Dáil Éireann debate -
Tuesday, 8 May 2018

Vol. 968 No. 6

Leaders' Questions

Deputy Micheál Martin

Susan Mitchell of The Sunday Business Post wrote at the weekend that last week was one of the worst in the history of the Irish health service. She was summing up the understandable anger at how Vicky Phelan was treated, the failure to tell women the truth about their misdiagnoses, forcing a sick woman through the courts and questions regarding the quality of our national cervical cancer screening programme. It is fair and objective to say that the response of the HSE directorate, the Department and the Minister in the early days compounded the crisis. Nobody appeared to be in charge and women were justifiably worried, anxious and angry.

Major issues have yet to be resolved. General practitioners, GPs, have yet to be properly advised, resourced and prepared to respond to the crisis. The help line has been way behind and has not been effective, as I know from people who contacted me over the weekend. Thousands of people are awaiting callbacks and, according to some reports we received this morning, some women were more worried after the calls than they were beforehand. Clearly, it is a rushed initiative that is not properly resourced. Many promises have been made. Will every woman who seeks a free smear test, as announced last week, get one? Is that the correct initial response? Does the capacity exist to do that? What criteria have been given to GPs to select and refer women for further smear tests? Surely, an initiative should be taken to proactively target women who are at higher risk of cervical cancer in an initial look-back exercise. There could be women walking around today who received false negatives and who actually have abnormalities and pre-cancerous cells. Some consideration must be given to a look-back programme that would focus on women at high risk.

We welcome the inquiry but, given the role of the Department, it should report back to the Taoiseach's office or to a different Department. There is precedent for that. While focusing on an inquiry, we must be conscious of the victims of this scandal, namely, the women whose screenings were misread on a number of occasions. We must listen to their voices. I was contacted by one of the 209 women this week. Her tests were missed on a number of occasions on an annual basis. She had to have a radical hysterectomy that could have been avoided. She was not told of this until late last week. She said, "The impact of finding out that cancerous cells were running around our systems for longer than we thought, in some cases years, due to the missed scans only raises fears of recurrence."

She does not want her medical team to be scapegoated and has stated:

My medical team are my only security. Whatever happens in this inquiry, any damage to them will damage me and I refuse to allow any further damage. Enough is enough and I want assurances that my consultant will be able to focus on me and my care and not on bureaucracy.

An Ceann Comhairle

The Deputy's time is up.

Deputy Micheál Martin

In the bubble of Leinster House, we can go in one direction but we must listen to what victims say to us and we must be proportionate. The woman who contacted me asked us to be balanced and proportionate and, above all, to keep her needs as a victim as our number one priority in whatever we do.

The Taoiseach

The Deputy must have spoken to a very strong, very brave and very sensible woman who is clearly somewhat forgiving of the mistakes that were made in her case. He is right that at the forefront of our minds at all times must be our concern and regard for the women who have been affected and also the many others who are not affected but who are understandably concerned because of the fact that confidence in our screening programme has been so diminished. The Deputy is correct to say that the week gone by has been dreadful for our health service. We have many problems with our health service that need to be resolved, whether it be people waiting too long to see specialists or to get the treatment they need or whether it be some of the patient safety incidents we have become aware of in recent weeks and those of which we have been aware for a very long time.

We must not forget some wider truths. In no way would I like to diminish or play down the seriousness of any of the issues we have been talking about in recent weeks but we need to recognise that there are also many good things happening in our health service. Life expectancy is improving all the time and people are living longer and healthy lives. This is due, in part, to our health service. When we ask patients what they think of our health service, 85% say they have a good or very good experience of it. We know that cancer survival rates are improving all the time. More people survive cancer than was ever the case previously. We have better outcomes in so many different areas, whether stroke, heart attack or cystic fibrosis. We now have nearly 10,000 doctors working in our health service - more than ever before - 1,000 more nurses and student nurses than we had a year ago and 114 primary care centres open, with another eight to open in the year ahead. This is just to give a small example of the kinds of things happening in our health service every day that are bringing about real improvements for patients and real changes for the better in people's lives. We do a disservice to the hard-working staff in our health service - all 100,000 of them - if we do not recognise the very good work they all do on a day-to-day basis. We also do a disservice to patients when we are not measured in how we speak about the health service. The Deputy has been very measured in the comments he has made to date.

I will pick up on some of the questions the Deputy asked. He asked about the smear test. The smear test is available to any woman who is concerned and would like to have a repeat one. The terms of this have been agreed with both the GPs and the smear takers. A financial agreement on the fee was made last Friday and the Minister for Health informs me that guidance has been issued to GPs as to how to go about the process. Obviously, there will be logistical and cost issues in getting the tests done as soon as possible but we will overcome them, and the agreement is in place with the GPs and smear takers. The clinical review being carried out will give consideration to whether or not a look back would make sense and be appropriate. Obviously, there are pros and cons to that but it is certainly under consideration. When it comes to the helpline, I am informed that 11,000 calls have now been logged and 7,678 women have requested callbacks. All the calls are being answered quite quickly but it does take time to get back to people because generally what is required is a relatively long clinical consultation with a doctor or nurse. Often these callbacks - these conversations - can, for understandable reasons, take 20, 30 or 40 minutes because women have concerns and questions. Those questions need to be answered and time needs to be given to women and to patients for that. So far, 2,686 calls have been returned, but it should be borne in mind that before the call can be returned, a doctor or nurse needs to check records and data quality and needs to assign a call to a health professional. The initial call is answered and, once the information is collated, a longer callback occurs involving a doctor or nurse.

An Ceann Comhairle

I thank the Taoiseach. His time is up.

The Taoiseach

I can accept some of the criticism the Deputy puts forward. If we had been in a position to plan for this, we would have planned for it and would have had all these things in place. However, the Minister for Health, the Government and all the people working around us had to respond to this very quickly and to put things together in a matter of days. In normal circumstances, we would have had time to prepare but we did not have it in this instance.

Deputy Micheál Martin

The point is that arguably the system did have time to prepare and did not respond initially as it should have to the Vicky Phelan case. That is why we have had these panicked, rushed measures that have not been properly thought through. There are 7,000 women waiting for a callback. That is an appalling number. Proper thought did not go into what type of helpline should be established and whether it would be a phoneline or a genuine resource that was resourced as such. A more primary-care focused response should have been developed.

On the free smear test, presumably there will be a fee for every general practitioner, GP, in respect of every woman who comes back. However, first of all we are looking to get the quality assurance right and restore confidence in that. It needs to be thought through. Women at a higher risk should have been targeted first, working with primary care and their consultants, because there are different categories and some are more high risk than others. There is an urgent need to focus on that aspect of it.

A redress scheme was announced last week and no one has an idea what it means. Initially, it gave the impression that everyone whose results were misread would get redress. During the weekend, there were newspaper reports that it would be for anyone who was not told. It seems as though things are being made up as they go along.

I want to hear more from the Taoiseach about the logistics of smear tests from every GP. Will the Taoiseach indicate what is envisaged by the Government on this?

The Taoiseach

The offer of repeat smear tests was a response to concerns expressed by women. A large number of women who contacted the helpline wanted to have a repeat test and the Minister for Health responded to that by making it available. The possibility of a look-back is under consideration but that would be based on a smear that may have been taken six months, a year or maybe two years ago or longer. A more up-to-date test might be the best way to get reassurance for people who want it.

As I told the Dáil last Wednesday, the Government's intention is to establish a redress scheme. The first thing we must do is establish the facts of the case and we do not yet know all the facts. There are women for whom open disclosure did not occur. While the State may not have a legal liability in that regard, in my view it does have a moral liability and consequently we will need to provide redress to women who were not told this important information about their health. We also will need to look at the various different cases, of which there are approximately 166, of women who were diagnosed with cervical cancer where it subsequently turned out they had been given a false negative smear. We will need to examine that in some detail because there are different forms of false negative, namely, those within acceptable bounds of normal margin of error and those which should not have been missed. Part of what we are doing is ensuring that this clinical review is undertaken not just of the 208 women, but of all 1,400 who were part of the cervical screen audit.

On Tuesday night, the Minister for Health announced that about 1,600 cases that had been notified to the national cancer registry of Ireland had not been notified on to CervicalCheck. Much work has been done in recent days to go through that. We can confirm that the vast majority of those 1,600 cases will not need to be part of the audit because, as we suspected at the time, many of those women did not have a smear test or had not had one for a very long period. We will have the exact figures quite soon.

Deputy Mary Lou McDonald

By now the Taoiseach will be aware of the harrowing story of Mrs. Irene Teap. Mrs. Teap was twice given incorrect cervical cancer screening results, in 2010 and again in 2013. Two years later she was diagnosed with stage 2 cervical cancer. Irene Teap died in July last year. She was 35 years old with her whole life in front of her. She has left behind a heartbroken husband, Stephen, and two young children. Irene died not knowing that she had received two incorrect smear test results. She died not knowing that she could have benefitted from earlier medical intervention.

I understand that Mr. Teap has spoken with the Tánaiste, Deputy Coveney, who conveyed his feelings and listened to what Mr. Teap thinks should happen.

He is quoted in today's Irish Examiner as saying:

I want Tony O’Brien gone and to help get rid of the panic that’s out there. Tony O’Brien cannot remain on while an investigation into CervicalCheck takes place.

Mr. Teap's words echo the same sentiment and message as those of Vicky Phelan when she asked how Tony O'Brien has the neck to stay in his job. The fact that the Taoiseach continues to back Mr. O'Brien sends a very negative message to the victims of this scandal and the public more generally. People look on and see the old boys' club that runs this State protected at all costs. The old boys' club is protected even when the lives of women have been placed in the gravest of jeopardy by its members' catastrophic failures. Now, despite Mr. O'Brien's gross incompetence and his failures, the political establishment is seen to circle the wagons around him. Earlier the Taoiseach spoke of the feelings of hard-working staff within the HSE. The Taoiseach's refusal to hold Mr. O'Brien to account does them the gravest disservice of all. Telling the women of Ireland not to worry because Mr. O'Brien will soon take his annual leave simply does not cut it. In fact it is downright insulting. It deliberately misses the point.

We tabled an amendment to the Rural Independent Group's motion seeking to create an opportunity tonight for Deputies across the House to debate and to vote on whether this Dáil has confidence in Mr. O'Brien. We should not have to do this but we have had to because the Taoiseach and his Minister for Health have failed to lead from the front. His Government refuses to act and now the Dáil has been silenced on the matter. The Taoiseach said that he would listen to women and their families. He said they would be front and centre in all of his efforts. I now challenge him to be true to that promise, to start the process of accountability, to tell us that he has no confidence in Tony O'Brien and to tell him to vacate his post.

The Taoiseach

First, I thank Deputy McDonald for her very warm tribute to our deceased colleague, Monica Barnes. The Deputy is indeed right. Monica Barnes often did not come across as a typical Fine Gaeler, perhaps in the same way that Deputy McDonald does not always come across as a typical Sinn Féiner.

(Interruptions).

Deputy Ruth Coppinger

This is a serious issue. Why is the Taoiseach joking?

The Taoiseach

We will put these down as-----

Deputy Michael Healy-Rae

Is this an olive branch, a courtship? It is nice.

The Taoiseach

-----compliments in both directions.

I have read and heard about Irene and Stephen Teap and their family. It is a very sad story and one which has affected everyone in the country. Indeed the Tánaiste met with and spoke to Mr. Teap over the weekend to hear about his concerns, to talk to him and to hear what he has to say. Many of us saw the photograph on the front page of The Sunday Times over the weekend. It was a picture of a beautiful young family, a perfect family which has been broken apart by the tragedy of cancer compounded by the fact that Ms Teap was not told about the false negative smear test, as she should have been, and by the two opportunities to intervene earlier which were lost. Everyone can understand the sorrow and anger which must be felt in equal measure by the family and by their friends.

In terms of accountability, of course people want accountability and the Government wants it too. I know that people are very annoyed about how this has been handled over the last few weeks, about the drip-drip of information and about the misinformation given on occasion. I assure the Deputy that the Government and I feel exactly the same way. We have had resignations already. The clinical director of CervicalCheck has resigned. The manager of CervicalCheck has stepped aside from her role and has been replaced by Damien McCallion. It may be the case that more heads may roll in the period ahead, but it is important that they are the right heads and that we proceed with this inquiry as the Government has indicated. I do not think that our focus should be on looking for heads. This should not be about any one man.

This should be about the hundreds of women who are affected and the thousands, or perhaps tens of thousands, who are very concerned about whether their smear tests were accurate.

Mr. O'Brien has about eight weeks to serve until his term as director general of the health service ends. His focus during those weeks should be fully on getting to the bottom of this issue. He was in CervicalCheck's offices over the bank holiday weekend. His focus in the coming weeks he has left should be on doing everything he can to get to the bottom of this, to put things right and to restore public confidence in our cancer screening. That is exactly what we expect him to do.

The post of director general will be advertised in the coming weeks. It is very important that we get a good person to take that job and lead the health service forward. The Minister for Health indicated again that it is our intention to re-establish a HSE board, one that can hold the organisation to account. I certainly would welcome the involvement of the Opposition parties in talking to us about how we might structure that board. I do not believe it should be established in the normal way, whereby we go to the Public Appointments Service and get applicants. We need to think on a cross-party basis as to how we can have a very high-powered board made up of people who can establish a layer of accountability between the Department of Health and the executive of the HSE.

Deputy Mary Lou McDonald

This is not simply a question of looking for heads, as the Taoiseach puts it; this is a matter of seeking and securing accountability. I said to the Taoiseach in my remarks that he told us - I understood this in good faith - that he would put the women and families who have been devastated by this scandal front and centre. I am now asking him to demonstrate his bona fides in that regard. Those concerned have said that, for them, the first step in achieving accountability is to hold Mr. O'Brien to account. That is what they want and that is what the Tánaiste has been told. So far, it seems we are going around in circles. On the one hand, the Taoiseach critiques the HSE and its leadership but, on the other, he is not prepared to act and lead from the front. That is his job. It seems to people looking in from the outside, not least the women and their families, that Mr. O'Brien is absolutely untouchable - untouchable even though wives have been lost to their husbands, untouchable even though mothers have been lost to their children, untouchable even though life itself has been lost to women, and untouchable even though the man has patently and clearly failed in his duties. I want to know what the Taoiseach is going to do about that today.

The only thing that has any credibility or that will honour the Taoiseach's promise to listen to the women and their families is for him to state clearly - as, I understand, members of his Cabinet have stated today - that he has no confidence in Mr. O'Brien, that Mr. O'Brien must go, that Mr. O'Brien is not part of the solution and that, in fact, his leadership of the HSE has been part of the problem.

The Taoiseach

I assure the House that the Government and everyone on these benches is putting the interests of the women affected and their families first. That is what has been foremost in our minds in dealing with this matter over the past week or so. It is not right for any politician or any leader of a political party to seek to appoint herself or himself as a spokesperson for all the women and families affected. These are people who can speak for themselves, and some have done so.

Deputy Mary Lou McDonald

They have done so.

Deputy Louise O'Reilly

They have done so.

The Taoiseach

We have heard Deputies McDonald and Micheál Martin recount some of their stories. I have also spoken to people who have been affected. It is not right for Deputy McDonald - or any other politician - to appoint herself as the spokesperson for a diverse group of women and families. That is really wrong.

In the context of what the Government is doing today, it is establishing a scoping inquiry. The inquiry will answer as many questions as possible as quickly as possible. We all know people want to get answers as quickly as we can get them, and we want that also. That is why we have decided to establish a scoping inquiry under the leadership of Professor Gabriel Scally, assisted by Dr. Karin Denton. They will examine these issues. Our intention is to have them produce, in June, an outcome answering all the questions that can be answered and establishing the facts that can be established and are not contested. After that, we will follow on with a commission of investigation to look into those matters that cannot be dealt with by means of a short scoping inquiry.

While that scoping inquiry is under way, I will certainly ask people to co-operate with that, respect it and allow these two professionals to get on with their work. Professor Scally is in the country today, and that work begins today.

Deputy Brendan Howlin

As the Taoiseach has just told us, the Cabinet discussed today the draft terms of reference of the scoping inquiry into the scandal of non-disclosure in CervicalCheck. Reports indicated that the scoping inquiry will look at the outsourcing of services and the background to non-disclosure. However, the grave concern and public alarm about CervicalCheck and the audit testing remains, and we are no closer to the truth.

This day last week, I raised with the Taoiseach a number of serious concerns about the responses then under way, and little has improved on that front since then. As of yesterday, as the Taoiseach has indicated, there were 11,000 calls, 8,000 people had requested a callback and only 2,686 have received it. That left 5,000 people still waiting for a callback. Many people have been referred to their general practitioners, GPs, but GPs are contacting us to tell us that they have not been properly informed as to what to tell them. What has the Minister told GPs, and what additional resources have they been given?

The key question from a patient safety perspective, however, is whether the cervical cancer screening programme was and is currently within acceptable parameters, both in administering the tests and, as importantly, interpreting the results. Vicky Phelan's case was that her 2011 screening test was wrongly interpreted. On proper reading interpretation, she should have been referred for further treatment. As we understand it, the HSE set out a CervicalCheck clinical audit to examine the screening history of all cases of cervical cancer, including Vicky Phelan's case. Of the 1,482 cases notified, 442 cases - 29% - were flagged for review of one or more elements. The most common review was of the smear test due to its known inherent limitations.

Tony O'Brien confirmed last week that in 208 cases the review team's interpretation of the smear result was different from the original reading of it. Further, he said that the difference in interpretation in those cases would have led to a different clinical escalation in 175 cases or a recommendation for an earlier repeat smear in 33 cases. The figure of 208 cases out of 1,482 is 14% of the total, or approximately one in seven. To be clear, that is 14% mistakenly read, not 14% mistakes, due to the inherent limitations of the screening system itself.

The key question for those women that the Taoiseach is telling to go back and have repeat smear tests if they are concerned and who are due to have normal clinical smears this week is whether this 14% reader error falls within acceptable or normal test standards. That is the question I am asking the Taoiseach to clarify now for the thousands of women and their families who are fearful about smear tests they have had and concerned about having it repeated. Is a 14% misreading level an acceptable international standard?

The Taoiseach

First, in regard to CervicalCheck, a daily report and update is being provided by CervicalCheck on its website. That comes out at about 5 p.m. every day. If the Deputy goes to the CervicalCheck website, he will see it gives detailed guidance for GPs and smear takers as to what is happening and it gives them advice and guidance as to how they should communicate with patients who come to see them. That has been on the CervicalCheck website now for a number of days.

One of the aspects the inquiry will look into is absolutely that question to ensure and give us assurance that our cervical screening programme is up to international standard in terms of the accuracy, false positives and false negatives, and also to look at the issue of the different laboratories, labs, and whether there is a statistically significant difference in the number of false negatives identified in one lab versus the other labs. As the Deputy knows, three labs are used, two in Ireland and one in the United States. It is important once again to put on the record of the House the inherent limitations that exist in cancer screening. Screening tests are not diagnostic, nor are they designed to be; they are screening tests.

The whole idea or concept behind screening is that a patient is invited to come in long before they have any symptoms of cancer. By screening, one can pick up many cancers early before they become symptomatic, but one does not pick all of them up. Even the best test done by the best people will have a proportion of false negatives but those who are picked up early can get treatment earlier, which, of course, improves their outcomes and life expectancy immeasurably. We know from the Cochrane review, which was the highest level of clinical audit or study across the world, that roughly for every 1,000 women who go for a smear test, 980 can be given the all clear and assured that there are no abnormalities whatsoever, roughly 12 women will have abnormalities detected and can then go for colposcopy, which will prevent them from developing cancer or being diagnosed with cancer at that point, and eight will be false negatives. It is understood, therefore, that for every 1,000 smear tests, for every 1,000 women who goes through the door of their GP's surgery for a smear test, there will be a false negative in roughly eight out of 1,000 cases.

False negatives do not necessarily equal incompetence, negligence or failure on the part of the pathologist looking at the slides. It is understood that this is a limitation of cancer screening. We must bear in mind that in the clinical audit that was done, what is called retrospection bias would have been understood from day one. Essentially, when one looks at these slides under a microscope, one is looking at cells dyed with a coloured dye. One tries to see whether or not there are abnormal cells in the pattern. When the audit was done and they looked back at the 1,400 or so individual slides, they looked back with a different set of eyes. They looked back knowing that these women had already been diagnosed with cervical cancer. When one already knows the outcome and what one is looking for, one is more likely to find it. All of these things must be teased out in the period ahead both by the scoping inquiry, which started today, and the clinical review, which is being carried by the Royal College of Obstetricians and Gynaecologists.

Deputy Brendan Howlin

The Taoiseach did not really answer the question so I will put it again. There is a huge difference between the known limitations of a screening test and cases where cancer should have been detected but were missed beyond normal error. An error that reflects known limitations is a normal error. The question I am asking relates to missed positives where the actual smear was misread. We are told the rate is 14%. For the women who are going to have smear tests today, tomorrow and next day before the scoping exercise is complete, I am asking the Taoiseach whether a 14% misreading is within international norms and, if not, can we do something now to improve it?

The Taoiseach

I again want to put on the record that we have no evidence that our cervical screening programme is below international standards in any way. We do not have any reason to believe that our cervical screening programme is any less accurate or is poorer that any cervical screening programme, but it does have limitations. Let us not forget that in the past ten years, 50,000 women have had lesions identified and because we had a cervical screening programme, those 50,000 women were treated early and many did not go on to develop cancer as a result. We should not forget that because this is a programme that works and saves lives. The biggest tragedy that could come out of this would be a significant fall off in the number of women going for smear tests because that will certainly cost lives and in some cases, cost women their fertility if they manage to survive.

It is a fine line. Discovering the difference between normal error and negligent error will be a fine line. We are talking about something that was within the limitations of screening compared to something that should not have been missed under any circumstances. It will not be as simple as just saying black and white. There will be areas of grey in between and that is part of what the scoping inquiry and the clinical review will have to work out. I explained earlier what I meant by retrospection bias. One cannot use that clinical audit and extrapolate from it that there is a 14% error rate because when they did the audit, they looked back at those slides knowing that these women had been diagnosed with cervical cancer. Therefore, they knew that it should have been positive.

That is not the same as looking at slides and samples de novo when one does not what one is supposed to be looking for on them.

Deputy Ruth Coppinger

At the weekend I met a woman; let us call her Anna. She had two smear tests, one in 2011 and one in 2015. Both came back as negative from Quest Diagnostics. A year later in April 2016, Anna was diagnosed with an 8 cm tumour. Thankfully today she is in remission, but the treatment means she cannot have children, which is a huge blow to her, a woman in her 30s, and her husband. We cannot adjudicate here as to whether it was excusable not to detect her cervical cancer. However, why is there an aura of such confidence in smear tests when they are, in fact, so fallible? Why were women with symptoms like Anna's dismissed by their own GPs when the clear smear test was cited to refute their concerns?

Last week Anna listened as the head of the HSE, Mr. Tony O'Brien, told the Joint Committee on Health that every slide is examined by two pairs of eyes. He was categorical about that. Last week, at the same committee I asked doctors from CervicalCheck if there is any difference in the results between the three labs, the public lab here in Ireland and the two private outsourced labs, one of which is in the US. They said "No". Strangely, they did not have the figures to back that up, but those figures have since become available when one went looking on the website. They reveal that over three years the outsourced labs have consistently lower detection rates, in particular Quest.

Let us consider the year 2013-14. I believe the Taoiseach took over as Minister for Health during that year. In the Coombe, the detection rate for abnormalities logged was 14.1%; for MedLab, it was 12.4%; and for Quest, it was 5.8%. The following year, the Coombe was 13.07%, MedLab was 11.2% and Quest was 7.8%. In 2015-16, the Coombe was 11.7%, MedLab was 9.3% and Quest was 8.46%. I know differences in demographics have been cited, but there would want to be massive differences in demographics to bring about those differences in results. The detection rate at Quest was nearly half of that of the Coombe, for example.

Why was Quest repeatedly given the contract when it has consistently shown these lower detection rates over these years? This is particularly true for lower grade abnormalities. Do Quest and the outsource labs meet the standard in the CervicalCheck quality assurance document of screeners not screening for more than five hours a day? Do its technicians screen not more than the 12,000 per annum or 50 a day? Why, based on the tendering document I have seen, are we not meant to give contracts to companies whose directors have been convicted of conspiracy, corruption and bribery and yet everybody knows the history of Quest from the 1990s, making settlements of $40 million in one decade, paying $11 million to the US Government in respect of lies over testing; and paying doctors kickbacks? Does the truth lie elsewhere in the tendering document that the most economically advantageous tender is the one that has to be accepted? Would the Taoiseach agree that it is serious cause for concern that for-profit private companies have been handed such a vital part of our women's healthcare?

The Taoiseach

I am very sorry to hear about Anna and very sorry to hear of her case, which the Deputy has shared with the Dáil. I am very sorry to hear what she has been through. I am glad she is now in remission but obviously the consequences of her cancer will be with her for the rest of her life.

The Deputy is correct in saying that we here cannot adjudicate on the issues she has put forward. That is exactly why we have established this inquiry - a scoping inquiry which starts today to be followed by a commission of investigation.

When it comes to any contract such as this, laboratories must be up to standard before getting a contract.

The issue as to which one comes in with the best price or the most economically advantageous price or bid only arises provided those labs are up to standard in terms of the quality of service they can provide, their accuracy and their ISO accreditation. Therefore, the cost only comes into it after standards are upheld. Cost is not a factor and if standards are not up to scratch, the laboratory would not even be permitted to make it to the final stage of the tender.

I am speaking on this as somebody who knows a little about how these things work but it certainly was never the case that any contract was ever run by a Government Minister for approval. That is not how contracts work and it is not how public procurement works, as the Deputy will be aware. It is also important to say that detection rates are not the same as error rates and it may well be the case that the batches sent to different labs are not all the same.

The whole point of establishing this inquiry is to get to the facts. We want to get to the bottom of this, we want to get to the facts, we want to put things right and we want to restore confidence in our cancer screening. Therefore, it is a specific term of reference of the scoping inquiry established today to, "examine the tendering, contracting, operation, conflict of interest arrangements, performance information and performance management, accreditation and quality assurance of contracted cytology laboratory services by CervicalCheck from initiation of the programme". That is exactly one of the terms of reference the scoping inquiry will examine not just for recent years, but going all the way back to 2008, to establish whether the suggestions the Deputy has made in the Chamber today stand up to scrutiny and are in line with the facts.

Again, I would encourage people to give their support to Professor Scally and Dr. Denton in the work they are going to do in the weeks ahead to try to answer those questions for all of us as soon as possible. I recognise the involvement and engagement of Opposition spokespeople on health in contributing to the terms of reference of this inquiry last week.

Deputy Ruth Coppinger

Since this scandal broke, the dogs in the street have been asking how it is good medical practice to outsource cervical screening to a privatised lab 3,000 miles away in a different time zone. Have we not arrived at the truth with these figures, given it is paying its technicians a fraction of what professionals are paid here? A private, for-profit company like Quest would be known to cut corners. I would like the Taoiseach to comment on its track record and why several Ministers stood over it being re-awarded the contract.

I do not expect us to adjudicate on the particular case because that will have to be done elsewhere. However, such big variations between one lab and another, which are clearly shown by this, should have warranted investigation over the years.

Research has shown that women are not listened to, and we know this because medical studies show women tend to get treatment later and are subjected to more pain before they get treatment. That has been combined with the perfect storm of privatising the screening service in this way and we are paying the price for that now.

The Taoiseach

The whole point of this, in many ways, is that we have not yet got to the truth and the Deputy is coming to particular conclusions without knowing all the facts. What we want is to get to the truth, and that is why we have established this inquiry and why it is a specific term of reference that the inquiry will examine the issues the Deputy raises. I ask her and all Members of this House to allow the inquiry to make its inquiries, allow it to look at the facts and allow it to get to the truth, and then we will find out whether there was a failing in that regard.

I ask Deputies, in the interests of women and their health, and in the interests of not causing additional concern or worry, not to jump to such conclusions until the inquiry actually happens and we find out the findings of that. Again, I inform the Deputy that, as I am sure she is aware, no Minister, current or past, has a role in contracts, tenders or public procurement. That is not how it works.

An Ceann Comhairle

That concludes Leaders' Questions. We have gone significantly over time today but I suppose, in light of the vital importance of the subject, that is understandable.