Dáil Éireann debate -
Wednesday, 4 Mar 1998

Vol. 488 No. 2

Other Questions. - Cancer Treatment Services.

Alan Shatter

Question:

17 Mr. Shatter asked the Minister for Health and Children his views on the criticism raised that there is no public hospital which has medical oncology, radiotherapy and oncology surgery, with the backup of specially trained oncology nurses and support staff, available in the same institution and that Dublin is unique as a European capital city in not having an integrated comprehensive cancer centre involving all the range of disciplines and providing a centralised cancer care concept, while also ensuring that adequate services are available in other parts of the country. [5940/98]

Mr. Cowen

The national cancer strategy, published in November 1996, is aimed at providing an integrated, comprehensive set of cancer treatment services comprising surgery, oncology and radiotherapy. The strategy was developed and agreed following an extensive process of consultation involving experts and organisations working in the field of cancer prevention, diagnosis, treatment and palliative care.

The strategy includes a plan for reorganising cancer treatment services around three supra-regional centres in which all of the major treatments for cancer will be available. Linked to the supra-regional centres will be a set of regional services in designated hospitals which will each provide a multi-disciplinary cancer service for patients within its area. Patients requiring more specialised services, including radiotherapy, will be referred to the appropriate supra-regional service.

The focus of the strategy is to provide comprehensive services in a designated set of high quality centres. The centralisation of all cancer treatment services in any one institution would be expensive and cumbersome and would not necessarily be to the benefit of patients, especially in terms of access to services. Instead, the strategy promotes close co-operation and co-ordination of services between hospitals and the development of regional self-sufficiency in appropriate specialties. I believe that the cancer strategy adopts the best practical approach in this regard. It emphasises the development of best practice and the promotion of agreement at local level as to which hospital is best placed to provide each type of cancer treatment.

An action plan to implement the strategy was announced in March 1997 by my predecessor. It included details of a national cancer forum to advise on implementation of the strategy and it announced the appointment of regional directors of cancer services for each area. The regional directors are making considerable progress already thanks to their commitment and the hard work of many others in the field of cancer prevention and treatment. The directors are currently drawing up regional plans for the development of services in their respective areas which are being funded by my Department.

I am committed to implementing the strategy as set out in the action plan. This year I provided £7.7 million for implementing the strategy, which is an addition to the £6 million provided for this purpose in 1997. In addition to this investment, £1 million was allocated in 1997 and again this year for the development of a national breast screening programme. The screening process is due to commence next September. A pilot programme of cervical screening is also in preparation in the Mid-Western Health Board area. I allocated £300,000 to this important project this year.

I have also provided the necessary funding for providing new consultant based services throughout the country in oncology, haematology, histopathology and palliative care. This will be implemented on a phased basis over the next few years and will ensure reasonable self-sufficiency to the greatest possible extent consistent with the provision of high quality services.

Mr. Shatter

Does the Minister accept that the lack of uniform access to services in addition to the absence of structured screening programmes and protocols for general practitioners and hospital doctors governing when and to whom patients suspected of having cancer should be referred, are reasons for the high death rate in Ireland from breast and ovarian cancer? Does he acknowledge it is unacceptable that proportionally twice as many women in this State die of breast cancer compared to the United States of America? Does he acknowledge that 41 out of every 100 women in Ireland who develop breast cancer lose their lives to the illness compared to 21 out of every 100 women in the United States? In the context of the implementation of his plan, at what stage does the Minister consider these figures will radically improve and the same level of care available to women suffering from cancer in the United States will be provided in Ireland?

Mr. Cowen

The Deputy is aware that the purpose of the national cancer strategy is to address the issues he raised. Its purpose is to provide equity of access to services in one's locality, to provide regional self-sufficiency and the necessary specialist care on an equitable basis. The model being used arose from an extensive consultative process undertaken by my predecessor. It has the support of all the specialists and their representative bodies. A specialist recently suggested a different model involving a centralised cancer treatment service. However, this model did not have the unanimous support of the specialist's representative body and others involved in this field.

It is not possible to redesign the entire health service delivery model. The service has developed since the foundation of the State and there must be co-ordination at local level to ensure the best possible care is provided. My confidence in the strategy is based on the confidence of the specialists who are working co-operatively to implement it in full. I commend my predecessor, as I have done previously, for bringing forward the strategy. It is an excellent approach and there will be definite improvements in the mortality rates mentioned by the Deputy once it is implemented.

There have not been proper screening services in the past. The breast screening service will begin in the Eastern, North-Eastern and Midland Health Board areas and involve the 50-64 age group, which is the highest risk category. It will cover half the national cohort when it begins in September. It was correct to ensure that the information systems were in place and that the population register was properly considered before screening began. From experience in Britain, we are aware that speedy implementation of screening can bring about false positives and negatives and even greater trauma than the absence of screening itself.

There has been caution but there has also been prudence and professionalism. There is confidence that this matter is being dealt with correctly. I acknowledge, in the absence of a strategy until now, that our mortality rates are higher than we would wish. The Deputy referred to the US which is probably the gold standard in success in this area. However, success involves resources and the level of specialist care and research facilities that are available. I acknowledge the statistical basis of the Deputy's comments but proceeding with the implementation of the strategy, as planned by the previous Administration, is the best way forward and has the best prospect of success.

Mr. Shatter

When does the Minister envisage that breast and cervical screening programmes will become national operations as opposed to initial programmes? Does the Minister accept that until such time as they are national and not regional programmes, the death rates from cancer will continue to be unacceptably high?

In light of new research that became available recently, will the Minister re-examine the need for a prostate screening programme? Such a programme was deemed unfeasible initially but it now appears more feasible.

Mr. Cowen

I will make inquires regarding the Deputy's second point about the prospect of a screening programme for prostate cancer.

National screening will begin in the absence of any database in this area. The first programme is not a pilot programme in that it will cover half the people who need to be screened.

Mr. Shatter

It is within a limited age group?

Mr. Cowen

Yes. A Swedish expert at a recent conference on this matter indicated that that age group is regarded medically as giving the best cost benefit. Younger age cohorts could be screened, but there is no evidence that the incidence of cancer would be detected earlier or lowered as a result. The Swedes have been to the forefront in this area and cost benefit analyses determine the position.

Once the first screening programme has been set up, the population registers in the other areas will then be considered. This is the way to proceed. If we were to wait until a national database was ready, it would not be possible to start anything in September this year.

Mr. Shatter

What is the timeframe for extending the programme nationwide?

Mr. Cowen

I do not have that information to hand but I will give it to the Deputy. I am concentrating on getting the programme up and running first.

Ms Shortall

The Minister correctly recognises the importance of screening and early detection for all cancers. It is regrettable that it is necessary to take a pilot project based approach to smear testing. Until there is a national screening project for cervical cancer, what is the justification for excluding smear tests from the medical card scheme? This is a huge gap in the service. People with medical cards must pay for smear tests.

An Leas-Cheann Comhairle

A question please, Deputy.

Ms Shortall

Why are smear tests not included in the services that are free of charge under the medical scheme? What is the justification for this disincentive to people to present for screening?

Mr. Cowen

I will give the Deputy a detailed and considered reply if she tables a question on that matter. Funds have been devoted this year to dealing with the delays in producing smear test results. This was a priority because results were not becoming available quickly enough. Funds were provided for improved resources and staffing.

In the absence of a systematic approach until now, it is obvious that we must have the correct database and information and IT systems. We do not want false negatives or to ultimately undo the good envisioned by the strategy. Regarding Deputy Shatter's comments, it has taken two years to get the breast screening programme up and running in the three health board areas. It will take a year or 18 months to formulate a population register for the rest of the country. This might be more difficult because it will involve more health boards and much more disparate populations where people may not be as readily available as they are in urban settings.

We should acknowledge that the strategy began under the previous Administration. There is now a strategic approach to screening and the development of cancer services. Much good work is being done and the resources, as set out in the plan, are being accorded. We should acknowledge the progress being made. Cancer is a major killer disease and political Administrations of every hue would give this area the top priority it deserves.