Leaders' Questions

I implore leaders to adhere to the time limit.

When the scandal in regard to the Vicky Phelan case and the women involved in the cervical cancer screening programme not being informed of the audit outcomes first emerged in this House, I used the phrase, "Everybody knew, but nobody knew". In terms of the documentation produced yesterday by the Department, these words ring very true because everybody within the national screening programme, CervicalCheck, at senior level in the HSE and key officials in the Department of Health and Children knew. When Deputy Donnelly and I met the Minister, Deputy Harris, and his officials at that time, we got a commitment from the Minister that notwithstanding any inquiry to be established, he would publish information as he got it and he would not seek to suppress any Dáil committee or the Dáil considering the issues pertaining to the cervical cancer screening programme.

I was amazed last week when the three memos emerged at the Committee of Public Accounts. I would have thought the Minister would have summoned his officials and demanded all of this documentation and published it in an ordered and structured way. It has taken us three weeks to get to the level of documentation received yesterday. The Taoiseach said on "Six One" last week that he does not think the Committee of Public Accounts is the place to discuss this matter, in respect of which Ministers followed suit. There appears to be an agenda to push the Committee of Public Accounts and other Dáil committees to one side. We got a commitment from the Minister that no attempt would be made either to prevent publication or to prevent Dáil committees doing their work on this matter and that the inquiry would not be used as an attempt to bury information away from the public domain. The Government should adhere to this commitment.

In regard to the documentation, it is clear that the policy of open disclosure is very much a live issue throughout 2016. Every month they are meeting and the CervicalCheck audit is on the agenda. These are joint meetings between the Department of Health senior officials, the chief medical officer, the National Cancer Screening Service and CervicalCheck, and they are saying that while CervicalCheck supports the principles of open disclosure, it is recognised that there are limitations to its universal implementation, particularly for screening services where there is an inherent recognised error rate. At the same time, the then Minister is proclaiming his commitment to introduce mandatory open disclosure.

Will the Minister, Deputy Bruton, commit to the publication of all the advice received by the then Minister from the chief medical officer on the policy of mandatory open disclosure? Is the position of the senior officials in the HSE and CervicalCheck that an exemption is required from open disclosure in terms of the screening programme, filtering across the wider policy of going against what the Minister originally proclaimed publicly, namely, that he would introduce mandatory reporting? This was subsequently changed in policy terms. What is the reason for this and will the Minister, Deputy Bruton, commit to publication of the advice in regard to the volte-face in terms of open disclosure?

I take this opportunity to express again my personal shock and sympathy to the people who have been so appalling affected. The non-disclosure was a major failure of public policy, given disclosure has been HSE policy since 2013. It is categorically clear, however, that this never came to the attention of any Minister. When it did come to the attention of Government, very swift action was taken to protect the people affected by way of a package of services, including the provision of a helpline, the establishment of international clinical oversight for any outcomes that come to light and the ones that have come to light, cancer screening rechecks and the establishment of an inquiry, headed by Dr. Scally, through which we will get answers such that this can never happen again. I assure the Deputy that no document that will be withheld from those who want to inquire into what has happened in this instance. There is no attempt by Government to restrict access to information, which the Minister made clear from the outset. The fact that the Committee of Public Accounts is receiving information shows there is no attempt to withhold any information nor is there any attempt to confine the work of Oireachtas committees. Oireachtas committees must work with others who are seeking to get clinical facts, but it is up to those committees to decide how they conduct their business. I fully support this.

On the reason for a staged approach to mandatory disclosure, this has been debated in the House. I understand that an all-party Oireachtas committee recommended the approach of a introducing a voluntary disclosure process initially to encourage a culture change where people could openly discuss failures where they occur and not have this process constrained by liability issues blocking the honest conversations that should happen in a system. We are moving, via the health information and patient safety Bill, to introduce mandatory disclosure for serious incidents. This will be legally binding such that it will be an offence to fail to do so. It was signalled in the programme for Government that we would do this over the five-year programme and we are doing it. The change in regard to civil liability, the policy of disclosure and the legislative framework put in place in this regard was openly debated in the Oireachtas and it was done in the knowledge that mandatory disclosure was to follow.

I will make two points. First, the Taoiseach made a statement to the effect that the Committee of Public Accounts should not be involved in this matter, which was supported by some Ministers. A meeting was held by the Committee on Procedure and Privileges to discuss whether the Committee of Public Accounts should do so and Deputy Harty, as Chairman of the Committee on Health, has stated in writing that he does not believe it should. I am not saying any of this is connected and I am not joining any dots. As party leader, I have never interfered with the Committee of Public Accounts nor given any guidance or instructions in this regard to anybody. It is important that the Government does not attempt to muzzle a key committee of this House. Whether one agrees with what it does or how it does it is beside the point. It is a parliamentary committee. Dr. Scally has also referenced the fevered atmosphere and so on. I am raising this issue in a plenary session of the House because I do not think we would have had sight of those documents last week but for the Committee of Public Accounts. The Minister, Deputy Bruton, said the Minister, Deputy Harris, is committed but he gave a commitment three weeks ago and we did not get information. I find it inexplicable that people did not front up at that early stage and provide the documentation.

Second, on open disclosure, what is evident in this documentation is an attempt to exempt the cervical screening programme from the strict rigours of open disclosure. The templates for the letters to the women concerned provide consultants with a way out in terms of the use of the word "may". It is clear there is a circumvention of open disclosure. Is there any link between this and the decision of the then Minister, Deputy Varadkar, not to proceed with his original commitment to introduce mandatory open disclosure? It is an interesting point from a policy perspective. Many people are making decisions without Ministers' knowledge and, equally, on substantive issues of policy, this appears to be the case also.

The documentation shows categorically that neither the Taoiseach nor the current Minister for Health had any knowledge of the non-disclosure and, as such, it cannot be linked to any decisions that were made by Ministers or the Oireachtas in terms of how they should deal with this.

It is very clear that there can be no link because no information was made available to the Ministers concerned.

Will the Government publish the advice?

The Minister will make available any documentation that is required by committees. That is always the case. What the committees should do is entirely a matter for them, and I fully acknowledge their independence. I have been around this House for a long time and I fully recognise the rights of committees to do their business. I must also be conscious, however, that the Dáil is anxious that Dr. Scally would produce a report in June so we can have timely answers around the clinical implications, the protection we need to provide for women and the further follow-up that needs to occur to help women who are concerned. It is not just about who knew what and when.

It is important and the House needs to take account of comments that come from an individual like Dr. Scally, if he has concerns. While we do not want to impede that, we also want to do our business. It is for the Oireachtas to make its decision and for the committee to makes its decision. I respect that but we also have to recognise that we have asked Dr. Scally to do an important job that clearly involves a wider range of expertise than we have. In striving to get accountability, we must ensure that we do not interfere with a process that is important, valuable and vital to the people concerned.

Over the past 24 hours we have learned that two women with cervical cancer who had contacted CervicalCheck in 2016 were refused direct access to the results of the audit of their smear tests. This information is contained in a letter from CervicalCheck to the chief medical officer, Dr. Tony Holohan, in October 2016. A separate memo in March 2016 says that doctors were told to use their judgment when deciding whether to inform women that their smear test results were wrong. Such revelations highlight once again the urgent need for mandatory open disclosure to be legislated for as soon as possible. I welcome the all-party support for Sinn Féin’s motion last night calling for this legislation to be introduced before the summer recess.

As Minister for Health, the Taoiseach promised to introduce mandatory disclosure but, following advice from the chief medical officer, he changed his mind. That was the wrong advice and the wrong decision in 2016. Many of the women who are affected by the CervicalCheck scandal are only now being informed of their misread results. The fact that the then Minister did a U-turn on his previous position on the basis of his advice indicates that the chief medical officer was a trusted and valuable source of advice for the Minister. When one considers the fact that the chief medical officer was informed of this scandal around the same time, it would be useful and important to know the nature of the advice given to the then Minister in that regard. Was it informed by knowledge of the CervicalCheck scandal or was it informed by any other medical scandal?

If the chief medical officer knew of the issues surrounding CervicalCheck, it raises questions around how or why he did not inform the Minister of the issues at the time, as has been claimed by the Minister. As the lead medical expert in the Department of Health, it is the job, duty and responsibility of the chief medical officer to advise and inform the Minister. The fact that he claims not to have raised these matters with the Minister raises profound questions on the operation of the Department of Health and what exactly Ministers are told. I ask the Minister, Deputy Bruton, to respond to this point.

Cultural, organisational and management failures have been identified as a result of this scandal. Central to building confidence in every aspect of our health service must be the need for information, clarity and accountability. All of that can be done if the political will is there. Sinn Féin supports cancer screening services. Let there be no doubt about that and let the message ring load and clear. Screening services are vital in assisting in the early detection of cancers, but we need to ensure there is full public confidence and trust in the service. Getting to the bottom of the failures identified as part of the CervicalCheck service can assist in rebuilding trust.

I put to the Minister a question that I put to the Taoiseach yesterday. Will the Minister tell the House when the cervical cancer screening audit and documentation relating to the US laboratories, which was promised to the Oireachtas Joint Committee on Health last week, will be published? Will the Minister ensure that this information is published today? He is in the Government, after all, so can he ensure it is published? Perhaps the Minister will also respond to reports in the media that despite the resignation of Mr. Tony O'Brien on Friday, he will continue to be paid until the end of his contract in July? Will the Minister inform Members what the Minister did when this information broke on the public airwaves as a result of the bravery of Vicky Phelan? Did the Minister not have a conversation with the chief medical officer? Did the Minister have a conversation with the director general of the HSE? What assurances did they give to the Minister about the knowledge they had on this scandal and around the fact that they had failed to provide the information to these women?

I believe it is very clear, and everyone in the House accepts, that there have been failures in this situation. It raises issues about the longer-term accountability of the HSE. The Minister has signalled that he will introduce legislative change to change the oversight mechanisms for the HSE. The House will have ample opportunity to discuss how best we do this. The Minister continues to consult and he will endeavour to ensure that the new structures deliver accountability with real cultural and structural change within the HSE to deal with some of the issues that have been unearthed.

With regard to the timing of individual documents and when they will be published, I cannot give the Deputy an answer because I do not have that information. A trawl is being completed of all documents. Any document that is needed will be furnished and there is no attempt to restrict access to any documentation.

Who knew what and why it was not escalated is one of the issues that needs to be assessed. Assessing this aspect and why it happened will be a central role for Dr. Scally. We all recognise that this was a failure. From the perspective of the women who have been affected, it has been appalling that they were kept in the dark on this. We see that and we understand the anguish it has caused. We have to make sure that we can get to the truth of why it happened, if there was responsibility, who was responsible, and how we can ensure it never happens again. We also need to make sure that women who are in any doubt have access to an international clinical audit, which we are now providing. This will be available to women to support them with regard to any tests that should have revealed issues but which failed, and independent clinical experts will be available to assist them.

We are seeking to resolve a massive failure that has occurred. There are immediate issues that must be addressed, which we are doing, and information must be provided to all the necessary parties so it can be done. We also recognise the longer-term issues. The Minister will revert to the House with details of how we ensure better information flow, accountability, culture and structures within the health service.

The information that is at the disposal of the Minister for Health and the Minister for Justice and Equality about the advice the former Minister for Health received on not proceeding with mandatory open disclosure is within the Government's own Departments. It can and should be published and there should be full transparency. We need to know why the Taoiseach did a U-turn on this issue when he was the Minister for Health. We need to know what advice was provided. When legislation was passing through the House in November 2017, which included sections on mandatory open disclosure, why did Fine Gael decide to vote against it? Why was Fianna Fáil convinced to abstain on that issue? These are important questions that need to be answered. The advice needs to be published at this point.

The Minister, Deputy Bruton, has said that all documents will be furnished, but they are not being furnished. The cervical cancer screening audit that has been available since 2014 has not yet been published, despite the requests for it to be published. It should be published and the Government needs to ensure it is published today. The information on the US laboratories' detection rates also needs to be published today. This information has been requested for more than one week now. The Oireachtas Joint Committee on Health was told this information would be published. We need to restore faith and confidence in the cervical cancer screening test to ensure that every woman has confidence that it will be dealt with accurately and appropriately, regardless of where the tests are sent for analysis. Will the Minister answer those questions and the questions around Tony O'Brien who resigned last Friday? Is Tony O'Brien still receiving a salary until the end of his contract in July?

I assure people that no concerns have been raised about the operation or value of the cervical screening process. It identified 50,000 cases in which there needed to be detailed information and saved 1,000 lives as a result of that work. The quality and worth of the clinical smear testing regime have not been thrown into question. Rather, what has been revealed is a problem with disclosure. It is important to distinguish between the two.

The centres where evaluations take place have been audited and found to meet international standards. Dr. Scally will need to look beneath those audits to provide additional assurance on the situation, but none of these documents has raised questions about the value of clinical screening. We are moving to a better test, namely, the HPV test, which will have a lower error rate. The Government is committed to doing that. I would not like the Deputy's comments to be construed as meaning there is some cloud over the value of clinical screening.

The payments to the former public servant will be in line with the contract under which he was employed.

The CervicalCheck scandal shows the importance of vigilance in our efforts to improve the health of our country. Essential tasks for our health service are screening and disease prevention. Ensuring that we prevent unnecessary blindness is one example. Approximately 75% of sight loss is avoidable. At the end of last August, the inpatient waiting list for eye procedures was almost 12,500 people, the largest of any medical specialty. If sight-saving treatment is not delivered, it puts people at risk of irreversible damage to their vision.

Cataract surgery can restore impaired vision, but a survey by the Association of Optometrists Ireland published today shows incredibly long waiting lists across the country. The average waiting period is 28 months, with up to a shocking five-year wait in some parts of the country, such as west Cork. The survey also expressed concern about inconsistency and gaps in eye care services for children, in respect of whom there is an average waiting time of 15 months.

The opening last year of a new eye and ear unit in the Royal Victoria Eye and Ear Hospital doubled the number of procedures it could perform. The Minister for Health, Deputy Harris, stated then that this would over time eliminate waiting lists in the Ireland East Hospital Group. That is welcome, but a nationwide programme is required. When will a plan for the rest of the country to deal with these unconscionable waits be rolled out? The lowest waiting time is in Sligo-Leitrim due to its award winning scheme. There have been repeated calls for the Sligo post-cataract scheme to be rolled out nationwide. Up to 20,000 procedures are carried out each year in Ireland, so this innovative scheme could radically reduce the number of appointments needed by people suffering blindness because of cataracts. The scheme is referenced in the programme for Government, the benefits are known by everyone and there have been repeated requests for it to be rolled out. As such, what will be done to increase the overall capacity for cataract operations in Ireland? We have an ageing population and we must be equipped to meet future health needs as well as the current health needs of people whose quality of life is immeasurably improved by having better vision after cataract operations. When will the proven Sligo model, which has had a positive impact on waiting lists in that area, be rolled out to every part of the country as promised in the programme for Government?

I thank the Deputy for raising this issue, which the Department and Minister have developed a plan to address. I checked the figures this morning. Just over 11,000 people are on the inpatient waiting list for cataract or ophthalmological surgery, with 75% of those seen within nine months. The Minister's plan is to eliminate waiting times of over nine months. To do that, he will use the National Treatment Purchase Fund, NTPF, which has been assigned €55 million this year. I understand that 5,000 cataract cases will be included in its programme for this year. That is significantly more than the number of people waiting longer than nine months. This matter is a high priority for the Government.

Large numbers of people are on the outpatient waiting list, but a target has been set for 80% of patients to receive an appointment within a 52-week period. There will be a joint initiative by the NTPF and the HSE to address that issue.

I am not aware of the strengths of the Sligo model, but I will ask the Minister to take heed of it as he rolls out this plan. If there are procedures that can accelerate access to care in a field where, as the Deputy rightly stated, any time lost is critical, the Minister will consider them. Significant emphasis is placed on this issue in the Government's plan and the Minister is confident that the targets will be delivered on this year-----

The Government let a lot of people go blind.

-----and that no one will be waiting for longer than nine months by the end of the year.

The bottom line is that people have been waiting for inexcusably long periods. One patient described the return of vision after a cataract treatment as the difference between day and night. It is not an expensive or complicated procedure and a sophisticated country like ours should be able to provide access to such an operation within a couple of months at the longest.

The Minister's statement that the future objective is to have 80% of patients dealt with within 13 months, which means that 20%, or one in five, would have to wait for much longer, is not acceptable. We have no details about how that target will be met, where specifically the new procedures will be carried out and where the new surgeons will be appointed. Will the Minister give specific focus to the questions I have asked and detail how the objectives that he set out are to be achieved?

The Deputy is confusing-----

What did the Labour Party ever do for them? Nothing.

It let them go blind.

The Labour Party let them go blind when it was in government.

What was it doing for those five years?


Deputies, please.

The Government let a lot of people go blind.

To clarify the question on procedures for Deputy Howlin, that is, where a person has been seen and a procedure identified as being necessary, the target is for there to be no cases waiting for over nine months by the end of the year. At the moment, a little over 2,000 cases have been waiting for longer than nine months. The NTPF will make provision for 5,000 operations, which is more than double that number. The Minister and the NTPF-----

Where will they be performed?

-----are confident that, between the existing flow of work and the additional procedures that will be contracted privately, the target will be met. I will ask the Minister to provide the Deputy with the additional detail he requires in terms of locations and service providers.

Given the demand from many Deputies for answers about a number of aspects of the cervical cancer issue, it is regrettable and unsatisfactory that neither the Taoiseach nor the Minister for Health is present to respond.

Notwithstanding that, more than two weeks ago on 1 May, the Minister for Health informed the House of a considerable additional number of women who had developed cervical cancer but had not been included in the CervicalCheck audit. We have been told that these cases were not audited because the National Cancer Registry had not notified them to CervicalCheck. This in itself raises important issues with the reliability of cancer data. There is a question of data protection concerns preventing the registry from notifying CervicalCheck, but I understand that has since been resolved.

One must ask why it took so long to resolve such a basic issue. We have since discovered that some 1,631 women were not included in the audit. It is estimated by the Department of Health that approximately 20% of the women had a smear test prior to their cancer diagnosis, meaning that approximately 320 women are involved. Many of them will have had their cancer indicated from their smear test but some will not and are left with major questions as to whether their smear test result was a false negative. On the basis of the false negative rate among the cohort of women whose test results were audited, approximately 15% of the test results for the second group of 320 women are likely to be false negatives. Thus, approximately 45 women who had false negative smear test results but who subsequently developed cervical cancer have not been responded to by the Government. One woman in that position contacted me recently and was highly frustrated and annoyed that she had not been contacted. How many of these women have been contacted and how many have had to contact the CervicalCheck helpline themselves? Have their smear test results now been audited? Will the Minister set out the Government's response to the women in terms of the provision of supports and services because they have not heard any information to date?