Martin Mansergh (Fianna Fail)

I welcome the Minister of State and I welcome the debate. Most of us have had relatives, friends or people who worked closely with us who had cancer and, in many cases, died of it. This area deserves a very high priority because in many cases life can be prolonged considerably with appropriate early treatment but there is a need for appropriate care in terminal cases. In that regard, someone I knew very well was looked after in the last period of his life in the Milford Hospice in Limerick. I was full of admiration for the care that was provided there.

If there is any area where there is no justification whatsoever for a two-tier system, it is cancer. Public patients have the same right to urgent fast-track treatment as private patients and there should be no distinction. If there is a distinction, that should be got rid of as fast as possible. There has to be a certain proportion of cases where time is of the essence. If somebody has to wait three months, he or she may die. If the patient is seen very quickly, something may be done for him or her. There are a couple of issues in the Minister of State's speech that are worth highlighting. One of them deals with prevention and a good deal is being done on that front. One area that impinges on my role as a finance spokesman is the taxation of cigarettes.

A very good job has been done over the past 25 years in gradually eliminating tobacco advertising and promotion. I regard the first legislation on that by the late Charles Haughey, when he was Minister for Health, as one of his finest achievements. As we know from all over the world, there are enormous vested interests that combat that type of legislation. Indeed they combatted the much more recent initiative, namely, banning smoking in public places. We have made a great deal of progress on that front. Indeed Ireland is one of the leading countries in that area.

These days the problem with taxation is that most people have sufficient disposable income. If they want to smoke they will, regardless of taxes. Unfortunately, that includes young people, especially young women among whom the incidence of smoking is now higher than among young men. The deterrent effect of increased taxation is a fairly blunt instrument. The inflationary effects of an increase in tobacco taxes can add one or two decimal points onto inflation, which can be worrying for the Minister for Finance, but it can easily be counteracted by lowering indirect taxes in some other area. People would not quarrel with that, but one must be politically realistic. The older generation in particular will hold it against the Government if it raises taxes on the pint or on the packet of cigarettes. There is no doubt that smoking contributes to cancer. However, on the promotion front in the past, as regards tax measures and banning smoking from public places, the Government has done a great deal and is to be congratulated.

The other controversial aspect is the whole question of centralisation of treatment facilities. This, perhaps, falls into two parts. There is radiation therapy, which I shall deal with first, and then there is the more general issue. There was a good deal of agitation in the south east because it was originally intended that Waterford would not be included as a centre for radiation oncology. As the road between Waterford and Dublin is still pretty bad, one is talking about journeys of three to four hours to the capital, perhaps on a weekly basis, and that was not at all acceptable to people in the south-east region. When people are not well they do not want to travel long journeys. In so far as radio-oncology is concerned, it is not primarily a centre for excellence issue, but rather economics and the cost of running the facility. In any event, I am glad that the Waterford situation seems to have been largely sorted.

I have some sympathy with public representatives in this House who come from the north west and Donegal because I do not believe that region is quite as well provided for. Belfast City Hospital is mentioned in the Minister of State's speech. However, if one lives in west Donegal that is probably at least a three hour journey. In terms of regional equity serious consideration should be given to having a centre in Sligo, Letterkenny or Derry. I have no problem about Belfast City Hospital being outside the jurisdiction, it is the distance I have reservations about.

This question cuts across all of medicine, not just cancer. There is tremendous pressure from the medical profession and experts to centralise all sophisticated and expensive facilities in a few hospitals. In some cases this may be justified on objective medical grounds, but sometimes while the motivation may be put forward on such grounds, much of the reasoning is based on economic considerations and maximising throughput. Some medical treatments are very complicated while others are much simpler and more routine. The Government needs to look somewhat more sceptically at some of the arguments made — I am not just referring to cancer services — which are all in the direction of the arguments made about the Hanly report. People want medical facilities in large population centres and do not want to have to travel for hours just to use a facility for 24 hours because it suits them to be in one place rather than in two. I do not believe the Government is sufficiently sceptical about aspects of self-interest that feature in the medical profession in this regard. There is reference in the Minister of State's speech about small numbers of cancer centres, and then managed networks in other hospitals. It is important, given the prevalence of cancer, that general hospitals around the country remain involved in its treatment. Apart from anything else, few people can regularly visit relatives and friends, unless it is a spouse or a child, 50 to 60 miles away whereas they can if people are only five to ten miles away.

Humanity and compassion matter as well as getting the best treatment. Many considerations are at play in this area and the Government must take account of that.