Dáil Éireann debate -
Wednesday, 15 May 2013

Vol. 803 No. 2

Leaders' Questions

Deputy Micheál Martin

There has been worldwide coverage and publicity given to the decision by the actress Angelina Jolie to have a bilateral mastectomy because she has a mutation in the BRCA1 gene. Her decision to go public is a very brave one and will undoubtedly save the lives of many women across the world. It has also stimulated debate here and elsewhere on the adequacy of DNA screening programmes.

Ireland has a nationwide mammogram screening service for women over 50, which has been very effective and successful, but we do not have a DNA screening programme for BRCA1 and BRCA2 gene mutations. At the moment, women who have a family history of breast cancer are generally referred to their GPs for advice and may be referred on to one of the eight cancer centres of excellence in the country or be referred to a private centre, where the costs are prohibitive. The Irish Cancer Society has confirmed that there are approximately 360 Irish women who have the relevant mutation in their BRCA genes. The waiting time for such tests to be carried out, at up to 18 months, is excessive due to a shortage of funding. This situation is unacceptable, particularly because any woman who receives a positive test result is in a position to make a decision to have surgery which could dramatically reduce her risk of developing cancer. The risk of developing breast cancer can be reduced from 87% to 5% and the risk for ovarian cancer can be reduced by up to 50%.

A month ago, the Health Information and Quality Authority, HIQA, published a report, undertaken at the request of the National Cancer Control Programme, NCCP, which recommended DNA screening for women aged between 30 and 49. Such screening could reduce the number of deaths and would be cost-effective. I ask the Taoiseach to confirm that this DNA screening programme, as recommended by HIQA, will go ahead. Does the Taoiseach accept that the waiting time for testing for BRCA mutations, at an average of 18 months, is totally unacceptable? Will the Taoiseach confirm today that urgent action will be taken to enable this test to be made available within weeks to the women concerned?

The Taoiseach

I, like millions of others, read the story of the actress Angelina Jolie and her decision to have a mastectomy, as well as her statement to her children that their mammy would always be the same. She made her decision based on the risk of death, as her mother had died of ovarian cancer. This is of particular interest to a cohort of women in this country and around the world.

The demand for counselling and testing for diagnosis of hereditary genetic mutations in the BRCA1 and BRCA2 genes for patients diagnosed with breast or ovarian cancer who have a strong family history of similar cancers occurring in relatives younger than 50 years has increased. The NCCP has established a hereditary cancer programme in collaboration with the National Centre for Medical Genetics at Crumlin Hospital to improve access to assessment and genetic testing for those patients whose cancer may have a hereditary component. There are outpatient clinics with genetic cancer expertise at St. James's Hospital and the Mater hospital, with a similar service planned for Cork University Hospital shortly. That programme is primarily focused on patients who have hereditary breast, ovarian or bowel cancer. A working group has been established to agree appropriate structures and best practice in the identification and management of those with hereditary cancer mutations.

Deputy Martin is correct that at the request of the HSE, HIQA recently completed a health technology assessment of surveillance of women aged less than 50 who are at elevated risk of breast cancer. The Deputy will be aware that the programme for Government contains a commitment to extend the breast cancer screening programme to those aged between 65 and 70. HIQA examined the potential of a standardised surveillance programme as well as the resources required to support such a programme. The report found that surveillance for these women can reduce the number of deaths when compared to a situation where there is no surveillance programme in place, which seems to be quite logical. Women at high risk tend to have far more aggressive tumours, so early detection in these cases is absolutely critical. For those women who have been identified as being carriers of certain genetic mutations, HIQA concluded that surveillance from ages 30 to 49 using annual MRI tests would be cost-effective, and for those aged between 40 and 49, the addition of an annual mammogram should be considered. In another small cohort of women who have a high probability of developing breast cancer before 30 - that is, those who are carriers of a mutated TP53 gene - annual MRI surveillance from age 20 to 49 is the optimal strategy recommended by HIQA.

For women with a high familial risk but no identified genetic mutations and for those at moderate risk the HIQA report found that surveillance is not cost-effective compared to offering no surveillance.

However, HIQA concluded that if the goal is to maximise health gains using existing resources and taking account of current international best practice then annual surveillance using mammograms for those aged 40 to 49 years is better than the current arrangements. For persons who have a high risk or who have a family history in these kinds of cases the reported waiting list is not as long. In cases where there is no history doctors have recommended that a test is not absolutely necessary. The HSE national cancer control programme and the report specifically identify the at-risk categories and the strategy and structure for that is being put in place now by the working group. I hope it will save lives.

Deputy Micheál Martin

The fundamental question is will the Government extend the screening programme and will the resources be made available to extend the surveillance programme, as recommended by HIQA? That is the first question on which I seek absolute clarity and confirmation. The establishment of a working group does not mean a great deal. It can mean something but it would have to be followed up by a clear commitment to adequately resource the provision of any programme or service. That would take funding but the numbers involved are not significant in terms of those with a genetic mutation that would create a higher risk of developing breast cancer and ovarian cancer. Let us consider the numbers at issue. I understand approximately 4,200 women are known to have familial risks but only one in 15 of these actually have a genetic mutation. The costs cannot be insurmountable in this case although I realise there will be logistical issues and so on.

That is the position in terms of surveillance and screening. Equally important, is it acceptable that if one wants to have the DNA test done one must pay approximately €1,400 or else wait 18 months? I call on the Taoiseach, the Government and the Minister for Health to focus on that specific area and issue. At the moment the tests are going to Birmingham. The Taoiseach mentioned the national centre in Crumlin. The spokespeople at the national centre maintain that their equipment is hopelessly outdated, that they require new equipment and that extra capital resources to provide the equipment necessary to do the testing here are required. That has been well commented on by many of the experts involved in the aftermath of this issue getting the attention it is getting today.

Is the Taoiseach confirming that the surveillance programme as recommended by HIQA is going ahead and that resources will be provided to enable it? Will the Taoiseach take urgent action to enable women who need DNA testing to get it as a matter of necessity? Will he ensure that the availability and accessibility will be enhanced dramatically from the current waiting time of 18 months, a period which, I imagine the Taoiseach would agree, is unacceptable? The numbers are not vast. Lives can be saved. We are discussing reducing the risk of getting specific cancers from 87% to 5% and reducing the risk of ovarian cancer by 15%. There are gains to be made.

The Taoiseach

The working group has a function. I have no wish for it to be like working groups in the past, which did not do anything other than make a report.

Deputy Micheál Martin

We did the breast screening.

The Taoiseach

As Deputy Martin is aware, this issue concerns the lives of women here. It is also true to say that if a general practitioner anywhere in the country has a concern about someone in his surgery who may be in this category, he will not say to her that he is sorry and that she will have to wait 18 months because of his concern that she cannot be screened. If the GP has a genuine concern that a person in his surgery has a family history of this and that there is a real risk, then obviously in such a case because it is in that category it has to receive priority and the patient must be given a screening.

Deputy Micheál Martin

They do not get it. I am referring to the genetic mutation tests not the mammograms.

An Leas-Cheann Comhairle

The Taoiseach, without interruption.

The Taoiseach

We are all interested in this. We need to understand and assess the numbers waiting for 18 months for assessment. Are they all for this particular category? Am I to understand that if a GP has a person in his surgery this morning, he must say that he is sorry and that they cannot do anything for the patient for 18 months despite the fact that she may have a serious possibility or probability of being caught in this particular function?

Deputy Micheál Martin

Patients must go private to get the DNA testing done or else wait 18 months.

Deputy Billy Kelleher

He is mixing it up.

Deputy Micheál Martin

That is what the GPs are saying.

An Leas-Cheann Comhairle

I ask the Taoiseach to conclude.

The Taoiseach

I do not have all the details of all these to hand this morning. However, I assume the working group-----

Deputy Micheál Martin

Will a GP refer someone?

The Taoiseach

Yes, a GP can refer someone.

Deputy Micheál Martin

Only to the private sphere because that is the only way one can get the treatment.

The Taoiseach

We have had cases-----

Deputy Micheál Martin

If a patient is on the public waiting list, she must wait 18 months.

Deputy Dinny McGinley

Listen to the Taoiseach.

An Leas-Cheann Comhairle

Please, Deputy Martin.

Deputy Alan Shatter

Does Deputy Martin want to get an answer or does he just want to interrupt?

The Taoiseach

Deputy Martin is aware that the breast screening system which operates here is one of the most effective of its kind.

Deputy Billy Kelleher

That is for mammograms.

The Taoiseach

Cases have come to my clinic involving those covered in the private sector who were advised to go through the public hospitals and actually got treatment there very quickly.

Deputy Micheál Martin

That is for mammograms.

Deputy Alan Shatter

That is for cases of immediate risk.

Deputy Micheál Martin

It is a different programme.

The Taoiseach

People who are at immediate risk can be referred by their GPs for immediate screening where there is a risk and a probability that they may well be in this category. I assume that the working group will assess all of these figures and realities. At the moment, if a GP has someone about whom he has a genuine concern to the effect that she may be in danger of being caught by this type of cancer, then she can be referred for priority screening.

(Interruptions).

An Leas-Cheann Comhairle

Sorry, no. I am calling Deputy Gerry Adams.

(Interruptions).

An Leas-Cheann Comhairle

Deputy Martin, please. I have called Deputy Gerry Adams.

A Deputy

He never listens.

An Leas-Cheann Comhairle

Can I have order, please, for Deputy Adams's question?

(Interruptions).

Deputy Gerry Adams

The test for good hospital services is that patients get the best treatment possible and they and their families have confident that this is the case. It is clear at the moment, despite the excellent work being done by health professionals and health workers, that this is not the case for many people. Yesterday's reports on hospitals groups and the framework for smaller hospitals have been described by the Minister for Health, Deputy Reilly, as a "fundamental modernisation of our health system organisation in line with best international practice". That is more or less what Deputy Micheál Martin stated as Minister for Health ten years ago when he claimed that the Hanly report would "change forever the landscape of the Irish Health Service".

Irish people are rightly sceptical about false dawns. If there is real potential in yesterday's proposals there must be full consultation with hospital users and local communities. They need to know whether these reports will actually affect the quality of health services for them and their families. Unfortunately, that information is not in these reports.

We must also factor into this that there is not much confidence in the Minister for Health and that there is outright opposition to the Government health cuts agenda. There is widespread concern. I have seen it in my constituency with regard to ambulance services. We have heard of the terrible tragedy of the toddler, Vakaris Martinaitis, who died after a fall in Midleton. This morning there were 290 patients on trolleys. Many hospitals have already lost 24-hour accident and emergency services and more will do so. That is clear from the report. There is a serious information gap in this report in respect of the detail of what services will be allocated to which hospitals. Will communities be given details? Will there be full, inclusive, meaningful consultation?

The Taoiseach

The answer to Deputy Adams's last question is "Yes". There has been extensive consultation in the last period with consultants, doctors, agencies, organisations, the people and with public representative about the major hospitals, the lower-tier hospitals and local hospitals. The impact of this is to have a situation whereby it is clear that medical personnel are working in teams in the interests of their patients. Generally, this has received a broad welcome from medical personnel working in hospitals. Contracts in future will no longer be to individual hospitals but to the group. There is an 18 month period for testing the effectiveness of this approach.

As the Minister pointed out, not every hospital can offer all specialties but there can be a system that operates in the interests of the patient across the country. These groups will eventually evolve into hospital trusts where chief executives and operators in each hospital will run their affairs in an efficient and effective way. We like to think we can by changing the structure of the delivery of hospital care make it in the best interests of every patient. Deputy Adams is an example of international health facilities and good luck to him in that. I am sure he could have got an even better service here in Ireland had he chosen to do so. This is one of the most fundamental changes in the structure of the delivery of health care through our hospitals in decades. It has taken extensive consultation to bring it to this point. There were a number of locations around the country where people were genuinely concerned that hospitals might close and they would be denied a range of services. That is not the case; the Minister has confirmed no hospital will close and smaller hospitals will have a range of different opportunities to provide services that are more appropriate for them and will keep them busy.

The Government is working very hard with medical personnel to reduce trolley waits. Consultants now see, treat and discharge patients on a 24/7 basis. The establishment of the hospital groups is another milestone in the changed structure and nature of health service delivery.

Deputy Billy Kelleher

The Taoiseach opposed that policy when he was in opposition.

The Taoiseach

It will take some time to see the real effect of these changes but it has been talked about for many years and at last we have a Minister who has put it together with a very fine report from Professor Higgins to see it is implemented in the interests of the patient, unlike the situation Deputy Adams would be aware of, where report after report gathered dust on shelves for years.

Deputy Billy Kelleher

The Taoiseach is a late convert.

The Taoiseach

This is doing something about it that is credible, practical, logical and in the interests of the patient. There will be a better delivery of a more effective and visible health service in the interests of the patient.

Deputy John Deasy

Dusty shelves, Deputy Kelleher, dusty shelves.

Deputy Billy Kelleher

Welcome to Cork, Deputy Deasy.

Deputy Gerry Adams

It may be the report has potential, we must wait and see. We must factor in the lack of confidence in the Minister and the fact he has broken promise after promise. He entered office promising to restore emergency services to Roscommon General Hospital and he broke that and other promises. It is deplorable, as it is for the family involved, that a patient should spend a night on a trolley. We have repeatedly raised this issue - Deputy Ó Caoláin before me - and it is totally deplorable. We must also factor in the fact the Government is cutting resources to the health services, not enhancing them.

The Minister is reported as saying yesterday that his proposals will make it more difficult for rogue operators to inflict damage on patients. We deserve to know who these rogue operators are. We deserve to know what patients have been damaged and what the damage was. Across the State the same system that existed under the last Government is in place, with people struggling with the same excessive GP fees and numerous beds lost, along with services and staff.

I do not recognise the consultation process the Taoiseach outlined earlier on. I have been consulted as a Teachta Dála but in terms of local communities of hospital users and their families, that is not a mark of how we do our business in this State. Would the Taoiseach acknowledge there is genuine concern about what these proposals mean for local hospitals? There must be a consultation process to clear that up. Could the Taoiseach clarify the Minister's remark about rogue operators inflicting damage on patients?

The Taoiseach

As Deputy from County Louth representing Drogheda, Deputy Adams should not have to ask that question about rogue operators. What is involved here will put an end to that. Accountability and transparency, with effective delivery of hospital and medical services for all people, are what is at stake. We do not want to see a repetition of the scandals in the north east in the past. We will not tolerate that and that is why the structure is being changed so there is real accountability and transparency. Deputy Adams above all people should know that question should not have to be asked.

Deputy Gerry Adams

I know what happened there. It was a systems failure and there is no evidence it will be corrected by those proposals.

Deputy Alan Shatter

It shows how the Deputy is so disconnected from his constituency that he does not know what went on there.

Deputy Gerry Adams

I know exactly what went on and Deputy Shatter, as Minister for Justice and Equality, would not rectify it.

Deputy Mattie McGrath

Yesterday the annual national farm survey was released by Teagasc. It shows that farming continues to be highly reliant on direct support payments. The single farm payment continues to be the most important component of direct payments. It comprises 58% of farm income on average, and over 80% of income on cattle farms. These are astonishing figures. Shockingly, it also shows that 26,104 farm households are not viable and neither the farmer nor the spouse works off the farm. This highlights the desperate situation the agriculture sector is in. All farming associations, including the IFA, have said the main reason for the drop in income was bad weather and the impact of Government cuts.

The Taoiseach might believe he can do something about the weather, but he cannot. He can, however, do a lot about the Government's response to the fodder crisis the weather has caused. The Government response to the fodder crisis has been inaction and paralysis. A lot can be done about the levels of cuts the farming associations have said are causing real and substantial pain to farming families all over the country. It is clear these farms are particularly vulnerable to cuts in direct payments because they are so vital to farm income. Given that information, will the Taoiseach categorically acknowledge that there is a real crisis in the agriculture sector? All of the evidence points to the seriousness of the situation and the fodder crisis is getting worse. All reports are saying its effects will continue for the next number of years if it is not dealt with. So far this year there have been 133,000 fallen animals.

This is a real crisis and it is time for a national plan involving the relevant Ministers who can contribute to the easing of this suffering. There is a national strategic committee that comes together under the Taoiseach's direction at times of flooding, snow and other crises which are much smaller in area than the country-wide crisis in fodder. I demand the Taoiseach to convene that committee. Will the Taoiseach use his position of President of the European Union to tell his EU colleagues how bad things are in Ireland, that there is a real crisis and that there must be emergency measures put in place, including the making of all payments up-front while delaying farm inspections? The Teagasc inspectors should go into the banks with the farmers to see the refusals at first hand. The Minister says they are ready and willing to lend but they are not lending and farmers can no longer borrow because milk cheques and everything else are being consumed. This is an ongoing crisis that will get worse if the Taoiseach does not act.

The Taoiseach

It is nonsense to say nothing is being done about this by the Department of Agriculture, Food and the Marine or by the Minister. They have been very proactive in dealing with the fodder crisis, which principally arose from the very cold and bad weather that has been unusual this year and has had a direct impact on the input costs for farmers having to buy feedstuff. The lack of fine weather has also severely impacted grass growth. Teagasc figures show bad weather resulted in a drop in family income by 15% in 2012 to €25,483. That is still 10% ahead of the 2010 figure. It is clear from the survey that the increase in input expenditure was brought about by poor weather, everyone understands that. Gross output declined by less than 1% on average, while total production costs increased by 9%. In addition, expenditure on concentrate feed was up by 30% and bulk feed by 28%.

These are input costs that have arisen because of the bad weather. Clearly, the Government has been acutely aware of the crisis facing farmers over fodder.

Deputy Michael Healy-Rae

The Government has not done much about it.

The Taoiseach

Almost a thousand loads have been imported, with further large quantities expected. The transport subsidy scheme has been doubled, to €2 million, and the closing date is extended to 24 May. The animal welfare helpline is manned on a constant basis and is dealing with calls from farmers with concerns. Some 150 farmers have received direct aid under this system.

The Minister, Deputy Coveney, and the Department are liaising directly with the banks, the co-operatives and the suppliers to urge flexibility and favourable credit terms are being offered where that is possible. Over 2,000 payments from the agriculture environmental options subsidy have issued during the past two weeks and together, these payments are valued at approximately €3 million. Some 29,200 of the remaining 30,200 REPS 4 participants have been paid a total of €167 million in respect of the 2012 application period and an additional €1 million will issue this week to a further 200 REPS 4 farmers.

Teagasc has also launched a national campaign aimed at supporting farmers who have a particular fodder crisis. A number of co-operatives have introduced positive measures, such as reduced prices or rebates on compound feed, and interest-free credit for fertiliser. Although there has been some small improvement in grass growth in the past short period, heavy rain has resulted in difficulty in getting animals out on grass in some areas of the country and all efforts will continue to ensure farmers are assisted through what is a difficult period. While current conditions are difficult, the longer term outlook remains good overall and the positive expectations for dairy, beef and lamb prices mean that farmers should see improved return on prices in the period ahead.

The Minister has been very busy, as has the Department, in dealing with the question of the international plan, which is the reform of the Common Agricultural Policy, and we are hopeful of bringing that to a conclusion during the course of this Presidency, in the next five to six weeks.

Deputy Brendan Howlin

That was a comprehensive reply.

Deputy Mattie McGrath

It is the Taoiseach who is talking nonsense, not I. He stated the Minister is very busy. Why would the Taoiseach not appoint a second Minister of State? Of what is the Taoiseach afraid? Promises keep all the backbenchers quiet.

The Taoiseach's response to the fodder crisis is disgraceful. He has refused to call together the national infrastructure committee-----

Deputy Brendan Howlin

Deputy Mattie McGrath had that written before he heard it.

Deputy Michael Ring

Deputy Mattie McGrath himself should take the job.

Deputy Mattie McGrath

-----on the day when the Farm Contractors of Ireland are outside the gates of this House protesting about the plight of the farming sector.

All the waffle in the world, and all the spin, will not put grass on the fields or food on the tables. Shamefully, the Government is neglecting the main industry in this country. Coming from a rural county, the Taoiseach should understand the position in agriculture. When the farmers are doing well, the country is doing well.

At the Cement Roadstone AGM, I called on the company to provide a cargo ship to bring in the aid that the IFA and the co-operatives, both of whom I salute, have sourced abroad. The Minister, Deputy Coveney, promised us at committee a month ago that he would organise a ship. Unless he sailed away on it, we have not seen it. Cement Roadstone has plenty of cargo vessels. The company has made considerable profits. It is one of the strongest companies in Europe and it should provide one of those. I ask the Taoiseach to call on the company to transport the fodder from France and elsewhere to those who need it. Did the Taoiseach watch the television last night? He should talk to the Teagasc staff.

On a day when we salute the bravery of the late young Donal Walsh being laid to rest in Kerry this morning - God rest his soul - for the efforts he made to deal with those on the verge of suicide, and when Teagasc and Pieta House and many others dealing with this area are telling us of the suicides and threat of suicides in the farming community, it is the Taoiseach who is talking nonsense. The Taoiseach has a habit of doing that lately on all matters and as for answering a question, he has given it up for two years.

Deputy Brendan Howlin

It is the silliest point I have ever heard.

The Taoiseach

It is disrespectful of-----

Deputy Michael Healy-Rae

What is silly about it?

Deputy Micheál Martin

It is not silly. The Government is out of touch.

An Leas-Cheann Comhairle

Please, please.

The Taoiseach

It is disrespectful of Deputy Mattie McGrath to raise the matter of the death of a young boy in these circumstances.

Deputy Paul Kehoe

Hear, hear.

Deputy Micheál Martin

It is not disrespectful.

Deputy Mattie McGrath

I made it in the context-----

The Taoiseach

The Minister, Deputy Coveney, has just concluded a 36-hour marathon negotiation in dealing with the Common Fisheries Policy-----

Deputy Mattie McGrath

Where is the Minister of State the Taoiseach was going to appoint?

The Taoiseach

-----which has been talked about for 30 years and about which nothing was done. At long last, real reform is in prospect.

Deputy Mattie McGrath

The Taoiseach has left agriculture without a Minister of State.

The Taoiseach

As I pointed out to Deputy Mattie McGrath, the scheme has been doubled, with a €2 million investment, and a closing date for applications of 24 May. This is about logistics. Deputy Mattie McGrath will be aware that the feed has been sourced.

Deputy Mattie McGrath

They cannot get it in.

The Taoiseach

It has already been purchased. It is a matter of getting it here. Deputy Mattie McGrath makes his flippant comment about ships, etc.

Deputy Mattie McGrath

The Minister promised a ship a month ago.

The Taoiseach

Those involved in this, Teagasc, the IFA, the feed suppliers and the farmers-----

Deputy Mattie McGrath

Everybody except the Government.

The Taoiseach

-----are well capable of dealing with the logistical challenge of getting fodder into the country.

Deputy Mattie McGrath

Everybody except the Government.

The Taoiseach

They are already planning in terms of next year. Farmers who might normally take three cuts of silage will not be able to do that this year under the current weather conditions.

Deputy Michael Healy-Rae

They will be lucky to get one.

The Taoiseach

For the immediate future, the transport subsidy is in place, the scheme has been extended to 24 May-----

Deputy Mattie McGrath

They have no ship. It is no good to have subsidy.

The Taoiseach

-----and I hope that today will see the arrival of more, and adequate, fodder already purchased and that it will be distributed to farmers who need it.

Deputy Mattie McGrath

The Taoiseach cannot tell me.

The Taoiseach

From where he comes, Deputy Mattie McGrath is well aware of the connection and co-ordination of activity in the farming community to get this fodder delivered to those who need it and as I stated previously, the direct line to the Department is there for anybody who has a particular problem.

Deputy Mattie McGrath

They need action, not telephone lines.

The Taoiseach

We have had the action.

Deputy Mattie McGrath

Where is the ship?

(Interruptions).

The Taoiseach

The Minister has met-----

Deputy Mattie McGrath

Where is the ship?

Deputy Finian McGrath

Captain Simon on the ship.

(Interruptions).

The Taoiseach

-----all the banks.

An Leas-Cheann Comhairle

Order.

The Taoiseach

He has met the lenders. The feed suppliers-----

Deputy Finian McGrath

Captain Birdseye.

Deputy Mattie McGrath

Deputy Coveney is not the captain.

An Leas-Cheann Comhairle

Sorry.

The Taoiseach

-----the farmers, Teagasc and the Department all are working in the interests of seeing that this matter is resolved.

Deputy Mattie McGrath

All except, and in spite of, the Government.

The Taoiseach

I hope the weather improves and that it will bring about grass production. It is six weeks behind where it should be. We do not have any control over that, much as Deputy Mattie McGrath might like to think we have.

Deputy Mattie McGrath

The Minister promised a ship at committee a month ago.

An Leas-Cheann Comhairle

That concludes Leaders' Question.