Mary Harney (Dublin Mid West, Progressive Democrats)
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I reiterate the apology I made in the other House to the women in Portlaoise who have been caused needless anxiety by a necessary review of their mammograms. Most of all, I apologise to those women who have been badly let down by a false negative initial reading of their mammograms. We owe it to them to do all in our power to ensure it never happens again. At least these women are now to get the expert care they should have received from the start.

I welcome the opportunity of this debate to reiterate our plans to deliver the best possible cancer care and control. There is only one over-riding motivation in this. It is not about money, hospitals, institutions, winners or losers, consultants and staffing, constituencies or counties, rural versus urban, east versus west, large versus small or HSE versus health boards, but simply about the best cancer care we can provide.We will make significant changes in cancer care because it is the most effective way to offer the best care possible to all who present with cancer in Ireland both today and in the future.

I say to women and men: if you have cancer, this plan will give you the best chance of survival. If you are worried about cancer, this is the best assurance we can give you that the best care will be there if you need it. If you live in rural Ireland or outside a major city, you deserve the same care as a person living beside a major cancer hospital and you will get it. It is a fundamental to this cancer plan that you will get the best cancer care regardless of your income, address or age. We can only do this, and we will do it, with teams of cancer specialists working together in major centres on a large number of cases. We will provide you with as many aspects of cancer care as close to home as possible. And if you need help travelling to a major centre for surgery we will assist you.

We are at the start of the journey to achieve these things. I recognise that as we leave present and past arrangements behind, in some parts of the country people are worried about whether we will reach our destination. I am confident we will. I am also confident we will bring with us the best aspects of what we have provided hitherto as we expanded our cancer services in recent years. There are excellent surgeons, nursing staff and levels of real care and support being provided. We value all of this and I am determined that none of it will be lost as we make the transition to the best quality-assured cancer care we can possibly organise. We will work with all concerned who provide care now to make sure of this.

The background to our plan is as follows. Last year, the Government strongly endorsed A Strategy for Cancer Control in Ireland, which was prepared by the National Cancer Forum and launched in June 2006. While the HSE is the centrepiece of the delivery of these services, the framework also provides a role for HIQA and the voluntary sector. It also makes recommendations to allow quality of care standards to be applied equally between the public and private sector. The implementation of the cancer control strategy is a major priority for me and for the Government. One of the basic reasons we set up the HSE to replace the health boards was to ensure that national level decisions could be made and implemented to deliver the best possible health outcomes for all people.

There is now a real opportunity for cancer control to be the key driver of overall health reform. It will require a significant change in how things are done. To facilitate this, the HSE has decided to establish a national cancer control programme and to appoint Professor Tom Keane as its director. Professor Keane took up his position yesterday. He is on secondment from his post as consultant radiation oncologist and head of the division of radiation oncology at the British Columbia Cancer Agency in Vancouver. I acknowledge the valuable contribution by the British Columbia Cancer Agency to the Irish health care system by agreeing to second Professor Keane for a period of two years to lead and manage the establishment of the HSE national cancer control programme. Professor Keane has my full support and that of the Government in this regard.

Professor Keane is expected to quickly designate clinical national leaders for radiation, surgical and medical oncology. I understand the HSE is making arrangements to enable him to take control of all cancer developments from 1 January 2008 and progressively take control of all existing cancer services and related funding and staffing. In consultation with various people and organisations, Professor Keane intends to designate locations for a range of cancer specialties from among the eight centres by early January. He will therefore be engaging in detailed planning to facilitate these designations and the orderly phased transfer of services between locations.

The designation of cancer centres is being carried out with the aim of ensuring that patients receive the highest quality care while allowing local access to services where appropriate. Patients enjoy a 20% improvement in survival rate if they are treated in specialist centres which provide multi-disciplinary care. If diagnosis and treatment planning is directed and managed by multi-disciplinary teams based at the cancer centres, much of the required treatment, apart from surgery, can be delivered in local hospitals. The implementation of managed cancer control networks will require the establishment of appropriate capacity at the cancer centres as we move services from other locations. It will be necessary for the distribution of other acute services in the hospital sector to be rebalanced by the National Hospitals Office. It is likely that those hospitals withdrawing from the provision of surgical oncology will be in a position to receive non-oncology services displaced from the cancer centres as a result of their increased oncology workloads and resulting demands on core services and facilities. The HSE plans to have completed 50% of the transition to the eight designated cancer centres by the end of 2008 and 80 to 90% by the end of 2009.

Much has been said about the requirement for extra resources to be provided in the designated centres in support of the implementation of standards for symptomatic breast disease. This is fundamentally about bringing together people with the best expertise to deliver the best care. Building up our centres of excellence will involve a continuing effort to build teams of excellent people delivering excellent care in major centres. That is what we will see, rather than cranes on the skyline and new buildings. We will of course continue to add investment to provide facilities for patients and to support clinical expertise but the main focus will be on people working together in new ways. We will be changing how we do things, not simply doing more of what we do already.

In Ireland we have high admission rates for cancer compared to other countries and when patients with cancer come into hospital they spend far longer on average in hospital than patients in other countries — longer than they need to be there. We can make better use of our existing hospital resources for cancer patients while not compromising on the objective of improving quality of care and cancer survival rates. To exemplify this, I am advised that there is significant variation among different centres in terms of the time that patients with similar care requirements spend in hospital. The average length of stay for patients having breast cancer surgery, for example, varies from as low as four days to more than ten days. The best patient care should mean that people are ready to go home as quickly as possible the moment they are medically ready, as most would wish.

We have been making progress in this area too. Between 1997 and 2006, the average length of stay for women having breast surgery has fallen by three days from nine to six days. The effect of this is that we have increased the number of women who have been treated with surgery each year by almost half — 44% — while at the same time slightly reducing the numbers of bed days they require. This not only represents a significant improvement in the efficiency of our hospitals, but it is a significant improvement in access to the services that women with breast cancer have received in the last decade. No patient wants to stay in hospital longer than is medically necessary, so we will ensure that this trend continues.

I am expecting Professor Keane to make symptomatic breast disease services a priority. I am confident there is now a clear pathway that is understood by all to enable the implementation of the quality assurance standards for symptomatic breast disease services in accordance with the time frame set by the HSE last September. I welcome the important and significant progress made by the HSE in announcing the cessation of services in hospitals undertaking low volumes of breast cancer surgery. I agree that the difficulties in recent months have been a source of worry for the women concerned, their families and the wider public. We must begin to learn lessons from these cases and to take all actions necessary to minimise the chance of mistakes. I strongly favour a culture of blame-free reporting of adverse incidents and I look forward to this being promoted more in our health service.

At present there are approximately 2,500 new breast cancer cases per year in Ireland. Data quoted in the OECD report published last week shows that there has been a rapid increase in survival rates for breast cancer in Ireland in the last decade — greater than in most other OECD countries. We are now getting close to the EU average. We recognise that there is room for improvement in cancer survival rates relative to other EU countries. This has already been clearly set out in the strategy for cancer control. That is precisely why the journey on which we are now embarking is so necessary.

The two most important contributors to improving this pattern will be enhanced access to early diagnosis through the roll-out of BreastCheck and the implementation of the quality assurance standards for symptomatic breast disease services. BreastCheck has commenced screening services in the south and west. There have been major developments and improvements in cancer services over the past years. Ongoing work in the National Cancer Registry shows that survival for most cancers continues to improve in Ireland. For example, breast cancer patients diagnosed during the period 1999-2003 had a five-year relative survival — 6.7 percentage points higher than those diagnosed in the period 1994-98. However, there is some way to go before we can attain the survival performance of the best European countries.

I particularly appeal to our doctors to work with us and lead this change to the best cancer services. All doctors are aware of the evidence about what provides the best outcomes for their patients. I am encouraging them to support Professor Keane in the tough challenge he has taken on as director of the National Cancer Control Programme. With the support of our many excellent cancer doctors I am confident that Professor Keane will succeed.

I will chair regular review meetings involving the HSE and Professor Keane to monitor delivery of the programme. Progress will also be considered on an ongoing basis by the Cabinet sub-committee on health and children. My Department will engage on an ongoing basis with the HSE on detailed arrangements for the progression, monitoring and evaluation of the programme.

One result of recent events is that the public better understands and accepts the rationale for the development of cancer centres and the changes that must follow. It is now incumbent on all of us in the health system to ensure that we deliver on this.

There have been major developments in cancer control. We are embarking on a journey towards the best cancer care we can provide in our country. We will take with us the value we have built up in the recent expansion of cancer services. We are asking people to come with us. There will be no reduction of cancer care services as we go on this journey, only an assurance of improvement in quality and outcomes.

We are moving in the right direction and we have a national leader in Professor Keane to ensure cancer is given the priority and expertise it deserves. We will work to ensure the implementation of the National Cancer Control Programme is fully supported and that it is given every opportunity for success and, ultimately, for excellent patient treatments and care. This will benefit our cancer patients nationally and prove that Ireland can become a benchmark for other countries in the provision of quality assured cancer care. Both I and the Government are committed to delivering these improvements.

Frances Fitzgerald (Fine Gael)
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I welcome the Minister to the House and I hope that she will leave us with an understanding of the degree to which the health service, under this Government's leadership over the past ten and a half years, has failed the citizens of this country. When it comes to cancer, for example, people expect the health service should be capable of accurate, speedy diagnosis. They expect that treatment should be effective and being quickly. They expect this, they are entitled to it, but they no longer have the confidence that it will happen.

This crisis of confidence is built out of individual tragedies like those of the eight women who underwent tests at Portlaoise General Hospital and were told they were free and clear, only to find out later that they have cancer, and like the other six women who must face the agony of being retested to find out whether earlier tests failed to diagnose cancer.

The response of the Government and the HSE to this crisis in confidence in breast cancer services has been terrifying. At the outset they blamed the public for failing to accept the closure of local services. This is an attempt at distraction. I have stated already that the Taoiseach is acting like a man who has just woken up and found himself in Government Buildings, not a man who has been head of Government for ten and a half years. Fianna Fáil and the Progressive Democrats have controlled the Department for more than ten years with Deputies Cowen and Martin, and now Deputy Harney, as Minister, yet, for example, until RTE exposed the existence of a letter from the radiology department in Portlaoise General Hospital to the hospital management, the Government and the HSE claimed they knew nothing of the matter.

Another example is the Minister's statement that she was not aware of the problems in Barrington's Hospital until August 2007. The reality is that the Department of Health and Children wrote to the HSE in January 2006 about the issues there. Why then did the Minister not know? What kind of Administration prevents early warnings from being acted on efficiently and effectively?

Fidelma Healy Eames (Fine Gael)
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Hear, hear.

Frances Fitzgerald (Fine Gael)
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Why does one side of the health service not know what the other side is doing? On 7 November last, for example, The Irish Times reported that the BreastCheck service double reads mammograms for safety. One day earlier the HSE had stated double reading is not a requirement at symptomatic breast disease centres. This kind of information fuels confusion and fear, and it is not a one-off example.

The waters were also muddied very much in this area by the Taoiseach incorrectly defining triple assessment in the Dáil. He stated, on 7 November, that "Triple assessment only applies where cancer is identified" but we know that this is incorrect. It is a diagnostic system to determine treatment for the patient. It arises once a patient has shown symptoms of breast disease, but it is incorrect to state that it takes place only after the patient has already been identified as having cancer. Clearly, in both St. James's Hospital and St. Vincent's Hospital, triple assessment is a means of arriving at a diagnosis and this has been confirmed by the Irish Cancer Society.

After more than ten years in power there is a sense of being out of touch with what is happening and with the reality of cancer services in this country because so many incorrect and misleading statements have been made. Mysteriously, the expert who could make the public see precisely what the Taoiseach is doing was stood down by the national broadcaster from a television programme dealing with the issue. It is amazing that the person who is the most angry and lucid critic of the Department's approach to cancer services should be removed from the panel of such a programme in the interests of balance.

The Minister said she welcomes people who want to point out what is really happening in the health service. I am not suggesting that she has direct influence but a number of incidents have arisen that have caused concern. There is also concern about the Medical Practitioners Act 2007 that, far from encouraging an atmosphere of disclosure and clinicians stating what they are finding in the system, there is a belief that it is a case of put up or shut up.

Fidelma Healy Eames (Fine Gael)
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Hear, hear.

Frances Fitzgerald (Fine Gael)
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I want the Minister to return to address that aspect.

Instead of clear incremental progress, we see one tragedy after another. I must put to the Minister what many people say, that the HSE in its present form is a failed entity. It would seem that the burdensome administrative difficulties prevent it from carrying out its intended function. This view comes from all of the partners in the health system, where there is considerable concern.

There was not a re-organisation when the HSE took over, although there has been a significant increase in management. There was no redundancy package and no attempt was made to streamline services and responsibilities. It seems that this failure is coming home to roost.

There is a cloud of confusion as well over the difference between governance and implementation, which the Minister should address. Professor Drumm's visit to the Oireachtas showed up the confusion between governance and administration. I recognise his visit constituted an attempt to give us direct information on his experience of the services, but at its heart there is confusion. Surely it is the HSE's role to implement the Government's health policy.

The Minister must be concerned about this. I read with interest her article in The Irish Times today in which she referred to the establishment of the health forum but there is a real sense within the health service at present that there is a lack of partnership and trust between all of the interested players, and the frontline players feel this greatly. There seems to be a policy which favours the unilateral approach on many issues. One example is co-location, where there was no Green Paper, no White Paper, no consultation and merely an ideological view that it was the way to proceed,——

Fidelma Healy Eames (Fine Gael)
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Hear, hear.

Frances Fitzgerald (Fine Gael)
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Another example is where all involved want to be paid as they were in charge but nobody wants to show leadership or responsibility.

The Minister states she wants her legacy to be one of good access for everybody, whether he or she is a public or private patient, but I wonder whether her legacy will be one of supporting a range of private facilities while the public health service remains under enormous pressure. There seems to be a preferred policy of confrontation by the Department and the HSE with partners at local, regional and national levels. I call on the Minister to replace this with a culture of consultation and the concept of working with all the partners in the health sector. The Minister stated it in her article today, but it has not been the experience on the ground on a range of issues. There is a real problem.

This was evident in the report published last week dealing with hygiene in hospitals. There is a feeling that the HSE does not deliver and is not accountable. There are no guarantees of performance, no measures and no targets. The hygiene report states there is no managerial responsibility and no governance in hospitals. There were no targets or clear management guidelines on what they wanted to achieve in years one, two and three. The Minister spoke about that issue some years ago when she said she was determined that, for example, MRSA and the hygiene problems in hospitals would be addressed. Three or four years on we have a report clearly stating those targets were not set in the first place, which is extraordinary. Last week in the House I quoted a number of lines about the gaps in management regarding that issue. That is just one example. We have the advantage of having this carefully prepared report in contrast to the Health Service Executive report on the same topic which came out more favourably in terms of the hospitals. There is something missing in terms of the issue of management and responsibility.

The structures of the HSE in its performance to date should haunt the Minister. She repeatedly said she wanted to return to the Department of Health and Children and that she has said she is delighted to be there but how can she be satisfied with the results to date? The issue of the structures of the HSE have not been tackled head-on by the Government. For example, the Minister was in power in 2000, although it was a Fianna Fáil Minister then, when Portlaoise hospital was designated as a centre of excellence. The Minister prides herself on delivery but what steps were taken at that time to ensure Portlaoise hospital, then designated a centre of excellence, had the state-of-the-art equipment needed for the diagnosis of cancer? The announcement was made but there was no follow through in terms of giving it the services it needed to be a centre of excellence as it was designated at that time.

There have been many announcements but the concern is that there has been no follow through. That is the same challenge the Minister will face in terms of what she told Senators earlier. Many Members of this House would agree with much of what the Minister said but to persuade people that it will work is a major task.

Paddy Burke (Fine Gael)
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The Senator has one minute remaining.

Frances Fitzgerald (Fine Gael)
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The radiographic equipment at the centre was also old and at the time it was designated a centre of excellence, audits and follow-up audits were not done. There was a problem. Funding for the centres of excellence was not ring-fenced, and that is a question for the Minister.

Many members of the public are of the view that "centre of excellence" is a title put by the Minister and the HSE on an existing service with a promise of some vague unfunded improvements in the future. The challenge is to convince people that funding will be provided for those centres of excellence because to some degree, patients are being asked to live in the future and tolerate misery in the present in terms of services.

There has been a breakdown in communications between all the players. I do not have time to go into that in detail but the Minister has said repeatedly that she is happy to be back in the Department of Health and Children. She quoted surveys indicating that the majority of patients are happy with the service they get, but when patients are in pain or fear and a good health professional responds to them, it is always the case that they are happy with the service. I put it to the Minister, however, that the surveys did not seek out or represent the women who were told they did not have cancer and were deprived of treatment for a full year. They did not seek out or represent——

Paddy Burke (Fine Gael)
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I ask the Senator to conclude.

Frances Fitzgerald (Fine Gael)
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I will conclude now. The surveys did not represent the people who die every week in our hospitals from MRSA, nor did they seek out and represent the people who must travel hundreds of miles for services. I put it to the Minister that the transport issues are major ones. More than 50% of people diagnosed with cancer are over 65. The transport issues must be addressed. The Minister has a lot of persuading to do to convince patients, the public and medical staff that she has a real plan and vision for the health service. Currently, there is no conviction that money spent in the health service is being spent properly. That is a major challenge.

We have had the first and second O'Higgins reports. The first report was received seven years ago but where is the implementation plan arising from that? The Minister might indicate——

Paddy Burke (Fine Gael)
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Senator, I ask you to conclude.

Frances Fitzgerald (Fine Gael)
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——later when the implementation plan for her current cancer strategy will be published. When will she come back to this House to announce the implementation plan for the cancer strategy?

Geraldine Feeney (Fianna Fail)
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I hope you will be as generous to me, a Leas-Chathaoirligh, when I go over my time. I welcome the Minister, Deputy Harney, back to the House and thank her for giving three hours of her time today. Whenever she is asked to come to the House, she never sends a Minister of State but instead comes herself. That is an indication of the way she is perceived in her Ministry and how she takes responsibility for her portfolio.

I said last week that I hoped this debate would get away from all the talk about Professor Crown, the Late Late Show and so on but I will refer to it briefly because it was mentioned by the main spokesperson for Fine Gael. RTE came out last week and, in clear language, said that the programme would not have been balanced if Professor Crown had appeared along with the other three people. It was left to RTE to decide who it would drop from the programme and on its own merit it dropped Professor Crown. In hindsight I am delighted Professor Crown was dropped because I had heard him two mornings prior to that on the Pat Kenny show and I do not mind saying that the way he personalised his remarks about the party of the Minister, Deputy Harney, was a disgrace. He was appalling because in my view he was only having a go at the Progressive Democrats and did not come up with any solutions regarding cancer care. I am glad he was the one dropped from the show and replaced by another oncologist.

We are here to discuss cancer services.

Fidelma Healy Eames (Fine Gael)
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Exactly.

Geraldine Feeney (Fianna Fail)
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I was delighted to hear the Minister begin her contribution by remembering the women who received the misdiagnosis from Portlaoise hospital. I heard her speak on "Prime Time" that week and was touched by the way she handled the matter and the concern she expressed. She said it was every woman's nightmare to be faced with what those six or seven women were facing. That is the case. It must have been a terrible shock. The Minister also said that night that what was most important now was that they would get the appropriate treatment and counselling.

Fidelma Healy Eames (Fine Gael)
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After the horse has bolted.

Geraldine Feeney (Fianna Fail)
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We did not interrupt once when Senator Fitzgerald was speaking. I would like some respect. We get this all the time in the House. It is a different matter on the Order of Business when people shout back and forth but when Members make statements, and this is for the benefit of newcomers, they are allowed to contribute. The Senator can contribute after me.

We must not lose sight of the fact that regarding early detection of cancer and cancer survival rates, we are among the lowest in the developed world. I welcome the Minister's comment earlier that we are placed a little higher than we were previously in the OECD report of last week. That is a start and it is welcome. I hope we will develop along those lines because we should hang our heads in shame in respect of the current statistics. There is nothing to be proud of in that regard. We are starting from a very low base. I said in the House three weeks ago that I support the centres of excellence. I am not afraid to say that. I have every confidence in the team that gave us the cancer strategy under Professor Niall O'Higgins. I am delighted that is the way forward. We are the lay people, the patients and the users of the services and we must put our trust in those who have gone abroad and witnessed best practice.

I am delighted also that Professor Tom Keane took up his position yesterday. I read a lovely review of him in The Sunday Business Post last Sunday. I smiled and wondered if the Minister ever took time out because the review — I am not sure if the Minister read it — referred to a dinner in Canada she attended with some of her officials from the Department of Health and Children. During the dinner she was observed gently nudging Professor Keane with her elbow and asking him if he would consider coming home to take up a position. I take my hat off to the Minister. She is a great woman to be able to persuade those type of people to come back to this country.

Professor Keane is being held up as a messiah. In an article, he was called "Medical Messiah". There is a notion that he will deliver results overnight, but he must be afforded the time and space to drive the strategy forward. It is important that the users of health services should remember that this is a process, not an event and our expectations must be tempered. Professor Keane is a physician, not a magician. We should allow him the time and space to get on with his job, but Senators will be looking for his head in 12 months or 13 months in the same way as the Opposition is looking for heads in respect of the HSE.

Fidelma Healy Eames (Fine Gael)
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We are looking for accountability.

Geraldine Feeney (Fianna Fail)
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We must follow the experts' advice and proceed with eight centres of excellence. In our previous debate, we discussed——

Fidelma Healy Eames (Fine Gael)
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What about Sligo?

Geraldine Feeney (Fianna Fail)
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I will deal with Sligo in my own time. The Senator should look after Galway and I will look after Sligo.

Fidelma Healy Eames (Fine Gael)
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Senator Feeney can be sure I will.

Paddy Burke (Fine Gael)
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Senator Feeney without interruption.

Geraldine Feeney (Fianna Fail)
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She is another Senator on the other side with a little too much to say.

While we are creating centres of excellence and putting infrastructure in place — I will address Sligo now — we must consider existing services. Sligo town has an excellent service, but it will be audited in the near future by Professor Keane. Sligo has a multidisciplinary team and good outcomes. I know the answer, but can we keep centres that have good outcomes like Sligo while putting services in place in other centres of excellence?

When the centres are up and running, can we consider the mode of transport to be used to transfer sick people? We need small luxury coaches because ill patients do not want to be exposed to train or bus journeys that must be shared with others. They should not be on buses that stop at every crossroads or pub, as has been the case. Every well-sized town should have a dedicated coach service for people travelling to centres of excellence. If someone is not feeling well, he or she could travel in comfort. This is an important matter, particularly in respect of the roads from Sligo to Galway. They are better than they were 20 years ago, but they are not motorways. Will the Minister bear this in mind?

There is a great deal of fear regarding centres of excellence, but an onus is on both sides of the House not to scaremonger. Cancer sufferers, whether they are men or women, are vulnerable to people's comments. I listened to Senator Fitzgerald, who spoke of differences and people's upset with the Medical Practitioners Act 2007.

Paddy Burke (Fine Gael)
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The Senator has one minute remaining.

Geraldine Feeney (Fianna Fail)
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No one on the Senator's side of the House said "Put up or shut up" when the legislation was before it. The Opposition's main concern was having a lay majority and taking expertise away from doctors. I was a spokesperson for my side. When the Opposition talks about putting up or shutting up, why does it not develop better cancer treatment plans than the Minister's? That is what should come from the other side instead of scaremongering.

When centres of excellence were rolled out three weeks or four weeks ago, Mr. John McCormack stated that it was the best thing to have happened to cancer care in the lifetime of cancer treatment. Those attending centres of excellence will have a 20% to 25% better chance of survival. This should be remembered when people seek to retain services in small towns such as Portlaoise, Tullamore and Mullingar. Services went to Portlaoise due to lobbying on the part of politicians at local level and the Tullamore cancer strategy was fragmented between it, Portlaoise and Mullingar. We know the results and must learn from the experience.

Mr. McCormack stated that if one's town has a hospital that treats ten to 20 cancer patients per year, one should bypass it and go to a centre of excellence. Recently on radio, a young man diagnosed with a rare brain and neck cancer discussed centres of excellence. His oncologist in Dublin told him that while the oncologist could treat him, he should go elsewhere. Were the man the oncologist's brother or had the oncologist been diagnosed, the oncologist would have recommended a centre in Liverpool. Had the man been told to go to Saudi Arabia or Cairo, he would have gone. While he needed to be away from home for three months at a time, he is alive as a result of being a patient at a centre of excellence.

Joe O'Toole (Independent)
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It is difficult to take an independent line in these debates. I welcome the Minister to the House and thank her for her generosity in making herself available, on which all sides can agree.

I support what the Minister is doing in terms of centres of excellence and the cancer strategy, but I have many codicils. I have listened to oppositional politics for 20 years and Senator Feeney, in a fine speech, told us not to scaremonger, but I will make a few statements. I became a Member in 1987 and, during my first week, I lunched with Barry Desmond, who had just finished his tenure as Minister for Health. He expressed his rage when discussing his problems in closing hospitals. I remembered the news coverage of the event, but he gave me a vivid image of when the leader of the Progressive Democrats and the Democratic Socialist Party's Jim Kemmy linked arms on their way through Limerick to try to stop the closure of Barringtons Hospital. Those two parties were looked after.

I remember the Minister for Enterprise, Trade and Employment, Deputy Martin, being in deep trouble for the appalling nursing homes mess. I went to the trouble of reading the background to the issue. The provision was introduced by a Labour Party Minister for Health who received legal advice from his Department to the effect that what he wanted to do was wrong. He brought the matter to a Fine Gael Taoiseach and Minister for Finance who, despite the legal advice, cleared the provision. Every subsequent Minister of all shades allowed the situation to continue.

I remember Deputy Noonan ten years ago, who I refer to because these people were at the centre of media demonisation. When Minister for Health, Deputy Noonan made a mistake in terms of the advice he received in respect of the Mrs. McCole case, but that did not take from my admiration for him as a Minister and what he was trying to do against all sorts of odds.

I have heard it all when it comes to people having a go at Ministers and it is occurring in the case of the current Minister, Deputy Harney. I admire her work, but I disagree fundamentally with some of her issues, which I will put on the record as I proceed. We need to examine the matter. Let us begin with the role of Professor Drumm. When the Health Act passed through the House in 2004, I raised concerns regarding the chief executive's role but got no support from any side. All parties accepted that the legislation would not allow the chief executive to be critical of Government and ministerial policies. I have raised this issue in respect of the appointment of every chief executive to every State body since I became a Senator. As the provision was voted on and accepted, there is no point in our whinging. I do not know Professor Drumm's policy, but we passed legislation that requires him to take on board the Government's policies and objectives. Before we examine those, we should examine how we make appointments. I have reminded some of my consultant friends how hard it was to appoint a chief executive to the HSE when it was established. It is important to recognise that the people who knew all about it then were not queuing up for that job. We demand that Professor Drumm be available to give an account of the general administration of the health services to an Oireachtas joint committee. I disagreed with this set-up then and I disagree with it still. Chief executives should be allowed have a view, say what they believe and drive policy as well as implement it.

I was delighted Senator Fitzgerald raised the issue of governance, accountability and responsibility. It is the height of nonsense to blame the Minister or the chief executive of the HSE when a hospital cannot be kept clean. Senator Fitzgerald is correct that there should be risk audits in hospitals to ensure they are kept clean. If they are not, someone in the hospital must be accountable and action should be taken.

My heart goes out to the consultants. They are afraid to criticise civil servants. If someone in a hospital says boo to them, that hospital will not be supported. I do not buy that one. I have spent my whole life fighting with civil servants and I will tell the House how it works. If one takes them on about a school, a hospital or any other matter, the word will come back to play it cool, to keep one's voice down and not put a head above the parapet because one knows what will happen. If one takes it that way, nothing will happen. Civil servants, however, are very predictable. The minute one puts the boot in hard, raises the ante and puts it in harder, raises the ante again and buries them, they recognise it is easier to do business than to walk away. That is how it works with civil servants.

It is unacceptable for a consultant who found dirty equipment at Portlaoise Hospital to claim the answer was to write a letter to the Minister. What do they do about dirty hypodermic needles? Do they write a letter about that? My view on this case is simple. They should have stopped using the equipment there and then and made someone deal with it.

Last week on radio, the Minister said she hoped to conclude the contract with the consultants by the end of the year, only for that to be contradicted an hour later by the consultants claiming that under no circumstances would it be finished by then. I want to hear more about this development.

I disagree fundamentally with the Minister, in principle and in practical terms, on bilocation. In practical terms, it is duplication. I believe consultants do a fabulous job and I am a great admirer of them. They are entitled to every penny they earn and I do not begrudge them a shilling of it. However, I want the world to know they earn their money using, at no charge to them, our hospitals, our beds, our nurses and our equipment. This is where I disagree with the Minister — I would make them pay for these services. Instead of building a second hospital on the one site, I would put a value on existing hospital services and let the consultants pay for them. I accept the Minister's plausible argument that bilocation releases more beds. However, it must be recognised that consultants are using State equipment paid for with taxpayers' money.

One important fact that emerged from the Minister's speech, of which I was unaware, is that 44% more patients are now treated using fewer beds, an important key performance indicator. It is important the Minister chairs a committee monitoring service delivery. I agree with Senator Fitzgerald that benchmarks of progress and key performance indicators are needed for us to buy into the Minister's policy in a practical way. I hope Professor Keane will outline the key performance indicators he hopes to achieve in the coming year. This will allow us to count them as they are delivered. If we get that, no one can object. Is a risk audit for the entire health system publically available? If so, where can I access it? Without bothering the Minister, I could then find out why a hospital in, say, Portlaoise is dirty and have an answer to both sides.

While I am not prepared to be critical of Professor Drumm, he has been somewhat unfortunate in the way he has handled some of his media outings. There needs to be a single voice for the HSE for it to give its views, leaving Professor Drumm to concentrate on running the executive.

The levels of administrative staff in the health services is an issue constantly raised in the House. Not one Member wants to see consultants answering the telephone or scheduling their diaries, and there must a certain level of administration. Earlier today on the Order of Business, I requested a debate on the review body on higher remuneration. The comments made by it on extra people in senior management in the HSE are troubling. If the HSE could not come to a conclusion as to what some of its senior management are doing, it must be reviewed. Having been involved at a senior level in the trade union movement I share some responsibility in this process. In the change from the health boards to the HSE, there was a need to accommodate many people. Like what happened elsewhere, they either had to be bought out, paid off or given jobs. There is some element of duplication but that does not mean people should not be working.

Déirdre de Búrca (Green Party)
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I welcome the Minister for Health and Children to the House. I acknowledge this is the second time she has been to the House in the past few weeks to debate the important issue of the reform of our health services.

The Minister began her speech by referring to the recent appalling misdiagnosis of a group of women with breast cancer. This has highlighted the shortcomings in our cancer care services. Ireland needs to follow international best practice in establishing managed cancer control networks consisting of primary, hospital, palliative and supportive care. I am delighted the Minister acknowledged that not all elements of such a network need to be at a remote distance from the patient and some can be provided closer to where the patient lives.

The 2006 national cancer strategy aims to equip each of the HSE's four regions with a broad self-sufficiency of services to treat the most common forms of cancer. It aims to establish eight special cancer centres in each of the four HSE regions to provide integrated treatment service for all forms of cancer including diagnostic, surgical, medical and radiation oncology services, centred around a multidisciplinary approach. The challenge lies in the transfer from a model of a much more locally dispersed cancer care service to a more centralised, specialised model of care.

I do not envy the Minister this challenge but one area where Members can assist her is in political leadership. Having been a local politician for eight years, I recognise there can be much concern and reaction in local communities when a local hospital is threatened with losing its cancer care services. It can be difficult for a local politician to stand up and say it may be necessary. It is the role of local and national politicians to educate, inform and persuade their constituents that this is necessary because the outcomes are 20% better from centralised cancer care services. That is a simple message that we all have a responsibility to deliver. It is not always easy but we must do it, even in the face of well-motivated campaigns against the closure of local services.

That, however, does not let the Government off the hook. We need to ensure that the transition from the local to the centralised service is managed properly. The provision of alternatives must be managed so that local services are not closed down in the absence of properly resourced centralised facilities. To date 13 hospitals which deal with approximately 20 patients every year have been told that their cancer services must close. That will be good in the long run but the large hospitals will pose a greater problem. Under the new criterion hospitals that continue to deliver cancer care services must treat 150 newly diagnosed patients per year. It is a greater challenge to close hospitals of this size than small ones.

Unless the new facilities are provided at the same time as old hospitals are to be closed it will be impossible to persuade constituents that this is in their interests and in the interests of better health outcomes, even if local politicians fully support the strategy. Services that are already overstretched will be under even further pressure and will not have the facilities or staff to deal with the added patient load and this will not result in better health outcomes. This will be a big challenge. The transition will incur significant extra short-term costs but this will involve only the concentration of the capacity in, not an addition to, centralised facilities. We must recognise, however, that the transition will be expensive.

Travel is a concern for people who must access services at a distance. Many of those with cancer are aged 65 years or more and travelling to access the services is a problem for them and for their visiting relatives. That raises the issue of providing family friendly accommodation where people receive treatment over time although the Minister said that hopefully this time will reduce. It may be possible to provide services such as chemotherapy in local hospitals. The Minister must consider which parts of the cancer care services should be centralised and which can be provided locally.

The programme for Government contains a commitment to provide for personal health checks to include the referral of men for early screening for prostate and other cancers. It will be important to increase the capacity of urological services to tackle prostate cancer. I agree with the Minister on the importance of expediting the roll out of BreastCheck which results in the early diagnosis and treatment of women. Ireland has the third highest rates of deaths from breast cancer in the OECD. Approximately 2,000 women a year are diagnosed with breast cancer. This roll-out is particularly necessary in the west and south where there is no proper cover. The programme also includes a commitment to introduce a universal entitlement to a cervical cancer vaccine when this becomes available. This holds out the possibility of putting an end to cervical cancer within a couple of generations.

I welcome the appointment of Tom Keane to implement the national cancer care strategy. That will be a significant challenge. We must support him as well as we can. He comes from British Columbia which, although it is the size of France and Germany combined, has only four specialist cancer care centres. I wish him every success in his new role and hope that we will be able to support him in what he is trying to achieve.

Phil Prendergast (Labour)
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I wish to share time with Senator Norris, by agreement. I thank the Minister for coming to the Chamber where I see her frequently.

What is the current investment in cancer control services? In response to a parliamentary question last year, the Minister said that an additional €20.5 million had been identified to implement the new cancer strategy. How much in total has been spent to date on that strategy and how was that broken down between administration and frontline services? When will the BreastCheck roll-out be completed? How many additional radiographers are employed to provide the service and are there enough of them? If not this may be a factor in the delay. Is there a blueprint and who are the advisers on this roll-out?

Are the 23 oncologists working here sufficient to provide the service required? I suspect we need three times that number but am open to correction. There are 140 general surgeons who provide an excellent service dealing with the many cancers they encounter, from diagnosis to treatment and management. Without wishing to be too parochial, will Mr. Courtney, an expert in gastroenterology in Kilkenny be required to travel to Waterford to operate on a patient from Kilkenny? Will surgeons who are experts in their fields spend time travelling between their local hospitals and others to provide a service to their patients in a theatre in another hospital at great inconvenience to many? It is no joke to travel home after having any of the interventions needed to deal with the complex problem of cancer.

Over 80% of cancers are treated surgically. For 2,700 cancers diagnosed and treated there were 14,000 episodes and clinical encounters. Where will these encounters, such as outpatient appointments, tests, scans, radiological, GP and ancillary services occur?

What percentage of the €12 billion budget is pay? Are there plans to introduce an immunisation programme with the cervical cancer vaccine which has proved effective and is produced in my region? I am pleased that the vaccine is available but we should have access to it. Could this be costed and a timeframe identified for when it might be implemented?

If cancer is the vehicle this week for centralising hospital services, will obstetrics and gynaecology be next? While rationalisation and specialisation are welcome, decentralisation of specialist services may not provide the best outcomes. Can all the proposals in the national cancer control strategy be achieved and be budget-neutral and if so, how? I look forward to seeing how Professor Tom Keane, the radiation oncologist, progresses in restructuring the provision of services and I await the Minister's reply to issues raised. Who will audit this process?

Some 2,000 breast cancer cases are managed surgically in the country's public hospital system but the BreastCheck screening programme will reduce the number of symptomatic presentations by between 33% and 50%. The programme is limited to women between 50 and 65 years of age but breast cancer does not stop at 65. Despite the fact that BreastCheck is still being rolled out it should be extended to women over 65 because around 67% of cancers occur in such women. It is not proper that there should be inequalities in access to services and it is not right that women of a certain age should be denied this vital service. I welcome the many positive aspects of this strategy and the initiatives that are to be taken but I foresee great difficulties.

Some 90% of testicular cancer cases are treatable yet it seems there is a need for four testicular cancer centres, one in each network. I am not complaining about this but colorectal cancer, for example, is very common and will also be treated in only four centres. How were the criteria relating to the number of centres treating different forms of cancer reached?

I realise I have asked many questions in my short presentation and I am very pleased the Minister is here. I await her reply with interest.

David Norris (Independent)
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I thank Senator Prendergast for allowing me this time to speak. I welcome the Minister because she is a brave woman who went into Angola but I wonder if she regrets that decision now. I will not engage in partisan political attacks because I agree with those who said recently that what is needed now is a Tallaght strategy. Rather than party members knocking lumps out of each other we should consider patients' needs.

I am glad to see that in her speech the Minister said, "if you are worried about cancer, this is the best assurance we can give you that the best care will be there if you need it". When will this happen? The word "will" is the crucial verb in this sentence and it means in the future. The Minister also said, "If you live in rural Ireland or outside a major city, you deserve the same care as a person living right beside a major cancer hospital and you will get it". Again I ask the Minister, when will this happen? Can she guarantee the Susie Long case will never be repeated in this country? Can she guarantee that the Portlaoise case will never be replicated? I believe this situation has arisen due to an ideology and that the notions of competition, co-location and so on are ideologically driven. I pointed out to the Minister previously that a three page script of hers mentioned words relating to business and these practices around ten times while patients went unmentioned. I know the Minister feels strongly about patients but they must be at the forefront of health policy.

Regarding private hospitals, the Minister pointed out previously that one needs a licence to own a dog but not to run a hospital. This is because hospitals are businesses but I do not feel that the health service should be a business; it should be an entitlement of the citizens of the State. I have no medical expertise but I believe, along with many eminent medical professionals, that we need a universal, accessible health service. The Minister once said we should be closer to Boston than Berlin but I would prefer to be close to some European models of health service than the American model. Has the Minister seen the film "Sicko"? It shows that the American health system is guided by the principles of competition and profit and while the United States has excellence in its health service it also has people routinely and ruthlessly excluded from the provision of health care.

I wish to put on the record my admiration for Professor John Crown. I have never met the man and have no connection with him but I listened to him with interest and I trust a lot of what he says. The Minister may agree with some of the problems he has identified in the health service including inaccessibility, inefficiency, unfairness and an uneven quality of delivery. He agrees with the Minister that the best clinical care takes place in large, comprehensive specialist centres. One may look at examples such as the Memorial Sloan-Kettering Cancer Centre and the Netherlands Cancer Institute when considering the poor resources we have.

We, as politicians, must take some of the blame because many Senators do not see their constituents as the councillors who gave them their seats in this House but as those in the constituencies where they may seek election to Dáil Éireann and they fight for local services. Professor Donal Hollywood from Trinity College produced a report in 1995 and had to have a police escort out of Portlaoise because of people stirring things up against him. Senator Harris was right when he raised the issue of vested interests, however those with vested interests are not, primarily, consultants but managers in the health service. Managers proliferate faster than any local service and this matter must be addressed.

I was interested to read a piece by Professor Maurice Nelligan.

Pat Moylan (Fianna Fail)
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The Senator's time has expired.

David Norris (Independent)
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Professor Nelligan cannot be silenced. He stated that too many promises are made regarding sophisticated services regardless of cost only for cutbacks to be made when the bills must be paid. The blame for this is then shifted elsewhere.

We need a universal health service closer to European models and we must stop political point-scoring on the health service. We should adopt a Tallaght strategy, not in the interest of private medicine and profit but in the interest of the delivery of appropriate services to the citizens of this country.

Maria Corrigan (Fianna Fail)
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I welcome the Minister to the House and thank her for making herself available. As other speakers have said she has been very generous with her time, rightly so, given the issues at hand, and we appreciate her presence.

This debate takes place in the context of recent events regarding the diagnosis of breast cancer. There are many other cancers and they all take a considerable toll on the country and population. Over 100,000 patients are treated for cancer every year in Ireland and 22,000 new cases diagnosed, yet Ireland does not compare favourably on outcome or mortality rates. Over 7,500 people will die of cancer this year. Approximately 1,500 will die of lung cancer, 650 will die of breast cancer, almost 900 will die of colorectal cancer and 65 will die of cervical cancer. I strongly believe that the national cancer strategy reflects the commitment to create a national framework that will ensure better diagnoses and better outcomes for patients. It is essential that we have a higher quality of care and, as the first step in the implementation of the national strategy, I welcome Professor Tom Keane's appointment, though I echo Senator Feeney's point that no individual can be a panacea for cancer services. It is encouraging that he has experience in implementing a regional strategy in a similar geographic and demographic area and I extend him every good wish in the job ahead.

The centralisation of care and the establishment of centralised specialist centres are core tenets in the national strategy and must find unequivocal support in the House as there is no room for parochial politics in this matter if we truly seek improved outcomes and improved quality of care. Research clearly shows that outcome is proportional to the size of the case load facing health professionals. Recent research from Tyneside in the United Kingdom, published in July, studied colorectal surgery and demonstrated that lower mortality rates apply in high-volume centres than in low-volume centres. It also showed that patients who went through high-volume centres received more appropriate surgery. In other words, the decision making was more accurate. For these reasons alone, it is fundamentally important that we in political life strongly support specialised and centralised centres of care.

The research also indicates that as long as decisions are made by specialised multidisciplinary teams in centralised specialist centres, aspects of adjuvant and neoadjuvant treatment, such as radiotherapy and chemotherapy, can be carried out at satellite or remote centres provided that practitioners reach critical mass in terms of their case loads. This research offers hope for certain centres throughout the State that have demonstrated their ability to meet quality standards.

Professor Keane faces significant challenges in implementing the national cancer care strategy. One of the most pressing of these challenges relates to accident and emergency services. What will happen in future to patients who present at local accident and emergency departments? For example, 20% of colon cancer patients who undergo surgery, or some 300 per year, initially present at accident and emergency departments. The procedure ordinarily is to go straight to theatre. However, if such surgical work is no longer to be undertaken on a planned basis at certain hospitals, staff will face a dilemma as to whether it is safe for patients who present in such circumstances to be sent to theatre. Professor Keane must ensure there is no ambiguity in this regard and that everybody is clear on what constitutes best practice. It is often the case that the transfer of patients to another hospital is not straightforward. Emergency cases tend, by their nature, to be more complex. There are logistical issues to be considered in transporting patients, as well as the possibility of a crisis en route.

Another issue to consider is the impact the strategy will have on the training of doctors. Under the new arrangements, for instance, many general surgical trainees will not get any exposure during the course of their training to those cases handled by the specialist centres. If these doctors happen to be on duty when a patient requiring such specialist treatment presents in an accident and emergency department, there may be an issue in terms of their skill and competence to respond appropriately. One option is to consider sub-specialising general surgery. Another solution might be to establish 24-hour, seven-days-per-week rotas that assign a named specialist to cover each region and to put in place a dedicated procedure whereby relevant cases will be assured of a compulsory, immediate and unequivocal transfer to the centre in which the named specialist operates. Taking this approach means we must accept the risk associated with transferring patients. However, this must be weighed against the risk posed when treatment is administered by an unskilled person.

Other challenges include dealing with benign cases, the treatment of which requires the surgical skills necessary in treating cancers. If these hospitals are no longer treating cancer patients, however, it is questionable whether they will attain the critical mass necessary to maintain competence to undertake such procedures. Other Members have spoken about issues relating to travel. In addition, we must address the status of the current case loads in the specialist centres.

I ask the Minister to make available as soon as possible the licensed vaccine for cervical cancer. Its availability renders completely unnecessary the 65 deaths per year from cervical cancer.

An important component of the national cancer care strategy is research. We must be realistic in terms of expectations and honest about the limitations that exist. Much has been made of the revelations regarding mammograms, but we must acknowledge the considerable technical limitations in this regard. Internationally there is a 12% miss-rate in respect of diagnosis via mammograms. If we employ the double reading standard of care, we can reduce the number of false negatives from 9% to 6%. As a result of technical limitations, however, there will be a percentage of patients whose cancers will not be detected. One option is to consider using an MRI reading or similar. There are various pros and cons in regard to such an approach. Funding for research, as is provided by the Health Research Board, offers the opportunity to reduce technical limitations and thus ensure better practice.

Fidelma Healy Eames (Fine Gael)
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I welcome the Minister for Health and Children to the House. I intend to ask her questions without in any way attacking her, as has been alluded to by Government Members.

At the opening of the Seanad term, Fine Gael put forward a Private Members' motion on the crisis in cancer care. At that time, we were aware of Rebecca O'Malley's cancer misdiagnosis and the Barringtons Hospital debacle. However, we had no notion of the crisis looming in regarding to Portlaoise Hospital and the life-changing effects of misdiagnosis for eight women with breast cancer. A further six must wait to discover whether they too have cancer.

The HSE seems to be stumbling from one crisis to another. I would dearly like to receive a response to a simple question. Will the Minister, in conjunction with Professor Drumm, put in place checks to ensure systems and departments within hospitals are accountable at every level? Such an approach may prevent future health crises, whether in cancer care, hygiene or, in the case of Oranmore health centre, through the discovery of rats? Will the Minister offer a guarantee that warning letters such as those that emanated from Barringtons Hospital and Portlaoise Hospital will be heeded and acted on in future? It is outrageous that action was not taken in response to those warnings. We will give Professor Keane time and space to oversee improvements in cancer services. However, we need to know in the meantime that the necessary checks are being put in place.

I listened with interest to Professor Drumm when he told Oireachtas Members last week that no additional bed capacity is required. In the past three years, I have not met a single surgeon, doctor or nurse who agreed with this. In Galway, the delivery of breast cancer services was described to me by the eminent surgeon there as "nitty bitty" and "all over the hospital". I was told that what is needed is more dedicated beds in order that a reliable service can be offered to women as they need it. Without beds, he said, he cannot treat patients. I accept what this surgeon tells me, but it cannot be reconciled with the view expressed by Professor Drumm.

Concerns were expressed in the media last week about the reliability of all clear results previously received by women. I received a telephone call from a woman in Galway who has been for three mammograms. The result of the first was grainy and she was asked to repeat the test within six months. She did so and received the all-clear. She subsequently suffered an accident in the home which involved an injury to her breast that led to the development of a blood clot. When this was checked it was discovered, within one and a half years of receiving the all-clear, that she had a tumour of 3.5 centimetres that was diagnosed as stage three, stage four being the most serious. This woman's question was whether the Department of Health and Children's recommendation that women should receive a mammogram every two years is safe. Will the Minister review this recommendation?

Cervical smear testing is another matter of great public concern. The Royal College of Surgeons in Ireland has the only laboratory in the State accredited to undertake smear testing but more than 1 million women require smears to be analysed each year. The cancer mortality rate in this State is in the third band out of four in the EU.

The clinical director of laboratory medicine at University College Hospital Galway, Professor Martin Cormican, at the end of October wrote to doctors in the south east advising them of the discontinuation of gynaecology cytology service in the region due to a shortage of five staff since September as a result of the Health Service Executive staff embargo and a 25% increase in its workload in this year. According to Professor Cormican, this has led to:

[T]he impossibility of providing a quality and timely service to the population of both the west and south east with the current level of staff. Unfortunately, therefore, any specimens received on or after 1 November ... will be returned unopened.

He very much regretted the inconvenience to patients and colleagues.

This responsible man had to shout "stop" when he knew he could not deliver or reliably stand over the results for women's health. The smear test gives women early information regarding cell abnormalities in the neck of the womb and cancer of the cervix. On 26 October the HSE denied there was a problem. Tom Finn, assistant director at the National Hospitals Office, stated cytology services for cervical smear testing currently provided to GPs in the south east by UCHG would continue, although we now know those tests are going to Quest Diagnostics in the US. I accept these tests are going to an accredited lab, which is very good, and I accept the Minister wants the results delivered in the four to six weeks delivery time.

Currently, 10,000 tests from the south east are going to the US, costing €200,000, which money would have kept the five staff at UCHG in a job. Surely it would be more sensible to employ these five staff and keep the work in this country. An extra 200,000 tests next year going to accredited labs in the US will cost €4 million. The problem is nothing is being done to develop our own services, meaning taxpayers' money is leaving the country. Why is the Minister not investing in our laboratories? With funding, laboratories with our own staff could become accredited. What are the Minister's plans to do this? UCHG must be supported to become an accredited laboratory in the short term, and there is a wish for it to do so. The laboratory at the Rotunda is also pursuing accreditation.

Investment must be made in our laboratories to achieve accreditation. According to the HSE, the national cancer screening programme has confirmed to the Minister that a quality-assured population-based cervical screening programme will be in place from January 2008 with the good intention of reducing cervical cancer rates. How will the Minister deliver on this and is an implementation plan in place?

I will return to the issue of rats in the Oranmore health centre as I have a very disturbing piece of information to share with the House. When I discussed the matter with HSE senior management in Galway last Friday, they were very understanding and empathised with me. I was told the management was powerless. When a HSE representative saw a related letter in yesterday's Irish Independent and heard I was going on "Drivetime", the same manager was far from full of empathy. I felt intimidated by her approach.

I have reliable sources indicating that women and parents with babies are not confident about returning to that rat-infested centre. The HSE official denied it was a rat, stating it was just a mouse that was seen. We know rats and mice do not co-exist. It is has become a serious issue because there is a witch-hunt of the nurse who spoke out. Nurses did not speak to me but I have reliable sources I will not disclose in this House. The Minister has indicated she welcomes people who give good information and she is not into blaming people for reporting. That is not what I am finding in the HSE in Galway since yesterday. I ask the Minister to address the matter. I do not want to hear that any nurse is afraid of losing employment.

I welcome the Minister to the House and thank her for being here. I am looking forward to answers to the questions.

Marc MacSharry (Fianna Fail)
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I welcome the Minister to the House. There were some comments on this issue some time ago when the cancer control strategy was announced. We all welcome the concept of centres of excellence. I will follow up on that, although certain matters are coming to light which show issues remain to be dealt with in the north west as a matter of the utmost urgency. I hope the Minister will take my points on board.

I fully support and commend the Government's efforts to improve outcomes. We are all agreed, forgetting any party allegiances, this is most important. With regard to best care, a centre of excellence already exists in Sligo General Hospital. Multidisciplinary teams, working in the context of a triple-assessment approach, have produced the best results for patients and it is a rewarding environment for the professionals involved. Such a multidisciplinary team exists in Sligo, comprising specialist surgeons, radiologists, pathologists, medical and radiation oncologists and a breast care nurse. These are fully supported by dedicated outpatient nurses and a clerical team.

Weekly meetings are held to discuss all cancer cases and other diagnostic problems. At these meetings, care plans are formulated and subsequently implemented. Such a system has been in place in Sligo for the past six years. In my humble opinion, it serves the people and patients of the wider region very well.

Under the O'Higgins report in 2000, 13 specialist breast care centres were designated, as opposed to the current number, with Sligo General Hospital being one. Work began and the hospital now successfully operates in a multidisciplinary capacity, which we aspire to have in other centres of excellence throughout the country.

I would not expect the HSE to know that as the deputy chairman of the National Cancer Control Programme advisory committee, Tony O'Brien, admitted to me on national radio that no audit of services or facilities had been undertaken. Neither had there been an audit of outcomes in the area. How could we possibly determine that we should wind down a service which exists and is carrying out all we would aspire to have in centres of excellence? It is already taking place in that area.

Fidelma Healy Eames (Fine Gael)
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Hear, hear.

Marc MacSharry (Fianna Fail)
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There are other details from the O'Higgins report, entitled The Development of Services for Symptomatic Breast Disease, which is a report of the sub-group to the National Cancer Forum. It states: "A unit seeing 100 cases of breast cancer per year would see at least 1,000 new patients with breast symptoms annually." As it stands, medical personnel in Sligo General Hospital carry out 4,000 mammograms per year.

Under the 2006 cancer control strategy, the HSE should:

[C]onduct a needs assessment for cancer services with a particular emphasis on hospital-based cancer treatment that addresses the need for continued expansion in capacity and maximises the use of ambulatory care. Diagnosis and patient management should be planned by site-specific multidisciplinary teams.

This has not happened yet. Professor Keane is going to prioritise breast services and we are led to believe, from Professor Drumm and John O'Brien from last week, that he will have plenipotentiary status in how he will carry out the service. If that is the case, why did we announce the centres of excellence in advance?

I do not have an issue with the eight locations and it stands to reason they should exist. Should there be a ninth, with Sligo being that hospital? At a minimum, we should be cognisant that an excellent service of a multidisciplinary nature is being carried out. We cannot ignore that. That National Cancer Forum agreed and recommended the concept of centres of excellence, the theory of which everybody would buy into, myself included. It did not recommend where the centres should be or that we should close down an existing service being carried out excellently.

I am not being parochial because I am from Sligo or I want services in every corner. I beg the Minister to allow common sense to prevail and not just a series of management consultants and health professionals in one expert group deciding there should be eight centres and the north-west centre should be closed. There is specific reference to Letterkenny, 18 miles from Altnanagelvin.

Last week Professor Drumm referred to specific issues geographically and on a cross-Border basis. What is happening on the North-South Ministerial Council? It is a no-brainer for there to be an outreach centre for Galway with Altnagelvin so close. Why is it not Altnagelvin, Letterkenny, Sligo, Galway? I am not saying that services should be taken from Letterkenny, I do not want anything taken from there unnecessarily, but where is the joined up thinking in removing an excellent service from Sligo? It makes no sense.

I am delighted that Professor Keane, on the invitation of the Minister of State, Deputy Devins, will be coming to Sligo to see at first-hand the nature of the excellent service there, with its multi-disciplinary approach. I will be interested to see the level of outcomes there. We must be logical in our approach to this. Everyone supports centres of excellence and applauds the determination and conviction in pursuit of them but we must not begin by winding down a centre of excellence in breast care in all but name. It is ridiculous in the extreme and the reaction of some HSE personnel when such points are made is a disgrace.

I know the Minister will show leadership in holding the HSE to account on behalf of the people, particularly those of the north-west. All of the locations are acceptable but we must re-examine the north-west region and be true to the people there. Various reports over the years have highlighted that Sligo should be a centre of excellence and in practice it is. We must acknowledge that and applaud the work being done there by consultants and others, people the HSE is anxious to relocate and has asked to do so.

A question Senator Healy-Eames will recognise is where will the 4,000 women park in University College Galway. It is all well and good to have the aspiration of centres of excellence and moving everything to Galway but it is an impossibility unless billions of euro are dedicated to it.

I ask the Minister to allow common sense to prevail, to allow Professor Keane to carry out an audit of service and outcomes in existing facilities in Sligo General Hospital and to grant him the authority to say we have got it wrong in this case. It is good to admit a mistake sometimes, such as with the driving tests, it is okay to say we have overlooked an issue, that an excellent service is being offered in Sligo and that the matter is being reconsidered.

The Minister is determined and does her business in the interests of the people. She wants to be true to the people of the north-west. I beg her to be cognisant of the points raised by me and my colleagues from the region.

Nicky McFadden (Fine Gael)
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I appreciate the Minister taking the time to come into the House. I admire the way she listens to people and the care she has for them. She has an extremely difficult brief and I ask her to be open to the points made in this debate.

Three weeks ago we heard the shocking news from Mullingar Regional Hospital. People say politicians should not be parochial but I must because if Portlaoise, Mullingar and Portiuncula cancer services go, we will have no service in the midlands. We were told all of the patients being treated in Mullingar Regional Hospital will be treated in the Mater Hospital and that the respected Mr. Magill would retire and not be replaced, even though a specialist breast consultant already works in Mullingar. When I contacted the HSE, I was told we did not meet the standard because Mullingar only saw 26 new cases last year and 150 cases are necessary to ensure the correct diagnoses.

I then put myself in the position of a woman from the midlands being diagnosed or finding a breast lump. In such a situation I would like to attend a centre of excellence and get the best possible care the country could offer and, like Senator MacSharry, I believe there should be centres of excellence where people can have a triple assessment on-site or through an affiliated radiological centre. Records should be held on-line, with paper files being phased out. I could then have my mammogram, scan and biopsy in my local hospital and have the diagnosis assessed by a radiologist, a surgeon and a pathologist. We had such a service in Mullingar, although Mr. Magill is retiring.

I thought about this further, however, and considered how I would travel to the Mater Hospital. I had to this in the case of a friend of mine. We would leave Athlone at 5 a.m. so we would beat the traffic and arrive in Dublin at 8.30 a.m. The Minister might think that is a very long time but once we reached the Spa Hotel, it could take 90 minutes to get into the city. That is cruel for a sick person. I feel emotional about this because a good friend of mine was involved. We then reached the Mater Hospital, which was already bursting at the seams. When I contacted the HSE I was told extra resources would be provided for the Mater to deal with the capacity from the midlands and to support those women suffering from breast cancer. The reply was very vague.

I was told that those with a medical card would be facilitated with transport. I went on to the Internet to find the national treatment transport policy and read with interest that HSE transport policy will identify the current patient transport needs throughout the country. So far the group has met on a number of occasions and is in the process of developing a service, it is not even in place. I thought again about my journey and about those who are not lucky enough to have friends who can travel with them. Those people might have to get off the train to vomit. Such is the reality for those travelling from the midlands because there is no service.

There is a good service in Portiuncula. There should be an outreach centre from there to offer care to people in a humane way. I do not want to raise the case of Susie Long but I am trying to convey that heartbreak. I know the Minister cares and is doing her best. I am fearful, however, of Professor Drumm and the HSE and I have no confidence in the system.

Under the national spatial strategy, we aspire to the doubling of the population of the midlands in the next ten years. If that is the case, we will have 150 new breast cancer cases annually, not to mention all of the other acute illnesses. Mullingar should be a centre of excellence or have at least an affiliated centre where we could offer triple assessment to the population of the midlands. We deserve the same quality of care as the people in Dublin. Why have four centres of excellence in Dublin and none in the midlands? I feel very strongly about this and must be parochial. I look forward to Professor Keane's decision on the location of specialist care for the sick of the midlands.

I must raise another serious issue with the Minister regarding the roll-out of primary care units. On first being elected to Athlone Town Council, I was informed the town would be allocated a primary care unit. As I have indicated to the Minister several times, Athlone lacks an accident and emergency unit. The councillors were informed the town would be allocated a specialised primary care unit and that the project would go ahead. Last week, the HSE indicated to Athlone Town Council that it would probably go ahead. However, the local Government Deputy indicated that the project would never see the light of day in the current financial climate. I seek clarification in this regard. What is going on? Are funds available? Do the Minister's colleagues in Government not discuss important initiatives, such as the primary care unit in Athlone? Six months ago, before the general election, the Government's representatives were parading around the town and talking about this wonderful facility. However, the Government Deputy who represents Athlone has stated she does not believe this will happen. As Athlone lacks a health service, the Minister should clarify this matter. An announcement will take place this week and I want to know what it will be.

Fiona O'Malley (Progressive Democrats)
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I am somewhat disappointed as I had expected there would be standing room only in the Chamber for a debate to discuss the cancer services. Since Members returned for this session, there have been calls for the Minister to come before the House. I understand this is the Minister's third visit to the House and I welcome her again.

Mary Harney (Dublin Mid West, Progressive Democrats)
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It is my fourth visit.

Fiona O'Malley (Progressive Democrats)
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Is it?

Frances Fitzgerald (Fine Gael)
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The time has been allocated.

Fiona O'Malley (Progressive Democrats)
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I would prefer if it was without interruption. I am glad she has returned to the House——

Frances Fitzgerald (Fine Gael)
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On a point of order, if the Senator wishes to extend the time, Fine Gael is perfectly agreeable.

Fiona O'Malley (Progressive Democrats)
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——-because it is important that when Members have a debate——

Frances Fitzgerald (Fine Gael)
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More Fine Gael speakers are available if she prefers. The time has been limited by the Government.

Fiona O'Malley (Progressive Democrats)
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——that people are——

Fidelma Healy Eames (Fine Gael)
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This is disingenuous.

Frances Fitzgerald (Fine Gael)
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On a point of order, the time has been limited by the Government and the Senator is being disingenuous. Fine Gael Members have filled the time available. If Senator O'Malley wishes to allocate another two hours to us to continue to debate the health service, we will happily take it. The Senator's comments were disingenuous.

Fiona O'Malley (Progressive Democrats)
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May I continue for the few minutes left to me? I wish to share my time with Senator Cannon, with the permission of the House.

Denis O'Donovan (Fianna Fail)
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Is that agreed? Agreed.

Fiona O'Malley (Progressive Democrats)
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I am disappointed because I had expected Members to fill the Chamber while the debate was under way.

Geraldine Feeney (Fianna Fail)
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Hear, hear.

Fiona O'Malley (Progressive Democrats)
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I am glad Senator Fitzgerald has returned to the Chamber because it is important to listen to the opinions of others.

Last week, Members saw an unfortunate incident in the Irish health service in so far as everyone, from politicians and radio announcers to journalists, suddenly became health experts. Apparently they knew what was best rather than allowing the actual experts, to whom responsibility has been given for delivering the health services, to get on with their jobs. While such experts should be accountable, they should be allowed to get on with their job. I wish to put on the record that Professor Drumm spoke well in his recent radio interview. He did not state that he was blaming local people. However, he did state that it is extremely difficult to deliver national services and, while I hate using the phrase, it is now common parlance, the centres of excellence, in the teeth of opposition, which is largely led by politicians of all hues. Such sentiments have been expressed in the Chamber today on all sides.

I listened to Senator McFadden, who made her points with great feeling. However, how can she state that she is prepared to offer her constituents a sub-standard service? She would prefer to offer them a service——

Fidelma Healy Eames (Fine Gael)
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She did not say that.

Fiona O'Malley (Progressive Democrats)
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She said——

Nicky McFadden (Fine Gael)
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I referred to an affiliated centre that would facilitate a centre of excellence.

Fiona O'Malley (Progressive Democrats)
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——she would like to have a local service. I would appreciate being heard without interruption.

Denis O'Donovan (Fianna Fail)
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The Senator——

Nicky McFadden (Fine Gael)
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Senator O'Malley is misquoting me.

Fiona O'Malley (Progressive Democrats)
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Allow me to——

Fidelma Healy Eames (Fine Gael)
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Senator O'Malley should not address Senator McFadden if she does not want her to respond.

Denis O'Donovan (Fianna Fail)
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Senator O'Malley, through the Chair.

Fiona O'Malley (Progressive Democrats)
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Senator McFadden stated she would like services. While all Members accept there will be a limited number of centres of excellence, in essence they are asking for one in their own backyards.

Nicky McFadden (Fine Gael)
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Dublin has four such centres. It is all very well for Senator O'Malley as the people of Dublin are being looked after.

Fiona O'Malley (Progressive Democrats)
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What is important——

Denis O'Donovan (Fianna Fail)
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Senator O'Malley, without interruption.

Nicky McFadden (Fine Gael)
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It is all about population.

Fiona O'Malley (Progressive Democrats)
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——for all citizens is a high standard of outcome. While this means that services may have to be curtailed and I can understand Senator McFadden's annoyance that they are curtailed in somewhere like Mullingar——

Nicky McFadden (Fine Gael)
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It is not annoyance.

Fiona O'Malley (Progressive Democrats)
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They are being curtailed because of safety concerns. They are not being curtailed——

Nicky McFadden (Fine Gael)
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I do not need the Senator to lecture to me.

Fiona O'Malley (Progressive Democrats)
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——to persecute the people. They are being curtailed to provide the best level of services that can be made available. This is what is needed and is why, as Professor Keane begins his work, Members should give him the space to be able to do it. They should not hop on bandwagons as soon as he makes a decision that may be unpopular locally. Members must rise above this.

Undoubtedly the health service has problems. However, I believe Senator O'Toole suggested that it is high time that Members realised it is in their interest as politicians to make patients feel confident and secure that those who are the best-placed clinical judges of decision-making are allowed to get on with it without political interference. This is the reason I applaud the Minister's decision to give the person who has the responsibility to deliver the service——

Denis O'Donovan (Fianna Fail)
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While four minutes remain to the Senator, she agreed to share her time with Senator Cannon.

Fiona O'Malley (Progressive Democrats)
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That will leave him with four minutes.

Denis O'Donovan (Fianna Fail)
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Approximately.

Fiona O'Malley (Progressive Democrats)
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Very well. I will finish on this point.

Mary Harney (Dublin Mid West, Progressive Democrats)
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We should allow some men to speak.

Fiona O'Malley (Progressive Democrats)
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The person who has responsibility for delivering services also has financial responsibility for them. This is the reason I applaud the work the Minister is trying to do and I only wish she was better supported in this regard.

Nicky McFadden (Fine Gael)
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For God's sake.

Fidelma Healy Eames (Fine Gael)
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He did not talk about quality of life.

Fidelma Healy Eames (Fine Gael)
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There is a major difference. Cancer care affects quality of life.

Pat Moylan (Fianna Fail)
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Each group has five minutes to put questions to the Minister. It is up to each group to decide how many Members will speak in that five minutes. If a Member talks for too long on a question, other Members will lose out. The Fine Gael group will go first.

Frances Fitzgerald (Fine Gael)
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The five minutes will be shared with my colleagues. I thank the Minister for staying to take our questions. When will the implementation strategy be announced? Is it the Minister's intention to close local hospitals before centres of excellence are fully operational? What work is being done with or for these hospitals in terms of their future role, perhaps as ancillary services or specialising in other areas? Does the Minister intend to close them? It would be helpful to know what is happening.

The Minister said yesterday she was happy with cervical cancer tests being sent to the United States. Why is that the case given that, first, there should be laboratories in this country and, second, serious concerns have been expressed in Ireland about the reading of some of those results as there is a different screening approach to cervical cancer in the United States?

Fidelma Healy Eames (Fine Gael)
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Will the Minister, in conjunction with the Health Service Executive, put checks in place to ensure every system and department in the HSE is accountable to prevent future health crises relating to cancer services, hygiene and so forth? Will warning letters be acted on in future? Does the Minister accept that dedicated beds are required in cancer care centres? Will she invest in laboratories in this country so they may become accredited, instead of investing in US laboratories which is another variation of the National Treatment Purchase Fund? When will there be a primary health care centre in Oranmore to replace the current sub-standard, rat infested centre built in the 1950s?

Paudie Coffey (Fine Gael)
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When will radiotherapy be available in Waterford Regional Hospital to serve the public in the south-east region? The early detection of cancer is a major priority for any cancer strategy. Will the Minister confirm when BreastCheck will be available in Waterford city and other areas? The Taoiseach gave a commitment in the general election campaign that the service would be operational in October this year. It is now November but there is no sign of it.

What plans does the Minister have, and what resources have been allocated, to promote early detection of cancer in males, specifically testicular cancer and prostate cancer? Despite the fact that cervical screening is known to be highly effective in detecting early pre-cancerous changes and preventing deaths from cervical cancer, there is still no national screening service for cervical cancer. I have consulted practice nurses who are waiting up to six months for results. This is totally unacceptable. When will these improvements be made and when will there be a national screening service for cervical cancer?

Maurice Cummins (Fine Gael)
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In January 2007 the Minister gave a commitment that Waterford Regional Hospital would have a 42-bed oncology-haematology inpatient unit and a 20-bed oncology day ward. The Taoiseach wrote a letter four days before the general election, a copy of which I have, stating that planning permission would be sought by the end of this year and work would begin by 2008. Planning permission has not yet been sought. Will the Minister give a progress report on the provision of these beds?

With regard to the 20-bed unit, at present there is only a room for six people although 26 people were in it a couple of weeks ago. Some people were getting sick. There is no dignity for people in such a situation. Will the Minister address this problem as a matter of urgency?

I wish to raise the issue of liaison nurses. The staffing situation is deplorable. After St. James's Hospital, Waterford Regional Hospital is probably the busiest. St. James's has 30 liaison nurses but Waterford only has five. Will the Minister comment on that?

Jerry Buttimer (Fine Gael)
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Will the Minister ensure that no man or woman will be obliged to wait for an X-ray, mammogram or other such service? I am aware of a case where a woman waited two and a half years on a public waiting list. If she had not gone to a private provider and paid for the service, she would still be waiting. The Minister must ensure this practice does not continue.

Paddy Burke (Fine Gael)
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In a letter to Deputy Enda Kenny, Dr. Hynes stated that all cancer services at Mayo General Hospital would be transferred to Galway. The Minister said 50% of the transition would probably take place in 2008 and 80% to 90% of it would be completed by 2009. Does that mean that within a two-year period all cancer services at Mayo General Hospital will be transferred to Galway?

Pat Moylan (Fianna Fail)
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I welcome and compliment the Minister. If the Minister can reply to the questions in five minutes, she is some Minister.

Mary Harney (Dublin Mid West, Progressive Democrats)
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Senator Fitzgerald asked about the implementation strategy. I have a meeting tonight with Professor Keane and am due to have a five-hour meeting with him on Thursday. He will come forward with the implementation plan early in the new year. He spent some time here before he agreed to take the position and he knows a lot of the clinicians and other people who work in the HSE. He wants to meet a lot of people and enter into dialogue on the way in which services can be relocated from smaller hospitals to the centres of excellence and from the centres back to the smaller hospitals. In the west, for example, many patients who are travelling to Galway for treatment could have their procedures performed in Portiuncula, Roscommon, Castlebar or Sligo. The intention is to move services that do not need to be in the cancer centres out to the smaller hospitals and to move cancer-related activities into the centres.

We must do as much as we can at local level. Some of the diagnostics may be carried out locally, with tests taken at a local hospital and read at the centre by the experts. That is not uncommon in other countries. Obviously, chemotherapy will be provided. The one area in which we are top of the class worldwide is in the treatment of children's cancer. That is because it is centrally planned in Crumlin and administered in 15 or 16 hospitals around the country. As the experts in Crumlin are involved in planning and supervising care, we are at the top of the class. That is what we want to do with other cancers as well.

Senators asked why I am happy about outsourcing. We have two accredited laboratories in Ireland. At the moment 300,000 opportunistic smears are taken every year. When the cervical screening programme rolls out next year we will be doing 240,000 per year. That is less than what we are doing at the moment. We have 80 cervical cytology specialists although we do not need anything like that number. I am asked why we do not have more, but we actually have more than we need. For the moment, to improve the speed of response — because six months is not a speedy response — the service was outsourced via a procurement process and awarded to Quest in the United States. This is an accredited laboratory with very high standards and the results are returned quickly. If we are to put the patient first, we must think of innovative ways of getting the results to the patient. In my experience, patients do not care how something is funded or who organises it. What they care about is getting treatment fast when they need it and, in particular, being provided with a quick diagnosis.

Fidelma Healy Eames (Fine Gael)
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Will the Minister invest in accredited laboratories here?

Pat Moylan (Fianna Fail)
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Please allow the Minister to reply.

Mary Harney (Dublin Mid West, Progressive Democrats)
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Yes, but we cannot have 35 laboratories.

Fidelma Healy Eames (Fine Gael)
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No, but will the Minister invest——

Mary Harney (Dublin Mid West, Progressive Democrats)
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The health forum was due to meet today for its third meeting, although it was postponed, for reasons of which Senators are probably aware, until next week or the following week. There are issues we want to discuss with the stakeholders, the social partners. This health reform is for all of us. There is one thing of which we can all be certain — we may never go back to school again, but we will all need to use the health services. Every citizen in this country is entitled to expect that the health service will reach the standard of progress that pertains in the country generally.

This brings me to the public-private issue. I do not believe it is acceptable that if one is a private patient or has money one has preferential access to publicly funded facilities. Senator O'Toole spoke about these facilities. They are funded by the taxpayer and staffed by nurses and radiographers who are paid by the taxpayer, yet the late Susie Long was told in one of these publicly funded facilities that if she did not have private health insurance she would have to go on a waiting list but if she did she would have the treatment the following week. This is fundamental to the new contract of employment for consultants. If I had said yes to current practices we would have had a contract two years ago. However, a fundamental aspect of changing our health system and guaranteeing equity of access is changing the contract of employment for consultants. In this way we can guarantee that citizens will be admitted as outpatients on the basis of medical need under an appointment made by the hospital, that they will be diagnosed on the basis of medical need under an appointment made by the hospital, and that they will be admitted to accident and emergency departments on the same basis. There should not be a division between the private group and the public group. These are unacceptable practices and changing this is at the heart of the new contract for consultants.

I cannot guarantee there will be no more crises. The best health systems in the world have failures. Human beings make mistakes and the health system is very labour-intensive. However, I can guarantee that whatever part of Ireland people live in, they will have access to the same quality of cancer care. The implementation of these standards will be overseen not just by Professor Keane and the cancer control group but by HIQA, the new standards body which is probably unique among health systems and certainly new in Ireland. We now have a State organisation whose remit is to set standards and monitor their enforcement. That is the greatest guarantee of all.

We also want to make sure that when mistakes occur people blow the whistle. The awful situation in Portlaoise was brought to the attention of the authorities by the director of nursing at the hospital. That is the reality. Letters were written to the Department of Health and Children in 2005 and were acted on robustly by the cancer division and the HSE. The medical director, Professor Hollywood, who was mentioned here earlier, spoke to Mr. Naughton about these concerns. However, it was the director of nursing, who knew about the false positives, who last August drew attention to what was happening and it was only after that complaint that the service was suspended. I commend her, as I have commended her previously. In addition, two nurses at Our Lady of Lourdes Hospital in Drogheda drew our attention to what was happening in the maternity unit. The new Health Act provides that people who make complaints are not adversely affected in their place of employment and I am a strong supporter of this. It is not that I want people going around reporting on everybody else but we must encourage people to come forward when they see something is wrong. For more than 25 years in Drogheda many people must have known that things were wrong, yet it took a report from two nurses to bring it to our attention. To be fair, an administrator in the North Eastern Health Board, Ambrose McLoughlin, took it seriously.

I do not know when we will have a primary care centre in Athlone. Deputy O'Rourke has spoken about this on many occasions. As a matter of interest, I understand that few people in Athlone attend accident and emergency departments anywhere, which is an interesting statistic.

Nicky McFadden (Fine Gael)
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We do not have an accident and emergency department. That is why we do not attend.

Mary Harney (Dublin Mid West, Progressive Democrats)
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I know, but there are fewer that use these facilities. Primary care generally works better in some of these places.

Nicky McFadden (Fine Gael)
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We do not have a primary care facility either.

Mary Harney (Dublin Mid West, Progressive Democrats)
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We are committed. There are 500 GPs involved in primary care at the moment and a further 700 GPs will be——

Nicky McFadden (Fine Gael)
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On what date will we get this?

Mary Harney (Dublin Mid West, Progressive Democrats)
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I do not have specific information on Athlone.

How cancer treatment is organised in a hospital is clearly a matter for the CEO and the hospital management. However, we would like to have a cancer unit in all hospitals. From the point of view of patients, staffing and resources, it would be helpful to have all units related to cancer situated together rather than being spread out all over the hospital, which is currently the case.

Fidelma Healy Eames (Fine Gael)
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I thank the Minister.

Mary Harney (Dublin Mid West, Progressive Democrats)
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These are management issues. In many cases it is not a question of new resources.

BreatCheck has been established in 17 counties and it will be rolled out in a further nine counties. The Tánaiste and Minister for Finance will announce the budget two weeks from tomorrow and I am optimistic that increased funding will be provided for cancer services, including the new cancer control programme, BreastCheck and cervical screening. We are committed to that.

Senator Prendergast asked about radiographers. On Wednesday of next week, 28 radiographers are being interviewed in places such as New Zealand. There is a worldwide effort to attract qualified staff in these specialties.

Pat Moylan (Fianna Fail)
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Unfortunately, five minutes were ordered for the Minister's reply, and other groups need to ask questions.

Frances Fitzgerald (Fine Gael)
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Could the Cathaoirleach not show a little leniency? There are only two other questions to be covered.

Pat Moylan (Fianna Fail)
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I have given the Minister four extra minutes to reply to the questions asked. There may be an opportunity——

Paddy Burke (Fine Gael)
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On a point of order, the Minister is answering other questions that were asked earlier in the debate rather than the questions that were asked in this session.

Pat Moylan (Fianna Fail)
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I ask Senators to respect the Minister. It is the first time I have seen a Minister come in here prepared to take questions.

Frances Fitzgerald (Fine Gael)
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We welcome that.

Senators:

We accept that.

Pat Moylan (Fianna Fail)
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I call on the Government group. They have five minutes.

Frances Fitzgerald (Fine Gael)
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Will the Cathaoirleach give the Minister an opportunity to answer the specific questions asked?

Geraldine Feeney (Fianna Fail)
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I wish to share my time with my Fianna Fáil colleagues.

Maurice Cummins (Fine Gael)
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The Minister might answer the questions if they are from the Fianna Fáil side.

Geraldine Feeney (Fianna Fail)
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I read with alarm at the weekend about the women in Portlaoise. One newspaper reported that they were to be given their results last week, but this has now been put back by two weeks. What is the position on this? I ask this because the Minister started off her presentation by speaking about the women in Portlaoise.

The Minister has answered my main question on BreastCheck. However, Senator Prendergast spoke today about the possibility of extending the scheme to women over 65. Could we consider, rather than extending the scheme to those over 65 — although I do not wish to leave them out — bringing the minimum age down to 40? Sometimes cancer is more aggressive in younger people than in older people. Perhaps I am wrong in thinking that and if I am, I stand corrected.

On the centres of excellence, would the Minister consider a strong advertising campaign along the lines of the advertisements for drink driving where one must almost switch the channel because they are so graphic? They are terrifying and have a terrible effect. If the Minister were to explain to the wider population just how good centres of excellences are for outcomes by interviewing people who have been treated at these centres, it might get the message across.

Fiona O'Malley (Progressive Democrats)
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Does the Minister intend putting a time limit on the consultant contract negotiations because this contract is pivotal to getting reform in the health service? I ask the Minister to update us on the position with the consultant contract.

Maria Corrigan (Fianna Fail)
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What is the position on the provision of occupational and speech and language therapists? At present there is an 18 month waiting list for very young children who wish to see such therapists.

What will be the position on private hospitals under the national cancer control strategy? Will there be quality standards to which they must adhere? Will residential facilities for children with disabilities, for adults with disabilities and for children of non-national refugees be included in the inspectorate's remit? Will it be possible for accident and emergency departments to undergo spontaneous and unannounced audits during the winter?

Terry Leyden (Fianna Fail)
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I ask the Minister to allay the fears of the people of Roscommon on the continuation of acute surgery at the Roscommon County Hospital. There was a large protest in Roscommon on Saturday last because of the fears expressed by the four consultants.

Joe O'Toole (Independent)
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Was Senator Leyden with them?

Terry Leyden (Fianna Fail)
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I was.

David Norris (Independent)
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Is it a centre of excellence?

Terry Leyden (Fianna Fail)
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The consultants, Dr. Charles Burn, Dr. Pat McHugh, Gerry O'Mara and Liam McMullen have written an open letter to the people of Roscommon stating that the proposal is to have day surgery only at Roscommon County Hospital, and no acute surgery. That would mean the accident and emergency department at the Roscommon hospital would have no future. I made the point to Professor Drumm here in the House on 8 November last when we had an open meeting with him. He stated the negotiations on Portiuncula Hospital and Roscommon County Hospital were under way and would be completed next year. Frankly, the position is that the people of Roscommon will not stand for this after all that has happened. Twenty years ago I was in a position in the then Department of Health to prevent the hospital being turned into a district hospital.

Paudie Coffey (Fine Gael)
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This is a speech.

Terry Leyden (Fianna Fail)
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Twenty years later I do not intend to be in this House and allow a situation where 24 hour, seven day accident and emergency department services are removed from the Roscommon hospital. I want the Minister to allay the fears of the people of Roscommon in connection with the continuation of acute surgery and of 24 hour, seven day accident and emergency services, which saved the lives of three young men at the end of September 2007.

Brian Ó Domhnaill (Fianna Fail)
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I ask the Minister for an update on the ongoing discussions with her northern counterpart on the provision of a radiotherapy treatment facility for cancer in the north west and, in particular, the possibility of such provision in Letterkenny, taking into consideration the ongoing discussions there with the proposed private hospital in Letterkenny. What will be the outcome? I understand that her northern counterpart indicated that the services in Belfast will not be able even to treat all of the cancer patients in the North, let alone those travelling from Donegal. Can we expect to hear some good news in that regard? Under the auspices of the Good Friday Agreement and the powersharing in the North, it would be a brilliant gesture if we could have patients treated on a cross-Border basis, preferably in Letterkenny if possible.

Mary Harney (Dublin Mid West, Progressive Democrats)
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There was a large number of questions asked. In reply to Senator Feeney, all of the mammograms have been reviewed by Dr. Ann O'Doherty at St. Vincent's Hospital and the final patient will be met tomorrow. Tomorrow afternoon, when the last patient is met, we should be aware of the outcome of all of the readings of the mammograms.

On the extension of the age for BreastCheck, I was asked earlier about it being an annual check. In Britain it is done every three years. In Ireland we meet the best international standard recommended, which is every two years. The National Cancer Forum does not recommend reducing the age criteria below 50. It recommends moving to an older rather than younger age and we must adhere to the advice of the experts. I do not make these decisions.

Senator Feeney also asked how we would inform the public. Communication is important here. I hope Professor Keane will engage in communications because in talking about some of these issues I find — I do not want to sound arrogant — that people are misinformed. Among those with whom we must communicate are clinicians because patients have great faith in their doctors. The reality is that surgery, for example, is moving towards specialist procedures and generalists are not appropriate for matters such as breast cancer, and many patients do not understand that. I hope that between the Health Information and Quality Authority, HIQA, with its emphasis on standards, and Professor Keane and the team he will assemble around him, we will engage in communications on many of these issues.

Senator O'Malley asked about the consultant contract. I stated publicly last week that we have come to the end. The independent chairman made recommendations a couple of weeks ago. I accepted them. The HSE accepted them. The doctor representative body seemed to accept them but, notwithstanding their acceptance, people want to start negotiating all over again and time is running out. We are recruiting virtually no new consultants into the system. We are depending, as people retire, on locums. That is not satisfactory but we cannot continue to recruit on a contract of employment that is unsatisfactory as far as the public health system is concerned. The advertising campaign, which was suspended at the request of the chairman, will now proceed. I have been discussing that with the HSE, with the chairman of the board, with Professor Drumm and with my officials in the Department of Health and Children.

On private hospitals, we have already written to the independent hospital group and to insurers on the new standards because approximately 500 breast surgeries seem to take place in the private system. Clearly, there is no licensing or accreditation regime in Ireland for private provision, and this is a significant deficit. We have established the patient safety commission, chaired by Dr. Deirdre Madden BL, to examine these issues and what kind of licensing or accreditation system we need in place, and she is due to report next summer.

The intention is that the standards will apply. The Minister for Health and Children has an obligation to patients, whether public or private, to ensure they are cared for appropriately.

HIQA's inspectorate will apply to places where children — whether Irish or non-Irish — reside, to the disability sector and to public and private nursing homes. It applies, not to asylum cases where families are living, but to places where children, people with a disability or older people are in care.

As Senator Leyden will be aware, if I recall correctly from my recent meeting, one of those surgeons is shortly to retire. The intention, given the recommendation from the Royal College of Surgeons which is the training body for surgery in Ireland, is that there should be a joint department of surgery between Portiuncula Hospital and Roscommon County Hospital and that their surgical affairs should be arranged on that basis. The HSE recruited the chief surgeon in Scotland who is working with both hospitals and with the clinicians to make that a reality. If memory serves me correctly, a meeting on these issues took place this week in Roscommon. From my point of view, and that of the Government, we want services to be provided as locally as possible to where people live provided they can be quality and patient-safety assured.

On accident and emergency department services, there is a new stroke drug which is suitable for only certain stroke patients. It must be administered within three hours of a person having the stroke. It must be administered by highly specialised staff or otherwise one could kill the patient. If we take people to a place where we do not have the expertise to administer a drug of that kind, for example, and if we have delayed the vital time in getting the person to the centre where that could happen, it could have dire consequences.

After 5 o'clock in the evening, in the main, our accident and emergency departments are staffed by junior doctors. These are doctors in training. That is not satisfactory. We must put patient safety and quality first in everything we do. That must come before constituencies, institutions, doctors and whoever. The Minister for Health and Children has an ethical obligation to stand up for what is right in terms of patient safety.

Donie Cassidy (Fianna Fail)
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Hear, hear.

Mary Harney (Dublin Mid West, Progressive Democrats)
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On therapists, money will be given to the Health Service Executive under the disability programme——

Terry Leyden (Fianna Fail)
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The people in Roscommon want an accident and emergency service.

Pat Moylan (Fianna Fail)
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Please allow the Minister to reply.

Mary Harney (Dublin Mid West, Progressive Democrats)
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Everything will be kept open provided it is safe to do so. The people of Roscommon do not deserve an inferior service, no more than people elsewhere.

Terry Leyden (Fianna Fail)
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They do not deserve not to have a service.

Mary Harney (Dublin Mid West, Progressive Democrats)
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On Senator Corrigan's question about the therapists, there has been a delay in recruiting some of those therapists. I regret that is the case, particularly in terms of speech and language therapy which has major implications for disabled children. I have seen the difference between a child that has speech and language therapy and one that does not. Resources will be given to the HSE. Some industrial relations issues arose regarding the recruitment of many of these therapists at community level where IR agreements specified that they had to have three years' experience in the hospital before they could work in the community. That is a crazy situation that applies to physiotherapists also, and 40% of our physiotherapists who qualified last year remain unemployed. We are working with the HSE on those issues and I assure the Senator it is on the top of my list of priorities in terms of the disability sector in particular.

Senator Ó Domhnaill asked me about Altnagelvin, or rather the north west; he does not represent Altnagelvin yet.

Brian Ó Domhnaill (Fianna Fail)
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Thankfully.

Mary Harney (Dublin Mid West, Progressive Democrats)
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I had a very good meeting with the Minister for Health in Northern Ireland, Mr. McGimpsey, and will meet him again next week in the North-South Ministerial Council. The only centre of excellence in Northern Ireland is in Belfast. They did what we are doing here ten years ago. They intend to locate another centre on the western side of Northern Ireland as a satellite of Belfast, which would be very beneficial for Donegal patients. We have offered to work together either on the capital cost of that or in procuring services from each other. I want to see that happen as quickly as possible because real issues of peripherality arise as far as Donegal is concerned.

Cecilia Keaveney (Fianna Fail)
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Hear, hear.

Senators:

Hear, hear.

Joe O'Toole (Independent)
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I thank the Minister for taking questions. I have three questions to put to her, the first of which was raised by Senator Bacik who has been unavoidably detained. She would like clarification on the recruitment freeze. That issue was discussed by a number of our people and we would like to know the current position in that regard. It is having a clear impact and we believe we are being misled, in a sense. We got a clear impression it would not impact at the coalface but that appears to be the case.

My second question is similar to one asked by Senator O'Malley. I am unclear about the current blocks in the debate on the consultants' contracts. I will accept it if that information is confidential but there has been so much discussion back and forth it would be useful if we were to know that.

The third question, which I raised earlier, is complex and crucial in terms of buying in to where we are heading, so to speak. It concerns the various issues we raised, including the monitoring committee the Minister is chairing, key performance indicators, targets — an issue raised by Senator Fitzgerald — objectives and the assessment process. I do not want to do the work of a remuneration committee or whatever but if the Minister could share with us information on those issues, in six months' time we would be able to ask what has been done, have we fallen behind, are we ahead or what is the position.

Also, is there an audit committee in every hospital? Is there a general audit risk register and is that a confidential document? If we knew that, it would save us having to ask many questions. If I had access to that information I could find out immediately who is responsible for dirt in a hospital.

David Norris (Independent)
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Hear, hear.

Joe O'Toole (Independent)
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We could then place the blame where it should lie. Those are the three issues I want to raise. The last one is on key performance indicators, targets and objectives and whether they can be shared with us or outlined publicly to allow us to inquire about them. The second one is on the problems with the consultants' contract and the third concerns the recruitment freeze. Senator Norris has a number of questions.

David Norris (Independent)
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I have three questions also. I support strongly the idea of centres of excellence. I know there are political difficulties because everybody seems to fight for their own back yard but it is important. It would have been better if they had got agreement in principle from everybody before they looked at the geographic location. That was a flaw. Also, the public must be reassured that no more local services will be closed until the centres of excellence are in existence.

Nicky McFadden (Fine Gael)
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Hear, hear.

David Norris (Independent)
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There is no point in doing it the other way around.

On that basis I would like an update on the position regarding St. Luke's Hospital. I ask the question because of the special benefits that accrue to patients there, large numbers of whom have contacted me. There are substantial grounds in the hospital where they can have a walk, sit down, enjoy the shrubbery and so on and many of them, as well as some of the staff, have told me that is vital in terms of assisting in their recovery. I understand there are proposals to move that to St. James's Hospital, possibly into some kind of tower block. Will the situations that have been proved beneficial in the special circumstances of St. Luke's be replicated? Will people have that kind of nurturing environment or will they be stuck in some type of tower block? Is there a timescale in that regard?

Regarding my second question, I have been very impressed, as have many members of the public, by the passionate advocacy of Professor John Crown. That may not be popular with everybody but we appear to have in this man a national asset, somebody who has international experience, a clear view and is a specialist in the area of cancer. Is there any way he can be brought on board in terms of getting to grips with the area of cancer treatment? That would go a long way towards making the public believe that we were all rowing in this together. I would link that with what I said earlier this afternoon about a Tallaght strategy. All of us must fight in that regard. I said it about politicians earlier and I say it now about doctors too. I would welcome it if he could be brought on board.

Taking up what Senator O'Toole said, my third question is about cleaning. My compliments to the Minister on the way she is taking these questions and dealing with them; obviously she is somebody who is in control of the information. We may not agree with every attitude, programme and ideology but she has the facts at her fingertips.

With regard to cancer patients, when they have had chemotherapy, radiotherapy or whatever, their immune systems are often weakened. They are particularly vulnerable in terms of infection and a lack of cleanliness. Would the Minister agree that a business model is not necessarily the most efficient in this regard? Many hospitals buy hours of cleaning, which might appear good in an accountancy statement but it is inefficient. Would it not be a good idea to have dedicated in-house staff to do the cleaning on the spot when required?

Mary Harney (Dublin Mid West, Progressive Democrats)
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I will start with the cleaning issue, if that is in order. We now have had three audits and to be fair to the last audit, it was much wider than the issue of cleaning. I have a quotation, which I will not bore Members by reading, but it complimented the hospitals on the hygiene issue but where they fell down was in risk assessment and taking the issue seriously at corporate governance level. If something cannot be measured, it cannot be managed. The fact that we now have an independent authority and that all of this data come into the public arena puts enormous pressure on people to perform. The audits are unannounced.

Regarding cleaning and the other two audits, whether they were insourced or outsourced, a new building or an old building, whether they had microbiologists or did not, there was no correlation. In the first audit Mallow hospital came number one. It had no microbiologist, it is very old and it had in-house cleaning. St. James's Hospital did very well; it was top of the class. It had outsourced some of its cleaning and insourced other aspects. If hospitals are outsourcing and buying in a service, they pay only for what they buy. In-house or out-house is not the issue. There are wider issues to do with how seriously the issue is taken. I have said previously and repeat now that in my previous job as Minister for Enterprise, Trade and Employment, if one went to Intel in Leixlip one was gowned from head to toe. I am not suggesting everybody going into a hospital should be gowned but one would not get near one of those semi-conductor chips inside the glass if one was not covered from head to toe. We must take seriously uniforms, visitors and so forth. In many of the world's best hospitals, there can be no more than two visitors per patient. I have seen hoards of people, sometimes bringing in take-aways, around four or six patients in wards. Hospital management should take seriously these matters, as this is not just Big Brother Minister saying something. A hospital is a place where there are many sick people. If they are not sick, they should be in alternative facilities.

Concerning St. Luke's General Hospital, every expert told us that a stand-alone radiotherapy hospital was not a good idea and that there must be multidisciplinary care where radiation, medical oncology and surgery are brought together. The decision was made to move the cancer treatment facilities at St. Luke's General Hospital to St. James's Hospital. Until recently, virtually everyone who received radiation oncology treatment undertook it at St. Luke's General Hospital. There is a significant attachment to the professionalism, the place and the staff. We want to keep the ethos in St. James's Hospital, an assurance I have given to the board of St. Luke's General Hospital.

The facilities at St. Luke's General Hospital have 150 beds, but there are 40 in British Columbia. When there are facilities in the centres outside Dublin, some of the people who would otherwise have gone to St. Luke's General Hospital may not need to travel to Dublin. Many must travel up on Sunday and return on Monday morning or Friday. Others would be more appropriately accommodated in a hotel or the like instead of a hospital-type facility.

These are the kinds of actions Professor Keane undertook in Canada and that I hope he will undertake here. The plan involves the Irish Cancer Society and Europa Donna, in which Senator Fitzgerald is involved. Patient groups, not just clinicians, were at the heart of the plan.

Dr. Crown is an excellent clinician and a world leader in his field. Memorial Sloan Kettering Cancer Centre, which I visited shortly after becoming the Minister for Health and Children, commended the fact that he was one of the two best doctors to have gone through it. I met him regarding a certain matter shortly after becoming the Minister, after which our relationship seemed to fall apart. I am not the one to bring him on board. He has strong opinions on my politics and I, but Professor Keane will bring him on board because we need people like him.

David Norris (Independent)
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Good.

Mary Harney (Dublin Mid West, Progressive Democrats)
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There are only 23 medical oncologists. We want all of them involved in this initiative, to embrace it enthusiastically and to work with us.

Jerry Buttimer (Fine Gael)
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Hear, hear.

Mary Harney (Dublin Mid West, Progressive Democrats)
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No one more than I wants key clinicians to work with our plans. Perhaps they will after the consultant contract is behind us. Senator O'Toole asked about the problem in that respect. There are a number of issues, but access to private practice in public hospitals is a large stumbling block. From time to time, others who may have different opinions have referenced other issues, but this remains a concern. We have endorsed the chairman's recommendations.

We want to move forward. The changes we want include having clinical directors, a clinician in charge of a surgical team with seven day cover, 24 hour service, longer working days and so on. I keep reading about people going to work seven days per week, but that is not the case. We do not want junior doctors in training staffing our hospitals' accident and emergency departments at 5 p.m. or 6 p.m. That is not a quality patient service.

Senators:

Hear, hear.

Mary Harney (Dublin Mid West, Progressive Democrats)
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If we are to provide a proper service, we need to double the number of consultants. There are 4,000 junior hospital doctors and 2,000 consultants. The sum total we pay them is no greater than what we would pay were we to have 2,000 juniors and 4,000 seniors. From a financial point of view, the current situation does not make sense. We want to appoint all new consultants on the new contract rather than the current one, which is unique among the world's public health systems. Last week's much-quoted OECD figures show that Irish consultants in the public system get 4.65 times the per capita income. Senators can read about it in the report. It is not a matter of what we pay people but of how they work, particularly in terms of equality of access to our public system. There is universal coverage, but some people have preferential access.

The recruitment freeze was done for budgetary reasons, but it affects relatively few numbers. The HSE has granted some 300 exceptions for essential or emergency cases. Recruitment will recommence after Christmas, but we are entitled to expect that the HSE will live within a budget as large as €15 billion.

I feel strongly concerning performance indicators, which have been introduced for hospitals by the HSE. Professor Drumm's summer announcement of more than 100 consultants is based on hospitals' performance. Those that perform will get more whereas those that do not perform well will get fewer.

Liaison nurses at Waterford Regional Hospital were referred to. That hospital has one of the country's best nurse-to-patient ratios and is one of the most efficient, but hospitals that do not do as well have much higher ratios. We want to reward the good performers.

Our health care system has the highest number of nurses in the world. I am told that there are no liaison nurses, but it is a matter for management to decide what nurses do. I want to keep as many nurses nursing as possible instead of moving them into management positions, but this may not be popular with nursing unions. I would like to reward nurses for doing the jobs they were trained for and are good at instead of allowing them to believe they must move. It is like other areas of life where one must move away from what one is good at to be promoted up the ladder. We must address issues in that respect.

There are considerable variations in bed stays between accident and emergency units. In the case of an appendix operation, one may be in hospital for two or three days or for a week, depending on the hospital. One thing is certain, however, if one is in hospital on a Friday, one has a 90% chance of still being there on Monday morning.

Money is being allocated hospital by hospital on the basis of performance indicators. The HSE has sent clinical and management experts to some of our hospitals, the results of which have been encouraging. A person is sent to work with the hospital instead of blaming or penalising it, which is a good approach.

Phil Prendergast (Labour)
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I thank the Minister, but I take exception to Senator O'Malley's comments. I have worked on the frontline of the health service for the past 23 years and was given this brief by my colleagues in the Labour Party. Their not being present does not mean they are not interested. They are interested, but they are busy.

Jerry Buttimer (Fine Gael)
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Hear, hear.

Phil Prendergast (Labour)
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I referred to breast screening and asked whether it would be extended to over 65 year olds and when it would be rolled out fully, which are important matters. The Minister answered Senator Feeney's question on the under 40 year olds. Generally speaking, those women are in tune with their bodies and good at noticing changes. Will the 23 medical oncologists be sufficient to provide the service in question?

I made an analogy concerning Dr. Courtney in Kilkenny, an expert in gastroenterology and surgery. When the services are centralised, will he travel from Kilkenny to Waterford to operate on a patient from Kilkenny? Does the Minister plan to introduce an immunisation programme with the cervical cancer vaccine? Testicular cancer and colorectal cancer treatment services will be available in four centres. While I do not want to diminish the importance of any cancer, some types are more easily treated or are more common. On what basis was it decided that each of the above types would be treated in four centres?

Babies are supposed to have developmental checks at nine months of age, but many are not being checked until they are two years old. That is late considering how many developmental issues can be detected and treated, and the earlier the better.

Fidelma Healy Eames (Fine Gael)
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Hear, hear.

Phil Prendergast (Labour)
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How much is being invested in cancer control? Of the additional €20.5 million, what is the total spend on cancer control? How much of the total spend on health services, some €12 billion, comprises salaries?

I agree with the Minister's point on hospital visiting hours and people's tendency to overstay. There is a poor public understanding that many hospital patients are sick with infectious diseases.

While it may sound old-fashioned, there were not many incidents of dirty hospitals when the nuns ran them. Recently a patient advocate recounted to me an incident in a hospital when a confused patient urinated behind a water dispenser. The hospital cleaner, who did not speak English, mopped the urine over the entire floor. That may be an exception but it does happen.

Uniform identification should not vary in order that the public and patients can recognise various grades. The staff nurse uniform in one hospital may be the same as that for a household services officer, a nurses' aid or a ward sister in another. Variance in hospital uniforms can cause confusion among the public. This was made apparent to me recently when I transferred a patient, who was deaf and could not read or write, to a Dublin hospital. It was difficult to explain to her that in the Dublin hospital, the person in the navy dress would conduct an intimate examination while the woman in the green dress might give her a cup of tea.

This is great opportunity to put these questions to the Minister this evening. I would be delighted if she could clarify the matters raised.

Mary Harney (Dublin Mid West, Progressive Democrats)
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The Senator's point on simplifying hospital dealings with the public is valid and not just in the case of her friend who is deaf. There are many foreigners living in Ireland who do not speak English. I recall a Chinese woman in Tallaght Hospital who was able to have direct communication only through her daughter because she had not a word of English. When I visited the children's hospital in Chicago, one item that attracted me was the use of children's cartoon figures to direct children to different services. It was simple on one level but it worked for children. In Vancouver, the cancer service facility we visited had a fantastic roof garden for patients. These are the types of services that must be incorporated in our new facilities. We are moving to fewer beds in wards. The hospital of the future will probably have mainly single rooms. The new national children's hospital, for example, will have single rooms with parent accommodation. These are the standards to which we are moving. No doubt, by the time we get there, there will be a new standard.

Dr. Courtney is not a surgeon but a gastroenterologist and will not be moving to Waterford Regional Hospital. There are approximately 20 patients there. The data from the local hospital and the report for funding are different but Kilkenny has relatively few breast cancer patients. The idea is that they will attend Waterford and some Waterford activity will move to Kilkenny. Kilkenny is one of our best hospitals. It is run extraordinarily well with a great spirit. Everyone works together with no little camps. They work well with their GPs and primary care providers. It is a model that has always impressed me. Dr. Courtney is one of the main drivers of change there. Sometimes it takes only one person to make a place function.

I cannot inform Members on the roll-out dates for BreastCheck for individual counties because I have told BreastCheck, part of the National Cancer Screening Service, that it must not be a political decision. This year, it has been rolled out in counties Roscommon, Galway and Cork. The remaining nine counties will be rolled out in the next 18 months. Without divulging budget secrets, funding is available for the continued roll-out of breast cancer screening, as well as cervical cancer screening. With changing demographics and the increasing cancer rate in the population, far more than 23 medical oncologists will be needed. While I do not know the exact figure, of the additional 2,000 consultants to be hired, a large number will be for cancer services.

We have expended €1 billion more on cancer services since 1997. The National Hospitals Office is examining the total spend on cancer services as it is difficult to differentiate between general and cancer surgery as they are sometimes combined. When the figures are ascertained, Professor Keane will have control of the cancer services budget. As Members are aware, if you cannot control the money, you are not going to make anything happen.

Fidelma Healy Eames (Fine Gael)
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We know that.

Mary Harney (Dublin Mid West, Progressive Democrats)
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On the further roll-out of cancer screening programmes, it is advised the next should be for colorectal cancer. This is already being prepared for, after the roll-out of cervical cancer screening.

Oral cancer is never commented on. It generally affects lower socioeconomic groups, particularly people who smoke and drink to excess. I was not aware until recently that there are 300 cases per year, an incredible number, particularly when one considers the 76 deaths per annum from cervical cancer. There are many cancers that we do not hear about in the media but which affect a large number of people. The emphasis of the centres will be on early diagnosis and, where appropriate, early treatment.

The health services budget comprises mainly salaries, approximately 75% to 80% of it. Service means employing people. The health services employ one in three public servants and expend a quarter of the budget spent on running the State. Every time a new service is rolled out, whether it is speech and language therapy or primary care, it involves employing more people. The public health system alone is labour intensive and employs 130,000 people. Some €15 billion from the public purse is spent on public health, and €3 billion to €4 billion from private sources. Up to 8.9% of national income is spent on health services, the OECD average, although 11% of the population is over 65 years of age as against 17% across the OECD. We are not getting the dividend for a young population. Hopefully, the health reform programme will get that dividend.

I have commented many times on the nuns who ran the hospitals. People were afraid of them. A consultant told me recently that the only person he was afraid of when training in the Mater Hospital was the matron, a nun. We do not want people to be afraid of anyone in the health services but the nuns worked hard. We must get everyone working on this. Before I am accused of having anything against them, we cannot get the nuns back simply because they are no longer available.

There is no excuse for a hospital or any health provision facility for not operating to the highest possible standards with the investments being made in them. This includes the case of the rat at the Oranmore health centre about which I was interviewed last Friday and of which I was not aware.

Frances Fitzgerald (Fine Gael)
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Since the Minister did not get to respond to several Fine Gael Members, will she give them a written reply or respond now?

Donie Cassidy (Fianna Fail)
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Members are concerned about the position in which pharmacists find themselves. They claim there have been no negotiations or consultations over the proposed pharmacy legislation. We are concerned in particular for the 400 family-run pharmacists. Would the Minister consider bringing together the two sides?

Mary Harney (Dublin Mid West, Progressive Democrats)
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In response to Senator Coffey, funding has been approved for a 42-bed unit in Waterford. I am told it will be in place in 2009 but work will begin next year. The radiotherapy service for Waterford will be a satellite centre. We have provided money to roll out that on a traditional basis and as a public private partnership. We will have all the capacity required by 2010. Meanwhile we are procuring services from Whitfield for public patients.

I have no brief about the Oranmore clinic. I will have to check on whether it is planned to put a new primary care facility there but the private sector is building many of these facilities which the State rents. This is a speedy way of getting facilities in place and of releasing the capital for other projects. I do not know if such a facility is planned for Oranmore. I will respond to the Senator.

Nicky McFadden (Fine Gael)
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A primary care unit in Athlone was promised in 1999.

Mary Harney (Dublin Mid West, Progressive Democrats)
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Under the competition Acts and the Treaty of Rome price-fixing provisions for self-employed professionals, it is not possible for direct negotiations to take place with the pharmacists. The Government has deliberated on this, Bill Shipsey, Senior Counsel, has been hearing the concerns of the Irish Pharmaceutical Union and I have discussed these matters with the HSE. I hope we will be able to put in place appropriate reimbursement for pharmacists. They earn their incomes from a combination of a percentage return on their sales from the distributors and the fee from the HSE and we want to separate the cost of the commodity from the professional fee for the pharmacists. I hope that can be achieved quickly. I fully support entrepreneurship and the pharmacy sector is an example of entrepreneurship providing a service to patients.