Dáil Éireann debate -
Wednesday, 9 May 2001

Vol. 535 No. 5

Private Members' Business. - Cancer Services: Motion (Resumed).

The following motion was moved by Deputy Gay Mitchell on Tuesday, 8 May 2001:

That Dáil Éireann condemns the Government for placing patients' lives at risk by its failure to implement and reach the targets set in the 1996 national cancer strategy and particularly for its recent unprecedented failure to provide adequate services to deliver essential medical treatment and care to patients with cancer.

Debate resumed on amendment No. 1:

To delete all words after "Dáil Éireann" and substitute the following:

"approves the Government's continuing and sustained commitment to implementing the national cancer strategy and welcomes the significant investment which the Government has made in enhancing patient care and in improving cancer-related services generally."

–(Minister for Health and Children).

Dr. Upton

I wish to share my time with Deputy O'Sullivan.

The Government has spent a lot of money on health services. Unfortunately, the statistics bear testimony to the appalling lack of effective health care for almost every section of the community. As always, those who are least able to afford health care are the ones who fall off the list. They either suffer on for months or years or die before they have the chance to receive treatment.

It is a measure of the priorities of the Government that the proposed Stadium Ireland is given precedence over the treatment of patients in our hospitals. The argument is not about spending money on sport. The problem of Stadium Ireland is that it will allow vast expenditure for the benefit of developing a monument to a few with access being confined largely to the privileged to the exclusion of the most needy.

Yesterday the Minister attributed our ills to the legacy of the lifestyles of 25 years ago. While none of us will deny that lifestyle impacts significantly on quality of life and health status, it is true nevertheless that many cancers are unrelated to lifestyle, but may be genetically determined.

It is ironic that one of my constituents is taking up a precious bed in a cancer treatment hospital. She is awaiting a bed in a rehabilitation unit which is unavailable. She does not want to be in a cancer treatment hospital as her treatment has been completed. She is, however, inadvertently denying another patient access to the bed in question and, possibly, life saving treatment. Surely this commentary on the general management of hospitals is a statement in itself. The lack of co-ordination of facilities within the public hospital sector must be addressed. It is not beyond the bounds of modern technology to identify places and vacancies and set priorities.

While it would not be easy to put in place, a centralised unit, operated with the co-operation of consultants, general practitioners and hospital management, would help to alleviate what is an inefficient and incomprehensible waiting list system. It is bordering on the ludicrous when the situation I have described is allowed to persist and limited specialised treatment is being denied because of the inefficiency of the system. The Minister for Health and Children should appoint a health ombudsman on a similar basis to that of the Office of the Ombudsman. Public affairs are increasingly being scrutinised by bodies such as the Public Offices Commission and the Office of the Ombudsman's, but some of the biggest scandals are happening in the health service. There have been shocking cases where patients have been very poorly treated when at their most vulnerable. We should recognise that customer care, particularly for those most vulnerable, should be provided for effectively and that medical students should be adequately trained in dealing with their customers, the patients.

There are many environmental factors linked to the increased risk of cancer, many of which we may not be able to reduce or eliminate. Radon gas is, however, one of the environmental factors about which we know, the level of which can easily be reduced within a dwelling. The cost involved is relatively small. Grant aid has been promised for a number of years. The purpose would be to allow residents to upgrade their homes to eliminate the risk from radon gas. It is unacceptable that the introduction of the grants scheme continues to be blocked. Many households across the country have been identified as having high levels of radon gas. Grants should be made available as soon as possible to enable these households to protect themselves.

The area of palliative care is one that has been neglected and deserves a serious injection of funding. The excellent home care services and palliative care units of hospices seem to spend a great deal of time fund-raising. While this highlights the good work done by the organisation concerned, it is a shame that such a worthy and valuable service has to be propped up by voluntary fund-raising when there is a glut of money available to the Exchequer, although it is true that the Minister for Finance will hear the same argument from the many interest groups seeking additional funding. Both he and his colleagues in government have to decide priorities, but I make the case for additional funds for palliative care. Such units should not have to await reviews or reports. They provide an invaluable service for patients and their families when at their most vulnerable. They are quiet and hard-working and while they might not have the punch of the country's biggest hospitals, their needs should be prioritised.

While the detection and treatment of cancer are complex and expensive, Ireland needs to keep pace with international best practice and new developments. For this reason, I urge the Minister to ensure cancer research is adequately funded. He must also ensure research funding is focused on substantial and relevant projects and that outcomes are measurable.

Ms O'Sullivan

Delay in access to diagnosis and treatment is at crisis level in much of the public health service, although funding for services should not be a problem in times of Exchequer plenty. In no aspect of health care is the delay more scandalous than in the detection and treatment of cancer. There are illnesses that will not become seriously worse or life-threatening if left untreated for a period of time. Cancer is not such an illness. Early diagnosis and treatment are crucial in combating it.

We all are aware of the personal stories, many of which were recounted in the House last night, of patients who must wait months knowing how crucial is the time factor. Great strides have been made in detection and treatment with the result that cancer is not the fearful word it once was. It can and does take lives, however, the lives of one third of all those who do not survive beyond the age of 65 years. Those who visit their general practitioner with worrying symptoms are referred for specialist tests for which they have to wait, they have to await results and treatment – in some cases treatment sessions are repeatedly cancelled – and endure enormous anxiety, stress and pain when they know that time is of the essence. I reject the Minister's view that this is scaremongering. It is a real concern which needs to be addressed by the person in charge of the health service, that is, the Minister for Health and Children.

We have all experienced cancer among our family or friends and know how vital it is that the national cancer strategy becomes a reality rather than an aspiration. I wish to address the area of screening, prevention and early detection. The organisers of BreastCheck have said that their screening programme can reduce the number of deaths from breast cancer by 20%. Screening for cervical and testicular cancer is known to be even more effective, both being preventable in the majority of cases if the signs are detected at an early stage.

Plans were put in place for screening for breast and cervical cancer before the Government took office four years ago. Pilot health board regions were agreed and implementing personnel identified. Four years on, they are not yet fully operational in the pilot areas. The delay is extraordinary. Also, as my colleague, Deputy McManus indicated last night, if one does not live in a pilot area, one will have to wait a long time to be included in these life-saving programmes.

There is a major concern which needs to be urgently addressed with regard to laboratory staff to carry out the tests central to the screening programme. Already patients have to wait months for results. The extra numbers that will come into the system through the screening programmes will exert serious pressure on an already overloaded system. I urge the Minister to address this issue. It is extremely urgent that extra staff are trained and put in place. Without testing within an acceptable timeframe, the screening programmes will not achieve the desired results. In the Limerick area, as I am sure in other areas, the provision of back-up staff is a major issue for specialists in cancer treatment.

The delays and inadequacies of the service experienced by those who have cancer are shared, sadly, by thousands of others who expect to receive treatment when they need it. There are many areas identified by health board members and others working in system which have not been addressed. These include the shortage of beds, overstretched staff, the need for more back-up staff, and the fact that full use is not being made of operating theatres. There are many hours when theatres lie idle when they could be in use. The health service has to constantly deal with crisis management because of the situation in accident and emergency departments from where the numbers taking up hospital beds are huge. Many patients are occupying hospital beds when, as Deputy Upton indicated, they could be removed from the hospital system.

All this is exerting huge pressure on the system and the Government, in spite of its inordinate wealth, is still not delivering quality care in this vital area after four years in office. The nation should not tolerate this.

Ms M. McGennis

I wish to share my time with Deputies O'Flynn, Dennehy, Brendan Smith, Moloney and Callely.

Acting Chairman (Cecilia Keaveney)

Is that agreed? Agreed.

Ms M. McGennis

In the short time available to me, I want to focus on breast cancer and breast screening services. Every year, significant numbers of women are referred to breast clinics for diagnostic purposes, which referral, thankfully, establishes for many that no active disease is present. For others, the diagnosis of breast cancer can lead to protracted treatment and ongoing fear and anxiety. The mere fact of being referred to a clinic can raise fears and it is vital that no delays are experienced in obtaining appointments or being informed of the outcome of breast examinations.

The Women's Health Council conducted a survey of the views and perceptions of women who attended symptomatic breast clinics. It found that the overwhelming majority of women discovered symptoms of breast disease through self-examination, after which they consulted a general practitioner. That finding surprised me as the 1994 ESRI report indicated that one in three women never conducted breast examinations. There is a need for a public information campaign to advise that breast health is an issue for women of all ages, not just post-menopausal women. Women must be vigilant about self-examination and at-risk groups must be identified, particularly women with a family history of breast cancer.

In the period January to March 2001, approximately 2,700 women per month were screened at the BreastCheck units. Less than 1% of those screened since the commencement of the programme have been admitted to hospital for further management. It is important that this fact is highlighted in order that women do not, out of fear, avoid attending their general practitioner or being screened.

The survey indicated that, by and large, women were satisfied with their treatment once they entered the clinical system. The top five care priorities highlighted in the survey were as follows: the first appointment should be within one week of referral; all diagnostic tests should be held in one session, where possible; any additional tests should be carried out within one week; unhurried time to talk to consultants on receiving test results; and continuity of care – if a second visit is required, an assurance should be given that a woman will see the same nurse and consultant. We must ensure these objectives are met.

Forty of the women surveyed took the time to write open-ended comments on how they could have been better supported. Their comments distinguish clearly between the care received and the manner in which it was delivered. On page 53, table 31 of the survey, the following participant comments are outlined:

Not to be left naked, waist up, for 30 minutes in a room with no heat . . . Doctor then entered with a chart, no "hello" and asked me how my mastectomy went – I was in for a cyst, his patient was next door . . . People entering the room as you were naked to speak with colleagues – doctor didn't make any introductions . . . A man sat there but he was not introduced and I did not know who he was or why he was there . . . Maybe more information could be provided . . . The radiographer was not pleasant, did not say a lot about the mammogram . . . Explain in more detail why the lump could not be removed – would it go itself? . . . Explain why no further examinations would occur once the lump was not cancerous – could it become cancerous at any stage? . . . As I was very nervous on my first visit, I would have welcomed some reassurance and being told a bit more about the procedures.

Much of the debate on the motion has centred on the need for improved services in this area. There is always room for improvement. However, in addition to investment in health care provision, the staff who care for women coming forward for examinations must be trained to deliver services in an appropriate manner which is responsive to women's needs.

Mr. O'Flynn

I congratulate the Minister for Health and Children on the actions he has taken in regard to cancer treatment services since his appointment. He has provided funding for research and invested heavily in centres of excellence throughout the country. In doing so, he has acknowledged a definite need to address treatable cancers such as breast and prostate cancer. I commend him on increasing funding for the national cancer strategy to £60 million and ensuring all the commitments outlined in the action plan are being implemented. I welcome the appointment of additional consultants in key areas of cancer treatment and research. There is a need for a greater number of awareness campaigns to encourage men and women to be screened on a more regular basis.

St. Patrick's Hospice in Cork is to the fore in the provision of palliative care. Palliative medicine is an integral part of the health service and has, since 1995, been recognised as a unique medical specialty. Tremendous progress has been made in recent years in the area of hospice services and this will be further advanced by the launch of the document of the National Advisory Council on Palliative Care due to be published by the Department in the near future. This document will provide the framework to support the development of services in this area. Traditionally, palliative care focused on patients with cancer, but the focus has expanded in recent years beyond malignant conditions. Patients with non-malignant conditions are also accepted into palliative care if it is believed they would benefit from it. This shift in focus requires the skills of a multidisciplinary professional team to address the changing needs of patients and families alike. If necessary, support continues into the bereavement phase.

The palliative care service works in tandem with established services in acute hospitals and the community. The role of general practitioners is central to the service's success as patients can be supported in their own homes. In 1991, the Southern Health Board, of which I am a member, was the first health board to appoint a palliative care physician and there are plans to appoint additional staff in the area. Marymount Hospice in Cork is the only specialist palliative unit in the health board region. The in-patient service comprises a 24 bed unit and the ward is staffed by specialist nurses, physiotherapists and a social worker. Together, these staff members provide multidisciplinary care for the patients. The day hospice provides further support for patients through the provision of diversional and complementary therapies. Some therapeutic intervention is also available to day patients, allowing them to maximise the time they spend at home with their families. The home care service based at Marymount serves both the city and county and up to 90 patients are cared for by the home care team at any one time. A specialist nurse was also recently appointed to co-ordinate the development of home care services in the north-south Kerry area.

Other developments at Marymount in recent years include the establishment of an educational centre. The hospice provides ongoing education for professionals working within the region who wish to expand their knowledge in the area of palliative care. Patients benefit from best practice in their own local areas. The commitment to training and education includes links with the medical faculty in University College Cork which offers a degree in palliative nursing and postgraduate medical training.

The history of St. Patrick's in Cork dates back to 1873 when the Sisters of Charity, who continue to make a major contribution in this area, first established a service. The service reflects the support of the statutory bodies and the Department of Health and Children and the tremendous voluntary contributions made by the Friends of St. Patrick's to improve services, particularly in lean times. The hospice receives assistance from a wonderful group of supporters and volunteers who give freely of their time to enhance the quality of the service provided. Many centres have modelled their facilities on St. Patrick's Hospice and Marymount Hospice. No family escapes the trauma of cancer. I thank the Friends of St. Patrick's for their dedication to the Sisters of Charity and patients of Marymount and St. Patrick's in Cork.

I am aware that the Minister for Health and Children, Deputy Martin, a colleague of mine from Cork, will continue to provide the necessary funding to enhance and develop new facilities for the treatment of patients with cancer. I thank him for the funding which he and his predecessor, Deputy Cowen, have provided in this area in the past four years. I thank the Minister and the Government for the huge investment they have made in hospitals in the Cork region since 1997. A sum of £120 million has been spent on capital programmes to date. I am aware that my colleague, Deputy Dennehy, a member of the Southern Health Board, will have something to say on that issue. I support the amendment tabled in the name of the Minister.

Mr. Dennehy

I join my colleague, Deputy O'Flynn, in complimenting my constituency colleague, the Minister for Health and Children, Deputy Martin, on his commitment and approach in dealing with all issues relating to cancer diagnosis and treatment. Cancer is, probably, the most frightening illness facing us and other European countries today. The statistics announced last week illustrate its seriousness and the potential that we may all suffer from one form of cancer or another. It does not discriminate between age, gender or lifestyles and we are always astonished when a friend or relative dies of it.

Those of us who have suffered bereavements as a result of cancer will not think too highly of the motion before the House. I have argued many issues in the House since 1987 and accept that there must be give and take on all issues. However, other issues within the health service might have been selected for discussion. Cancer is the scourge of our time and something of which we are all afraid. We must discuss, analyse and face up to the issue in a more open and responsible fashion. It can be very frightening when the illness visits ones friends or family.

It is very serious to suggest lives are being put at risk by a particular Government or Minister. Those of us who have witnessed the extra trauma endured by patients receiving treatment for cancer when machinery breaks down understand fully how distressed they and their families are. It is traumatic enough to be diagnosed as having cancer without having to face delays in receiving treatment. There has been a significant increase in the breakdown of machinery in the past ten years with the introduction of new technology, but the problem has decreased since the Government took office. One of the signatories to the motion would not fair too well if we were to look at the situation which prevailed when he was in office. That is very negative thinking.

We must look at the issue in a broader context. One of the major decisions to be faced up to will be whether people want centres of excellence located in each town or in Dublin, Cork and Galway as recommended by the forum. We will need to look at the issue from the point of view of patients' needs rather than political expediency. It is a big challenge. It is easy for me to opt for accepting three centres of excellence because one of them will be located in Cork.

There was a time when all heart operations had to be performed in the Mater Hospital, Dublin. We have moved on from that situation, but it has been a slow process. I ask people to be reasonable. Deputy O'Flynn outlined what is happening in the Southern Health Board area. People must face up to reality. Everyone is arguing their case. We had only one centre for heart operations initially, but branched out later.

The Minister for Health and Children is adopting the right approach to the issue. He increased finance from £25 million to £60 million, but we are now finding that that will not be enough.

Mr. Ring

The Deputy was not saying that about Cork when they were taking—

Mr. O'Flynn

Deputy Noonan bypassed us when Minister for Health.

Mr. Dennehy

This is a very serious topic.

Mr. B. Smith

I am glad of the opportunity to support the Minister's amendment. Among the many welcome and innovative measures implemented by the Minister for Health and Children, Deputy Martin, and his predecessor, Deputy Cowen, was the decision to allocate £2 billion under the national development plan for capital investment, thus providing new nursing units for the elderly, hospital extensions and modern equipment.

The Government has provided a new 30-bed nursing unit and community health facility in Ballyconnell while a new 50-bed nursing unit and community health facility is under construction in Virginia. The Minister has also committed substantial funding towards the provision of additional facilities at Cavan General Hospital. These are positive developments for which the Government has provided large-scale expenditure. This investment, in years to come, will contribute significantly to a much improved health service at local level in County Cavan.

I welcome the Minister's clear commitment to the implementation of the national cancer strategy. He is committed to the provision of the necessary resources in terms of infrastructure and personnel. The national cancer strategy and other fora have rightly identified the need to develop high quality cancer services throughout the country. Furthermore, it identified as a specific objective the need to provide access to equitable, effective, quality services throughout the regions. The Minister referred to the work of the sub-group of the National Cancer Forum in reviewing symptomatic breast disease services nationally. Alongside the national breast screening programme, there is a need for an equally excellent service for those with symptomatic breast disease. I welcome the Minister's commitment to the development of such a service. There is a need to reorganise and develop such services.

In developing centres of excellence it is important that there is ready access to such services throughout the country. The report of the sub-group recommending one mammography service for the Northern Eastern Health Board in Drogheda is unacceptable. There is a need to provide such a service at Cavan General Hospital to ensure people throughout the whole region will have easy access to such services. I hope the Minister will give further consideration to this proposal.

Mr. Moloney

As a member of a health board for the past 16 years, I have witnessed great progress in the delivery of health services to areas outside the main urban settings. I have welcomed the regionalisation of ENT and orthopaedic services. I welcomed, in particular, the publication of the national cancer strategy in 1996 by the rainbow coalition and the then Minister for Health, Deputy Noonan. I was particularly pleased that the Government continued that strategy. Its commitment to the implementation of the strategy is evident throughout the regions. One of the most effective decisions of the National Cancer Forum was the appointment of a regional director of cancer services within each health board.

I welcome the fact that the Minister has reappointed regional directors of cancer services to act under the chairmanship of Professor Paul Redmond on the second National Cancer Forum. One cannot stress enough the importance of such directors. Regional directors of cancer services should be supported in their key role of reorganising our cancer treatment services. Their only interests are to work to reduce the mortality rate from cancer and bring forward policies which will improve health status and quality of life.

I regret that the Government's commitment to implementing the national cancer strategy in the Midland Health Board area was held up unnecessarily for 18 months because some members of the board would not, or could not, accept the advice of the independent regional director of cancer services, Professor Donal Hollywood. The real losers were the 1,100 patients who had to travel unnecessarily to Dublin for cancer treatment. Our support for the cancer strategy was challenged in the High Court. Thankfully, Mr. Justice Kearns held that the applicant for judicial review had forfeited that remedy by reason of delay and the non-disclosure of essential and relevant materials to the court in the ex-parte application.

I am particularly pleased that the judge vindicated my position, and that of the majority of members of the board, by stating that we had acted on independent medical advice and that we had no other motive. Unfortunately, while this wrangling was going on at health board level, and in the High Court, patients were suffering unnecessarily by having to travel for miles outside the region for treatment. I feel particularly for those who had to travel on public transport.

People like me who supported the regional director and the National Cancer Forum were subjected to accusations of turning our backs on our local hospital. We were, and still are, vilified by some for not voting against the national strategy to deal with cancer. At all times we acted in the best interests of patient care and took the independent advice of the regional director.

I also wish to debate the issue of the popular choice vis-à-vis the independent medical advice. I would have liked to have taken the easy and popular course of rejecting the advice of the independent regional director and Professor Jim Fennelly, then chairman of the National Cancer Forum. I could have gone the popular road by demanding the location of a service, in our case, the central chemotherapy unit, in Portlaoise rather than Tullamore. That would have been a vote getting exercise, but it would have done little for cancer patients and their families in counties Laois, Offaly, Longford and Westmeath who still have to travel to Dublin for treatment.

To reject the advice of the regional director would have meant no cancer service for the region. If a similar issue arises in other regions, I respectfully suggest that to reject independent medical advice must have a significant bearing on the level of commitment and services in the region. This was spelt out to us at our meeting with Professor Jim Fennelly and the National Cancer Forum. At the time the forum would not support the service for our region unless it was centrally located to provide services for patients in counties Laois, Offaly, Longford and Westmeath. I wonder why the implications of rejecting the national cancer strategy were never examined by the local media and why Mr. Justice Kearns's findings received so little local coverage.

During the debate which concerned the level of care for those who suffer from cancer, it was unfortunate that accusations were made such as the suggestion that Deputy Cowen, located as he was in Tullamore, and Minister for Health and Children at the time, had used undue influence in the decision regarding the location of the centre in Tullamore. Anyone with an interest in cancer services, and who had taken the time to read the national cancer strategy, would have known that Tullamore was selected under the former Minister, Deputy Noonan, whom I have applauded for introducing the strategy.

Thankfully, all that is in the past and we now have a regional cancer service. I thank the Minister, Deputy Martin, for completing the cancer strategy for the midlands by allocating £500,000 to the health board as a first step towards its designation as the lead centre for breast cancer services. I urge him to take every opportunity to advise health board members on the important role of regional directors. Their overriding role is to reduce deaths from cancer. They have no ulterior motive in the location of cancer services, nor do they wish to have such a role.

At all times we should support independent medical advice and take every opportunity to deliver on the commitments in the national cancer strategy. The location of services should never be decided on the accumulation of votes, but on the best way to reduce mortality rates and improve general health. Public representatives should at all times, even when under pressure, remember that the two principal objectives of the national cancer strategy are, first, to take all possible measures to reduce rates of illness and death from cancer, in line with the targets established by the Minister in Shaping a Healthier Future and, second, to ensure those who develop cancer receive the most effective care and treatment in order that their quality of life is enhanced to the greatest extent possible.

Public representatives should remember these two guiding principles and support the Minister and the Government in delivering immediate strategies to fight the battle against cancer. This issue should not just be about the location of services, but how to deliver those services in the most effective way possible. Such a decision should be reached based on independent medical advice.

I commend the Minister, the Government and members of the Midland Health Board who have had the courage to recognise that this issue is about ensuring a better quality of life for those with cancer and providing the necessary supports for their families. That is the reason I reject the motion and support the Government's amendment. I know what this issue is about by way of ensuring funding is secured and delivered by the Government. I am proud that the Government has done so in the midlands and hope the strategy will work in the other seven health board regions.

Mr. Callely

As chairman of the Eastern Regional Health Authority, I am aware of the good work being done regarding cancer treatment in the region. I pay tribute to and salute those working in cancer services for their commitment and dedication to the provision of services for patients in such a professional and caring manner. This work is appreciated by all.

This year the Eastern Regional Health Authority is spending an additional sum of over £9 million in developing cancer services in the region. This will mean that men, women and children who develop cancer will have access to more services, a broader range of services, more expert services and more high-tech treatments, where necessary.

We all know how important it is to detect cancer at an early stage, because, frequently, the earlier it is picked up the better the long-term outcome. I am delighted that women in the ERHA region who fall into the at-risk category can now avail of a free mammogram aimed at detecting breast cancer at an early stage. I am optimistic that in the near future we will introduce a similar programme for men at risk of developing prostate cancer.

Under the BreastCheck programme being piloted in two areas of the country, including the east, women in the 50 to 64 year age group are being given the opportunity to avail of a free mammogram. If a lump is detected, it is followed up at clinics in St. Vincent's and the Mater Hospitals. In other countries this type of programme has been shown to reduce deaths from breast cancer by between 20% and 30% through detecting the disease at an earlier stage. I hope this programme will result in a similar outcome here.

Breast cancer is very common in Ireland. Approximately 1,600 new cases are diagnosed each year and, sadly, over 600 women die annually from the disease. Breast cancer is particularly tragic because it can hit women at an early age and it is our objective to reduce illness and death from this disease as quickly as possible.

The ERHA is spending an additional £1.5 million this year on treatment and developing services for women who have breast cancer. Following the recommendations of an expert working group, it has been decided to establish five centres of excellence for the treatment of breast cancer in Dublin located in St. Vincent's, the Mater, St. James's, Tallaght and Beaumont-James Connolly Hospitals.

The ERHA is also placing a special emphasis on developing cervical screening, diagnostic and treatment services for those with leukaemia and palliative care services. Additional consultants are being appointed – eight in the specialty of haematology alone – to ensure those who develop cancer have access to top-class care.

New drugs for the treatment of cancer are being constantly developed and we are in constant touch with cancer specialists to track these latest developments. The ERHA has allocated approximately an additional £2.5 million this year to provide patients with the latest drugs. Palliative care services are being extended and a new hospice will be provided in Blackrock. The services provided by Our Lady's Hospice and St. Francis's Hospice and the home care service continue to be developed. I pay tribute to St. Francis's Hospice and the home care service because they are located in my home patch and I am aware of their good work. The ERHA has made a submission to the working group on how radiotherapy services should be developed in the east. The group is examining this matter on a national basis and we are working towards the further development of these services.

Considerable progress has been made in the development of diagnostic, treatment and rehabilitation services for those who develop cancer and we have pledged to do much more to fight this scourge. I commend and welcome the developments under the Minister for Health and Children and his departmental team. I condemn the manner in which the motion was tabled.

Mr. G. Mitchell

May God forgive the Deputy.

Mr. Callely

Much good work has been done.

Mr. Ring

I wish to share my time with Deputies Crawford, Clune, Perry and Burke.

Acting Chairman

Is that agreed? Agreed.

Mr. Ring

It is sad that this motion is necessary given the record amount of money in coffers of the Department of Finance. However, people cannot get necessary treatment for all types of cancer. More than 80% of breast cancer cases occur in women over the age of 50 years and almost 10% of all women with breast cancer have a family history of the disease. I know women whose sisters died from breast cancer. They are aged over 50 years but they still have not been called for breast cancer screening. This is a dis grace and an outrage and something should be done about it immediately.

Screening for breast cancer is offered in certain parts of the country. Phase one of the BreastCheck programme is available in the Eastern Regional Health Authority and the North-Eastern and Midland Health Boards. Why can this facility not be extended nation-wide? What about the west and south of the country? All women should be treated equally in the prevention and treatment of this disease. In particular, women at risk should be offered this service regularly.

Women from all sections of society in Mayo recently put together a massive campaign to maintain the breast clinic service in Mayo General Hospital. The possible withdrawal of the service created upset and disturbance. It also frightened many women who had been reassured that the service was available in Mayo. Why does central Government always take services away from remote parts of the country and relocate them in big city centre hospitals where the services providers cannot cope with them? Services in country hospitals should be utilised instead of relocating everything in Dublin and Galway. Some specialities should be located in rural areas such as Castlebar. Why must people always have to travel to cities? Why can city people not travel to rural areas?

Most women health experts currently advise a three part programme regarding breast cancer screening and early detection. The programme should include an annual or bi-annual mammogram for women over the age of 40 years, yearly clinical breast examinations by doctors skilled in such examinations and monthly breast self-examination. These services should be available to women and they should be encouraged, given the high rate of breast cancer, to take all necessary precautions. This country has not always treated women equally. They have been let down by health services because they are women. However, at last, women are beginning to speak up and fight back. It is time women's health issues were taken seriously by the Government.

Money should be spent on education and the prevention of cancer. The waiting lists with regard to prostate cancer are longer in Ireland than in most other developed countries. An awareness programme regarding prostate cancer is most necessary. The matter is not being treated seriously and the Government must put a programme in place. It should invest in advertising that will encourage men to take their health more seriously.

I regret that the Fianna Fáil Party Deputies from Cork and elsewhere have left because I wish to highlight three cases. The first involved a man in my constituency who was waiting for surgery for prostate cancer last year. He was called to Galway regional hospital seven times. Each morning he was due to be admitted, he received a telephone call from the hospital to tell him a bed was not available for him and he could not be admitted that day. I raised this matter in the House and the man was finally admitted on the seventh occasion. Is this a proper health service or proper cancer treatment? Does this case demonstrate that proper resources are being provided for people who are sick because this is the type of service that exists at present?

The second case involved a man who was brought to Galway regional hospital. He was a single man and he remained at the hospital all day. He was to be admitted for surgery, but at 9 p.m. that night a neighbour received a telephone call asking that the man be collected. The man was collected at 11 p.m, but at 7 a.m. the following morning he was rushed back to the hospital because he became ill. He spent a number of months in hospital and he had surgery. This is the health service that some Deputies praised earlier. However, I do not consider that a proper health service.

The third case involved a woman in her 60s who was waiting to be called to St. Luke's Hospital in Dublin. She was told she had cancer and she came to me, begging for a bed so she could receive treatment. Is this fair? Is that a good service? Is this morally right? Can the Minister imagine what went through that woman's mind and the minds of her family? She was told she had cancer and that she had to go to St. Luke's Hospital, but the hospital said no bed was available for her. That is not right. Does this demonstrate that cancer treatment services have the priority they deserve? Proper resources are not being provided and an increasing number of people are losing confidence. People who are diagnosed with cancer worry about where they will be treated and if they will have to approach their doctor or politicians and beg for a bed. This is not right.

These cases involved people from my area and they demonstrate the health service that people experience at present. The cases highlight what is happening in the real world. Waiting lists are getting longer and the cry for beds is getting louder. There is no value for the money being spent on the health service. This is not right and the Minister for Health and Children and his Department must take responsibility for it. Something must be very wrong if resources are being provided but beds are still not available.

Bowel cancer is also receiving much publicity, but people are shy to approach their doctors if they have a problem. The Government should do something about this matter and try to make it easier for people to be screened and, if necessary, treated. It is wrong that men, women and children who have been diagnosed with cancer are waiting for beds. I get annoyed when I hear my Fianna Fáil Party colleagues because the only thing the Government has been good at – it has cost the taxpayer much money – is public relations scams. I wish more members of the media were present in the gallery. Some of their colleagues are working for Departments and spinning messages, but the media should investigate what is happening in the real world. I am willing to bring them to Mayo General Hospital in Castlebar, the hospital in Galway or St. Luke's Hospital and show them cases involving sick people, some of whom are dying. People are looking for beds and services. They are sick and tired of the Government's stories about how well the economy is doing when they cannot get beds for parents, husbands, wives and children.

Mr. Crawford

I welcome the opportunity to contribute to the debate on this serious issue. Very few homes in Ireland have not been hit by cancer. My closest friend and cousin died 27 years ago of Hodgkin's disease, which is a form of cancer. Thankfully, today there is a cure for it. The first time he spoke to me about it and the first time he spoke about death was on the second night of Christmas when he told me that he expected to have four and a half to five years to live. It is a very difficult sentence.

Shortly after I became a Member of this Dáil I visited a near neighbour and close friend in St. Luke's Hospital. He asked that no matter what else was done, funding should be made available to treat cancer and find cures. Although he came from a strong engineering background, he could not understand the reason he was often sent home because equipment was not working. He told me that if this happened in his contracting business, he would be expected to get or lease a new machine. Unfortunately, similar conditions prevail at times today. When Minister for Health my party leader made a major commitment to St. Luke's Hospital where significant improvements have been made.

Mammograms are idle in some places. A previous speaker had kind words to say about Cavan General Hospital, but a machine at the hospital has been unused for two and a half years. I am sure Deputy Boylan will elaborate on this later. When we became involved with some of the women campaigning to get the machine into use they told us of the trauma suffered by those with breast cancer who had survived. They would not have suffered to such an extent had they been tested in time. In that context, I welcome the BreastCheck screening programme and encourage all women invited for screening to take up the offer. I regret that the screening service is not available nationwide, but, thankfully, it is in our area. I also regret that the medical manpower and infrastructure are unavailable to extend it to all. Many years ago friends of mine across the Border were saved by having such a check.

Despite these welcome developments there is no danger of us becoming dazzled by the success of the new screening system or overlooking the gross inadequacy of investment in the service for symptomatic breast disease. Women who present for breast screening under BreastCheck are guaranteed timeframes within which they will receive treatment should they require it. Despite the best efforts of the medical and nursing staff at breast disease clinics in many of the major hospitals, women who have breast disease symp toms can receive no such services. This is one of the biggest problems.

The BreastCheck services show what can be done with proper resources. The long queues at the under-resourced out-patient breast clinics at the major hospitals tell a different story. This under-resourcing is a scandal. The Minister has proudly said that since the Government took office there has been a 70% increase in the health budget. Why can funding not be used to the benefit of this service?

Like Deputy Ring, I can highlight cases in my county hospital, Monaghan General Hospital. It could do much more to help patients at the outset if funding was made available. As it is they have been pushed down the list or sent to Dublin for different surgery. This applies especially in the case of prostate gland treatment. I recently made a request to the Meath and Adelaide Hospitals at Tallaght to explain the reason a patient was not being called for treatment. A doctor wrote to me saying that he would love to do more, but unlike the old situation at the Meath Hospital, where he had 50 beds available, he now has only 30. I tabled a question on the matter to the Minister. In his reply of yesterday he stated that responsibility for the provision of neurological services at the Meath Hospital rests with the Eastern Regional Health Authority services. He went on to say that his Department had asked the regional chief executive to provide more information. The hospital provides a national service on which patients in County Monaghan depend. Proper facilities are needed. If it was seen fit to close the Meath Hospital and incorporate it in a bigger hospital, surely at least the same, if not better, services should be available. Those living in rural and peripheral areas suffer the most. I hope the massive sums being made available to the Minister will be used in a more proactive manner as far as cancer is concerned.

Ms Clune

I compliment Deputy Gay Mitchell on moving the motion. Cancer treatment and services touch all families and cross all classes. None of us can be sure that we will escape it, whether personally or through family contacts. It strikes to the heart of all and has devastated many families, unnecessarily so in many cases. I am aware of three cases involving relatively young women in their forties who died from breast cancer. Tragically, they left families behind them. In many instances, similar tragedies could be avoided if there was proper care and screening services. In many cases, especially those involving breast cancer, treatment is successful if the disease is detected in time.

When I raised the issue of the BreastCheck service in the House a number of months ago the Minister said he hoped it would be available nationwide by the end of the year. Living as I do in the Southern Health Board region I hope that will happen. While I am aware of the obstacles, especially regarding the establishment of a data base to contact all women in the relevant age brackets, the extension of the service is both necessary and welcome.

The severe lack of funding for symptomatic breast services has been referred to. The report of the subgroup of the National Cancer Forum published last year recommended the establishment of a number of symptomatic breast cancer services nationwide. I welcome the report. If it is implemented, it will mean that surgeons, radiologists, pathologists, medical oncologists, radiotherapists plastic surgeons, nurses and counsellors will all operate in the one multidisciplinary setting. This is seen as the best way to treat breast cancer and provide the best services for women. An excellent service in Cork at the South Infirmary Hospital, which is due to be expanded, and a facility at Cork University Hospital serve the Southern Health Board region. The expansion of the service is long overdue and I hope the necessary funding will be provided.

I am disappointed at the level of funding – £4.35 million nationally – the Minister has provided this year towards the development of such services. A sum of £800,000 will be allocated to the Southern Health Board region. That is to include infrastructure, consultant appointments and the deployment of the necessary equipment. It is very little in the context of the life saving service to be provided. The national cancer forum recommends that counselling services be provided to relatives and the families of the person who is sick, although the person might not necessarily be terminally ill. Cancer strikes every family; it can be a strain on families. They need support, counselling and taxi fares to and from the hospital. These are basic elements of the service that should be provided.

There is a report on this issue but it needs to be developed further if we are to support family members who can, in turn, support the patient in such a tragic situation.

Mr. Perry

I thank Deputy Mitchell for tabling this important motion. Cancer has a major impact on the health of the Irish population. One in three people will develop cancer during their lifetime. Cancer causes one in four deaths each year so it places a formidable burden, both physical and psychological, on society.

There is a huge need to devote finance to both the prevention and treatment of cancer. We must redouble our efforts to reduce the level of smoking, to increase people's participation in physical activities and to promote a healthy diet. It is important that we increase consumption of fruit and vegetables. The health promotion campaign should be accelerated considerably through the media and through the Government's health strategy. The backbone of that strategy should be the promotion of health care and public health concerns. That is a huge area.

With regard to treatment, the priority is to ensure that patients are treated at the level of best practice internationally. That is not the case at present. One way of ensuring the highest possible standards of care is to increase the participation rate in national and international random control trials of cancer therapies. Why is that not happening? The health boards and hospitals need resources to support cancer specialists in their participation in large randomised trials. The Minister should report to me on this point because it is not happening at present.

Best practice in cancer care means patients should be treated in dedicated centres of excellence. That is not happening despite the amount of money available for the health services. These centres should have the facilities to ensure that patients receive care that is comparable to the best in the world. What is needed is a coherent strategy which addresses both the prevention and treatment of cancer. I am astonished that, despite the billions available to the health services, the north west does not have a dedicated service in Sligo regional hospital. I call on the Minister to examine the possibility of locating such a service in Sligo.

I pay tribute to the hospice in Sligo on its outstanding work. A considerable amount of money is given voluntarily to the hospice but there is also massive fund raising. However, a dedicated unit is now required so patients will be guaranteed they will receive care that is comparable with the best in the world. That is not happening. It is not an issue of spending billions but of effective management. That is where the problem lies. The country never had so much money to spend but questions must be answered with regard to the management of money within the health services.

In the new millennium the people of the north west should be entitled to the same service and specialised care as is available to people on the east coast. There should also be randomised trials and best international practice. The lack of them should be an embarrassment to the Minister for Health and Children. This is a most important issue. One in four people in this country die of cancer. The incidence of cancer has a huge impact on every family.

I pay tribute to Deputy Mitchell's outstanding document on health. It will be the backbone of Fine Gael policy in Government. We will have a coherent strategy which will address both the prevention and treatment of cancer. It will be the priority of Fine Gael and, when my colleague is Minister for Health in the not too distant future, I will be delighted to work with him in implementing that strategy.

Mr. U. Burke

I compliment Deputy Gay Mitchell on bringing this motion before the House. My concern is not only for the Government's lack of strategy but also its lack of commitment to the provision of an adequate service for children suffering from cancer.

Five minutes drive from here is a monument to this Government's neglect. The facilities of Our Lady's Hospital, Crumlin, which caters for chil dren throughout the country who are suffering from cancer, are an edifice of neglect, especially at a time when money is so plentiful we do not know what to do with it. I challenge the Minister of State and the Minister, if they have not already done so, to leave the comfort and protection of this House and face reality with a visit to St. John's ward, the oncology ward, of Our Lady's Hospital. They will there witness something they can no longer choose to ignore. Consultants, doctors and nursing staff have over the years, to provide a service for the children suffering from cancer, been obliged to beg on the streets and do everything possible to encourage the public to provide money voluntarily for a service which the Government should be providing.

The Government has neglected that hospital and as long as that neglect continues, the Minister cannot credibly claim to be delivering a service that is adequate for the people in need. I have spent six years visiting that hospital for personal reasons. I have seen the neglect and what is required in the hospital. If the Minister does not react, within whatever lifetime remains to this Govenment, to that hospital's need, he must be callous towards the suffering of young children. If the Minister walked through St. John's ward this evening, he would certainly be moved by the suffering not only of the children but of the parents and families who are trying to comfort them.

I hope there will be a response to my plea. This is the national hospital for treating children with cancer and it cannot be neglected, regardless of what other commitments the Minister might have for political reasons. It was sad to listen last night to Government backbenchers congratulating this Minister and Minister of State on their work. It is a disgrace. I do not believe they realised what they were saying. Their commitment is only shoddy, at best.

Does the Minister of State realise that a person from the west of Ireland who travels to St. Luke's Hospital for treatment must stay in a bed and breakfast? Can the Minister of State, as a professional doctor, not understand that it is time to stop this practice? People suffering from cancer are under huge stress without forcing them to stay in a bed and breakfast. That is not the Ireland of which I wish to be part. I cannot condone a Government and Minister who stand idly by and do nothing in those situations.

Minister of State at the Department of Health and Children (Dr. Moffatt)

Last night the Minister for Health and Children, Deputy Martin, drew attention to the wide-ranging efforts which have been made in dealing with the implementation of the national cancer strategy in a structured and comprehensive manner. This has involved re-organising cancer treatment services to promote a strong patient focus and ensure equity of access throughout the country, devoting resources to screening and early detection programmes of proven value, including the establishment of national programmes of screening for breast and cervical cancer, using health promotion activities to emphasise further the importance of healthy lifestyles, developing specialist palliative care services and facilitating greater co-ordination of cancer research.

I disagree with what Deputy Ulick Burke said about neglect.

Mr. U. Burke

The Minister of State should go and visit places to see what it is like.

Dr. Moffatt

It was estimated the strategy would cost £25 million at its launch. Some £60 million has been allocated since then and up to £20 million will be spent this year alone on the cancer strategy.

Mr. G. Mitchell

The Minister of State does not know what he is talking about.

An Ceann Comhairle

The Minister of State without interruption.

Mr. U. Burke

He is missing the point.

Dr. Moffatt

I am not missing the point because each hospital and health board area has been the beneficiary of the money invested in cancer services. I do not suggest everything is hunky-dory but the money is making an impact.

Mr. G. Mitchell

Will the Minister of State visit Crumlin?

An Ceann Comhairle

The Minister of State, without interruption.

Dr. Moffatt

I used to work there and know a little bit about it. The national cancer strategy derives from the original health strategy of 1994, Shaping a Healthier Future, and particular efforts have been made to ensure a high level of consultation and inclusiveness in the implementation of the strategy at national level through the National Cancer Forum and at regional level through the appointment of regional directors of cancer services.

The strategy is aimed at developing centres of excellence and concentrated expertise to ensure a critical mass for multi-disciplinary expert service provision. At the same time the strategy has aimed to bring services closer to patients' homes to ensure equity of access while ensuring that a high quality service is offered.

In addition to the general implementation of the national cancer strategy as evidenced by the appointment of qualified consultant staff in the fields of medical oncology and haematology among others, 55 of which have been appointed to date, I am especially glad to note the care and attention which has gone into the development of national screening programmes in the areas of breast screening and cervical screening. These programmes have been developed on the basis of the best evidence available and have been tar geted at pilot populations to ensure that optimum detection rates are achieved and quality services developed. It is intended to develop such screening services at national level based on the evaluation of the results achieved so far in these programmes.

It is vital that the techniques used in screening for cancer are proved to be medically effective and accurate before screening programmes covering large segments of the population are introduced. The question of introducing screening programmes for other forms of cancer is being kept under review and is being considered by the National Cancer Forum under the chairmanship of Professor Paul Redmond. The forum has established a working group on cancer screening which will examine all relevant issues relating to the introduction of cancer screening programmes. The forum will keep the Minister advised on these matters.

While significant progress has been made in implementing the national cancer strategy since 1997, discussions with health boards have identified a range of additional needs which have not been provided for in the strategy or the action plan. These needs have arisen mainly in the areas of surgery, radiotherapy, cancer nurses, drug costs and palliative care. It is clear that these and other areas will require further examination as the regional directors develop their regional cancer plans further.

In addition, funding has been provided which will be targeted at counselling and support services and nurse education. Projects will also be funded under the tripartite memorandum of understanding between the National Cancer Institute in the USA, Northern Ireland and the Republic of Ireland, including the production of an all-Ireland cancer report being compiled jointly by the cancer registries here and in Northern Ireland.

It is clear that the area of cancer treatment and care is one of the most complex and difficult areas which our modern health service has tackled. It is an area which requires a multi-disciplinary approach and the development of services must take into account the needs of patients and their families. The Government has demonstrated that it is committed not just to once-off investment but to an incremental and targeted investment policy based on the best professional advice available which is intended to achieve the best international standards of care. I support the amendment to the motion.

Mr. Boylan

I wish to share my time with Deputies Hayes and Gay Mitchell. This is one of the most important debates we will have this term, and I thank our spokesman, Deputy Gay Mitchell, for bringing it forward. We will be judged on our response to this debate. Many individuals and families will be watching to see our response, and they will be extremely disappointed by the Minister of State's response to the issues raised and brought to his attention within the past five minutes and which he has sought to ignore.

The health services are in a shambles, but we are focusing in this debate on cancer treatment and the care of cancer patients. Both are close to non-existent. They are not available. Early detection and immediate treatment will bring results. We read in the daily papers and medical journals of the great advances made in medical science in the treatment of cancer. It is important people have regular screening, especially women.

In that regard, the response of the Minister of State and of the Minister, Deputy Martin, to the early diagnosis of treatment within the North-Eastern Health Board area is as follows. A mammography machine was purchased by the Friends of Cavan General Hospital, brought to the hospital and lay for two years in the crates in which it was packed, despite the fact the same good people raised funds for its commission. It has not been commissioned although we were promised it would happen. One of the largest public meetings on this issue was organised by councillors Madeleine Argue and Maura Maguire Lynch and others in Cavan Town Hall and was supported by the men and women of County Monaghan. It is not often the people of Cavan and Monaghan come together, but there is an understanding on this issue that there cannot be screening equipment in every general hospital in the country and that it must be done on a regional basis. Cavan General Hospital is an ideal location for a mammography machine for that region. The response of the Minister, Deputy Martin, the Minister of State and the Department of Health and Children has been—

Dr. Moffatt

We are putting in place centres of excellence. You must accept that.

Mr. Boylan

Never mind your centres of excellence. Cavan General Hospital is a centre of excellence.

Dr. Moffatt

You cannot have it both ways.

Mr. Boylan

Do not run down Cavan General Hospital, one of the finest buildings in the country but, unfortunately, understaffed and under funded by you. You are responsible.

An Ceann Comhairle

The Deputy should address the Chair.

Mr. Boylan

The Minister of State is responding to me and I will respond to him because this is an issue for which he is responsible. The decision of the Minister is that this machine will be placed in Drogheda. It is very difficult for people to travel to or from that hospital. Everything must be on the east coast.

However, that move will not happen because I have given a public commitment that this mammography machine will be commissioned in Cavan General Hospital by Fine Gael in the next Government. That undertaking was given by Deputy John Bruton, our former leader, and our current leader has also agreed to honour it. It will happen, but it is unfortunate that we must wait another three to six months before it happens. Time is important and it is also important to have early detection and immediate treatment. Marvellous results could be but are not being obtained.

I was appalled and saddened to hear my colleague outline the position of the Children's Hospital in Crumlin.

Mr. G. Mitchell

Another centre of excellence.

Dr. Moffatt

It is not the only hospital.

Mr. Boylan

It is frightening, unacceptable and not good enough and the people will not put up with it. If the Government cannot deliver health services to the people, it is not delivering as a Government. Will the Minister of State admit that the Government is incapable of managing the health services? I am not convinced the problem is only due to a lack of funding. It is also due to a lack of good management. The Government is not managing the country. It is failing to manage the health services and people are suffering. I am not making up fairy tales. I can stand over every claim I have made. I invite the Minister to visit Cavan General Hospital to see for himself.

Mr. Hayes

The response of the Minister of State, Deputy Moffatt, to the debate was pathetic. The Government has been in office for four years but the Minister of State forgets that he is responsible.

Mr. Perry

Where is the Minister this evening?

Mr. Hayes

Why are Ministers who are paid huge sums of money and given responsibility for a service by this House not responsible? In his reply Deputy Moffatt made more than 16 references to reports. The Taoiseach gives the same blather every day during the debate on the Order of Business. We heard from him again today about report upon report.

I agree with the Minister of State that the issue is not one of money. For some bizarre reason we have decided that we must have a local health authority responsible purely to its own health board. This is nonsense. Our population is less than that of Manchester which has one health service, but we have built bureaucracy upon administration and our increasing expenditure gets lost as a result. Deputy Crawford got to the nub of the issue when he said he is tired of getting letters from the Minister for Health and Children telling him the chief executive of the Eastern Regional Health Authority is responsible for the matter in question. When will politicians take responsibility for the expenditure of the money we vote in this House? The Minister of State failed to grasp this issue in his response.

I welcome the BreastCheck programme which has been put in place for women throughout the country. However, why is the same emphasis not put on dealing with testicular and prostate cancer? These are important issues. No equivalent screening programme has been established for these conditions.

Dr. Moffatt

Any general practitioner can screen for those diseases.

Mr. Hayes

The Government, and previous Governments, have failed to address these issues. We have spent huge sums of money on health promotion for women. There is a health promotion unit in the Department of Health and Children but we do not place the same emphasis on screening for cancers among men. This issue must be addressed and I encourage the Government to do so.

Mr. G. Mitchell

I thank all who contributed to the debate. I am particularly grateful to Deputy Ulick Burke who addressed the issue of Crumlin hospital, which is in my constituency. I could not have made the case more eloquently myself. Had I done so I would have been accused of special pleading. What Deputy Burke said about Crumlin hospital is absolutely correct. It is time to invest in the hospital which has not been given the long-term financial commitment it deserves. The hospital was built almost half a century ago and needs a major upgrade.

I spoke last evening about the difference in the life expectancy enjoyed by the populations of France and Ireland. I do not understand why four million French people collectively live 13 million years longer than the Irish population will. One would imagine that we, an island people who are supposed to be relaxed, would live longer than the French. Why do we accept the fact that our neighbours live longer than we do?

Because more young French women have begun to smoke, it can now be predicted that 25 years from now the cancer rate among women in France will have significantly increased. In Ireland there has been a decrease in the use of tobacco from 47% to 25%. However, within those figures there are significantly high numbers of young people, and young women in particular, who are smoking. Tobacco companies are putting tastes into their products in order to attract and addict young people to them. We do nothing about this. We can predict that, 25 years from now these young people will present with cancer, unless we take steps to stop them.

If individual states in the United States can receive $347 billion as a settlement from the tobacco industry, simply for the health costs they had to incur because of the damage done by tobacco to the health of the citizens, we should receive £6 billion. Legal advice available to me is that this case is waiting to be heard. The Minister should take legal advice, sue the tobacco companies and use the money he wins to drive down the levels of cancer in the country.

The dangers of drinking and smoking and their implications for cancer are very serious. I like a pint but I do not smoke and when I go into a public house I do not like having to smoke someone else's tobacco. I spoke last evening about passive smoking and its carcinogenic effect. I will facilitate the speedy passage of legislation to stop smoking in public houses except in designated smoking sections, so that the rest of us do not have to inhale the cancerous and addictive product. I ask the Minister to require public houses to have proper systems of ventilation and air extraction so that people can enjoy a drink without being open to the danger of cancer.

Last night the Minister said he had made several million pounds available for this and that element of the health service. If the Minister had made those amounts of money available he would be summoned to a tribunal of inquiry. As far as I know the Minister does not have that sort of money and he is not the sort of person to hold an off-shore bank account. We made the money available. Dáil Éireann took that money from the people and entrusted unprecedented amounts of it to the Minister. The Minister has been given the biggest amount of money any Minister for Health has ever been given to spend on the health service and he still cannot do the job. This is called incompetence. The Minister tells the Members of the House, who take the money from the people and entrust it to him, what he is doing in providing extra money. The Minister did not provide an extra brass farthing. We provided the money and we are entitled to expect greater accountability. In his tenure of office in the Department of Health and Children we expect the Minister to learn from the mess he left in the Department of Education and Science. The Minister clearly does not understand the problem of the health service.

The Minister does not wish to answer the question I tabled last March regarding the number of reviews, committees, inquiries, commissions and standing committees established by him. If I were the Minister I too would be ashamed to answer it.

Mr. Martin

The Deputy should get off the stage.

Mr. G. Mitchell

The report of one committee is sent to another committee. We do not want committees. We want a healthy country and explanations as to why our people die younger than the French and why tobacco companies are allowed to sell products to which our children become addicted, instead of the smart alec photo opportunities which pass for management.

Mr. Perry

Spin doctors.

Mr. G. Mitchell

I wish to quote the chief medical officer of the Department of Health and Children who, in his 1999 annual report, stated:

One third of all cancers are preventable and one third are potentially curable. Good palliative care can provide significant improvements in the quality of life. The appalling reality is that in a society awash with money, this is not being tackled.

The Government has failed to give priority to ser vices which could help more to survive cancer. If we took seriously the advice of the chief medical officer of the Department of Health and Children, more people with cancer could enjoy many more years with their loved ones. I commend the motion to the House.

Amendment put.

Tá

Ahern, Dermot.Ahern, Michael.Ahern, Noel.Andrews, David.Ardagh, Seán.Brady, Johnny.Brady, Martin.Brennan, Matt.Brennan, Séamus.Briscoe, Ben.Byrne, Hugh.Callely, Ivor.Carey, Pat.Collins, Michael.Cooper-Flynn, Beverley.Coughlan, Mary.Cullen, Martin.Daly, Brendan.Dempsey, Noel.Dennehy, John.Doherty, Seán.Ellis, John.Fahey, Frank.Fleming, Seán.Flood, Chris.Foley, Denis.Fox, Mildred.Hanafin, Mary.Haughey, Seán.Healy-Rae, Jackie.Jacob, Joe.Keaveney, Cecilia.Kelleher, Billy.Kenneally, Brendan.Killeen, Tony.

Kirk, Séamus.Kitt, Michael P.Kitt, Tom.Lawlor, Liam.Lenihan, Conor.McGennis, Marian.McGuinness, John J.Martin, Micheál.Moffatt, Thomas.Molloy, Robert.Moloney, John.Moynihan, Donal.Moynihan, Michael.Ó Cuív, Éamon.O'Dea, Willie.O'Donnell, Liz.O'Donoghue, John.O'Flynn, Noel.O'Hanlon, Rory.O'Keeffe, Batt.O'Keeffe, Ned.O'Kennedy, Michael.O'Malley, Desmond.Power, Seán.Reynolds, Albert.Roche, Dick.Smith, Brendan.Smith, Michael.Treacy, Noel.Wade, Eddie.Wallace, Dan.Wallace, Mary.Walsh, Joe.Wright, G. V.

Níl

Allen, Bernard.Bell, Michael.Belton, Louis J.Boylan, Andrew.Bradford, Paul.Broughan, Thomas P.Browne, John (Carlow-Kilkenny).Bruton, Richard.Burke, Ulick.Clune, Deirdre.Connaughton, Paul.Coveney, Simon.Crawford, Seymour.Currie, Austin.D'Arcy, Michael.Deasy, Austin.Deenihan, Jimmy.Durkan, Bernard.Enright, Thomas.Farrelly, John.Finucane, Michael.Fitzgerald, Frances.Flanagan, Charles.Gilmore, Éamon.Gormley, John.Hayes, Brian.

Healy, Seamus.Higgins, Jim.Higgins, Joe.Higgins, Michael.Hogan, Philip.Howlin, Brendan.Kenny, Enda.McCormack, Pádraic.McDowell, Derek.McGahon, Brendan.McGinley, Dinny.McGrath, Paul.McManus, Liz.Mitchell, Gay.Mitchell, Olivia.Moynihan-Cronin, Breeda.Naughten, Denis.Neville, Dan.Noonan, Michael.O'Keeffe, Jim.O'Shea, Brian.O'Sullivan, Jan.Penrose, William.Perry, John.Rabbitte, Pat. Reynolds, Gerard.

Níl–continued

Ring, Michael.Ryan, Seán.Sheehan, Patrick.Shortall, Róisín.Spring, Dick.

Stagg, Emmet.Stanton, David.Upton, Mary.Wall, Jack.

Tellers: Tá, Deputies S. Brennan and Power; Níl, Deputies Bradford and Stagg.

Amendment declared carried.

Motion, as amended, put and declared carried.