and I do not completely agree on this point either.

I do not suggest that spending more money is necessarily a remedy. However, one must consider the possibility that although an efficient health service is a necessary condition for a good health service, it is not necessarily — in the manner in which logicians speak of it — a sufficient condition for a good health service. Both are required and there is a question of resources in this regard. In addition to a strategy, I would have wished for an unequivocal commitment to providing the requisite resources to implement everything within the strategy within a realistic timetable.

With regard to timetables, it is difficult for women, particularly in the south and south west, as well as other observers, to countenance the interminable delays in the expansion of BreastCheck. While I hold an unequivocal belief in the public provision of services, there appears to be a public sector timetable regarding the expansion of services which takes the view that implementation should be carried out as quickly as one can, according to the manner in which things are normally done. However, many people would argue that such services should be implemented as urgently as possible, given the scale of the need.

I am also sceptical about pilot programmes for everything, although good planning and structures are necessary. An inability to concentrate on more than one thing at a time is often attributed to men. It may be that too many men are involved in the delivery of health services, because it would be possible to set up a pilot programme, as has been done in respect of cervical screening, while simultaneously beginning to carry out the logistical planning required to extend it nationwide. Such an approach could be taken, instead of the serial thinking which appears to dominate the delivery of health services, whereby one waits until the end of the pilot programme, reviews the outcome and then begins the next phase.

If it is believed that it is correct in principle to deliver a national BreastCheck service, a national cervical cancer screening service, a national prostate cancer screening service or whatever, there is good reason to start with a pilot programme to learn how best to do it. However, that does not necessarily mean that one is obliged to wait until the pilot scheme is complete before beginning to consider repeating the process elsewhere. It is possible to plan and organise matters in parallel. Moreover, it is possible to be well-advanced in respect of other aspects and to have in place funding, a recruitment strategy and a building strategy, as well as having secured planning permission in those cases for which building would be required. Consequently, after the useful lessons from a pilot programme have been learned, one can deliver the next phase.

As for BreastCheck outside the pilot regions, it has emerged that nothing was planned and that it was necessary to carry out every single step of the developments de novo, from scratch, as though nothing had been done previously. Plans could have been made in respect of the location of buildings, organisation of planning permission, ring-fencing of funding and consideration as to whether there were sufficient trained radiologists, radiographers or whatever specialties are required for BreastCheck. All of this could have been done in parallel with the pilot programmes. Increasingly, this issue has become a hobby horse of mine.

This is the purpose of project planning and project management. It pertains to the consideration of one's timescales and of how to ensure that matters fit together in an optimal fashion. This was not done in the case of BreastCheck and I have concerns that the proposed national cervical cancer screening service will suffer a similar fate, that is, serial thinking will be employed in which people will wait for one phase to be completed before beginning to consider the next matter. This is unnecessary. As I stated earlier, it is probably because men perform poorly in this regard that entire structures and technologies of project management and project planning have been developed as a separate skill. Otherwise, we men could not juggle two things simultaneously, in the manner of which women are capable. I do not dispute that.

This constitutes a significant issue. While I believe in pilot programmes, I do not believe that one must wait until such a programme has ended before doing anything about the remainder of the project. Once can identify the critical areas, particularly if one receives continuous feedback from a pilot programme. One could interpret a pilot programme which waits until the end to feed back information as being a deliberate way to avoid spending money. If I was in a more political mood this afternoon, I would say "would interpret". I am not in the humour to say that this evening.