Cancer Screening and Care Services: Discussion

I wish to introduce our witnesses from the HSE and the Irish Cancer Society. They will be presenting remotely to us this morning and will provide us with an update on cancer screening and care services in these demanding Covid-19 times. I welcome from the HSE Professor Risteárd Ó Laoide, director, national cancer control programme, Ms Fiona Murphy, chief executive, National Screening Service, and Dr. Nóirín Russell, clinical director, CervicalCheck. From the Irish Cancer Society, I welcome Ms Rachel Morrogh, director of advocacy and external affairs, and Mr. Donal Buggy, director of services.

Before we hear opening statements I need to point out to our witnesses that there is uncertainty over whether parliamentary privilege will apply to evidence from a location outside the parliamentary precincts of Leinster House. Therefore, if they are directed by me to cease giving evidence in respect of a particular matter, they must respect that direction. I call Ms Morrogh to make an opening statement.

Ms Rachel Morrogh

In Ireland today, many cancer services are struggling to meet patient demand. At the Irish Cancer Society we see the impact of this every day. Through our support line, daffodil centres, night nurses, advocacy network, fundraisers and volunteers, patients share their experiences, and the human side of cancer care is revealed. Patients have told us about the layers of additional anxiety and distress of having cancer in a pandemic. As well as this, we have been struck by the overwhelming fear and loneliness felt by people who have received life-changing news alone and who have spent considerable periods of time cocooning since March. We thank every healthcare worker who has made this journey easier through his or her kindness, professional knowledge, understanding and empathy shown to the thousands of patients who are currently using Ireland's cancer services.

The Irish Cancer Society is in the business of hope. We know that cancer numbers are growing, but we believe things can and must get better. We point to the national cancer strategy and the incredible cancer workforce in Ireland and we say that the future is positive. Yet, the performance of some cancer services is getting worse, not better, due to historical underfunding, lack of capacity in the system and an under-resourced and incomplete workforce.

Thankfully, this has been recognised by the Minister for Health and cancer services received substantial funding in the budget this year. However, the scale of the challenge is immense. While increased funding is vital, money alone will not solve all the problems. Covid-19 has had a devastating effect on a system that for many years had insufficient capacity to be able to assure people that they would get diagnosed and treated for cancer as quickly as they should. Insufficient hospital capacity, inbuilt inefficiencies and too few healthcare professionals along with an increase in cancer cases of between 3% and 4% annually has led to lengthy and growing waiting lists. Longer waiting lists mean delays in diagnosis and treatment. Delayed diagnosis and treatment can mean worse patient outcomes. The truth is that, in Ireland, access to care is being rationed by waiting lists, and until these are eradicated, patient care and, sometimes, outcomes will be compromised.

I appeal to committee members to imagine being symptomatic but being unable to get timely access to a test to find out what is wrong. This is the reality for thousands of people waiting for a diagnosis in Ireland. For instance, we understand that there may be in excess of 100,000 people waiting for a radiology appointment. This includes urgent, semi-urgent and routine waiters for ultrasound, CT and MRI tests. The demand for radiology services is steadily rising at an annual increase of between 8% and 10%. In the national cancer strategy, the vital role of radiology in diagnosing cancer was called out and the strategy document outlined that there are substantial deficiencies in access to such services. In Ireland, recent reports have found that we have fewer radiologists and radiographers than is recommended by international best practice. This has led to high workloads compared with peers in other countries and correspondingly high waiting lists for patients.

Timely access to cancer treatment is vital. Yet, capital investment to expand capacity and infrastructure in many oncology day wards throughout the country was badly needed pre Covid. Medical oncology was routinely working above capacity. Now, the reduction in hospital occupancy capacity to 85% in line with clinical guidance on safe practice for patients and staff and the ongoing risk that staff will need to take Covid-19 leave puts further pressures on waiting lists. Even if capacity is expanded, we doubt that additional staff are available. In the case of surgical treatment, only seven in ten patients were able to get care within the appropriate timeframe up to the end of 2019. Covid-19 has made accessing operating theatres more difficult, and timeframes from diagnosis to surgery are of particular concern to us.

One of the most critical key performance indicators in the national cancer strategy, which relates to the centralisation of surgery, will be missed at the end of this year. Progress must be accelerated in this area. We have previously called for protected surgical time for oncology cases and we believe the national cancer control programme needs to consider how to improve diagnosis-to-treatment timeframes.

Another area I wish to draw to the attention of committee members is genetic services. Waiting lists exist at every point on the pathway for people who have or may have a genetic risk of cancer. Currently, genetic services and the downstream services that are needed by patients are underdeveloped and under-resourced. As well as the development of genetic services as envisioned in the national cancer strategy, we are keen to see the development of a dedicated pathway for breast cancer gene, BRCA, positive patients and an audited quality-assured screening programme for them. More capacity needs to be created in downstream services so that a dedicated group of physicians can follow these patients and discuss options and psycho-oncology support. Patients have told us that the lack of capacity is illustrated by the fact that if they choose to have risk-reducing surgery, some women cannot be given a date for when reconstruction can happen.

Lastly, great cancer care is intertwined with cancer research. Research is the driving force for ongoing improvement in cancer outcomes and motivates hope among patients and the world-class experts who give them care in this country. Yet, the metrics suggest that research activity is significantly declining rather than growing. Some of the issues I have illustrated are related to a lack of investment in capital infrastructure and service development. Equally, the challenges associated with the cancer workforce are a significant threat to the success of the national cancer strategy. The implementation of many recommendations is wholly reliant on having enough staff with the right skills and access to the best equipment to deliver cancer services. Healthcare professionals underpin the success of the entire strategy.

The Irish Cancer Society believes that there has never been a more urgent time to focus on cancer services. We are grateful for the funding injection into cancer services that the Minister for Health, Deputy Stephen Donnelly, announced as part of budget 2021. We believe it will be one element of the many that are needed to build a strong and resilient cancer service.

I thank committee members for remaining focused on the performance of cancer services and for acknowledging the major challenges that have built up over a considerable period. Committee members have refocused political attention so that cancer does not become the forgotten C during the pandemic. Covid-19 has had a devastating impact on all of our lives. When it comes to cancer, however, it is the things we do today and the measures we put in place here and now that will decide the ultimate impact of this pandemic on our cancer outcomes.

I said we are in the business of hope. Together all stakeholders - patients, healthcare professionals, representative groups, members of Government and Members of the Oireachtas - need to turn hope into action. We do this by demanding improvements, listening to and learning from experts, putting in place best practice and making sure we have efficient, well-funded and well-staffed cancer services. I firmly believe that everyone here today can play a role in achieving that.

Professor Risteárd Ó Laoide

I thank the committee for inviting me to meet with it to discuss cancer care and screening services. I have been the director of the national cancer control programme since the end of July 2020. I will begin by discussing the effect of Covid-19 on the symptomatic cancer services and then outline some future developments.

In common within many other countries, the Covid-19 pandemic has had a significant impact on cancer services in Ireland. The maintenance of cancer services during the pandemic has been prioritised by the HSE, the Department of Health and the Government. Early in the pandemic, the national cancer control programme, NCCP, led a co-ordinated response on behalf of the cancer services. Close engagement between clinicians from key disciplines addressing difficult clinical questions and facilitating the urgent need for the development of national guidelines helped to deliver safe services and maximise survival in an extremely uncertain environment. Communication with primary and community care and with the public at large was prioritised to ensure clear messaging on the availability of safe cancer services.

As Ms Morrogh mentioned, this has been a very difficult period for cancer patients and their families. To mitigate the risk to their care in a Covid environment, the cancer services have enabled as much care as possible to take place outside the acute hospital setting while ensuring robust infection prevention and control measures are in place to ensure patient safety within the hospital setting. The NCCP, the Irish Cancer Society and Cancer Care West established a virtual psych-oncology service called Together 4 Cancer Concern to address the real problem of anxiety and worry facing many cancer patients. The Department of Health funded 26 acute oncology nurses to help ensure those patients on cancer treatment avoided emergency departments and stayed outside hospitals.

The pandemic required adapting diagnostic and treatment pathways to ensure patient and staff safety. The impact of these measures has unavoidably reduced capacity. However, staff in the cancer services have responded with great dedication and agility and have adopted measures to optimise triage, pre-screen patients, utilise telemedicine, make local infrastructural changes, alter locations of diagnosis or treatment and increase capacity using extended days and additional weekend clinics. I sincerely thank all the staff for their unstinting efforts on behalf of cancer patients during what was a very challenging time in the health services.

We are continuing to optimise capacity in the cancer services in a safe manner and would encourage people with symptoms suspicious of cancer to consult their GP so they can be referred for appropriate investigation. During the initial pandemic wave, there was a reduction in cancer presentations and referrals; in attendances at rapid access clinics for breast, lung and prostate cancers; and in the number of patients undergoing treatment. Reduced cancer presentations were likely related to an understandable fear with regard to Covid infection and a response to the restrictions in place at that time. Since then there has been a gradual recovery in all metrics, a recovery which has continued despite the second autumn pandemic wave. There was a decrease in the number of cancers diagnosed at the rapid access clinics during the first wave. There has, however, been an increase since then and at the end of September, the year to date number of primary cancers diagnosed at these clinics was approximately 90% compared to 2019. It is expected that this percentage figure will continue to increase for the remainder of the year with a consequent reduction in the number of "lost cancer diagnoses".

The Minister for Health has allocated a total of €34.35 million to the NCCP in the winter pandemic plan and the national service plan for 2021. This is a marked increase in funding compared to recent years and is greatly welcomed by all in the cancer services. The funding will be used in two key areas: increasing resilience in the current cancer services; and progressing key elements of the cancer strategy.

Experience during the Covid-19 pandemic has accelerated the development of welcome new initiatives in the cancer services that will require further consolidation. These include the increasing use of ICT in the delivery of care and the optimisation of diagnostic and treatment pathways to reduce footfall in the acute hospital setting. Increasing clinic efficiencies using various streamed pathways for patient care will be progressed. Staffing resilience will be improved through additional recruitment and optimising skill mix. It must be noted, however, that the greatest threat to resilience in the cancer services in the short to medium term is increased community transmission of Covid-19.

With regard to progressing cancer strategy 2017-2026, the priorities for 2021 will include the progression of cancer prevention initiatives; improved access to diagnostics for all cancer patients; addressing the increasing and more complex demand for radiation oncology, including the provision of stereotactic ablative radiotherapy; further centralisation of cancer surgery to ensure safe, quality care for patients; enhancing medical oncology services to meet the growing complexity and demand; development of appropriate models of care for rare cancers; further development of the cancer genetics and molecular diagnostic services and improved services in the hereditary cancer programme; continued development of survivorship services, including psycho-oncology services, to improve the quality of life of those living with and beyond cancer; and supporting a research culture in the cancer services, including promoting clinical and academic collaboration.

In summary, Covid-19 has posed significant challenges to cancer services in 2020, particularly during the first pandemic wave, with a significant increase in activity since then. The recent significantly increased funding for cancer services will allow us to increase resilience in the current services while progressing key cancer strategy priorities in 2021. I thank the committee for its attention.

Dr. Nóirín Russell

I thank the committee for the invitation to attend this meeting. The Covid-19 pandemic has challenged healthcare systems throughout the world in a way that was inconceivable this time last year. In March, when we knew very little about Covid, screening services internationally played their part by pausing their programmes in order to prevent infection based on best public health advice. Since then, we have assessed the risks of delivering screening in a Covid environment and have put in place measures to reduce these risks.

In restarting cervical screening, we are focused on managing capacity across the whole screening pathway so that people get their results and any follow-up assessment in a timely manner. CervicalCheck resumed screening on 6 July by prioritising inviting the longest waiters to reduce the risk of the people delayed. By the end of December 2020, we will have issued a first invite letter to everyone due screening in 2020. We issued more than 270,000 invites in 2020 and screened more than 117,000 people in primary care.

While the global demand for Covid-19 testing has put pressure on laboratory supplies internationally, our laboratory is continuing to meet our capacity needs. For women, this translates into approximately 80% of result letters being issued within six weeks of the test. We continue to appeal for people to book their test when invited.

We have been asked how the pressures of the global pandemic will affect the people we care for in screening. These concerns are also our concerns. While we continue to work to minimise the impact of Covid-19 on screening, evidence shows that because of the typically slow progression of cervical cancer - over five to 15 years - the beneficial outcomes do not reduce if screening is delayed for six months.

The purpose of screening is to improve population outcomes for the condition being screened for. In CervicalCheck, that is decreasing the incidence of and mortality from cervical cancer. We do this by assessing risk in individuals and referring those with a higher than normal risk for further assessment in colposcopy. All screening programmes involve finding a balance between their benefits and potential harm. Our rigorous quality assurance systems ensure the programme meets the highest international standards and keeps risks as low as is possible.

Our new primary HPV screening programme will lead to a temporary increase in referrals to colposcopy in year two. We have investment in place to grow our colposcopy provision. However, we must also work with the HSE national women and infants programme to ensure capacity is created in the gynaecology service for women with symptoms who may previously but erroneously have been sent to colposcopy for quicker access to gynaecology services.

We are concerned when we hear people from all walks of life confuse screening services with diagnostic services, and we welcome the opportunity to talk to the committee about this today.

In March of this year, the HPV test was introduced as the primary cervical screening method. It brought CervicalCheck in line with international best practice in cervical screening. With HPV screening we are testing for a different risk factor in the development of cervical cancer: the presence of the human papillomavirus, that is, HPV.

We know that HPV screening is better at predicting which women are at risk of developing cancer but it will not detect everyone. No screening programme will pick up all potential cancer cases; none is designed to do so. When a potential case of cancer is not detected in screening, this does not mean that the screening test has failed. It illustrates the boundaries of the test. Furthermore, when these women go on to get cancer and their cytology slides are reviewed retrospectively, there is a four in ten chance that abnormalities will be seen that were not seen at the time of screening. This is called retrospective bias. It is important that as a society we acknowledge this uncomfortable truth.

The National Cancer Screening Laboratory, NCSL, build will begin in January 2021. In time, it will become the principal provider of cervical screening laboratory services. For now, a high-quality laboratory service continues to be delivered by Quest Laboratories in the US.

We are grateful that GPs and practice nurses are continuing to fulfil their important role as key sample takers for CervicalCheck. We thank our colposcopy colleagues who, during the pause in screening, continued to work hard to reduce the waiting list that had resulted from the issues affecting CervicalCheck in 2018. Our colposcopy turnaround times are continuing on target.

In October, the National Screening Service, NSS, welcomed the publication of the expert reference groups’ interval cancer reports. These reports were commissioned as part of the Scally review in 2018 and their publication marks the completion of 113 of the 116 Scally report actions. The reports acknowledged that Ireland’s cancer screening programmes operate to the highest international standards. They emphasise, however, that every year there will be people who develop interval cancers. This is a difficult diagnosis for people to receive. We are now working to implement those recommendations in full. We plan to consult widely with patients and their doctors about the future process. Finally, we are grateful to the many patient representatives who voluntarily give up their time to support our screening programmes this year at an especially difficult time. We remain committed to having patients at the centre of our screening programmes.

I thank Dr. Russell. Finally, I will call on Deputy Burke from the Fine Gael Party.

I thank the witnesses for their presentations. I know this is a challenging area and it has been even more difficult during Covid-19. I thank the witnesses for the care and assistance they gave to every person who came under their care.

I want to deal with Dr. Russell's presentation and about the increase in referrals to colposcopy in year two. Regarding the capacity to deal with increased referrals, will we have a sufficient number of people with the expertise to deal with it? Will we have the facilities in our hospitals to deal with that increase? How is that being planned out? When does the start of year two begin? Is it now or in three- or six-months' time? Perhaps we might get some clarification on that.

The other issue is about additional oncology nurses being available during Covid-19. With regard to a roll-out of increased level of services, do we have a sufficient number of nurses with oncology qualifications and expertise? Do we need to further increase the number of people in that area so we can continue to improve the service?

It is also important that while there has very much been a focus over the last few years on CervicalCheck and the difficulties that have arisen from it, none of the presentations today has set out the improvements that have occurred since CervicalCheck started. Perhaps it would be helpful if we got some figures on the reduction regarding the number of people who died as a result of cervical cancer and information about what improvements have occurred over the past five to eight years in that area. The witnesses might give us some figures on that.

Dr. Nóirín Russell

I thank the Deputy. I will start by addressing his first point about capacity in colposcopy. Year two of the programme will commence in the middle of next year so from June onwards in 2021. We are delighted to have secured €2 million in extra funding for colposcopy services for 2021.

One of the key points we are planning for closely with the national women and infants programme is to ensure we increase capacity in gynaecology services. Currently, one third of women who are referred into colposcopy clinics are referred in because of symptoms. Those women would be more appropriately and holistically assessed if they attended rapid access gynaecology clinics under the care of the national women and infants programme. That would free up capacity in the colposcopy clinics to look after women who screen positive and need further investigation.

As I said, we are delighted to have received funding and we are working collaboratively because it is actually a small community in Ireland who have the necessary skills to provide colposcopy. We need to ensure we match the capacity of women's needs and make sure we have the appropriate healthcare professionals to see them. It is, however, absolutely key that women who have symptoms, first, do not delay presenting to their GP. They must be seen urgently and assessed and the GPs and primary care specialists must have an avenue of rapid access to gynaecology clinics for women with symptoms. I believe that was the first question. The Deputy will have to remind me on the second point he addressed.

We had a presentation that talked about an additional number of oncology nurses. Do we have enough people there? Do we need more people to be trained up in that area?

Dr. Nóirín Russell

Professor Risteárd Ó Laoide might respond.

Professor Risteárd Ó Laoide

I will take that question, if that is okay.

Dr. Nóirín Russell

I will come back to the Deputy about the reduction in cervical cancer, which he addressed earlier.

Professor Risteárd Ó Laoide

I thank Deputy Burke for that question. He raised an important point because I believe it is acknowledged overall that medical oncology staffing in Ireland is not up to the levels of optimally performing countries. As he said, 26 cancer nurses were employed during the Covid-19 pandemic. These were employed specifically to ensure patients avoided the emergency department in what was an uncertain environment in the hospitals. They have proven exceedingly valuable because they work with the patients in the community and liaise with the GP, and really, direct patients away from the hospital and deal with any acute problems that arise from them.

Obviously, we have received a significant amount of funding this year, as I outlined in my opening statement. That will allow us to plan for additional posts in the systemic anti-cancer therapy section of the NCCP. We are hoping a further 40 positions will be recruited in 2021 to allow us to increase our staffing, which would be an overall increase of approximately 66 staff. That will therefore be a significant upgrade. That is particularly required in our oncology day wards and also to help the emergency department and acute oncology nursing staff.

Do we have sufficient a sufficient level of training available to provide the nurses we need in this area?

Professor Risteárd Ó Laoide

That is obviously a difficulty. Getting the funding in place is an issue, which we have obviously gotten some help with this year. Recruiting these highly trained staff, however, is difficult and it is obviously a competitive environment internationally for them. Hopefully, we will be able to recruit them but that certainly is clearly an issue.

Dr. Nóirín Russell

The Deputy asked me to comment on the good that CervicalCheck had done. Between 2010 and 2015, there was a 7% reduction in the incidence of cervical cancer year on year. Every year, CervicalCheck refers onwards for treatment approximately 6,500 women. That is 6,500 women who have a treatment for precancerous cells and, therefore, do not go on to get cervical cancer. The Deputy's request of me to mention these positive results from cervical cancer screening was timely and appropriate.

We must balance this with the fact that cancer screening will not prevent all cervical cancers. However, screening with cytology, which was our previous programme, prevents 75% of cervical cancers. With our new programme - primary HPV screening - screening will prevent 90% of cervical cancers from developing.

Could we be given a presentation on the reduction level of cervical cancer as a result of the screening programme? We are not getting that message out there to the media. Since much of the focus has been on the negative side, it is important that we get out a message about the positive side as well. It would be helpful for the committee if we could get the up-to-date figures for reductions over the past number of years and the benefits that have occurred as a result.

Dr. Nóirín Russell

We would be delighted to provide that information.

I will start with Dr. Russell. I am pleased that she drew a distinction between screening and diagnosis. It is important to repeat that they are not one and the same.

Do the witnesses know the up-to-date number of people screened this year compared with last year? We all accept the reasons for Covid interrupting screening services this year, but do they have the up-to-date figures for January to the end of November compared to 2019?

Dr. Nóirín Russell

I thank the Deputy for his comments about screening versus diagnosis. He has always been supportive of the programme and of making that distinction. The programme screened more than 117,000 women in primary care this year to the end of November. We had an incredibly busy November where we screened 24,000 women when we were expecting 21,000. I thank all of the women who made it their business to make their appointments and the GPs and practice nurses who performed those tests. As the Deputy rightly pointed out, the number is less than what was predicted before we knew about Covid, but more than 117,000 women up to the end of-----

How does that compare with last year?

Dr. Nóirín Russell

It is approximately 46%. We predict that, by the end of the year, we will have screened 50% of the number of women we would have expected to screen. Obviously, we will need to create capacity in the system to screen those other women next year.

It is important that I make a distinction. In CervicalCheck, when we invite a woman for screening, we do not make an appointment for her. Rather, we send out an invitation. We have invited 270,000 women for screening, but many of them have not got to make their appointments yet. We expect they will for the end of this month, at the start of next year and onwards. We will need to create capacity for that.

Dr. Russell is saying that CervicalCheck hopes to achieve a 50% screening rate this year compared with last year. For those who would ordinarily have been screened this year but were not, what is the estimated time to catch up on what could be described as missed screening?

Dr. Nóirín Russell

It is important to emphasise that what we have done is restart screening. We are not going to "catch up". Catching up would mean doing double the work, that is, screening twice as many women in a month as we normally would. With Covid-19, we are dealing with reduced capacity across all areas of screening. In our wheelhouse, we have primary care, screening labs, colposcopy clinics and histology labs. There is reduced capacity in all areas across our screening programme and we will not suddenly be able to double up,-----

I know, but I have limited time.

Dr. Nóirín Russell

-----but we will restart. We are never going to catch up. That pause is going to be a permanent one.

That is what I wanted to establish. We are essentially starting from scratch again and will try to screen as many people as we can as quickly as possible. I hope that next year will see a return to the numbers of previous years.

Before I move to Professor Ó Laoide, I will ask Ms Morrogh about her opening statement. Screening is important, but rapid access to assessments, testing, diagnoses and treatment is more important. She posed a scenario: "Imagine being symptomatic but unable to get timely access to a test". Is the lack of timely access down to a lack of CT or MRI scanning equipment, a lack of specialists or both?

Ms Rachel Morrogh

I thank the Deputy for his question. There are a range of issues, with the workforce being a major one. When we spoke to clinicians in advance of today's presentation, the questions of workforce and capacity in the system were highlighted to us time and again. Clinicians are being asked to do more with less. As a result of Covid, 85% of hospital capacity is needed for a surge in Covid hospitalisations, putting additional pressure on a system that was already struggling. When we look back at-----

Is it down to a lack of equipment and a lack of specialists?

Ms Rachel Morrogh

I do not know where the question on equipment is concerned, but we need an increase in the cancer workforce.

Ms Morrogh stated that 100,000 people were awaiting radiology appointments. Is that correct?

Ms Rachel Morrogh

That is the information that has been shared with us. Those approximately 100,000 people are urgent, semi-urgent and routine waiters.

I tabled a parliamentary question on consultant radiologists. The official HSE response was that of the 314 posts in total, 27 were vacant, or 8.5%. The Irish Hospital Consultants Association says the figure is 60 posts when some of the positions filled by locum or agency staff are included. If he has the figure, will Professor Ó Laoide confirm the number of vacant consultant radiologist posts?

Professor Risteárd Ó Laoide

Since I am a radiologist myself, I am familiar with the issues that Ms Morrogh raised. I cannot confirm the figures precisely because I do not have them with me. The waiting lists for diagnostics do not just include cancer patients. Rather, they are for all treatments within the health service. From my personal experience, the figures given where consultant radiologist posts are concerned fall in the right place. As Ms Morrogh pointed out, the diagnostics are a crucial element in cancer services. This area has to be considered within the overall context of the health service. The figures that the Deputy and Ms Morrogh outlined show us that there is an issue with diagnostics-----

We have very little time available to us and I have many questions to ask, so I will get through as many as I can. There are many vacant radiologist posts and 100,000 people waiting for radiology assessments. I tabled a parliamentary question on the number of consultant oncologists. According to the national cancer control programme, NCCP, there are 41 approved consultant medical oncologist posts. How many of those are vacant? The programme wrote: "This is the equivalent of 1 Medical Oncologist per ~100,000 population in Ireland.... by 2028, a further 58 Medical Oncologists are required". That is more than double. What is the programme's objective for the number of additional consultant posts to come on stream next year to achieve the 2028 target?

Professor Risteárd Ó Laoide

I do not have the precise figure of the number of medical oncologist vacancies. Within the cancer strategy, one of the key elements is an increase in numbers.

I am sorry, but this session was an opportunity for us. I specifically told the clerk to the committee that I wanted to raise the issues of capacity, oncology, radiography, staffing, including consultants, and so on. We should have the figures. If Professor Ó Laoide does not have them with him, will he ensure that they are sent to us?

Professor Risteárd Ó Laoide

We are hoping to appoint between seven and ten oncologists in 2021.

Professor Risteárd Ó Laoide

Between seven and ten. I do not have the exact number yet. We are finalising the national service plan at the moment and are hoping to appoint seven to ten consultants in 2021.

I wish to ask about surgeries now. A response to a parliamentary question indicates that the number of oncology surgeries performed over a number of months this year was less than half of the number performed in 2019. We can only assume that was caused by Covid-19 and we can all accept that there was an obvious interruption to all services but in terms of cancer surgeries, the numbers are problematic. In April 2019, 1,304 oncology surgeries were performed but in April of 2020, the number was 487. In May of 2019, the number of surgeries performed was 1,429 and only 584 in 2020 while in June of 2019 the figure was 1,256 compared to 725 in June of this year. These figures seem to suggest that we have an awful lot of catching up to do. Does Professor Ó Laoide have the most up to date figures for how many surgical oncology procedures were performed this year compared to last?

Professor Risteárd Ó Laoide

The most recent figures I have are to the end of August. These figures are collated from Hospital In-Patient Enquiry, HIPE, data, which takes a number of weeks to collect. The number of cancer surgeries performed in the public hospitals in the year to date in 2020 is 7,287 compared to 10,158 year to date in 2019. That equates to approximately 72%.

That is an awful lot of procedures that were not carried out that maybe would have been carried out-----

Professor Risteárd Ó Laoide

To clarify, these figures-----

What is the timeframe to catch up on those missed surgeries?

Professor Risteárd Ó Laoide

To clarify, these figures do not include the surgeries that were performed in the private sector during the Covid period. Surgeries were performed in a number of private hospitals around the country at that time. We have been doing some work with the faculty of pathology in the College of Physicians to analyse the surgical resection figures. That work indicates that the reduction was not as great as we had thought. Between March and June of this year, when one includes the private sector numbers, the reduction is 12.5%. Surgery is now back at 90% to 100% capacity. Obviously it slowed because of pretesting for surgery, prescreening and cocooning but we have clear Covid and non-Covid pathways in the hospitals. At the moment, there are effectively no waiting lists for surgical oncology in most of the centres. Some local deviation takes place because one of the main issues for capacity at the moment is transmission of Covid-19. St. James's Hospital, for example, had a Covid outbreak a number of weeks ago and that seriously diminished its surgical capacity. Similarly, the radiation unit in Cork had a Covid-19 outbreak a couple of weeks ago and again, capacity was dramatically decreased at that time.

What we are trying to do in the national cancer control programme, NCCP, is ensure that there are protected beds, protected theatres and appropriate staffing to continue to provide surgical oncology services.

I ask Professor Ó Laoide to provide a note on those figures to the committee.

Professor Risteárd Ó Laoide

No problem.

Deputy Shortall is next.

I welcome all of our guests and thank them for their presentations. I am concerned about a number of issues that were raised by Ms Morrogh. Answers should be available from the screening programme, so I will direct some of my questions to Professor Ó Laoide. The first question relates to staffing levels generally across cancer services. While the additional funding that was provided in next year's budget to improve cancer services is very welcome, there is nothing more infuriating and frustrating for people working in services and for patients than the fact that money is available but it is not possible to get staff. What work is being done on auditing the existing provision of staff and identifying those areas where there is a need for forward planning in relation to training and the provision of staff generally? Who is taking responsibility for that and what work is being done?

Professor Risteárd Ó Laoide

Within the radiation oncology programme, the systemic anti-cancer therapy, SATC, programme, the surgical centralisation programme and the rapid access clinics, work is ongoing to assess the staffing needs of the services. That work is being done by the NCCP. Workforce planning is also being done for pharmacists and nurses within the SATC programme and for oncologists and radiation therapists in the radiation oncology programme. The training of staff takes place in some of the academic institutions. The NCCP does not run training courses directly but we encourage institutions to make that kind of training available-----

In fairness, we are seeing this kind of mismatch all over the health service, with people throwing their hands in the air, saying that they cannot get staff and that something must be done about it. I am interested to know what exactly is being done about it. The witnesses said that staff shortages have been audited. Has that work been published? Is it possible to get a report that sets out where the main shortages are and what the needs will be in the context of workforce planning over the next five years, for example?

Professor Risteárd Ó Laoide

There are different elements involved but we will certainly provide any of the data we have on workforce planning to the committee. Work on this is ongoing at the moment. Radiography staffing, for example, would be a key element for diagnostics programmes. Deputy Shortall has asked what is being done and UCD, for example, has doubled its intake for radiography training-----

Leaving aside the individual training colleges, I am keen to know if there is a report available that can be provided to the committee and also where that report will go. Will it be submitted to the Department of Health or to the Department of Education? At what level is that workforce planning taking place?

Professor Risteárd Ó Laoide

Workforce planning is taking place within the NCCP. We will be in discussions with the Department of Health on that and hopefully we will be able to publish it. I do not have an overall-----

Is this something that will happen in the future or is there a current audit?

Professor Risteárd Ó Laoide

Workforce planning for pharmacy and nursing is ongoing.

When does Professor Ó Laoide expect to be in a position to make a submission to the Department?

Professor Risteárd Ó Laoide

I do not have a date for that.

Professor Risteárd Ó Laoide

We are working with UCC on the nurse workforce planning and have made a submission for an independent evaluation. I do not have a timeline for that but I will revert to the Deputy on it.

It is very difficult to get a handle on what exactly is happening and what steps can be taken to address this very significant problem. We are not going to be able to provide services unless we have staff available. Action obviously needs to be taken at Government level in that regard. I ask Professor Ó Laoide to provide us with details of the auditing done to date and the available data on staff shortages across different disciplines.

I also want to ask about delays in progress towards ensuring that cancer surgery only takes place in centres of excellence. What is the position in that regard?

Professor Risteárd Ó Laoide

The surgical centralisation programme did not make a lot of progress, to be quite frank, in the past number of years because there was very limited funding for it in the cancer strategy. We have got funding this year and are hoping to make progress on centralisation. We are going to start with rectal cancer surgery and are also hoping to look at gynaecological oncology as well as the sarcoma, hepatobiliary and pancreatic cancers.

Again, I ask Professor Ó Laoide to provide the committee with an update on progress in this area.

This has been in the pipeline for many years and it is a central aspect of the cancer strategy.

Professor Risteárd Ó Laoide

Absolutely.

Can Professor Ó Laoide confirm that funding has been provided for capital projects in that regard as well as for staffing?

Professor Risteárd Ó Laoide

Funding has been allocated for both capital and staffing in that regard but I do not have the precise breakdown of the funding today because that is in our planning process for the centralisation programme.

Can Professor Ó Laoide provide a rough timescale of when he expects to have achieved those centres of excellence?

Professor Risteárd Ó Laoide

We will do so.

Can he do that today?

Professor Risteárd Ó Laoide

No. We are in the planning process for it. We have not had funding for surgical centralisation. I came into this job at the end of July. We have begun to look at the surgical disciplines and at prioritising the centralisation programme. That is the process we are in at the moment. Rectal cancer is a key one because it has a significant benefit for patients' survival. Gynae-oncology is another one, particularly in the area of ovarian cancer. That also has significant benefits and we are currently in the process of planning that.

It is clear that we have a long way to go in implementing the cancer strategy.

Professor Risteárd Ó Laoide

Yes.

There has been quite a bit of slippage on that. I ask for an update on the two other screening programmes. Where are we in terms of backlog at this stage and when do the witnesses expect to catch up on breast screening and bowel screening?

Ms Fiona Murphy

I will take that. I thank Deputy Shortall. What the committee heard from Dr. Russell applies equally to all the other screening programmes. They are all back up and running, unfortunately at reduced capacity. We are all prioritising the safety of patients and staff. We have had a fantastic response from patients, particularly in our resumption of breast screening. The uptake in breast screening has been very high and we thank patients for their patience on that. We have had to move to a very different system with a reduction in the number of people who can be in our mobile units and in our centres.

In BreastCheck, we have invited close to 70,000 participants so far and approximately 46,000 have attended for screening, with another just over 2,000 attending for assessment.

I am out of time. What is the expected timescale for catching up with the backlog? How long will it be before we get back on track?

Ms Fiona Murphy

In the same way Dr. Russell outlined for cervical screening, we have restarted. It will not be possible to double up on screening so we do not have a timetable for catch-up. We have a timetable for restarting. We have approximately 70% capacity in our screening units. We hope that with the introduction of a vaccine and the reduction in requirements for restrictions in 2021, we will be able to increase capacity further. We have had funding allocated to us to increase our number of mobile and static units. We have been lucky in our staff response as a number of staff have agreed to take on additional hours and provide additional capacity. For example, in the west, where until now we have maybe only had screening three days per week, we were up to five and even six days in recent weeks. We will do our utmost to maximise capacity but we will not, as Dr. Russell said, double our capacity. It will not be possible.

To offer some reassurance, Dr. Russell said that in cervical cancer a delay of three to six months does not worsen one's outcome and we know the same applies for other cancers. In bowel cancer, for instance, evidence published this month on a European study of over 200,000 patients with a positive fecal immunochemical test, FIT, showed that a delay of up to nine months did not have a negative impact on their outcome. This is because in screening we tend to look for slower progressing diseases------

I accept that but I suspect it is different with breast cancer. In relation to BreastCheck, there is not the long lead-in period. What are the implications of not being able to catch up?

Ms Fiona Murphy

For breast screening and the cohort we are screening for, there is still a long period of checking and growth of cancer. Our message is always that if one has symptoms, one should go directly to the GP and get them checked. A screening programme will never pick up a very aggressive, fast-growing tumour because we only screen every two to three years. The message is clear: if one has symptoms, attend a GP and get them seen to.

In terms of impact, we do not know yet and will not know until the end of the screening round. It is particularly difficult to assess because, for the period of six or seven months in which we paused breast screening, we put all our resources into supporting the symptomatic service. That is why we found that in breast cancer, in particular, there was a fall-off. Some of the impact will have been positive over the last few months and at the end of the round we will look, as will everyone internationally, to access the impact because we anticipate it will have an impact.

Will Ms Murphy supply the figures for each of the three screening programmes to us? We did not have time to go through those. I ask for a note in relation to BreastCheck, because breast cancer is not as slow-developing as the other two cancers referred to.

Ms Fiona Murphy

Sure.

I will take a moment to talk about cancer genetics. I thank the Irish Cancer Society for its excellent briefing note. That was an interesting section to me. I am interested in the area. The overview the Irish Cancer Society gave was succinct and I thank the representatives for that. Cancer genetics in the future will be even more important because not only do they allow us to access particular patients, but they impact families and, therefore, bring a whole cohort of people into the system.

In the briefing note, the lack of a dedicated pathway for BRCA-positive patients was outlined. From the overview given, it seems we have no dedicated pathway for cancer genetics, no quality-assured screening for the service and no dedicated health teams to follow patients who have been identified. What plans are to be put in place in the next couple of years and how do they interact with Sláintecare?

Professor Risteárd Ó Laoide

I thank the Deputy for the question. Medical diagnostics and genomic medicines are critical in the modern delivery of cancer care. Medical diagnostics are important because they identify somatic mutations in tumours and biomarkers, which predict a response to drugs. This is commonly known as precision oncology and is routinely incorporated into clinical decision-making. The majority of newly approved cancer drugs are required to be accompanied by a comparison molecular diagnostic test.

The cancer strategy suggested we put in place a national implementation framework for molecular diagnostic testing so it is provided in a co-ordinated and standardised way. To date, the investment has not been put in place for molecular diagnostics, although we in the NCCP have set up a framework to look at molecular diagnostics as it relates to drugs and the provision of drugs, where the test is important in deciding whether the drugs should be given to a patient. Some of this testing is currently done in Beaumont Hospital and St. James's Hospital but there are a number of other centres doing molecular diagnostic testing. The NCCP is focused on putting a framework in place so we have a network which optimises the provision of these molecular diagnostics because they change quickly. Five years ago, a patient would go for one molecular diagnostic test, while now there are panels of 50 such tests being performed in some departments.

It is important that we put a framework in place for molecular diagnostics. This is something we are going to do this year coming. Professor Maeve Lowery chairs our cancer molecular diagnostics advisory group in the national cancer control programme. We have put a framework in place to decide which molecular diagnostic test should be done. This is tied in with our drug approval process also.

When can we expect to see that in the public realm? When will that molecular diagnostic report or framework be published?

Professor Risteárd Ó Laoide

That is a framework or plan to use this network, which will be done in 2021 because we now have funding again. I keep going back to the fact that there was not a significant amount of funding for any of this in the cancer strategy for a number of years. Now we have funding so we will develop it this year.

How long would the development of something like that would tend to take?

Professor Risteárd Ó Laoide

It is important to say that we are appointing a national lead for molecular diagnostics who will be appointed into the position in early 2021. That person will lead out on the development of this framework. More generally in genetic medicine we are also appointing, early in 2021, a national lead for genomic medicine and the genomic network, and that recruitment process is under way. This person will lead on the development of genomic medicine and the treatment of hereditary cancers.

How much of the current genetic testing, genomic testing and mapping of genomes is done in Ireland?

Professor Risteárd Ó Laoide

The molecular diagnostics some of the rarer test are sent abroad but a lot of diagnostic testing is done in our own laboratories and in private laboratories in Ireland. Some diagnostic tests are sent abroad, but I do not have those precise figures on the percentages for the Deputy today.

That is fair enough. It is possibly an obscure question. Will it be possible to get a sense of that figure, perhaps in writing to the committee? I would like to understand what percentage of testing is done through private clinics and laboratories and what percentage is sent outside the State.

Professor Risteárd Ó Laoide

Yes. There are two types of test, one of which is somatic molecular diagnostic testing. I will try to get the figures for the Deputy on that. There is also germline testing, which is basically the hereditary mutations that occur in patients, particularly in the ovarian and breast cancer area and in the Lynch syndrome colon cancer area. I will try to get those figures for the committee.

I thank Professor Ó Laoide. I now turn to one of the briefing notes the committee members were given on the lung cancer screening delay in Limerick. I am not sure which witness can answer my question on this. I was interested in the previous conversation around the lag we have experienced during Covid and whether this will have an impact on outcomes. Earlier we heard that for cervical cancer a six-month delay may not impact. It is my understanding that a three- to six-month delay for a lung cancer diagnosis can mean that a person could progress from one stage to the next. Will one of the witnesses talk about what the lung cancer diagnostic delay in Limerick looks like? The briefing note we have been given shows that, in 2019, there were 210 people referred and, in 2020, there were 128 people referred. This is nearly 80 people who have fallen outside the net. A certain amount of funding was put aside in the winter plan for GP diagnostics. From the note we have been given, it seems that this is where the lag appears to be coming into play, as GP referrals are down. Will the witnesses outline the plan to get those 80 people identified and back into the system?

Professor Risteárd Ó Laoide

From the lung cancer perspective and the figures overall for this year, 2,469 patients were seen at the rapid access clinic nationally in 2020 and 2,716 people were seen in 2019. This is 91% of numbers. There needs to be a caveat to this in that some patients are actually going through other pathways this year. Because of the presence of respiratory issues with Covid, this has seen some patients go through that pathway. When we consider the number of diagnoses of lung cancers this year, and if we look at the primary lung cancers diagnosed through the rapid access clinic, there have been 942 as opposed to 979 last year. That is a 96.2% number of lung cancers diagnosed.

That is not the case for Limerick though.

Professor Risteárd Ó Laoide

The issues that arise are diagnostics, and one of these in particular is CT scanning. There has been an alteration in the pathway in some centres for lung cancer whereby they do the CT scan before they see the patient. The reason for this is to reduce the footfall in the hospitals. We try to liaise with each of the clinics monthly to look at the numbers for all the rapid access clinics and the breast clinics to see what specific problems they have. Some of this may be around staffing or some may be around diagnostics. We will use up funding we have available to increase the staffing or the diagnostics, whether it is insourcing or outsourcing, as required.

Is it possible to get a note on the approach that will be taken in Limerick? There seems to be an emerging issue there. The committee would appreciate a briefing note on that.

Professor Risteárd Ó Laoide

Certainly.

Ms Fiona Murphy

If I may, I would like to clarify the remarks I made earlier. The reason we have a reduced worry in screening is because everyone who comes for breast, cervical or bowel screening is otherwise well. Population screening is about screening healthy people for risk of disease, and so a delay from a positive test or a delay in screening is considered a much lower risk because these are well people. I would not like the Deputy to think that a delay for people with symptoms is an acceptable delay. Again, I am referring to screening that is for a lower risk group of people who are otherwise well and healthy. Symptomatic services are for those who have any symptoms or any concerns. Just to be clear, a delay in screening is a much lower risk than a delay in symptomatic services.

I thank Ms Murphy for that clarification.

I thank all of the representatives speaking to the committee today. We are all in agreement that Covid-19 has caused chaos in our health services and continues to do so, no matter who one is.

One of my questions is for the HSE. The procurement of private hospitals over the past seven months has cost the State an astronomical amount of money, nearly €330 million to date. What capacity was used in those private hospitals for diagnostic services? People in the public health system were not being referred at the vortex of the Covid outbreak. What capacity has been used in those private hospitals to date for acute services and cancer services?

Professor Risteárd Ó Laoide

There were a number of elements to the private sector involvement and cancer services being sent to private hospitals. Some of the chemotherapy and day care wards were transferred in total to the private institutions. For example, St. Vincent's University Hospital went to St. Vincent's Private Hospital and University Hospital Waterford went to UPMC Whitfield, and there are a number of other examples. A significant amount of day care oncology activity was transferred for the safety of patients because, in the environment at that time, a risk of Covid was a significant concern to us. Where the day care units were not sufficiently separated in the hospitals, they were transferred to the private sector.

The second area was in surgical oncology. Again, because at the time there was a significant concern and we had seen what had happened in northern Italy, a lot of the theatre capacity and the ICU capacity was being kept for Covid patients and the potential Covid wave we were expecting. A lot of the surgical oncology was sent out to the private sector. Different hospitals went to different private sector locations.

They were the two main areas that went out. Since then, most of the surgical oncology has returned to the public hospitals. This is what the national cancer control programme wants. We have spent a lot of time in the past pushing centralisation because of its importance for patient care and patient outcomes. The idea that we would be involved in an element of decentralisation by sending out surgical oncology was a concern to us. Occasionally, however, there are patients who still go out for surgical oncology.

For example, some patients from St. James's Hospital are going to the Beacon Clinic for oesophageal surgery at the moment. That depends on whether there is a stress on the system within the hospital, secondary to Covid, at that time.

Most of the day-care units have come back to the public hospitals now. The exceptions include the Waterford unit, which is remaining in UPMC Whitfield Hospital, the Wexford unit is in Ely Hospital, and the Kilkenny unit is still in Aut Even Hospital Kilkenny. The reason for that is capacity in the public hospitals and their ability to deal safely with a vulnerable group of patients.

There is also a framework in place for the private hospitals as part of the winter and pandemic plans. This will allow us to access the private hospitals, acutely if necessary, depending on the Covid situation. That is what we would use.

My second question is for the Irish Cancer Society. I note the reference in its opening statement or possibly a supplementary document to people receiving cancer diagnoses when they present at hospital emergency departments. Why are people forced to resort to emergency departments to get diagnoses of such a magnitude?

Mr. Donal Buggy

The Irish Cancer Society was so concerned about emergency department presentations that we commissioned a report on the matter three years ago. It confirmed that 14% of all cancers are diagnosed in emergency departments; those cancers are more likely to be late stage cancers; and persons from a deprived community background, versus an affluent community background, are more likely to be diagnosed in an emergency department. There are challenges within our system in that we have rapid access to clinics for more common cancers but those pathways do not exist for rare and less common cancers. There are challenges to find ways to ensure we pick up the early signs and symptoms in patients who can present to general practice and diagnostic services earlier and quicker to ensure these patients can be diagnosed at an earlier stage and have a better chance of successful treatment. One of the recommendations in the national cancer strategy is that numbers presenting in emergency departments be reduced over the ten-year period of the strategy. We need to see progress on that. We also need earlier reporting on it and we need to understand the reasons these patients present at emergency departments.

Some of my questions have been answered. Young people have been bombarded with public health messages about Covid, for example, they are told not to go near people. I am worried that not many women availed of the offer to engage with cervical screening services when they resumed recently. A former Minister for Health expressed a hope that human papillomavirus or HPV would be eliminated in the coming years. When young people do not engage with screening services to the greatest extent possible it is a major public health issue. I engage with many young people and I am concerned that there is still a stigma among a lot of young women in their mid-20s about smear tests. They believe they are too young to worry about screening or choose to wait because their lives are too busy. What steps are being taken to encourage young people, particularly young women, to get tested?

A recent survey by the Irish Cancer Society found that approximately one in four respondents did not attend a GP or a hospital appointment when it was necessary. Of those who did not attend, three in ten decided to wait because they did not believe the issue was sufficiently serious. Further, one in four respondents did not attend because they were afraid of catching Covid-19 and 23% did not want to bother their GPs. All of those are terribly Irish reasons not to attend. Has Covid-19 affected people's perception of whether they need to attend a doctor? We want early intervention to catch illnesses, particularly cancers, at a very early stage so the prognosis is better. As public representatives, we can encourage people to seek help. Are there plans for campaigns to re-engage people and emphasise that they need to see their doctors?

Dr. Nóirín Russell

I thank the Senator for her excellent questions. I will respond on the messaging about HPV and what we did when the programme changed last March. We had a full campaign that had been worked up and was ready to go. We were ready to launch our new improved cervical screening programme, moving from a cytology-based service to primary HPV, but it coincided with the Covid pandemic. As the Senator rightly pointed out, there was a great deal of messaging at the time. We decided, therefore, not to launch our full campaign in March. As such, while we changed the programme, we are behind in the messaging about HPV.

Since we restarted on 6 July, we have been running a campaign to inform women about the new primary HPV programme. We have had significant uptake in recent months. November was a bumper month for the cervical screening programme. We expected to screen 21,000 women but 24,000 women attended for screening. The Senator is right. Initially, we were worried that women would not respond to their invitations to attend cervical screening but women are attending in huge numbers and we are delighted with that. Again, that is thanks to the screeners, GPs and practice nurses who carry out these screening tests for us. We have that engagement. Our public health awareness programme, which involves media campaigns and advertisements, is up and running. We plan to do more of that in the future.

To answer the Senator's question about young women, she is correct in this regard. We know that 25-year-olds have a lot going on in their lives and their first screening test is not always top of their priority list. Our communications team is working on that engagement. We are also working on our website as younger women engage with messaging differently from older women. We are always looking for new ways to engage with younger women about the programme so we would be delighted to consider any suggestions the Senator may have.

As to whether there has been a change in how people react to healthcare, there has been an incredible amount of fear over the last year. We have seen that with all healthcare services across the world so it is not just an Irish issue. People were terrified to go into healthcare settings because of the risk of catching Covid-19. We know a lot more now than we did in March and we are a lot clearer about how to reduce the risk. What we are seeing now is people re-engaging with healthcare. We need to keep working on this issue but I am confident from a CervicalCheck point of view that women are re-engaging with the service. I am delighted to see that.

Professor Risteárd Ó Laoide

From the national cancer control programme point of view, as Dr. Russell said, there was a significant fear in the community initially. We did a lot of work with the Irish College of General Practitioners to provide educational tools on Covid and cancer. To reduce fear in patients we developed two publicity videos that showed a cancer patient's journey to the hospital and a patient coming for diagnosis. As Dr. Russell said, we have a learned a lot since then.

We are certainly very conscious of the fact that we must get the message into the community that cancer services are as safe as they can be in the Covid-19 environment, that they are open and that anybody with symptoms needs to come forward, because the services are available for them.

Talking to young people about cancer prevention is also critical. We work with the Irish Cancer Society, the Marie Keating Foundation, a number of voluntary bodies and cancer community centres to ensure we get appropriate messaging out on the early symptoms of cancer, awareness of cancer and advice on healthy living. We also work with Healthy Ireland, a cross-government body, on developing these messages. We are particularly looking at lung cancer now, and messages have been going out through the media in November in that regard. There will be a focus on this early in the new year.

I commend my doctor and the public health services as there was encouragement to get screening done. I commend the doctors on that.

Ms Rachel Morrogh

We want to ensure it is not just health-literate people who are returning to healthcare. It must happen across society and we must pay particular attention to this, with campaigns as necessary to ensure that people from lower income areas are accessing healthcare in a timely way. Once people seek medical advice in a GP setting, there should be pathways for patients to get free diagnostic tests within those key performance indicator timeframes set out in the cancer strategy.

On the screening, there is anecdotal evidence that with BreastCheck, for example, a high percentage of people are not turning up for appointments. That was happening before the pandemic. Are there any figures on this or a strategy to encourage people to turn up for appointments?

Ms Fiona Murphy

Uptake of breast screening is variable across the country. It is very high in some geographic areas and it is higher, as Ms Morrogh has stated, in affluent areas rather than deprived places. We have seen very good uptake since we restarted screening in October, with more than 70% of women who were called having come forward. It is important that those who have not come forward have let us know they are not coming so we can use the appointment for somebody else. Again, we ask people to do this and if they are not coming to an allotted appointment, we can maximise the space we have and give the appointment to somebody else.

Major work has been done over many years trying to increase uptake and ensure people can make an informed decision about whether they want to take up screening. There are areas where we need to pay particular focus. Our health promotion teams have worked with Traveller communities, those who are more deprived and, as Ms Morrogh mentioned, those with lower health literacy to try to encourage them to avail of the service.

With breast screening we try with deployment of mobile units to ensure geography is not a barrier to access. A mobile unit will appear in an area at some stage over a two-year period and there would be an opportunity to take up screening. It is a continuous process. No single campaign is the answer and we can never let up. We must continuously go out with messages. In new social media, for example, we have some fantastic influencers who use their Instagram to encourage followers to take up screening and let them know there is nothing to fear. That is very welcome. It is part of our plan every year to try to encourage uptake.

Like everybody else I thank our witnesses for coming to the committee this morning and for the information. I was a member of the previous health committee and there are some matters I will focus on for the moment.

Public confidence in the system was affected by the cases where CervicalCheck did not go right and the women were not informed in time or the results were read incorrectly. To what extent has confidence been restored not only in respect of women and the system's ability to deal with their cases quickly, effectively and efficiently but also in respect of all forms of cancer early diagnosis?

Mr. Donal Buggy

One of the really important aspects of what happened over recent years in CervicalCheck was the insistence by anybody impacted that screening services are important. They continually pushed to ensure that women continued to attend the screening programmes and promoted the importance of screening and early detection. That helped significantly in ensuring public confidence was retained. That is not something that should be taken lightly, and as our colleagues from the NCCP and the screening services have attested, we must continue to ensure we promote our screening and early detection services so that the public can understand the message that we are promoting. Our cancer patients now and in future must be diagnosed as early as possible to ensure positive outcomes. The message must be continued, and although there has been some damage, much has been repaired. We must continue to promote the message of the importance of screening and early detection.

Dr. Nóirín Russell

The supporting of screening means rebuilding trust and encouraging women to attend. All of us attending today have that responsibility. The support of screening also means acknowledging that not every cancer will be detected. That means that in every screening programme in Ireland and the world over, there will be people who have a negative screening test and who will go on to develop cancer. That is part of the societal commitment to screening that we need to discuss, acknowledge and move forward with in Ireland.

Does this relate to retrospective bias and where abnormalities are not seen in the initial tests? Will Dr. Russell expand on that?

Dr. Nóirín Russell

I would love to expand on that. When we speak about screening programmes, and I will speak specifically to CervicalCheck, we know that when we screen 1,000 women, within them there would be 20 women with a risk factor for developing cervical cancer, and screening with cytology or smear tests would detect 15 from those 20, or 75% of women with that risk factor. Screening with primary HPV will detect 18 from 20 women with that risk factor or 90%. There is no screening test for cervical cancer that detects all women at risk. There will always be women with a screening test that is negative but who will go on to develop a cancer.

As a clinician, I have been in the room with such women and it is devastating to receive that diagnosis. These are women who have done everything right, gone for their screening test and followed up where asked but who still went on to get cancer. That is a really hard diagnosis to get. We know from international literature and the reviews of the CervicalCheck programme that when we look back on the slides for women who were screened and go on to develop cancer, there is a four in ten chance we would see a different result looking back than was seen at the time of screening. That is the reality of what a review is likely to reveal. That is retrospective bias. When we look back on something knowing the outcome, we see things differently and it is not a simple test.

The line between normal and abnormal is not firmly drawn. There is a variety of appearance. Some normal cells look very abnormal and some abnormal cells look very normal. That is the point about looking back.

There were other elements that affected the confidence of the patients, including the length of time it took to have the screening, the laboratory sequence of tests and the locations of the laboratories and so forth. Has all of that been resolved in the interim? That was an area of alleged incompetence.

I fully accept, incidentally, what Dr. Russell says about the accuracy of tests because it is true. It is appalling that a woman must face a situation in which she is diagnosed and told the problem is final and there is nothing she can do about it. If it is treatable and manageable and patients can get the information in time, I presume that is now being addressed. Getting the information and treatment in time are crucial elements in the whole sequence. How are we progressing in those areas now, including returns from the laboratories, etc.?

Dr. Nóirín Russell

To address the Deputy's question about reviews, the review only starts after the diagnosis of cancer is made. In 2018, all of the women were told that they had a diagnosis of cancer once that information was available. That process of review can take a long time. The Deputy is right that it is a long process. It does not change the prognosis or the treatment for the woman She will have questions. She will ask why, when she had a screening test that was normal, does she now have cancer. That review is very important but it does not change prognoses or further treatments. That is the first important point.

The Scally report looked specifically at the laboratories for the CervicalCheck programme and concluded that the laboratories were operating to the quality assurance standards in the countries of origin and that there was no reason to discontinue laboratory contracts with any one of those laboratories. That was the conclusion of the Scally report. To be absolutely crystal clear, we are happy that the laboratories we use for the CervicalCheck programme are quality assured.

May I ask one more question? In relation to all other forms of cancer, to what degree are the witnesses satisfied regarding the alacrity with which they can respond?

Professor Risteárd Ó Laoide

I do not understand the question.

I am asking about the detection of other forms of cancer - through BreastCheck, for example. How short is the wait for access to diagnosis and treatment now? Are the witnesses satisfied that an adequate response is available? This goes back to ensuring confidence in the system.

Ms Fiona Murphy

Absolutely. To add to what Dr. Russell said, our turnaround times for the laboratory tests in cervical screening at the moment are up at 99% within the expected three weeks that they have to do their tests. Our referrals to colposcopy and the time that colposcopy takes to see a patient are excellent and 100% of patients who required urgent attention were seen on time in the past month, with over 90% of the people with high-grade abnormalities seen within four weeks. We are content with our pathway there for cervical screening.

The situation is similar for BreastCheck. We monitor our turnaround times for tests and after screening when patients come in for assessment. After assessment, they are then referred on through surgical intervention and we monitor those tightly and are content that they are within our acceptable parameters.

Equally for BowelScreen, we expect anyone referred on for colonoscopy, if they have a positive faecal immunochemical test, FIT, to be seen within 30 days. We are well over our targets for that. The pathway is very good. Our concern remains that the capacity in the entire pathway is still limited by our need to protect against Covid-19. That will remain a concern for a period of time. For those patients who are assessed and moved along that pathway, the response times are very good.

As someone who has had a battle with cancer this year, I thank all of the witnesses very much for the work they do in their professional capacities. It is appreciated. Before I ask my questions, I will add my voice to urge and encourage women to use the CervicalCheck cancer screening. Despite all the media reports and questions around it, the programme plays a valuable role in protecting women's lives.

I recently received a reply to a parliamentary question which showed that 231 legal cases related to CervicalCheck have been launched in recent times. That is shocking in many ways. The Tánaiste told us that women would not have to go through the court system to achieve justice in this regard and we have been long promised a tribunal to deal with this matter but it is still not in place. The Government stated that women had been wronged and rightly apologised for that. The courts have also stated that women had been wronged. A long list of doctors have stated that certain slides were misread. There were flashing red lights that should have been seen when those slides were read in the first instance, but that did not happen. While I agree with the clinical director of CervicalCheck that there is always a significant margin of error in screening and that is part of the process, there is a Government policy and a court decision that notes that there have also been difficulties outside of that margin of error, as such.

I received a letter from CervicalCheck in the past couple of weeks and had a conversation with its clinical director. I was taken by surprise that CervicalCheck seems to have a different view on this from the Government and the courts and it does not believe that women have been wronged and that the courts have adjudicated correctly. I am worried about that because it has an effect on the women who have gone through the system and received an apology. I am also concerned about other problems that we may find within society. There may be other women, outside the normal margin of error, who had their slides misread and are currently asymptomatic. If we carried out a sample reading look-back on those slides, we might be able to ensure that lives are protected and people get diagnoses and receive treatment faster. The reason I came to this view was as a result of the very sad case of Ms Patricia Carrick, God rest her. She did not have cancer at the time of a look-back so her case was not read. I will perhaps ask the clinical director of CervicalCheck if there is not a danger here if different elements of the State have radically different opinions on the matter. Does that difference of opinion not make it difficult for us then to ensure that we proceed with a look-back on other samples?

Dr. Nóirín Russell

I thank the Deputy for his questions. It is nice to chat to him about these things again. I think he and I had a productive conversation last week where we agreed that we have a common goal of rebuilding trust in our world-class screening programme. I have been a doctor on the front line and given that information to a woman who has been screened and goes on to get a cancer diagnosis. We all agree that it is a challenging and difficult place to be, as a woman, and it is worse still if that woman believes that somebody did not do their job right and that is why she is getting this diagnosis. However, as a clinician, I can tell the committee that a smear screening test will never detect all cancers. Every year, on the CervicalCheck programme, there will be women who have an interval cancer, meaning they will develop cancer after a normal screening test.

That is a reality. It will happen next year and it is happening this year, because screening will never detect all cancers. Internationally, few countries carry out reviews. When Public Health England reviewed slides for women who got cancer, four in ten women had an abnormality detected on look-back that was not seen on review. What we have found is very helpful is the Supreme Court ruling, which clarified that absolute confidence does not mean 100% detection. That is really important. The Supreme Court clarified that a new standard has not been introduced and that screening tests are not expected to detect 100% of cancers because, of course, that is impossible. The court also outlined in great detail the reasons a competent screener could be doing his or her job to the best of his or her ability with the tools he or she has, and a cancer may still not be detected. That was outlined in great detail in the Supreme Court and it is very welcome for cancer screening services.

I thank Dr. Russell for that answer but it does not get to the key issue. I fully agree that there is a significant margin of error in the screening and it cannot be any other way. That is inherent in the process. I also understand, however, that the Government has taken responsibility for slides that were read incorrectly and that should have been picked up in the initial reading, and has apologised for this, yet Dr. Russell is of a different view from the Government.

Dr. Nóirín Russell

I am not here to discuss opinion; I am here to discuss facts. The fact remains that no cervical screening programme in the world detects 100% of cervical cancers. There are interval cancers in every cervical cancer screening programme in the world. That is a straightforward fact. I am delighted the Deputy is raising these questions because they are questions for broader Irish society. Do we accept as a society that we continue with screening because, for the majority, it reduces the risk of developing cancer? If we do that, we have to acknowledge there will be women who are screened for cervical cancer, have a negative result and go on to get cancer. That is the minority, but it is really tough for a woman if she ends up in that minority. We as a society have to decide how we look after women in that minority.

We also have to decide whether we will treat some people with cancer differently from others. Every year, as we have heard from Ms Morrogh, 24,000 people in Ireland are diagnosed with cancer. The majority of these people, approximately 22,600, are diagnosed with cancer when they get symptoms. Some 1,400 people are diagnosed with cancer on a screening programme. We have to decide as a society whether we will treat people who are diagnosed with cancer on a screening programme differently from those who are diagnosed because they present with symptoms.

The reason I think this is important, and it is probably the reason our engagement initiated in the first instance, relates to a statement I made in the Dáil a couple of weeks ago. We might park the issue of the margin of error to one side because I understand that is a natural part of the process. The State has acknowledged there is another section of women, outside of the margin of error, whose cases should have been picked up. The reason I raise this issue is that some of those women will not have a look-back until they are diagnosed with cancer, such as Patricia Carrick. For those women, it may be too late to carry out the necessary treatment to protect their lives. I suggested we would take a sample of those asymptomatic women and determine whether there are mistaken readings. "Missed opportunities", "mistaken readings", "red lights": these are not my words but those of the doctors who have given evidence in court cases relating to the matter. If we take the decision that there is not a problem here and that the Government is not wrong, we will not take that step to check those asymptomatic women and we may not understand how big their problem is.

Dr. Nóirín Russell

If a better test could be applied in cervical screening, I can assure the Deputy that I would be one of the first people in the Houses asking that Ireland move to it. We have done that once already, in March of this year, when we moved from cytology screening to HPV testing because it is a better test. The Deputy's question about whether we should perform a review of all the women who have received a normal result is the exact same thing as screening, and screening will never find all the women with cancer. The same test can be performed over and over again, and the women can be screened and rescreened, but it takes away valuable resources from screening the women who were due to be screened to look back and rescreen women who have been screened. One will never find and predict all the women in that cohort who will go on to develop cancer. Screening is not able to do that.

On that subject, I fully understand and appreciate the difficulty in being 100% accurate. However, a major issue and controversy arose in respect of a look-back. In the case of a considerable number of look-backs, it was determined in the courts and elsewhere that the existence of cancer should have been identified in the first instance. It was not that it was identified but that it should have been. I realise that is a very difficult conclusion to come to, from a diagnostics point of view, but the courts came to that decision and medical evidence was adduced in court to the effect that on the look-back, there was evidence that cancer should have been recognised but that it was not recognised.

The other issue was that the patients in many cases were not informed. There was a lack of evidence and women had to suffer on for a considerable period without any knowledge of what their results were.

Ms Fiona Murphy

Deputy Tóibín noted that there were currently 230 cases in the courts system, approximately 160 of which are in legal proceedings while the others are notifications. A number of those cases, I imagine and hope, will go through the CervicalCheck tribunal, which started on 1 December, and people have started to put those claims through. It will be very useful for all of us to see the outcome of the tribunal and the results that come through. To date, relatively few cases have gone to court. Some have been settled before they went there. It is always the State Claims Agency's intention to use mediation to prevent people having to go to court if they can, although a few tragic cases have gone through the High Court and had their evidence assessed. There is not a medical intervention known to us that has not on occasion been found to be negligent, but they are very small numbers. We do not anticipate that all 230 cases that are going through now will show evidence of negligence. As Dr. Russell outlined, the unfortunate reality of a test that is not perfect is much better now, thank goodness. Even at that, however, interval cancers will continue to come through in future. Our concern is how we try to avoid people going to court in future. Patients rightly say they hate it and doctors do not like it either.

We have to find some other way of thinking about and addressing the issue that we will continue to have interval cancers. One of the good things about screening is that we repeat it regularly. In the case of cervical screening, for example, anyone who tests positive now for HPV will come back for another test a year later and then go on to have cytology. We call people back on a two-, three- or five-year schedule, depending on their risk levels, so the chance is always there that if the cancer is not picked up on the first screen, it might be picked up on the second. Because these are generally slow-growing cancers, we will often pick up the cancer at a later point. Over the course of the next cycle or round of screenings - in other words, from 2018 until now - all the women who were called previously will be called again this time. Therefore, a patient's call for looking back at those will be done anyway because we will recall and look at everybody's screen. If they come for screening, we will look at their tests again over this round. Once this round is finished, we will start the next round. We do repeat screening all the time, so I do not see a benefit in taking a further sample. If we are talking about one or two per 1,000 who might have an abnormality that we have failed to pick up, there is a risk that either we will do that again in the subsequent screening, as Dr. Russell said, or that the numbers will be so small that they will be impossible to find, unless we repeat the entire round, which we are already doing. Screening is a complicated system, but I hope we can offer some reassurance that by repeating and screening regularly we increase the chance of finding anything that perhaps was not found in a previous round.

Dr. Nóirín Russell

I wish to come in on just one point Deputy Durkan made. I want to be absolutely clear that in 2018, no diagnosis of cancer was withheld from any woman. I want to say that really clearly. No diagnosis of cancer was withheld. The information that was not disclosed was the audit result. That we can do better on, but no diagnosis of cancer was withheld.

I have just a quick question for Dr. Russell about the national cervical screening laboratory, on which building will begin in January 2021. Does she envisage that when it is built the screening laboratory service of Quest in the US will be discontinued? This has been controversial, to say the last, in the cervical screening scandal that has engulfed Ireland. Does Dr. Russell see, when the laboratory is finished, the services provided by Quest being discontinued?

Ms Fiona Murphy

I will take that question. I co-chair the project board with the master of the Coombe, where the new screening laboratory is being built. Just today, I think, the next step of that is being considered by the Coombe board, and we hope to start building in January, with the intention that we will open up the laboratory in mid-2022. Our biggest rate-limiting step for that is, as we have mentioned a few times this morning, making sure we have the staff in place and that there is an adequately trained workforce available, but we have good plans in place towards that.

As to where we send all our samples, our ambition is that the new laboratory will become the main provider of screening in Ireland. We will always need a backup, both from the point of view of resilience and to ensure we build in a safety mechanism to make sure we always have somewhere to send samples. We have not yet chosen where that backup will be. That will be a discussion for us with the Coombe. We may have a joint agreement with another laboratory but we will have a backup, and I am very confident that that backup, if it continues with Quest, will be very safe for patients in Ireland. We have now had three different reviews of CervicalCheck, including a review of the laboratories and a review of Quest in the US. We personally conduct quality assurance visits to Quest, or at least we will do so again once we are able to travel to America, and we are very assured of the quality of the process it provides for us. Its rate of detection is similar to that of every other laboratory across the world. I would have no hesitation continuing with Quest if that is the route we go down in a few years. However, our ambition is, as I said, to bring the vast majority of those tests back to Ireland to redevelop cytoscreening in Ireland, and-----

Our meeting is coming to an end.

Ms Fiona Murphy

The new centre at the Coombe will be a centre of excellence not only for service provision but also for the training of staff and research into cervical screening in future, which will be a fantastic asset for Ireland.

Our meeting is coming to an end. A number of Members still want to contribute, but I want to ask a couple of questions myself.

The Irish Cancer Society talked about people receiving life-changing news alone. I myself have been in that position, like Deputy Tóibín, in that I have got that difficult information and was told I had cancer. Can anything be done about this, bearing in mind we are dealing with a pandemic? Is there anything that can soften that blow or is there some other way of giving that information? I presume it is being given over the phone at present. Are the witnesses looking at this? Is there any way of doing it?

Second is the issue of the financial cost of cancer. We have a drugs payment scheme, but for many of those who have had or who have cancer the difficulty is that they first have to reach that ceiling, but many of the things one might need are not covered by the scheme. Perhaps the Irish Cancer Society representatives might talk about the real cost of not only the psychological and physical impact of cancer but also its financial impact. Is there anything they feel they need to say about that?

Finally, it is usually around this time of year in November and December that we talk about men's health. Are there any discussions ongoing in that regard? We know that men, particularly men of a certain age, do not talk about their issues, but it is important that people go forward and get tested. Is there any possibility of a screening programme, a proactive campaign, to get men in for screening, particularly for prostate cancer, although not solely for that? That would be important.

Those few questions probably need to be addressed. Before the witnesses come back in, I wish to thank all the staff they represent, particularly those in the HSE, for their dedication and commitment. They turn up every day and have done so during the pandemic, often at great risk to themselves and their families. It is important we as a committee say that and that we learn from mistakes. One of the things I noticed during my time attending was that many of the appointments were at the same time. I would get an appointment for 9.30 a.m. and another 40 people would turn up at the same time, or I would get an appointment for 2.30 p.m. and there would be another 40 people there. Clearly, people have busy lives, but there must surely be ways of improving that. We have learnt a lot from the pandemic about what we can and cannot do, and perhaps lessons can be learned from that.

I have asked a number of questions. If I can, I will try to fit in one of my colleagues after the witnesses' responses.

Ms Rachel Morrogh

In the Irish Cancer Society one of the things we hear about regularly is the financial impact of cancer. Cancer is not something for which one sets aside savings or puts financial supports in place to manage its cost.

One of the things we have heard is that people are not prepared for that cost, so in all of our pre-budget submissions we have asked the Government to step in and try to reduce current levies, such as car parking, inpatient charges and outpatient charges. A reduction in these levies would make the lives of cancer patients much easier, so we encourage all members of the committee to do what they can to drive down those costs.

On the issue of those who have received their cancer diagnosis alone, or who have received some bad news in the last number of months, our support line, which is staffed by oncology nurses, has dealt with many calls from those feeling the loneliness that has permeated the Covid period. We spoke earlier about fear, and cancer patients in particular have been very fearful about accessing healthcare and getting Covid, and it is likely that this fear has translated into them not seeking healthcare when they should. It is important that we do everything we can to enable people to share those moments with those they love. If anything, the pandemic has highlighted the human side and what is important to all of us is our health, our families and our friends. It is important to remember those things. Psychological support has been invaluable throughout Covid, and the Irish Cancer Society has stepped up in that respect. We are pleased to partner with the NCCP and Cancer Care West in providing additional psychological supports for people, but these supports need to be provided to everyone and need to be woven into the cancer system so that they are available as a standardised model of care, and this has been approved by the NCCP. That is going to require putting people into roles to provide this support, because having cancer is a very traumatic experience, both physically and psychologically.

With regard to men's health, like every other sector of society, we need targeted approaches to encourage people to access healthcare to make sure they get diagnosed as early as possible. The supports required need to be put in place, and the Irish Cancer Society would very much like to partner with others in that area to ensure we can work together and get people into care as quickly as we can.

I would have liked the HSE to respond, but we just do not have the time.

I want to ask about the mobile breast cancer screening units that are in operation around the country. There are 21 of them, one of which operates from the car park of Clare County Council's headquarters in Ennis. It has been hugely successful, and many women throughout County Clare and beyond have had mammograms done there. As we start to - hopefully - emerge from Covid in the months ahead, I am wondering if there are plans to expand this service. In particular, would the witnesses consider introducing a mobile screening service for testicular cancer and prostate cancer, and perhaps a mobile checking point for testing prostate specific antigen levels for the men in this country? The mobile screening units have been hugely successful in more rural areas, where, unlike cities, people cannot go into physical clinics. I would like these services to be expanded, and to receive assurances from the witnesses that these services will be retained and possibly increased.

Ms Fiona Murphy

I am happy to confirm that we will be maintaining the mobile screening service. In the case of BreastCheck, our intention is to increase the number of mobile screening units. We have 21 at the moment, and we plan to increase that by one, but perhaps by up to three, depending on whether we can get a static centre or a mobile unit. Reducing geographical access issues greatly encourages people to come forward for screening. I am glad to hear that the Deputy thinks the service works well in Clare. I think it works well around the country.

I am delighted that the Deputy raised the issue of men's health services because there is a real message to send out to men around bowel cancer screening. Currently our uptake for this service is approximately 50%, so half of the people who could come forward for quite a simple bowel check are not doing so. It can be done in the comfort of one's own home, and it is a simple test to do and to send back. The benefits of doing this test are enormous. Over a ten-year period of screening, we anticipate that deaths from bowel cancer for those who come for screening will reduce by one third. That is a huge number for a cancer that is the second most common cause of cancer-related deaths in Ireland. We will do anything we can to encourage people to come forward for bowel screening. Over the course of the next five years our ambition will be to expand the number of people who can take up bowel screening.

I apologise, but I must cut Ms Murphy off there, because we are way over our time limit, and there is a safety element to consider in respect of members of the committee and staff here.

Ms Fiona Murphy

I would be happy to send a note of my response to members.

I thank the witnesses for their engagement today. At next week's meeting, the joint committee will hear from Professor Brian MacCraith, who is the chair of the high-level task force on Covid-19 vaccination, and representatives of the Department and the HSE.

The joint committee adjourned at 1.35 p.m. until 11.30 a.m. on Wednesday, 16 December 2020.