Tim O'Malley (Limerick East, Progressive Democrats)
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I am pleased to have the opportunity to describe the substantial developments that have taken place in recent years in all aspects of cancer policy and, in particular, to outline for the House the main elements of the new national strategy for cancer control 2006, which the Tánaiste launched on 12 June last. Cancer is a major challenge to our health services. It is a major cause of morbidity in Ireland, with 20,000 people diagnosed each year. Effectively, tackling the problem of cancer means providing specialist services of a consistently high quality with sufficient capacity as well as appropriate support services for patients, their carers and their families.

Improving cancer care is a major priority of this Government. We have invested over €900 million in the development of cancer services since 1997. We have appointed over 100 additional consultants specialising in cancer. About 34,000 more people were treated for cancer in public hospitals in 2004 compared with 1998. That is a very significant increase of nearly 60%. The key goal of the 1996 national cancer strategy, which was to achieve a 15% decrease in mortality from cancer in the under 65 year age group in the ten-year period from 1994, was achieved in 2001, three years ahead of target.

Despite continuing improvement in mortality rates, the burden of cancer continues to rise mainly as a result of our growing and ageing population. The number of patients with cancer to be treated in 2020 is expected to be nearly 29,000, almost double the number in 2000, which stood at approximately 14,000 patients. A further significant issue is the variation in survival rates within Ireland and our relatively poorer cancer survival rates for many common cancers when compared with other European countries. In part, this is a result of our fragmented cancer services.

The central message of the new national strategy for cancer control is that the reorganisation of cancer care delivery is essential. There is clear evidence that people who have surgical treatment for many common cancers in centres with higher throughput experience better quality of care and better survival rates. The Tánaiste is especially concerned that many hospitals currently performing small volumes of cancer surgery do not meet international best practice. To ensure that patients receive the highest possible quality of care, we must develop a small number of cancer centres, which can pool together knowledge, expertise, experience, skills and the latest technology.

The development of managed networks around these cancer centres will allow for cancer care to be delivered in other hospitals within the network, with diagnosis and treatment planning directed and managed by multidisciplinary teams based at the centre. In such circumstances it is possible for much of the treatment to be delivered in local hospitals. It will be necessary to ensure that all cancer care is quality assured by the relevant cancer centre. This is the model which is operating successfully in paediatric oncology. Every child in Ireland who develops cancer has his or her diagnosis established and treatment planned at Our Lady's Hospital for Sick Children in Crumlin. For many children, significant components of their treatment are delivered in one of the networked hospitals under the supervision of and in accordance with the protocols of Crumlin.

As many as one third of cancers could be prevented by public policy initiatives and the promotion of healthy lifestyles. Cutting down on tobacco consumption and improving diet could help to save many lives. The adverse impact of tobacco consumption on human health is well documented. Over 7,000 deaths in Ireland each year are attributable to tobacco-related illness. Tobacco is a significant burden on individuals, family and society through death, illness and medical costs. Even a modest reduction in the huge burden of disease caused by tobacco consumption will result in significant health gains.

There have already been a number of positive steps to reduce the consumption of tobacco such as Ireland being smoke-free at work since 29 March 2004 and the availability of nicotine replacement therapy to medical card holders. The Tánaiste will explore with the Minister for Finance the scope for further fiscal measures to reduce the consumption of tobacco.

The Tánaiste is especially concerned that children are using sunbeds. This is a totally unacceptable practice which greatly increases the risk of melanoma cancer later in life. The Government has approved the Tanaiste's proposal to regulate the use of sunbeds, including prohibiting their use by those under 16 years and the placing of warning notices in sunbed salons and other places where sunbeds are available for use by the public.

Screening for certain types of cancer plays a crucial role in early detection, saving lives and reducing morbidity. BreastCheck, the national breast screening programme, is available to approximately 160,000 women in the 50 to 64 year age group in the former eastern, north-eastern, south-eastern and midland health board areas. Since the commencement of the programme in 2000, approximately 245,000 screening visits have taken place which is a massive endorsement of the programme by the women invited to attend.

The Tánaiste is most anxious that BreastCheck be rolled out to the remaining regions as quickly as possible. Revenue funding of €2.3 million has been made available to BreastCheck to meet the additional costs involved and an additional 69 posts have also been approved for this purpose. BreastCheck has selected two clinical directors to lead the roll-out and they are currently undergoing additional training for their new roles. BreastCheck will shortly begin recruiting consultant radiologists, consultant surgeons and consultant histopathologists.

An additional €21 million capital funding has been made available to BreastCheck for the construction of two new clinical units and the provision of five additional mobile units and state-of-the-art digital equipment. BreastCheck is confident that the target date of next year for the commencement of roll-out to the rest of the country will be achieved. A pilot cervical screening programme commenced in the mid-west region in 2000. Screening is offered free of charge to approximately 74,000 women in counties Limerick, Clare and north Tipperary.

The Tánaiste wishes to see cervical screening rolled out nationally by 2008. Up to 200 lives a year could be saved by such a programme in Ireland. To progress this initiative, the Tánaiste has announced her intention to establish a national cancer screening board to manage both the BreastCheck and the cervical screening programmes. This will maximise the expertise in both programmes, ensure improved efficiency and develop a single governance model for cancer screening.

The new board will also advise on the implementation of a national colorectal cancer screening programme, specifically on the population to be screened, at what intervals screening should take place, the type of test required and the requirements for a quality assured, well organised and cost-effective symptomatic service.

The Department of Health and Children is working closely with the HSE and the National Development Finance Agency in implementing the national plan for radiation oncology. The plan consists of four large radiation oncology centres in Dublin, Cork and Galway, and two integrated satellite radiation oncology units in Limerick Regional Hospital and Waterford Regional Hospital. In addition arrangements for access for patients in Donegal to radiotherapy services at Belfast City Hospital are being progressed as part of North-South co-operation in the health sector. These developments will result in a significant increase in the numbers of patients receiving radiation oncology treatment throughout the country over the coming years.

I have already outlined the substantial investment that has taken place in cancer services since the publication of the first national cancer strategy, as well as the additional appointments and increased cancer services activity. We will continue to invest significant additional resources in cancer control. The Tánaiste asked the HSE to prepare a robust needs assessment for cancer control for the next five years that reflects the projected increase in cancer cases.

We need to make our health care system more accountable, more focused on outcome and more committed to quality care. Many of the services available for patients with cancer in this country are on a par with, if not better than, services in many other countries, but we need to tackle the problems identified by the National Cancer Forum in fragmentation of services and the variations in outcome experienced by those who use them.

We will address this by developing a framework for quality in cancer control. Through this framework we will be able to ensure that services perform to the highest standards in all parts of the country and that the interests of patients are protected. It will help to show where this is room for improvement so that we can ensure that people with cancer get a consistently high quality of service irrespective of where they are treated.

The work of the quality assurance group on symptomatic breast cancer services under the expert chairmanship of Professor Niall O'Higgins will point the way forward for quality assurance. This group is currently at an advanced stage of developing guidelines for the interdisciplinary management of breast cancer. On completion, the Tánaiste will ask the HSE to apply these guidelines in hospitals it funds and to monitor adherence to the guidelines as part of its performance management system.

An information model and infrastructure to address the information needs of patients, professionals, managers and policy makers is also essential. One of the functions of the Health Information and Quality Authority will be to evaluate and provide advice on the clinical effectiveness of health technologies, including drugs. The Tánaiste will be asking HIQA to establish a cancer health technology assessment process to facilitate speedy introduction of proven health technologies in the field of cancer.

Cancer research stands on the threshold of unprecedented opportunity. Recent developments in science and research hold out the potential for more effective, safer targeted treatments tailored to the specific characteristics of each individual patient's cancer. The Tánaiste considers that it is timely to ensure that cancer control research is better planned and integrated to ensure that Ireland can develop as a centre of excellence. Significant opportunities exist in cancer research given the commitment and investment of the Department, the HSE, the Health Research Board, Science Foundation Ireland and the Irish Cancer Society.

The Tánaiste is convinced that there is a need for a more identifiable national focus on research to harness the disparate financial and intellectual capital and thereby achieve a better return nationally. The aim is to ensure that current and future resources are invested to support an overarching national cancer control research plan. The Tánaiste will arrange for this to be scoped in consultation with the various stakeholders. We will seek to ensure that priority areas in cancer research are identified, that current gaps in cancer research are effectively addressed and that duplication of effort is reduced.

The developments which I outlined here today in cancer services are a clear indication of the considerable progress that has been made in addressing the burden of cancer in Ireland. I ask the House to commend the Government on its positive and demonstrable commitment to cancer services.

Fergal Browne (Fine Gael)
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I welcome the Minister of State to the House. His speech was good but it reminded me of someone about to paint a room, it filled a lot of cracks.

The opening paragraph of the report states that 20,000 Irish people develop cancer every year and 7,500 die from the disease. One in four people will die from cancer and 60% of cancer patients die within five years of diagnosis. Cancer incidence appears to be falling but because we are aging and living longer, the chances of developing the disease are expected to increase. The number of new cases by 2020 will have increased by almost 107% of the number dealt with in 2007. There are now 120,000 cancer survivors. Such figures are startling and give an outline of the work ahead for any future Government in the area.

Much work is being done. Fine Gael welcomes the report and acknowledges the huge amount of work put into it by those involved. We are concerned, however, that a person's address can have a major impact on his or her treatment and survival rate. That should not be the case for a small country. We are told every day that we are one of the richest countries in the world but this stark fact confronts us.

We welcome the national cancer strategy but are disappointed that the Tánaiste did not publish an implementation plan outlining where cancer services will be located, the funding that will be given to the strategy and the timeframe for implementation, although the HSE is due to announce such a plan in seven weeks. We admire the research and work the National Cancer Forum put into the strategy and we hope its work is not let down by the Government, which has not yet published its policy.

The Government's record is worrying. In 2001, the national health strategy promised a revised implementation plan for the 1996 national cancer strategy by the end of 2002. Here we are four years later and the Government is late publishing the strategy, never mind implementing it. The HSE will be obviously responsible for implementing the strategy and will devise an action plan within the next few weeks. It will decide which hospitals retain services and will appoint a national director to oversee implementation of the plan. Cancer care will be delivered at eight centres across the State, in four regional networks each serving a population of approximately 1 million. The Government has launched the strategy, yet has not told us where these cancer centres will be based or what areas will be covered by the four networks. If the Minister had done so, perhaps the strategy would have had more credence.

The Minister of State in his speech spoke about key areas, which to my mind are the easy topics. Immediate action was taken on sun beds, for example. While the Minister of State also mentioned tobacco control, as far as I recall in the two most recent budgets the Government did not increase VAT or excise duty on tobacco, which seems to send out the wrong signal. While the Minister of State stated in his speech that the Tánaiste would consult with the Minister for Finance on this issue in the run-up to the next budget which indicates there will be an increase in tax, we must do everything in our power to deter people from smoking. Certainly, it is quite worrying to see young women smoking now. Whereas it does not seem to be as big a problem among young men, for some reason young women seem to think it is fashionable and "cool" to smoke when the opposite is the case.

As I stated earlier, there is a significant variation in the level of service meted out around the country. For example, Professor Paul Redmond, who is chairman of the National Cancer Forum, told us that there are major variations in treatment of cancer between the regions; there is inconsistency in treatment of cancers at the same stage; there are major variations in survival rates between the regions in Ireland; and our pattern of care and survival are generally poorer than those of the other EU countries.

Prostate cancer is the most common cancer, after skin cancer, among men in the Republic yet there is no mention of a national screening programme for prostate cancer in this strategy. I accept that the best international medical advice is that there should not be one, although I am totally baffled by it. In every debate on health, Senators, in particular Senator Glynn, correctly point out that we should be doing everything in our power to encourage citizens, in particular men, to get regular health screenings. I cannot understand why one cannot get one's blood tested for PSA. I availed of such a test myself recently in the Houses under a health screening programme. My father had prostate cancer and my uncle died from it. Lately, the former Taoiseach, Charles J. Haughey, died from prostate cancer and the cancer was much publicised as a result. I do not understand why we cannot put in place a scheme that would raise awareness of prostate cancer or even an advertising campaign to encourage men to go to their doctor to be tested. I am totally baffled by this. I accept that the Department is being told it is not best international practice, but Ireland could take a lead on this. If the Department does not implement a strategy on it, perhaps they should at least undertake an aggressive advertising campaign or take some initiative on the issue.

Despite nine years of reports and promises, a nationwide free cervical screening programme has not yet been rolled out. Only 30% to 40% of the population is being screened opportunistically and only 9% of the population is covered by the pilot national cervical screening programme, whereas a screening programme would cover between 80% and 90% of the population. Approximately 150,000 smear tests are being done each year and this number could double under a screening programme. It is worth noting that such a programme would only cost an additional €10 million, which is a drop in the ocean. A while ago when the PPARS system failure came to light the Minister for Communications, Marine and Natural Resources described €150 million as a small amount of money. It is a pity that for want of such a small amount of money the Department cannot implement a full national screening programme for cervical cancer. The Minister of State, Deputy Tim O'Malley, in his speech accepted that there are considerable economic and social implications for the family of a person dying from cancer.

The number of women diagnosed with breast cancer has increased by 25% since 1994 and a comprehensive national screening programme is still not available to facilitate prevention and early detection. Next year Fianna Fáil and the Progressive Democrats will have been in power for almost ten years but there is still no nationwide breast cancer screening programme. It is six years since phase 1 of the service commenced in the eastern region and five years since publication of the national health strategy, which promised that breast and cervical cancer screening would be extended nationwide. In the intervening period there has been a litany of announcements that have come to nothing and women must wait until 2007 or 2008, according to the latest announcement. It is particularly upsetting for people in the south and west who were led to believe in 2003 that a service would be rolled out nationally in 2005.

I was shocked to learn lately that in 2008, women in Northern Ireland will be celebrating 15 years of breast cancer screening and a reduction of one fifth in deaths from the disease. By that time in the Republic of Ireland hundreds of women will have lost their battle with breast cancer and hundreds more will have endured devastating radical surgery. I accept that much good work has been done but, on behalf of the Opposition and of many people in Ireland, I must express frustration that the national screening programmes have not been rolled out as promised and ask why this is so.

The Minister of State spoke about the radiation unit for Waterford Regional Hospital and I hope that will be announced in six or seven weeks time. It is vital that the south east would have a centre in which people could receive radiation therapy as part of their cancer treatment. On the last occasion the Minister of State was in the Seanad, he raised the issue of people in Donegal receiving radiotherapy services in Belfast. I was not familiar with the case and thought that was quite good news until I checked it out. What appears to be happening is far different from the picture he painted on that occasion. I noted he referred to it in his speech again today. Although I am open to correction, the service is only available to people in Donegal if there are treatment spaces available which is not as satisfactory as we would wish. Senator McHugh spoke on the matter on the day in question. The Minister of State, in his concluding comments, might outline exactly what is the position on the treatment of people in Donegal through the services in Belfast.

While I have no difficulty with the report, it is a question of implementation and setting deadlines. I hope that the Tánaiste and Minister for Health and Children, in conjunction with the HSE when it announces the next phase of centres in eight weeks time, will clearly indicate achievable targets. It should not be the case in 2006 that where one lives could have a major impact on one's survival rate and treatment rate.

Camillus Glynn (Fianna Fail)
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I welcome the Minister of State, Deputy Tim O'Malley, to the House. I compliment him and the Tánaiste and Minister for Health and Children, Deputy Harney, on the strides that have been made in the area of cancer control. Certainly, I am not for one moment saying that we are enjoying a utopia but many significant steps forward have been taken in addressing this serious matter.

I thank Deputy Tim O'Malley, in his capacity as Minister of State with special responsibility for the psychiatric services, for his hospitable and proactive response to me and a number of organisations which sought his assistance recently.

Turning to A Strategy for Cancer Control in Ireland, cancer is the one word in the English language that strikes so much fear and desperation into the hearts and minds of people that there is a reticence among most people to refer to it as cancer and they refer to it in terms of "the bug", "the boy", "the lad" or whatever. They have this innate fear of saying the word "cancer". No doubt the incidence of cancer has been noted as having increased over the past number of years but there has been a decrease in the recent past which must be recognised and appreciated.

At the outset, it is important to remember that everybody has a responsibility for his or her own health. In terms of what we are doing to control cancer, we must remember that in the main we are providing reactive services rather than proactive services and this debate is so important because it addresses control and diagnosis.

The proposal to limit the number of centres might strike a note of disharmony in the minds of those who have such a facility close to them but it has been proven that the more procedures carried out at a centre, the more efficient is the service. If fewer procedures are carried out at a centre, the results are not what we would wish.

A number of positive steps have been taken on cancer control. I have been a member of the Oireachtas Joint Committee on Health and Children since 1997 and when representatives of tobacco companies appeared at committee hearings, they denied all the way to hell and back that tobacco was injurious to a person's health. However, the world and his wife knew it was and even if the reality jumped up and bit them on the nose, they would still make the same claim.

The onus is on everybody, but especially men, to be responsible for their own health. Women are more inclined to have themselves checked out. When we buy a car, we make sure it is serviced regularly but men are not as inclined as women to consult their general practitioner or consultant. In many cases, when men seek a medical opinion, it is at the prompting of a female.

I worked in psychiatric services and many psychiatric patients smoked. I often walked through the door on to a long-stay ward to be met by a fog of smoke but that has diminished in recent years, which is welcome. Environmental tobacco smoke is a carcinogen. I commend the initiative of the Government and the former Minister for Health and Children, Deputy Martin, who led the way in banning smoking in the workplace. Senator Browne correctly referred to the number of young women who smoke and the general consensus is they smoke to control their weight. However, they could adopt healthier options.

The issues of cervical cancer and BreastCheck are frequently raised and the target date for the complete roll-out of BreastCheck is 2007 but more must be done. The HSE and the Government must be proactive rather than reactive. Reference was made to the PSA test but it is only an indicator of prostate cancer and does not provide a conclusive result. According to medical opinion, a prostate cancer screening programme would not be useful but that is difficult to understand.

We are what we eat and we should pursue a healthy lifestyle by avoiding processed and fast food and addressing obesity. For example, a major tumour was removed from the brain of a 15 year old constituent of mine recently. The poor boy is completely inactive, as he does not have the use of his limbs and that is another example of what cancer can do, even to the very young.

We are all responsible for our own health. Most of us have a general practitioner and at least one visit a year for a check up is not out of the question. We service our cars; why do we not service our own bodies to make sure they are healthy and we are doing everything we should?

Cancer is an affliction that impacts on large numbers of people, irrespective of background and status. Naturally it frightens many people. Accordingly, it is essential that the State takes an active part in providing the resources for prevention, diagnosis and treatment. As the strategy highlights, much progress has been made in cancer treatment in recent years and there is much cause for optimism that medical advances mean major strides forward in prevention and cure are possible in the coming decades. Such advances will have serious implications for resourcing our health care system but if they have financial implications, so what? What price health? Current services will not meet the substantial demand for treatment, cure and care. Meeting demand will require a significant Government commitment to cancer services in the years ahead. This will also mean decisions being made soon on investment, planning and organisation. The goal must be to deliver a universal, quality-based and timely service in line with the best available internationally.

The strategy recommends a wide-ranging cancer control policy programme. It also places a major emphasis on measurement of need and on addressing inequalities. The strategy also focuses substantially on reform and reorganisation of the way cancer services are delivered to ensure future services are consistent and of a high quality. The strategy notes there is evidence of considerable variation in cancer survival rates between regions and also significant fragmentation of services for cancer patients. The strategy recommends that all cancer care be provided through a national system of four managed cancer control networks. Each network must serve a population of approximately 1 million people providing primary, hospital, palliative, psycho-oncology and supportive care. Patients should be fully integrated between each of these elements within each network. Each network should have a formal structure of clinical leadership. The emphasis of the network should be on integrated connection and partnership rather than on segregation and self-sufficiency, distribution of resources rather than on centralisation and on maximising the benefits for all patients.

The strategy states primary care is fundamental in the co-ordination of the wide variety of services patients may use. It is a key partner in the delivery of effective secondary care services. The strategy calls for cancer centres, each serving a minimum population of 500,000, to be designated by the HSE as soon as possible. Ireland will require about eight such centres. The cancer centres within each network should be looked on as equal partners to ensure adequate case volume and expertise, and a number of centres should provide a higher level of care for those cancers that need larger volumes than would present in a single centre.

The strategy contains a number of key messages. Approximately 60% of cancer patients die from the disease within five years of diagnosis. Although it must be recognised that the incidence is falling, it is important to note that the aging of the population will lead to large increases in the number of people who will develop cancer. There has been a transformation in the range and capacity of cancer services as a result of the 1996 national cancer strategy, as well as the work of the first National Cancer Forum.

This is an important matter because as I stated at the outset, the word strikes fear in people's hearts and minds to such an extent that they are unable to bear mentioning it. Hence, the condition has been bestowed with many nicknames and terms. While this may be self-delusional, it indicates clearly the great fear of cancer and of developing the condition among the public and all Members.

Brendan Ryan (Labour)
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Cuirim fáilte roimh an Aire Stáit. Cé nach raibh mé i láthair, bhíos ag éisteacht leis. Moreover, I have examined his script thoroughly. Senator Glynn's last remarks regarding the extraordinary terror which cancer strikes into most people were spot on. I recall that my own late and much-loved father could never describe it as anything other than "the lad".

Camillus Glynn (Fianna Fail)
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Other terms are "the boy" or "the bug".

Brendan Ryan (Labour)
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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.

Camillus Glynn (Fianna Fail)
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Go on. The Senator should not be so hard on himself.

Brendan Ryan (Labour)
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I had enough fun with Senator Mansergh for one day.

I genuinely believe this raises an issue about how Departments do their business. They are not good at parallel thinking and planning. Will the Minister of State seriously consider this matter?

I am disappointed at how limited our efforts on prevention are. I am not sure what current statistics are on young people smoking. From anecdotally observing the large number of young people at my place of work, I believe the number standing outside the doors smoking is decreasing. Smoking was prohibited in most of the buildings for years and it is absolutely prohibited everywhere now.

However, if one drives through Cork as I often do on a Thursday night at 11 p.m. or midnight, which is the student night out, the number of young women in particular outside student bars in freezing weather during February in clothes more appropriate to the southern Mediterranean than cold Cork——

Geraldine Feeney (Fianna Fail)
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The Senator is not meant to notice that.

Brendan Ryan (Labour)
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I assure the Senator I am young enough and healthy enough to notice all of that, thanks be to God.

Evidence suggests a certain level of smoking still occurs. We must consider everything. The idea that increasing the price of cigarettes too much encourages smuggling is a classic Department of Finance excuse. It is not to do with smuggling, it is to do with declining revenue. It is probable that various Members on the other side of the House will give lectures on the imposition on old people by putting up the price of their 20 cigarettes, one of the few pleasures they have. I could make the speech myself. I still believe an overwhelming case can be made in favour of increasing the price of cigarettes.

Either the Tánaiste or the Minister of State, Deputy Tim O'Malley, proposed selling a minimum quantity of cigarettes. My view is that a minimum quantity should be 40, 20 at the very least. It should be illegal to sell fewer than 40 cigarettes at a time to make it more difficult for people who are young enough to have extremely limited amounts of money to buy them at a cost of €15 or whatever. I am not a prohibitionist as I do not believe prohibition works. However, we should put up every obstacle possible. We should not have any cigarette advertising anywhere in the country, which we have nearly achieved.

We should restrict the number of outlets in which cigarettes are sold. A case can be made for the introduction of regulations to prohibit the sale of cigarettes in third level institutions, such as CIT where I work. I do not know whether shops in hospitals sell cigarettes.

Diarmuid Wilson (Fianna Fail)
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They do.

Brendan Ryan (Labour)
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If they do, it should be prohibited. Places with large numbers of people and public access should not have retail outlets which sell cigarettes. They should not be sold within a 100 yard radius of such places. Putting up every obstacle possible is the most effective action that can be taken.

Regarding diagnosis, I fully accept the need for a limited number of centres of excellence and the overwhelming medical evidence to that effect. The consequence of accepting that is to ensure people geographically remote from those centres can get to them comfortably, easily and without undue financial burden, even if this means using air ambulances. It is no excuse to state it is expensive. If the best way is to have a centre in one city, which involves a 100 or 150 mile round trip for people, we must ensure it is no more difficult for them, apart from the extra bit of time, than for someone living next door to that centre. That is a fundamental element of a proper treatment scheme.

If we are to optimise results through the development of centres of excellences, we must ensure the experience of patients is not related to whether they are geographically near to or far from those centres. An ambulance which does a "Wanderly Wagon" trip and takes five hours to complete a 60 mile journey is not a solution, nor is a minibus. People must be provided with an efficient and comfortable means of travelling.

Without being pessimistic, part of a cancer strategy is to ensure the availability of both hospital and home-based palliative care of a high standard throughout the country. Will the Minister of State ensure that happens? According to the lobby groups on behalf of hospices that is not available as services are provided unevenly and in patches. It should not be the case that the quality of palliative care one receives depends on where one lives.

Geraldine Feeney (Fianna Fail)
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I welcome the Minister of State, Deputy Tim O'Malley, to the Chamber. I also welcome A Strategy for Cancer Control in Ireland. It makes extremely interesting reading.

This is not the first time I have spoken in the Chamber on the issue of cancer, and at the outset of each occasion I spoke about what an emotive issue it is. Everyone knows someone within his or her immediate family, a relation or close friend who has been affected by the terrible scourge we know as cancer. I am delighted with the report. Once and for all someone took the bull by the horns and set out a blueprint to tackle all types of cancer. In early June when she launched the report, the Tánaiste stated 35 hospitals administer and treat all types of cancer. In her own words, she felt this was excessive.

Two weeks ago, I attended a UN convention on HIV-AIDS in New York as a member of the Oireachtas Joint Committee on Health and Children. We took the opportunity to visit Sloan-Kettering, the largest cancer hospital in the world. Until then, I questioned whether it was excessive to have 35 hospitals delivering cancer care. Having visited Sloan-Kettering I can state it is. I will discuss Sloan-Kettering later. The strategy points out that we have eight centres in four regions each serving a population of 1 million. We do not know whether the 35 units will be involved. However, many of them would link into one of those eight units and that is welcome.

The cost has yet to be worked out. I remember thinking at the time it was a knee-jerk political reaction by the main Opposition parties when they had a go at the HSE, the Department and the Tánaiste for not costing it. The best expertise came together to set it out and the group was chaired by Professor Paul Redmond. The biggest and best of those delivering cancer services sat on the forum. Professor Drumm raised the issue of resistance and he could have screamed about it because there is resistance every time we discuss centre of excellenced. I see Deputy Connolly smiling at me from the Gallery and he is part of that resistance. I know I should not mention anyone by name.

Rory Kiely (Fianna Fail)
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No, the Senator should not.

Geraldine Feeney (Fianna Fail)
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I will not.

We must move away from the days of having or wanting a centre of excellence in every town, village or county. We must not continue to espouse this policy. Professor Drumm talked about clinicians having to accept that they must operate evidence-based systems focused totally on quality outcomes for patients. This, in addition to quality assurance, is what it is all about.

Some 60% of breast cancer cases are treated by doctors who treat fewer than ten cases per year and this cannot be allowed to continue. I say this on foot of having spoken to the clinicians, surgeons and oncologists in the Memorial Sloan-Kettering Cancer Centre. They believe it is not right and that our continuing to operate in such a vacuum will result in an increased number of deaths. We will not have good outcomes if we continue as we are doing.

I was interested to read that Professor Paul Redmond has asked for strong political, medical and executive leadership in addition to significant investment. The Government is committed in this regard and will make the necessary funds available. However, Members on all sides should show political leadership and move forward as required. There is an onus on all parties to ensure we provide what is best for people suffering from cancer.

Of course there will be uncertainty regarding the capacity of smaller hospitals to adapt and implement further changes in the delivery of cancer care, especially where complex cancers are concerned. The smaller hospitals do not have the expertise to deal with complex cancers and one cannot compare a surgeon, male or female, who deals with ten cases per year with one who deals with 30 or 40 cases per month. There is clear evidence that those who receive surgical treatment for many common cancers in centres with a high throughput experience better outcomes and have a greater chance of surviving their cancer.

Last week or the week before, I read that 70% of surgical interventions from prostate cancer may be unnecessary. It is in this regard that a centre of excellence would come into its own. It would show us what kinds of treatment and care are best in respect of individual cancers.

The strategy is all about patients, patient care and patients winning and the implementation of its proposals cannot be achieved outside a centre of excellence. It was stated that 20,000 people develop cancer in Ireland each year and that 7,500 die of it each year. If we had better cancer care, this number would decrease.

As I stated, I had an opportunity to visit the Memorial Sloan-Kettering Cancer Centre when I was in New York. Even its presentation pack was impressive. Five of us visited the hospital and my four colleagues were just as impressed as I was. We were met by clinicians who were the most experienced in their field. The centre's presentation pack is entitled A History of Commitment and it certainly portrays commitment. The clinicians are extremely committed to their particular areas of interest. The centre trains many young Irish trainee doctors and we would have its expertise if we were to adopt its approach.

We visited a pediatric unit and a general adult unit in the centre and also looked at its scanning equipment. The paediatric unit was by far the saddest unit. It was so sad to see such young children, from neonates to young teenagers, in need of treatment. Everybody seemed happy and I did not see any sad faces. If there were sad faces, they were those of the Irish visitors who were so taken by what they were seeing and being told. The paediatric unit in particular interested me because we had been told its method of treating of paediatric cancers was the blueprint and way to go. We have some of the best outcomes in the treatment of paediatric cancers in the whole of Europe.

I support the current campaign for a radiotherapy unit for the north west, to be based in Sligo. The Tánaiste and Minister for Health and Children, Deputy Harney, told us when we met her that one linear accelerator unit would not suffice for Sligo and that two would be required. There is a school of thought in Sligo that suggests one is sufficient but when I was in the Memorial Sloan-Kettering Cancer Centre, I took the opportunity to ask the experts and discovered that the Minister was correct. They confirmed her advice that two linear accelerator units would be required in a radiotherapy unit based anywhere outside a main centre of excellence.

It is important that there be centres of excellence with expertise. Practitioners with expertise will have time to keep an eye on the radical developments in cancer treatment and research.

Sheila Terry (Fine Gael)
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I welcome the Minister of State and many of the aspects of A Strategy for Cancer Control in Ireland. One hopes the proposals will be implemented as soon as possible and one could ask why we have been waiting so long for them to be implemented.

The Minister of State and everybody else will know very well that it is far cheaper to prevent cancer than to treat it, irrespective of the fact that prevention would save many lives. Over the years, we have missed the opportunity to save lives and, because of our inaction, we have put many people through a lot of pain. Had their cancers been diagnosed earlier, their treatment would have been far less aggressive.

While I welcome the strategy, I must state the circumstances that now obtain are a disgrace. We all know early detection is the secret to preventing the spread of cancer and saving lives. As my colleague Senator Browne stated, early detection and the kind of treatment one receives depend on where one lives. BreastCheck is one of the best services I have ever availed of and I highly commend the efficiency of the people involved. It amazes me because we are not used to that kind of service. I had an appointment recently for around 4 p.m. and expected to have to wait in a queue but I was the only person there. I was in and out in ten minutes. BreastCheck is a free public service. Women are invited to come in to have their breasts checked. I missed my appointment on one occasion but BreastCheck wrote to me telling me that I had missed it and offering me another appointment. It is an excellent service and the people involved are fantastic.

After the examination they write to the person to inform her, thankfully in my case, that everything is fine. When cancer is detected, women are given the opportunity to get treatment at an early stage and therefore have a much better chance of survival. Unfortunately, women in other areas of the country currently are not entitled to that service. While I welcome the fact that BreastCheck will be rolled out in the coming years, it must be done as quickly as possible. It should be in place already, as I said earlier. I will not bore the Minister of State by repeating it; he accepts that the service should be in place already. Similarly, cervical cancer screening should be in place. We should have a national screening service because as the Minister of State said in his contribution, there are approximately 200 deaths every year as a result of cervical cancer. Most of those deaths would have been avoided had they been detected at an earlier stage.

The cost of attending for a cervical test currently prevents many people from doing so. Another aspect that concerns me is the delay in getting the results of a test. If the results of the test do not come back for some months in the case of somebody found to have cancer cells, that delay can be extremely serious. We must have a national screening service for cervical cancer and ensure that the results come back speedily. The same applies to prostate cancer, which is very treatable if found at an early stage, and colorectal cancer. We have much catching up to do in that regard and I am not surprised that we fall way behind other countries in terms of detection and successful treatment.

We must focus on cases where there is a family history of cancer because we know that specific genes in families cause cancer. Family members should be tested regularly and followed up, regardless of whether it results in a death. If there is a history of breast cancer, colon cancer or other types of cancer in families, those family members should be screened on a regular basis. There is no reason that is not being done but I understand that is the case.

We must plan ahead. We look forward to the further report the Minister will publish in the coming weeks outlining the location of the centres. We must plan and ensure that the expertise and the trained staff are in place. That will take some time but we must plan now because we are playing catch-up in that regard.

Another issue I want to raise is palliative care for persons dying of cancer. I understand it can three to six weeks to get hospice home care. The hospice service is wonderful but I am sure the people involved are stretched in terms of resources. I was told by a public health nurse last night that it can take from three to six weeks to arrange to have a patient visited on a daily basis. We must not leave the provision of that service to charities. We must put a system in place to allow families care for their sick and dying loved ones. A package of community care must be put in place. We all know someone, whether a family member or a friend, who has died at home. Where possible, families want to have their loved ones at home with them but a great deal of support is needed both for the family and the patient, which is not available. I have seen that at close hand and am aware of the difficulty in getting such help.

The hospice home care team does wonderful work and the Irish Cancer Society also provides an excellent service to families. I would like to recognise its work but I want the Minister of State to focus on providing that type of care, which is part of the overall package. If someone is not responding to treatment and is dying, we must ensure we can support that patient and his or her family in the best way we can, namely, by providing all the necessary services. Services that are available in other countries are much better than those we provide here.

I agree with the provision of centres of excellence. The best treatment can be given in centres where all the necessary expertise is provided. I realise that causes difficulties for many families who must travel, particularly those who require radium treatment on a daily basis, but if people have a life-threatening illness they will go where they know they will get the best service. Ensuring we put all the systems in place to support them is essential. It would help if accommodation can be provided nearby to support families who have a loved one in hospital.

The key aspect is early detection and early treatment. It is all very well if one can attend the Blackrock Clinic or the Mater Private Hospital as a private patient where, if cancer cells are found, one can get treatment within a few days but that is not the position for public patients. That inequality should not exist.

Martin Mansergh (Fianna Fail)
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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.

Maurice Cummins (Fine Gael)
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I wish to share my time with Senator John Paul Phelan.

I welcome the Minister of State, Deputy Seán Power, to the House.

I listened with interest to the Minister of State's speech. Whitfield private hospital will open in Waterford later this year. The company involved, UPMC Cancer Centres from Pittsburgh, is anxious that all patients who require treatments such as radiotherapy will have access to this facility, irrespective of whether they are public or private patients. This health care organisation is investing in Waterford and the south-east region, yet it seems to be coming up against a brick wall in dealing with the HSE and the Department as it tries to plan its services.

If public patients are to be treated, UPMC needs to know now so that it can put a second linear accelerator in place when the facility opens later this year. The appalling prospect currently looms of private patients going to the top of the queue for treatment at Whitfield, while public patients continue to join the bus and ambulance queues for the horrendous journeys to Dublin and Cork. This reduces their quality of life and impacts on their chances of responding well to treatment. A voluntary organisation has spent thousands of euro to provide people with proper transport to Dublin. The country is awash with money and it is a shame to see those poor people having to travel to Dublin for this therapy.

There is talk about developing another hospital under a public private partnership on the grounds of Waterford Regional Hospital that would also provide radiotherapy services. The Government seems to be in favour of such facilities one minute yet reviews the situation the next minute. All patients in the south east must have proper access to radiotherapy as a matter of urgency.

The Minister of State mentioned that BreastCheck has been rolled out everywhere, including the south east. It has certainly not been rolled out in Waterford, which is a cause of great concern to the women of Waterford and its hinterland. I am disappointed that the long-awaited cancer strategy does not have a comprehensive implementation plan with costings, a detailed breakdown of funding and an indication of the location of the new cancer networks and cancer care centres.

There is no doubt that the National Cancer Forum put much work into this strategy, for which it must be complimented. Given the serious concerns recently expressed about breast and cervical screening, why was the Tánaiste not in a position to deliver a detailed and comprehensive cancer care plan for the launch of the national cancer strategy?

It is imperative that we act on this plan. We believe that centres of excellence are necessary, as are satellite centres. Difficulties encountered by the Department and the HSE must be overcome in the interests of patients, be they privately insured or holders of medical cards.

John Paul Phelan (Fine Gael)
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I welcome the Minister of State, Deputy Seán Power, and I welcome the speech by the Minister of State, Deputy Tim O'Malley. I agree with much of his speech, but I would like to make a couple of points.

Senator Cummins spoke about Waterford Regional Hospital and radiotherapy facilities in the south east. The Minister of State also referred to this in his remarks, but even after those comments and the report of the national strategy for cancer control, the policy for the provision of radiotherapy treatment facilities in the south east is still very unclear. People suffering from cancer are obviously very ill, but to compound their difficulties, trauma and illness, they must travel to Dublin to receive treatment. It is completely inappropriate that they be subjected to this extra trauma at such a distressing time in their lives. It should not be happening at a time when we seem to have the requisite amount of funding to solve this situation. I urge the Department of Health and Children to do everything possible to ensure full radiotherapy facilities for the south-east region. Everyone in this House has had a family member or friend affected at some stage. The treatment facilities in large parts of the country are still substandard and that is not acceptable. Under this national cancer control strategy, I hope we can work towards a situation where people all over the country can expect a minimum standard of service.

In his opening remarks, the Minister of State referred to the fact that the poor cancer survival rates in this country may be due in part to our fragmented cancer services. That is an understatement. We need to do our utmost to improve those services. Senator Cummins spoke about the BreastCheck programme, which has been rolled out in parts of the country. It is stated that it has been rolled out in the south-east region, but there are areas in the region that are not covered, such as Waterford and south Kilkenny. There are also problems with screening for other types of cancer, including types of cancer common to men. The Government has not yet embarked on a programme of rolling out a screening scheme across the country for those cancers. We should be aiming at that for the future.

The Minister of State, Deputy Tim O'Malley, spoke about the Tánaiste's efforts to control the use of sunbeds. I commend her for trying to curtail their use by children. I was in a house in my own area recently and was shocked to find a child under the age of 16 on a sunbed. There is a direct link between some forms of skin cancer and the over-use of sunbeds, especially by children under 16.

If we are serious about implementing the strategy and decreasing the number of those who suffer from cancer, we need to ensure that we have a proper screening programme and that facilities for treatment are available as uniformly as possible. We cannot provide radiotherapy services at every crossroads, but they should be available in major regional centres. As the regional hospital in the south-east region, I am making the case for Waterford Regional Hospital. People in my area who are affected by cancer should be able to get the treatment in the region, rather than facing a six-hour round trip to and from Dublin.

Eamon Scanlon (Fianna Fail)
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I welcome the Minister of State, Deputy Seán Power, to the House. This debate touches everybody. When I was 17 years old and the eldest of six children, my mother was diagnosed with cancer. I remember the trauma in our house at that time. I am delighted to say she is alive and well in 2006. It certainly brought it home to me and I have never forgotten the effect the longest day I have ever lived had on our lives at the time.

It is good that we are having the debate during which many issues have been raised, including that of BreastCheck. That service is not yet available in the north west. I served on the North-Western Health Board for many years and I know the difficulty in trying to get fully trained staff to carry out the work particularly in a specialised area such as BreastCheck. I welcome that the programme will be extended by the end of this year or early in 2007. It is not a question of money, but of getting trained and qualified staff to carry out the work, which takes time.

I recognise the work done by the hospice movement. The North-West Hospice in Sligo is supported by thousands of people. Approximately €700,000 is raised each year through voluntary effort. I am glad the North-West Hospice is back in operation again. It had difficulties with an oncologist and it had no cover. It took 12 months to get an oncologist to work in the service in the north west. There are issues with getting properly trained and qualified people to do such work.

The Sligo Inner Relief Road opened last year. The mayor of Sligo, Councillor Rosaleen O'Grady, had the brainwave of holding a charity walk on the new road, which is approximately 5 km in length, on the evening before the road was opened to raise funds to provide a mammography machine for Sligo General Hospital. Some 5,000 people came out that evening. What had started as a small idea mushroomed into a massive explosion of voluntary effort. Some €80,000 was handed over to Sligo General Hospital to fund the machine, which shows the extent of the public support. Cancer affects everybody in the country and we should ensure we do everything we can.

I recently attended a public meeting in Sligo organised by people who had suffered from cancer and their family members in an attempt to provide radiotherapy in the north west and in particular in Sligo General Hospital. It was heartrending listening to the patients and their relatives outline the hardship they suffer in travelling long journeys for radiotherapy. Senator Mansergh mentioned the radiotherapy satellite that centres exist. We should provide more satellite centres to alleviate the hardship experienced by these people who need to leave their homes and families at a very vulnerable time. I know a patient from Sligo who must stay in Dublin even though the treatment only takes ten minutes.

While some people travel every day the majority do not have the strength to travel those distances every day. This treatment comes at the worst possible time in their lives and those of their families. It would be better for those people to be treated closer to their homes. I know it is not possible to provide such a service in every hospital. However, given the location of Sligo, it should be considered. I ask the Minister of State to consider providing the equipment in Sligo to prevent patients from travelling those distances at a very difficult time in their lives.

Peter Callanan (Fianna Fail)
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I welcome the Minister of State, Deputy Seán Power, to the House. Earlier the Minister of State, Deputy Tim O'Malley, asked the House to commend the Government for its positive and demonstrable commitment to cancer services and I do so. I spoke here a few years ago on the topic of cancer. Normally I do not go outside my brief of agriculture. However, cancer and I are friends, and have visited each other. I have had three attacks of cancer and because of this experience I take some interest in the matter.

When I spoke four years ago I said I was not interested in excuses. I wanted funding provided for the service. In 1989 I had the experience of radiotherapy unit that broke down and took six months to replace. The people from Cork were bussed to Dublin. It cost more to bus the people from Cork to Dublin than it cost to buy the unit. However, as Senators know, the units are not available off the shelf.

I recognise what has been done since 1996, when the then Minister for Health, Deputy Noonan, recognised the need to do something about cancer. Since then great progress has been made. A Strategy for Cancer Control in Ireland is a fine document, which is beautifully written and reads well. However, did any of those experts who wrote the document ever sit in a queue for radiotherapy? Do they know how it feels to be on a terminally-ill line? By and large the answer is "No". If they need such treatment they have much more ready access to it than the ordinary people like us.

I have reason to congratulate the Government and support its efforts. I welcome the extension of radiotherapy treatment to Waterford and Limerick, which regions had previously been overlooked. Senator Scanlon spoke about the north west. The people of the north west deserve a service and are just as entitled to it as the people in any other region. Making arrangements with Belfast for those in the north west is fine. However, it comes back to how it feels for the person in the queue for cancer treatment. It is a lonely place and they need the support of their families and friends. They should not be isolated. From a psychological point of view, it is easily understood why I say that we should give to the north west that to which it is entitled.

Regarding BreastCheck for women between the ages of 50 and 64, a body of opinion believes that screening service should take place before 50 and after 64.

Mary White (Fianna Fail)
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Hear, hear.

Peter Callanan (Fianna Fail)
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I do not understand why specialists recommend confining the treatment to that age band. While it is somewhat late, I welcome the pilot cervical cancer screening programme. However, there appears to be no mention of male-specific cancer. For example, what is being done to address prostate cancer and testicular cancer? Cures are readily available and can be successfully administered for such cancers if addressed in time. A previous speaker pointed out that men take their cars, tractors and machinery for servicing but are slow to do the same for their health. We are shy to discuss these matters. I regularly listen to discussions by female Senators of cancers affecting women. Similar discussions should be held by men. I commend the Government on its efforts in this respect but it has more to do.

Mary Henry (Independent)
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I welcome the participation by the Minister of State in this debate on the national strategy for cancer control. Figures for the National Treatment Purchase Fund were released the other day, which revealed that the top ten procedures were those involving cataracts, procedure scopes, tonsillectomies, varicose veins, joint replacements, cardiac surgery, cardiology, skin lesions, hernias, grommets and cholecystectomies and gall bladders. However, the two procedures which might involve cancer, procedure scopes and skin lesions, involve considerable delays before treatment, with potential effects for patients. We should be careful to ensure that any patient suspected of having cancer is referred much earlier than is the case at present. Delays arise, for example, in referrals for appointments with specialists, diagnostic procedures, operations and chemotherapy. All these delays increase the chance of a poor outcome.

Everyone was incensed about the report from Europe which indicated that we are 25th out of 26 countries on an index of consumer satisfaction with health services. Senator Quinn said on yesterday's Order of Business that we should try to learn from this report rather than pretend it is of no significance. I am concerned about the report's findings that our neonatal figures are not as good as countries with which they should be comparable and that we have poorer medical outcomes in many areas.

The appointment of additional consultants is to be welcomed because there had been a shortage of oncologists and specialists in cancer surgery. However, we should realise that teams must be appointed. The team approach to cancer treatment is now considered extremely important because, while a surgeon with great expertise in colorectal surgery may be appointed, if he or she is not complemented by a chemotherapeutic expert, patients' chances of survival may not be increased as much as expected. The appointment of such experts will be of great help to a service which has already made great strides over the past ten years.

The Tánaiste is right to point out how good it is that, since 1996, mortality from cancer has decreased by 15% in the under 65 age group but she is also correct that more work is needed. As a result of our fragmented cancer services, the survival rate in Ireland in respect of many common cancers is significantly different from other European countries. The comments of some Senators about having cancer services in every corner of the country made me somewhat anxious. It is not possible to provide that level of service nor will we achieve the best results through such a policy.

The Sloan-Kettering centre in New York is not one of the major cancer treatment centres in the world because it treats 50 cases of this or that but because it treats thousands of cases and has developed an expertise which gets the best results. We will have to do the same. I sympathise with Senator Callanan's remarks about people who suffer from a lack emotional support because they are far from their relatives. However, I would prefer to spend the money to move the relatives to be with the patients at centres which can provide the best treatment. Too many centres treat 50 cases a year when they need to treat 500 if they are to develop any sort of expertise. I appeal to Members on all sides of the House to remember that we are trying to deal with survival rates rather than parochial interests.

The state of radiotherapy services is disappointing. The Hollywood report is now four years old, yet we have not yet decided where to locate radiotherapy centres. While I have little expertise in radiotherapy, others with even less expertise have called for linear reactors in various parts of this country, which will not allow us to ensure the best treatment for patients. We have to listen to the advice of the people with the most expertise.

The Minister of State's proposal with regard to a cancer care network is welcome. Chemotherapy could be easily carried out in regional hospitals, thereby avoiding a great deal of travel. Such a network should be developed as speedily as possible.

With regard to cancer prevention, while genetic factors are relevant, such as the incidence of breast or colorectal cancers in families, there is strong evidence that environmental factors are important to the development of cancer. Clearly, the population of this country will experience an increased incidence of cancer because we are all living longer and our control over cellular development and degeneration apparently decreases as we get older. That is why some of our cells turn haywire and produce cancer cells. However, we can do something about environmental factors.

The smoking ban was extremely effective and only 25% of the population now smokes. That must be one of the best rates in Europe. Not having smoked since I was 11, I can feel particularly smug about this issue. Evidence on passive smoking increasingly supports the decision by the then Minister for Health and Children, Deputy Martin, to introduce a ban under health and safety legislation. The Tánaiste announced that she would take a fiscal approach to this issue. It would be helpful if tobacco was taken out of the consumer price index. Can we take this step on our own or must we find agreement with the rest of the EU to do so? We might have more sympathy now on the matter, given that a number of countries have followed our example.

I was astonished at how easily a ban was introduced in Italy, where people appeared to have to give up overnight. Apparently, there was virtually no discussion about the issue in the Italian Parliament and people were told they would not be allowed to smoke by the end of the month. Scotland has also introduced a smoking ban and efforts are currently ongoing in the rest of the United Kingdom in that regard. If tobacco was taken out of the consumer price index, it could then be heavily taxed. Those involved in trying to limit the consumption of tobacco and alcohol agree that price and availability make a difference. If we could remove tobacco from the consumer price index and increase taxes on it, we would all pay less income tax. It would be better than the current situation, where smokers pay for the rest of us. It would also be good for their health.

I am pleased that legislation on sunbeds was introduced but I wonder why the minimum age is 16. It might be better to have it at 18, the age at which childhood ends. Warnings should be displayed because people do not realise how it affects skin. It makes people look like old saddlebags. The Minister should be applauded for trying to prevent this.

The speed of the implementation of the BreastCheck screening programme is very disappointing. I understand that cost is not the only reason and that we have a shortage of radiographers, histopathologists and specialists to examine X-rays. We have had a considerable amount of time to produce more radiographers. Many of the people involved in BreastCheck had not been working for some years but felt they had a moral duty to return and train for specialist work. We are short of radiographers and rather than take them from other countries we should train them here.

The level of screening for cervical cancer is woeful and it is in this area that the Government is found wanting. It is entirely preventable if cases are detected early. The scheme has been in place in Limerick since 2000. It is known internationally that this screening is quite easy and the pathology of the disease is even easier to carry out than before. A sense of urgency is needed. Some 80 women per year are dying and they would not die if there was screening. The average age of those who die is 56, leaving husbands or partners and young children. This issue is most serious.

Several Senators referred to screening for men. The problem for screening for prostate cancer is that the international jury is still out on its effectiveness. One can have cancer of the prostate without elevated levels of androgen and one can have elevated levels of it without prostate cancer. When one is screening for a condition, it must be common. Cancer of the prostate is a common condition and, perhaps for environmental reasons, it is increasing. The results of screenings are not good enough at present. I am most anxious about men receiving the wrong information and advice, having unnecessary biopsies and being told they are healthy when they may not be.

Screening for colorectal cancer is very successful and only requires a piece of paper. The person can use it for three days running and if blood is present it can be analysed and a scope can be arranged. Haemochromatosis is more common in men and can lead to cancer of the liver. Screening for this and colorectal cancer should be encouraged because accurate results can be obtained. In the case of haemochromotosis a patient can be bled and in the case of colorectal cancer the colon and rectum can be examined. The results are good for those who have early diagnosis.

I am delighted to see that more money is being allocated to cancer research. It is important that all hospitals give patients access to new drugs. I was shocked by what happened in the Mater Hospital some months ago when some women in a trial were denied access to new drugs for the treatment of breast cancer because the sponsor of the trial advised participants to abstain from sex or to use contraception. This denial of access should not happen. However, I am pleased that we do not deny people access to drugs because of price. In England the so-called postcode lottery determines whether one will receive the best new drugs. I commend the Minister of State on the fact that this practice does not happen in Ireland.

I am pleased Senator Scanlon mentioned the hospice movement. It is important that, if treatment has not been successful, the best palliative care is available. A patient recently referred to the Blackrock Hospice, stating that the food is very good. It is wonderful that someone could be savouring food even when undergoing palliative care. I commend the speech of the Minister of State and hope he takes note of what I have said.

Mary White (Fianna Fail)
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The chairperson, Professor H. Paul Redmond, and the second National Cancer Forum, are to be commended for producing this comprehensive, clear, concise document. The onus falls on those in the Oireachtas to ensure the strategy is fully and properly implemented.

Approximately 170 cases of diagnosed cervical cancer and 76 deaths occur each year. We must urgently roll out the national cervical cancer screening programme provided for in the strategy. A nationwide programme for cervical screening was recommended by a Department of Health committee in 1996. Ten years later we are still without a programme. Some 700 women have died unnecessarily from cervical cancer since 1996. Of the eligible female population, very few have had the screening. Women, by their nature, put their children first rather than spend money on cervical cancer screening.

The Minister for Health and Children has stated that a programme will be introduced but as a business person I want to hear a timeframe. While studying child care and ageism my office was full of reports. So many reports are carried out and so few are implemented. I wish to hear a timeframe for the implementation of the national screening programme the Minister has promised.

The new strategy states that it is imperative that BreastCheck is rolled out nationally in line with current plans. It has been subject to unnecessary delay at a terrible cost to women affected by breast cancer. I wish to see a clear plan of action from the Minister and to hear an assurance that BreastCheck will be operational nationwide within the next 18 months. The Minister should drive a clear plan.

The people know there are good intentions but they should receive clear indications of when certain steps will be taken. Breast cancer has overtaken lung and colorectal cancer to become the second most common cancer in Ireland. In Ireland, skin cancer is the main cause of cancer deaths among women. It is an excellent recommendation by the Minister that young people not use sunbeds. In fact, if I were Minister for Health and Children, I would not allow sunbeds to be used at all. I used one about ten years ago and my sister, who is involved in the medical sector, warned me against it saying it is too dangerous. Certain people could be more susceptible to skin cancers and the sunbed could activate it in one person but not another. They are very dangerous.

I also wish to acknowledge the great drive of the former Minister, Deputy Martin, in implementing the smoking ban. I am proud of his achievement. When I see him or hear his name I think of the tremendous vision and drive he had in this regard. I am an ex-smoker. I gave them up 20 years ago but I understand the pleasure of smoking. Deputy Martin had the drive to implement the ban and fair dues to him. That is what politicians should do — when they believe in something and talk about it, they should implement it.

The work of the Irish Cancer Society, chaired by Mr. John McCormack, should also be acknowledged. I spoke at one of the society's public meetings on cancer screening awareness. I am involved with the society and am helping it to try to get a national cervical cancer screening programme implemented. The commitment of the Irish Cancer Society, Mr. John McCormack and his team is to be lauded. He is a zealot about his mission and it would be wrong not to refer to it.

I had the breast cancer check about two months ago and I felt quite guilty as I left. It is not only appalling that women in the rest of Ireland do not have the service but also that women over 64 cannot avail of it. In my document, A New Approach to Ageing and Ageism, recommendation No. 4 is that——

Frank Feighan (Fine Gael)
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It is a very good document.

Mary White (Fianna Fail)
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I thank the Senator. I recommend in the document that the 64 years of age limit on breast cancer screening be abolished. Professor Des O'Neill is one of the senior gerontologists in Ireland and one of the men who inspired me to produce my document. When I started on this mission 18 months ago I knew nothing about ageing, ageism and the health aspects. Professor O'Neill has said that women are at the highest risk of developing cancer between the ages of 55 and 75. This man is an authority on ageing and the body and its propensity for contracting illnesses. How dare anybody introduce an age limit for a service? That is downright ageism. There is no justification for introducing an age limit on any health service in this country.

As a business person, I love to see implementation plans which contain a timeframe. When will the national breast screening programme be available nationwide and when will the cervical cancer screening programme be introduced? I apologise to the gentlemen that I am just speaking on a women's issue. It does not mean I do not have empathy——

Rory Kiely (Fianna Fail)
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Apologies are not necessary.

Mary White (Fianna Fail)
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I am always in trouble so I must be careful. I thank the Minister of State for attending the debate. As the Minister of State with responsibility for the elderly, he should put his foot down and insist there not be an age limit on cancer screening. All the international reports state that 55 to 75 year old women are at greater risk of getting cancer.

Frank Feighan (Fine Gael)
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I wish to share time with Senator McHugh.

Rory Kiely (Fianna Fail)
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That is agreed.

Frank Feighan (Fine Gael)
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A woman called to my constituency office about five weeks ago. She was disturbed and agitated that there did not appear to be a co-ordinated effort with regard to cervical cancer. Her general practitioner volunteered to carry out a smear test but the general practitioner was not paid for it. She did it from the goodness of her heart. My constituent believed there should be a proper system in place. I agree. There should be a system whereby all women, regardless of age, could be screened.

I welcome the publication of the national cancer strategy. I do not wish to undermine this important strategy but, like Senator White, I believe certain issues must be addressed. There must be a timeframe for the implementation of the strategy. Women from the west, north west and south west have a greater chance of dying from breast cancer because the systems have not been rolled out on time.

The condition of haemochromotosis has become more well known in the last few years. It is not anything to do with the Minister for Health and Children but approximately one fifth of the male population of this country will have haemochromotosis due to the presence of the gene. Many of the insurance companies appear to look on it as a type of Klondike in that they are imposing serious loadings on policies. Perhaps we should examine what the insurers are doing. It is a side issue to the health system but it is time we checked this. I believe they see it as a Klondike for themselves. It is an issue we must address.

Senator White is correct that over 700 women have died because of a lack of urgency about this issue. I hope the strategy will be delivered soon. The former Minister, Deputy Martin, has been complimented for introducing the smoking ban. I believe it is a wonderful ban but Deputy Martin more or less looked away from setting out and implementing a national cancer strategy. He deserves to be rapped across the knuckles for not dealing with that.

The Minister of State, Deputy Seán Power, is very concerned about this situation. I wish him and the Government the best because this is a serious issue that should be above politics. I hope these matters will be dealt with sooner rather than later.

Joe McHugh (Fine Gael)
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I thank Senator Feighan for sharing time with me. This debate is an opportunity for politicians to put forward their views on the cancer strategy and to examine the anomalies within the strategy. We owe it to the electorate, whether we are in the Opposition or in Government, to continue to debate this issue. We have not found solutions although, ultimately, there will never be concrete solutions for some cancer issues.

I wish to highlight two matters to the Minister of State. There is need for centres of excellence. There is a need to pool expertise, skills and knowledge to provide specialised cancer services. That is accepted. People who are undergoing radiotherapy and chemotherapy and who are availing of these services in the centres of excellence will travel to avail of them. That is a fact.

However, there is the issue of peripherality. Senator Scanlon made that point very well when he articulated the point of view of people living on the periphery. There are varying types of cancer and varying degrees of suffering. Some cancer sufferers are not in a position to travel. They feel the journey is sufficiently arduous without having to go through the process of chemotherapy and radiotherapy. That is the challenge for us. On the one hand we must pool resources in centres of excellence but we must also argue for peripherality. There is no stronger voice for this argument than the Donegal Action for Cancer Care group. Nationally it has a high profile and it has been vociferous locally, organising a demonstration of over 15,000 people in Letterkenny to protest the possible downgrading of cancer care services in Letterkenny General Hospital. That is the argument for peripherality. It does not come from scientific research, it comes from the people. The people involved in the Donegal Action for Cancer Care group are cancer sufferers who have been through the mill. They know what they are talking about and they do not want to hear the argument that centres of excellence should be in the east of the country, in Dublin, Galway, Limerick, Waterford and Cork. They will not accept that.

Senator Scanlon mentioned his constituency. Sligo, Leitrim, Donegal, Tyrone, Fermanagh and Derry form a nucleus for a centre of excellence. The people demand it and it is up to us as legislators to follow through.

Seán Power (Kildare South, Fianna Fail)
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I very much welcome the opportunity to contribute to this debate on the national cancer control strategy and wish to acknowledge the significant work of the National Cancer Forum which developed this strategy following a detailed consultation process with stakeholders in cancer, including major voluntary groups such as the Irish Cancer Society, ARC Cancer Support Centre and Reach to Recovery. I thank Members for their contributions.

It is fitting that the House should allocate time to discuss cancer because not only is it a major element in health and social policy but also because it has major implications for so many people. Many contributors today have shared their experiences of the difficulties created by cancer for their families. Cancer has a major impact on society, in economic and health terms and, most important, on those diagnosed with cancer and their immediate family and friends. The statistics are stark: one in four people will die of the disease and 20,000 people annually will suffer from it. The number of cancer cases will double over the next 15 years. There are around 120,000 survivors of cancer, reflecting the improving diagnosis and more successful treatments for cancers generally. Thankfully there will be greater numbers of survivors as survival rates improve for many cancers.

Some of the facts that emerged during the preparation of the strategy are worrying, such as the variation of survival rates and the poor rates of survival for common cancers when compared with other EU countries. This can be attributed to the fragmentation of cancer services where too many hospitals are involved in cancer treatment. That cannot continue if we are to deal with cancer realistically, instead of trying to provide a service in every small area.

The House has already been advised of the substantial increases in investment which have resulted in increased medical, nursing and support staffing. This investment has delivered real improvements in care. An evaluation of the 1996 national cancer strategy, including a broadly-based consultation process, was commissioned by the Department of Health and Children. The key achievement of the 1996 strategy most commonly commented on by those consulted was that it provided a framework for the development and funding of cancer services in Ireland. In fact, the National Cancer Forum has concluded that "there has been a transformation in the range and capacity of cancer services since 1996".

Palliative care is a component of integrated cancer care that is of particular interest to me. Since October 2001, almost €17 million has been invested in palliative care services and funding of €9 million was provided by the Government for specialist palliative care in the budget for 2006. A further €4 million will be allocated in 2007 to develop the service, giving the full year cost of €13 million. The funding provides for the following: 24 extended care beds in Our Lady's Hospice, Harold's Cross; €1.9 million to open six palliative care beds at Blackrock Hospice; ten new palliative care beds in Milford Hospice; a €1 million increase in funding for St. Francis Hospice, Raheny; €2 million for the development of palliative home care and community-based initiatives throughout the country; and the development of palliative care services in the midland, western and south-eastern areas.

Questions have been asked about future investment in cancer control. This Government has invested heavily in cancer services and the House can be assured that we intend to invest substantially in cancer control in the coming years. As a first step, the Tánaiste has asked the Health Service Executive to conduct a needs assessment for cancer services with a particular emphasis on the need for reorganisation and reform; the need to maximise the efficient use of resources; the need for the development of cancer service capacity at national and network levels; and the need for appropriate linkages with the national roll out of BreastCheck, the cervical screening programme and the national plan for radiation oncology services.

The executive has already commenced work on this exercise, which will take several months to complete given the importance and breadth of the work involved. Investment will be made based on demonstrable return on investment, an equitable distribution of resources and priority setting that maximises ambulatory care.

There are major challenges in the way we deliver and organise cancer control. These include the need to expand capacity, the need to ensure equity in access and delivery of care. Outcomes are variable and poor in some cases where efficiency is poor and we have fragmented services. The future investment and delivery of care must build on the positive achievements while at the same time addressing the deficiencies I have outlined. This will require significant leadership at medical, executive and community levels.

Senator Henry spoke about leadership but we are all guilty when it comes to the provision of services of trying to ensure our own area is looked after and that centres are as close as possible to our constituencies. That is simply not possible with cancer services. Expertise is needed and it cannot exist in every county. Politicians on all sides should look beyond the next election when dealing with this and should not give false hope to constituents. All parties have been guilty of doing that.

Joe McHugh (Fine Gael)
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Is that official Government policy for the north west?

Seán Power (Kildare South, Fianna Fail)
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I congratulate Senator Henry for her contribution. This is about poor survival rates in comparison with our European colleagues. If we are to tackle that in a meaningful way, we must be more mature in commenting on the location of such centres.

Joe McHugh (Fine Gael)
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Is that policy for the north west?

Seán Power (Kildare South, Fianna Fail)
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I understand Senator White's desire for a timetable for the roll-out of the strategy. The HSE has announced the establishment of the national cancer control programme to implement this new strategy and the details will be outlined by the executive in the coming weeks. I hope the issues to which Senator White referred will be dealt with.

As a Government, we aim to develop a comprehensive and integrated cancer control programme across the continuum of care involving prevention, screening, diagnosis, treatment, supportive and palliative care and research. Cancer patients should receive multidisciplinary care from cancer specialists in radiology, pathology, surgery, medical and radiation oncology and oncology nursing — all working together as an integrated team. We will organise the delivery of cancer care to ensure that cancer patients will receive quality care regardless of where they live. I thank the Members for their contributions.