Joint Committee on Health debate -
Wednesday, 1 Feb 2023

Cancer Treatment Services: Discussion

Chairman

The purpose of today's meeting is for the joint committee to consider the matter of services for the treatment of cancer, in particular waiting lists for such treatment. The committee will be joined separately by representatives from the Irish Cancer Society and the HSE. For the first part of the meeting, I welcome Ms Averil Power, chief executive officer of the Irish Cancer Society, and Ms Rachel Morrogh, director of advocacy for the Irish Cancer Society.

All those present are asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid-19. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make judgments against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if statements are potentially defamatory in relation to an identifiable person or entity, witnesses will be directed to discontinue such remarks. Compliance with any such direction is imperative.

Members are also reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable. I also remind members of the constitutional requirements that members must be physically present within the confines of the Leinster House complex to participate in public meetings. I will not permit any member to participate if they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. I ask members using MS Teams that, prior to making their contributions, they confirm they are on the grounds of the Leinster House campus. To commence our discussions, I invite Ms Averil Power to make her opening remarks on behalf of the Irish Cancer Society.

Ms Averil Power

I thank the Chairman and the committee for inviting the Irish Cancer Society here today. My colleague Ms Rachel Morrogh and I thank the members for continuing to focus on cancer services and for listening to how the performance of these services affects patients and their families.

I start by sharing our central concern, which is that in Ireland today, people are not being given the best chance of surviving cancer and having a good quality of life. As we know, the earlier cancer is caught, the easier it is to treat and the greater the person’s chances are of surviving the disease. For example, when a person has their colorectal cancer picked up at stage 1, they have a 95% chance of survival. However, if it is not detected until stage 4 their likelihood of surviving the disease is just 10%. Similarly, the five-year survival rate for breast cancer is 94% at stage 1 but only 19% at stage 4. Similar patterns are found with many other cancers.

Early diagnosis can literally be the difference between life and death, yet we know that 2,500 fewer cancers than expected were diagnosed in 2020 alone. That is 2,500 real people with loved ones for whom a cancer diagnosis is not a statistic; it is a whole world collapsing. We know that other cancers will have been missed in 2021 and 2022. While we do not have official data, we know that others will have been missed as our services struggled to catch up.

Thousands more people are waiting for periods far in excess of the official targets for vital diagnostic tests after visiting their GPs with potential cancer symptoms. Others are so discouraged by the current state of Ireland's health services that they are putting off seeking help until they end up presenting at an emergency department in extreme pain caused by an advanced cancer. Opportunities to pick cancer up early are being missed and patients and patients and their families are paying the price.

Covid did not create this problem. Our health service was struggling to keep up with rising demand for cancer diagnostics and treatment prior to the pandemic but it has made things worse. Previously, Ireland's cancer services were running to stand still. Now they are sprinting and cannot catch up.

Radiology tests such colonoscopies, CT scans, MRIs and X-rays play a vital role in the diagnosis of cancer. Despite this, the Irish Cancer Society understands that there are currently more than 200,000 people on the waiting list for radiology appointments. A total of 150,000 of these have been waiting longer than three months for a vital scan, despite the target in Sláintecare being just ten days.

One in four people who are sent to rapid access clinics with symptoms of breast, prostate and lung cancers are waiting longer than the HSE target. On 31 October last year, it was reported that the then Taoiseach, Deputy Micheál Martin, warned his parliamentary colleagues of a frightening wave of delayed cancers. This was not a Hallowe'en scare, but the reality faced by people we know, people we love who will have worse outcomes, poorer quality of life, more invasive treatments and less time with their families, all because of the existing barriers which deny people timely access to cancer tests and treatment.

The burden of this is being felt the most by those on lower incomes who cannot afford to skip the public queue by paying for tests privately. The current crisis in our health service is also impacting cancer treatment and having a hugely detrimental impact on patients' physical and mental health. Cancellation and postponement of surgery is causing huge anxiety for patients as they worry that the chance to remove their tumour before it has spread may be missed. Patients, many of whom are elderly, are being left standing for hours in hospital corridors waiting for a chair. Pressure has increased and a medical oncologist recently described the current situation on his day ward as being inhumane. Healthcare workers are doing their very best in intolerable conditions but they simply cannot give each patient the time they would like to. Ongoing visitor restrictions in our hospitals are depriving patients of vital emotional support. Irish Cancer Society nurses and counsellors are supporting people who are hugely distressed and anxious, far above levels normally associated with a cancer diagnosis. The conditions in our hospitals are compounding the fear and worry that comes with cancer. On top of this is a feeling of helplessness and frustration at being disempowered by a system that simply cannot cope. This is the reality of cancer in Ireland today. This is the chaos that the members' constituents face. This cannot go on. It is simply not good enough and we need the help of our elected representatives to change it.

Cancer care used to be the poster child for Ireland's health service, with improvements in cancer prevention, detection and treatment delivering a doubling in the overall survival rate in just 30 years. Our national cancer strategy set out clear and achievable roadmaps and our politicians provided both the resources and the leadership needed to expand services and to push through vital changes such as the centralisation of cancer surgeries, which improved outcomes dramatically for patients.

Prior to Covid, our cancer outcomes were still behind those of many other European countries but we were closing the gap. The Irish Cancer Society was hopeful that, if sufficient resources were provided to implement Ireland's third national cancer strategy, patients and their families could look forward to a brighter future. Now, however, we are worried not only that progress has stalled but also that we are going backwards in so many areas. We need the committee's help in highlighting the impact the current delays and disruption to cancer diagnostics and treatment are having on patients and their families and ensuring they are addressed.

There has never been a more urgent need to focus on cancer services. We are deeply grateful for the funding injection into cancer services the Minister, Deputy Donnelly, has delivered in recent years and we hope the services plan will confirm that sufficient development funding will be provided in 2023 to empower the national cancer control programme, NCCP, to implement the national cancer strategy. However, we need so much more. We need investment in bricks and mortar, beds and equipment. We need protected surgical time for oncology cases so that vital and often time-sensitive cancer surgery is not competing for theatre time against other life-saving unscheduled care. We need a strong and resilient cancer workforce who make an active choice to work here and whose conditions are not deterrents to delivering public health care. We need more investment in cancer research and trials to find new and better ways to prevent, detect and treat cancer and, ultimately, to save lives. We also need proper data because it is outrageous that we are planning in 2023 on the basis of the National Cancer Registry Ireland, NCRI, data from 2020 on cancer instances and survival. Indeed, the data published today on cancer inequalities are only on the period ending in 2018. We know that inequalities have got so much worse since then during Covid-19 and have affected people on lower incomes and people from disadvantaged areas a lot more than those who are better off. We simply cannot plan properly without proper and up-to-date data.

A cancer diagnosis is devastating and the prospect of treatment and the inevitable side effects that follow is terrifying. In addition to the physical and emotional suffering, the knock-on effect on family life, finances and work is considerable. That is before the stress of delays, cancellations, financial barriers, crowded corridors, overworked healthcare professionals and ultimately the worry that your care is not as good as it should be. Cancer patients and their families deserve so much better. The Irish Cancer Society believes everyone here today can play a role in delivering that and we are grateful to the committee for prioritising this area.

Ms Morrogh and I are happy to take any questions members may have.

Senator Martin Conway

I thank Ms Power. Unfortunately, she paints a very bleak picture and it is unfortunate. Some of the statistics Ms Power quoted, resulting, I suppose, from the pandemic and other issues, are quite worrying. Has the Irish Cancer Society quantified how many people have lost their lives as a result of not getting the treatment they needed during the Covid-19 pandemic? Did the numbers of those lost to cancer increase during that period and do the witnesses have any statistics regarding that? What are the three immediate steps that need to be taken urgently now in quarter 1 of 2023 to start redressing the challenges and to try to put together something that is more appropriate than what we are experiencing at the moment?

Ms Averil Power

We do not have full data. Ms Morrogh can give more detail on exactly how many people have died as a result of staging, that is, people being picked up maybe at stages 3 or 4 who would have been caught previously at stages 1 or 2. Indeed I saw mention in the NCCP statement, whose representatives will be in after us, that they do not have data on staging. They do not have data either on how many people are being caught at stage 3 who we would have expected to get at stages 1 or 2. Then there is the second step as to how that has affected their outcomes. What we do know is that oncologists are telling us, and many have gone on the record to say this publicly, that they are seeing people with much more advanced cancers than they would have previously. That is the reality on the ground and, in their professional opinion, it is resulting in worse outcomes. Patients are also contacting our services saying that is their experience, and there are others who are now being picked up late who have that worry about whether their outcome could have been better had they been caught earlier, which is an awful thing to have to live with.

Senator Martin Conway

Do other countries have a better reporting system than we do? Should we have better statistics in terms of what stage people are at when they present? Is there best practice internationally we should be learning from?

Ms Averil Power

Other countries have real-time data on what is happening in cancer services, and that has always been a challenge in terms of planning now but was a massive challenge, as the Senator knows, during Covid-19. For example, in the NHS, our colleagues in Cancer Research UK, CRUK, and Macmillan Cancer Support were able to tell us they had real-time data the whole way through the pandemic on what was actually happening and how it was affecting cancer diagnosis. We did not have that and, as a result, we were planning blind without actually having proper data to use. The latest data the NCRI has published are from 2020. We get some more regular data in relation to the rapid access clinics, but that is only for prostate, breast and lung cancers, and in some ways those are the cancers that are better served because they have the rapid access clinics. The data we do not have are for the cancers with worse outcomes and pathways.

Senator Martin Conway

Does Ms Power feel, or do the figures in the statistics the Irish Cancer Society has, show that people do not have the same confidence in screening as a result of the controversies with CervicalCheck and so on? How are we performing in terms of screening programmes and the participation in them now?

Ms Averil Power

According to figures published by CervicalCheck last week, for example, I understand that levels are back at 80%, which was where we were before Covid-19, that is, 80% uptake for people who are invited to participate. They have cleared the backlog though I know there are still backlogs in the breast screening programme which they are working through. In terms of public support, while it is awful to say there is anything positive to come from what Vicky Phelan or the other women who died as a result of the CervicalCheck crisis went through, one of the positives is that they really highlighted the importance of screening and how important it is for patients to take up that invitation, and it was something Vicky was very passionate about. That has helped but there is still a lot of work to be done, particularly with those from disadvantaged communities where the take-up traditionally has been lower and has not been improving in the way it should be. Ms. Morrogh may want to add something on the data, if that is okay.

Ms Rachel Morrogh

On the Senator's question as to whether we know if more people have died as a result of the pandemic and the impact on cancer services, we know there are international data published in the British Medical Journal which outlined that, for some cancers, a delay of just four weeks in cancer treatment can increase mortality, and that is across surgery, chemotherapy and radiotherapy. Naturally, this is a huge concern to us because people are waiting to be tested for cancer and they are then waiting for treatment. It is not just about deaths from cancer. The issue for the Irish Cancer Society is that people's quality of life is very affected when they are unable to access the treatment they need at the time they should. There is a race against time now to find those 2,500 missed cancers from 2020 to make sure they are in the system and that, when these people undergo a cancer test, they can access that treatment as quickly as they should.

As Ms Power said, this is not a pandemic problem. This is a problem with the Irish health service and we are becoming desensitised to it. A number of years ago, if Ms Power had given her opening statement and had outlined these extremely serious concerns which the Irish Cancer Society has about cancer services, people would be appalled. Sadly, I think we are desensitised to it now.

Senator Martin Conway

I thank Ms. Morrogh. How is the witnesses' organisation in terms of funding? Is it well funded, is funding down as a result of the pandemic, or has it recovered? How is the organisation doing funding-wise?

Ms Averil Power

As the Senator knows, we rely on public fundraising for most of our funding. We get approximately 3% from the State, so we raise 97% of our income every year. We took a big hit in 2020 and had to cancel Daffodil Day with just a few weeks to go, but the public rallied around and helped us respond so that we could keep our services going. We actually had a very good year in 2021, particularly because we had a special on "The Late Late Show" for Daffodil Day which helped boost our income.

We had our strongest ever Daffodil Day. As a result we have grown our services. For example, we have doubled our investment in counselling and our investment in cancer trials. We have opened new services like early detection roadshows to help pick up some of these missed cancers. It is great that our funding has been growing because it is helping us to step up. However, there is so much more that we could do and that we need to do. We are finding the second half of last year and this year much more difficult, because people have less money in their pockets.

Senator Martin Conway

Have any proposals been made to the Government to increase funding from 3% to a little more?

Ms Averil Power

We have put in for extra funding for night nursing. Just before the end of last year we got a bit more. We are always open to getting any funding we can and that can be directed towards meeting the demand for existing services, as well as helping to step up and open new ones to help cancer patients with immediate needs. We are always grateful for any support the Senator or anyone else can give.

Chairman

I should have mentioned at the start how the system usually works. Normally, each individual who comes in gets ten minutes and it is questions and answers within that period. That is how it normally goes. However, some ask a number of questions together while others ask questions individually. Some even make statements and do not ask any questions.

Ms Averil Power

We are delighted with questions because it shows the committee is interested and it cares. We are happy to answer.

Chairman

In last week's session we touched on digitalisation and the lack of it within the health service. The witness is again highlighting the chronic need for us to move in that direction, not only to find out the real challenges we are facing but also because of the importance of digitalisation and information for future research. I call Deputy Gould, who is stepping in for Deputy Cullinane. He is welcome to the committee.

Deputy Thomas Gould

I thank the Irish Cancer Society for its submission. There is no doubt that what they have spoken about is really serious. I want to start off on a positive. This touches on what was said at the start. I know this from my own family experience and that of my friends. If people are caught at stage 1 the success rate is 95%. I know family and friends who have been very lucky. They have gotten the treatment in time and it has worked. Unfortunately, the other side goes back to the point where people get delayed diagnosis because they have not gone to be seen, or looked for help early enough. There are serious consequences both on their quality of life and unfortunately in losing their lives. It is really shocking when one reads the submission and the point is makes that in January 2023 almost three out of ten people have put off going to a GP or a hospital because of the pressures on the health service over the past three months. That has consequences for people in terms of delayed diagnosis. The witnesses also made the point that even a four week delay has a huge negative effect on people's outcomes. They are speaking to the committee today and there will be recommendations coming out. What are the main recommendations they would make that would make an actual difference in the delivery of cancer treatment and in trying to reduce deaths and increase outcomes?

Ms Rachel Morrogh

I thank the Deputy for this question and highlighting that the health service can itself sometimes be a barrier to an early cancer diagnosis. Our research shows that three out of ten people have put off accessing a GP or hospital appointment because they are hearing this narrative that they should not attend a hospital or emergency department unless it is urgent. However, 14% of cancers are diagnosed in an emergency department. People are not well placed to identify whether their symptoms are urgent, and who should or should not attend. When one hears this message, we know it has a chill effect on people's behaviours. They may decide to try to manage their symptoms as home. They may search the Internet for information or ask family and friends. The message from the Irish Cancer Society is "please go and seek medical advice." We are very conscious of the pressures taking place across the health service. However, the blame should not be put on patients for trying to access medical care. What we need is a health service that can meet the demand from citizens so they can access care in a timely way. What this committee can do, and what politicians can do, is make sure that the narrative coming from all of them is that people can get timely care when they need it. That is sadly not the case at the moment. We need additional investment. There has to be a focus on the workforce. We know that people who have been working in the health service over the course of the pandemic are burned out. They were not empowered to deliver the service that they want to deliver. It is hugely distressing for them also to be working in the conditions they are. We think there needs to be an unwavering focus on getting people into cancer services so they get an early diagnosis because we know their quality of life and their outcomes will be so much better. We cannot keep on going from crisis to crisis, because that is the way the health service is performing at the moment. It comes up for air over the summer months, and is then plunged into another crisis. That is not sustainable healthcare. The cancer czar in the UK has called the National Health Service, NHS, a late diagnosis service currently. That is sadly reflected in Ireland as well.

Deputy Thomas Gould

When one looks at it, if cancer is diagnosed early and people are treated early, they are actually being kept out of the hospitals. Would it be correct to say that?

Ms Rachel Morrogh

Yes.

Deputy Thomas Gould

By investing in hospitals, and staff and technologies, time will be freed up so that more people can be treated. There is then a positive domino effect, where people are being treated earlier, quicker and are freeing up more space for people to come in. I also want to note Ms Morrogh's point relating to the message. When they saw the crisis in the hospitals, most people with an ache or problem they did not think was serious felt they were doing the right thing by not going. They know the staff are under pressure. They know the hospitals are full. They know the trolleys are everywhere. People are telling themselves they had better not add to it. However, Ms Morrogh is saying that because of that delay they will be adding to it and making it worse down the line, when they finally go in two, four, or eight weeks' time.

Ms Averil Power

I hope the Deputy does not mind me interrupting. Cancer symptoms are vague. It is not necessarily like where people are clear that a breast lump can mean breast cancer. Stomach symptoms, abdominal pain, bloating and fatigue could be irritable bowel syndrome, IBS, or it could be a stomach cancer. The reason we have some of the worst prognoses for cancer is that we have pancreatic cancer, stomach cancer or gynaecologic cancers where the symptoms can look like something else. As the Deputy has stated, that is precisely the problem. People are going through those and saying something is not right, is not normal for the person's body, and is definitely strange, but that it might not be serious so the person will not go to a GP. They then end up being diagnosed with a late-stage pancreatic cancer that has a 20% chance of survival. It is crazy. I apologise again for interrupting but the Deputy is absolutely 100% correct and hitting the point. It is harder to treat, which means people getting more invasive treatments that have a much worse impact on their quality of life if they survive. It is also more expensive for the health service to treat them, as the Deputy has said. It does not make sense.

Deputy Thomas Gould

I was unfortunately in Cork University Hospital with my father over Christmas. Thankfully he was fine, but we were there for ten hours. My Dad, who is 81 years old, was saying to me, "come on we'll go home." I said, No. I understand people not going. Who would want to sit in an accident and emergency room for ten, 12, 24 hours or longer? One can understand why people would either not want to go or would leave. There is another shocking statistic here, which is that one out of four people put off seeking medical advice because they cannot afford it. There is no way finance should be a barrier to seeking medical treatment.

What can be done to help with that?

Ms Rachel Morrogh

We have been running this research across the course of the pandemic to understand what the barriers are to people accessing healthcare. For the first time, just before Christmas, we saw that cost was going to be the biggest barrier for people making the decision about whether to seek medical care or not. That is hugely troubling for us in the Irish Cancer Society and, I am sure, for the committee as well. Sláintecare is there, it is our ten-year strategy. I heard Deputy Shortall on "Morning Ireland" yesterday talking about the difference between entitlement and eligibility. It is important that all of us are entitled to access care at the earliest point we can and that cost is not a barrier. We have been focusing on the fact that the costs are huge for people with cancer. They have a drop in income and they also have additional expenditure. It is a huge financial crisis for people. They end up in debt and borrow from family members. It is not just about the health consequences of this life-changing diagnosis, it is the financial impact as well, which has ripple effects across entire families. We want people to make decisions that are in their best interests when it comes to health. When they cannot afford it, it is an empty message from the Irish Cancer Society to go and seek help when people are saying they cannot afford to pay the electricity bill or to pay for their children's gym classes, for example.

Deputy Thomas Gould

I have two more questions. If the Irish Cancer Society representatives do not have the time to respond now, they will get back in later. I know a lady who has had an issue with skin cancer. We are not sure how bad it is. She has had a number of serious operations on her face. This lady has been looking for a medical card for years. I think she is something like €20 a week over the limit. It is terrible that people who are either diagnosed with cancer or could be diagnosed with cancer do not have access to a medical card. The witness made the point that we do not know how many people unfortunately, tragically, have died because of late diagnosis due to Covid-19. Would it be accurate to say that it is probably going to take years? People look at Covid-19 as a two-year or three-year period but the consequences will run into perhaps three, five or ten years because of late diagnosis, people not having the same quality of life and some people passing away earlier than they should have. It could take years. What can be done to get that data so we can prevent that happening in the future?

Ms Averil Power

I can answer the question about data. The committee looked at this recently and we all heard the public comments from the gentleman who just resigned from leading up the HSE digital transformation. I am sure the committee discussed electronic patient records last week. They are vital so the data can be captured electronically and is then available to everybody involved in a patient's care. For example, one of the issues in cancer is that people can be treated in different centres. You may have surgery in a centre of excellence but then get radiotherapy through the St. Luke's Radiation Oncology Network separately or in Cork or you may get chemotherapy in your local hospital. There is not even a centralised record for that patient necessarily that is shared across sites. That is a huge challenge. Having the electronic health record put in place urgently is important. It is being piloted but it needs to be put in place so everybody involved in the patient's care has access to their full history. It is also important that decisionmakers can access that information, such as The National Cancer Registry, NCRI, which from a cancer perspective can pull that data in real time, as well as sharing it with policymakers in the Department, the Minister and the committee so they can understand and interrogate what is happening. For us, it being publicly available to the same extent that it is in other countries would be a big move forward so we can have the data to make proper decisions and, frankly, to hold people to account. It also means that people will be held to account. In five years' time we will have the information but those who were leading services or some of the people involved or political leaders will have moved on. You do not have the ability to hold people to account for what is happening either. That is vital. Digitalisation is vital.

Ms Rachel Morrogh

On the question about medical cards for cancer patients, it has been in our pre-budget submission for the last number of years. Ideally, Sláintecare would be implemented. We see that as a stop-gap but there is that magnificent strategy that has been adopted. It has agreement from patient groups like us and medical organisations and politicians, so it is a powerful strategy and we want political focus on the implementation of that.

Deputy Thomas Gould

I thank the witnesses. I have to go to the Chamber but I will be back shortly after I speak.

Chairman

I look forward to that.

Deputy Róisín Shortall

I welcome the witnesses. Overall it is very disappointing that there has been so much slippage in what was regarded as the jewel in the crown of the health service. A number of years ago, we seemed to be taking the right approach regarding the cancer strategy and governance of that, the political priority and the clear decisionmaking around it. It is worrying that the Irish Cancer Society has reported to us the serious difficulties. Where do the problems actually lie? In this committee, we are conscious of the overarching dysfunction within the health service and big-ticket items like the lack of e-health, of workforce planning, of integrated care and of access and the fact that cost is a barrier. They are the big planks of Sláintecare and we are pursuing them. They have a big impact on cancer services as well as mental health services, as I said last night, and right across the board. Leaving those aside, if that is possible, for a moment, within cancer services and the strategy, are there particular problems either in relation to governance of the strategy or resources or decisionmaking? Are there inherent problems within cancer services that need to be addressed?

Ms Rachel Morrogh

I will start and Ms Power may supplement what I say. Deputy Shortall is right. It was the jewel in the crown of all different disease groups and the committee will probably remember that the National Cancer Control Programme, NCCP, used to sit under the Department of Health. It was moved to the HSE and there was a recent article in The Medical Independent which outlined that the NCCP lost some of its power in that move. We would like the National Cancer Control Programme to sit under the Department of Health so it has additional powers. The competition between cancer services and other acute services which the health service has to deliver means that it is more difficult, particularly regarding treatment, to be able to guarantee timeliness of treatment. Ms Power mentioned the recent NCRI report on inequalities. Unless we focus on the people who are most vulnerable, most at risk of cancer and have the lowest survival rates, we are not going to make the big improvements we want to see. That is going to require a whole-of-Government approach to tackle health inequalities, rather than just a singular Department of Health issue because of the social determinants of health. It needs that wide focus and it needs to be a Government priority to implement the national cancer strategy.

Sadly, the cancer strategy is going to expire in 2026. We have not seen progress in implementation we would like to have seen at the midway point. The committee may be aware that some of the KPIs do not even have data for us to understand how much progress has been made. As Ms Power said, it is challenging for us to get data on cancer services in real time. All of those things combined mean that cancer services are not in the position we want them to be. Governance is part of that.

Ms Averil Power

Other cancer-specific things would be centralisation. I mentioned that where centralisation of cancer surgeries has taken place data has been published to show that it has significantly improved outcomes for those cancers. The centralisation programme as a whole has not been completed and is particularly important for some of the rarer cancers that have not yet been centralised. That is very important. We mentioned protected surgical time and theatre time and Ms Morrogh touched on cancer services not competing with road traffic or other emergencies that come into hospitals, and not competing for beds with Covid-19 and flu. I know the Deputy has spoken about this every year and before Covid-19 also, but that is a constant issue. Another one is protected time for research. Internationally we know the best cancer centres and we do not yet have a comprehensive cancer centre in Ireland. In the best cancer centres the doctors have protected time for research so they are not having to try to find time for research on top or a busy clinical load. That is really important.

Another cancer-specific one and I know is an issue for all conditions is direct GP access to diagnostics. If it especially important for cancer and direct access has improved over the past few years but there is still more that can be done to ensure GPs can send people directly for cancer tests.

Deputy Róisín Shortall

A particular issue that was highlighted in the media today and that the witnesses referred to is the disparity between people of different income brackets in terms of cancer outcomes where we know that people from lower socio-economic backgrounds have a 28% higher risk of dying from cancer than more affluent people. It is very concerning that it is one of the metrics that is not changing at all. Progress is being made across a lot of different aspects of cancer care but not in that one in particular where there is that enormous disparity between people who have money and people who do not. From the Irish Cancer Society's perspective, what are the top issues responsible for that disparity and inequality?

Ms Averil Power

There are a number of them. Part of it is, as I mentioned, the lower uptake of screening in disadvantaged areas. For example the uptake of breast cancer screening is much lower in disadvantaged areas than in more affluent ones where almost everybody takes their appointment. That is part of the challenge. Other things like access to diagnostics is a big one. If somebody goes through the public system and their GP tries to get them a public appointment for an MRI, an x-ray or other scans to find out if they have cancer and they realise they will have to wait for a long time, if they can afford it they can get the test privately, perhaps in a week rather than waiting for months through the public system. So access to diagnostics is a crucial one. There are other issues around, for example health behaviours are different in disadvantaged areas so there are much higher rates of smoking. It is complex. There are factors such as health literacy and diet and as Deputy Shortall knows inequality is very complex and multifaceted. For that reason we need a multifaceted approach to make sure everybody is empowered to live their lives as healthily as they can without being put off by the cost. Healthier food is more expensive. To be truly empowered to engage with healthcare professionals is something many people struggle with. I think all of us can sometimes feel intimidated when we try to engage with our GP or consultant but it is a greater challenge for people with lower levels of education. The key one we can fix and that the Irish Cancer Society has highlighted is the diagnostics piece. The ability to pay privately for tests means other people can jump the queue whereas those from lower backgrounds cannot.

Deputy Róisín Shortall

Sure. Or to out it a different way, the public diagnostic services are completely inadequate.

Ms Averil Power

Yes.

Deputy Róisín Shortall

Unfortunately, that is increasingly the case in relation to health, social care and disability services that if someone can pay-----

Ms Averil Power

Yes.

Deputy Róisín Shortall

-----they can skip the queue and get quicker services. We know that all of those underlying reasons are very complex, as Ms Power said, but sometimes that can result in nothing being done about it-----

Ms Averil Power

Yes, 100%.

Deputy Róisín Shortall

-----if it is complex. Is there any particular strategy to target the high levels of inequality in accessing services?

Ms Rachel Morrogh

Deputy Shortall will be aware that in the national cancer strategy there are a number of different key performance indicators, KPIs, that commit to the reduction of-----

Deputy Róisín Shortall

Sure, and sorry to cut across Ms Morrogh as my time is nearly up. Is anything being done about that? It may be listed in the cancer strategy but is anything happening to tackle that issue?

Ms Rachel Morrogh

Not nearly enough.

Deputy Róisín Shortall

Okay, I thank Ms Morrogh for that. The Irish Cancer Society acknowledged earlier the additional resources that have been provided in recent years. In some services the problem is now that there are resources but no staff and that is the difficulty. Would Ms power say that applies to cancer services generally? I am particularly asking about radiation therapy where we are told there is a staff shortage rate of around 30% across services which is extraordinary in relation to cancer services. Why are these things happening and why do we not have a sufficient supply and why are the training places not being provided to enable the additional staff that are desperately required? Would Ms Power then describe the problems as being more due to lack of planning in workforce needs or is it resources? Are we in the position that the resources are there but we cannot get the staff?

Ms Averil Power

We often hear about key roles that go unfilled, where the resources have actually been allocated and the roles cannot be filled because we cannot attract people to take them up. As Deputy Shortall knows, that is happening at every level within the health service and it happens a lot in cancer services. In the briefing we circulated to the committee we highlighted particular areas including radiotherapy and other areas where we have far less staff per capita compared with other countries. That is a huge challenge affecting both the workload on the remaining staff and making the situation intolerable for them, and patients cannot get access. Deputy Shortall mentioned training, for example, and whether we are training enough people. As we all know, the people we are training vote with their feet and decide not to stay here because of the conditions in which they would be working. Between January and May 2022, 402 Australian work visas were issued to Irish doctors and in all of 2019 it was 272. That has been an issue for years but has gotten a hell of a lot worse and we hear from recent medical school graduates that almost their entire class is going to Melbourne or to the US where they will have enough time with their patients because it makes doctors and nurses really distressed when they try to provide care and cannot do it to the best of their abilities. As Ms Morrogh said there are huge levels of burnout. Cancer staff come to us really upset saying they go home from work feeling guilty and stressed because they could not do their jobs. Who would want to work in those conditions? Understandably, people are voting with their feet and leaving Ireland but it is a viscous circle. I think the Deputy hit the nail on the head as regards to the staff. It is about giving people confidence that things will change. We still do not have that despite Sláintecare and the national cancer strategy. People in Ireland do not have confidence the health service will get better. I think if the staff had that confidence they would stay and that would end the viscous cycle of the more people leave the worse it gets and the less attractive it is for graduates and for others to stay.

Deputy Róisín Shortall

Yes, absolutely. Finally, are we training enough radiation therapists? I fully accept what Ms Power said about healthcare workers generally who are leaving because of stress, house prices and all those other things. In terms of training places are we training adequate numbers?

Ms Rachel Morrogh

I cannot give a direct answer to Deputy Shortall but I can point to the fact we have not met the time to treatment target for radiotherapy that is set out in the national cancer strategy for the last five years. The Deputy's question was whether we are planning well enough for this vital cancer service-----

Deputy Róisín Shortall

I know the answer to that. It is definitely in the negative.

Ms Averil Power

Can we come back to the Deputy on that?

Deputy Róisín Shortall

Yes, that is fine.

Ms Averil Power

I know that per capita we have less radiation therapists than other countries but I do not know if that is because we are not training enough or because we are training them and they are leaving.

Deputy Róisín Shortall

Okay.

Ms Averil Power

Maybe we can look into that.

Ms Rachel Morrogh

Yes, we can find that out.

Deputy Róisín Shortall

Thank-you very much.

Chairman

I thank Deputy Shortall. I will move to Deputy Gino Kenny who is on the Leinster House campus.

Deputy Gino Kenny

Yes. Good morning and happy St. Brigid's Day. This is the first day of the Irish spring and a very positive day of the year. My first question relates to people who have a terminal cancer diagnosis and present themselves in emergency departments.

What is international practice when someone with a terminal cancer diagnosis presents in an emergency department with their condition deteriorating? I have recent first-hand experience of this because a member of my family spent an inordinate amount of time in an emergency department. It beggars belief. The system should be better than having someone who is terminally ill spend two days on a trolley. It is incredible. Is there international practice where that does not happen? It is not acceptable that someone could be waiting two days in an emergency department. Is there a system in place elsewhere where people with a terminal illness are not allowed to stay in an emergency department for so long?

Ms Averil Power

I am sorry to hear the Deputy had that experience. It is horrific. It is awful going through cancer at all, but having to go through an emergency department is crazy, especially at the moment. It simply adds to the distress.

Best practice is that cancer would have a separate pathway and a patient would not go through the emergency department at all. People would not have to go to an emergency department to be triaged and seen by someone from the cancer services. There would be a separate pathway for that care.

The national cancer control programme, NCCP, has stated that acute oncology services are ensuring patients can be assessed without attending an emergency department but we often hear from patients who have to go to emergency departments to access care. It would be good to raise that issue with representatives from the NCCP when they are before the committee. Healthcare professionals tell us that, especially at weekends and overnight, going through emergency departments is the only way that patients, including those with a terminal diagnosis, can get into the system. It is intolerable. It is not the practice internationally where there are proper separate cancer pathways.

Deputy Gino Kenny

What is that practice?

Chairman

I will cut across the Deputy on that issue. It would make more sense if people who are attending St. Luke's Hospital or St. James's Hospital, for example, would attend the emergency department in the hospital where their files are available. Would Ms Power advise people that if they have to go to an emergency department, they should go to the hospital where their files are located? That would probably help staff and speed up the process. I apologise for cutting across the Deputy.

Deputy Gino Kenny

That is fine.

Ms Averil Power

Part of the challenge is that people may not necessarily be getting their cancer treatment in the nearest hospital, and for good reason. It is better they go to a centre of excellence such as one of the cancer centres. However, if people have an emergency they would normally go to the local hospital. Other countries have separate pathways for that. For people who are getting their cancer treatment in St. James's Hospital and then have an emergency or are in extreme pain, it is true that going to St. James's Hospital means their files are available, but they should not be going through an emergency department. It would better if they were going through a cancer pathway in St. James's Hospital, an out-of-hours service for cancer patients, rather than sitting in a crowded waiting room. As members will be aware from Covid-19, the infection risk is much greater for people who are on cancer treatment. It is terrifying to think they have to go through an overcrowded emergency department and put themselves at risk to get access to urgent care. It is simply not acceptable that for many people that is the only route into hospital, especially out of hours. It should not be that way.

Deputy Gino Kenny

Is that better alternative pathway in place anywhere in Ireland?

Ms Rachel Morrogh

With respect to what is happening elsewhere, everyone agrees it is not the ideal pathway and other countries are doing it better than we are. The NCCP made 26 oncology nurse appointments to try to avoid patients going through emergency departments but, as Ms Power said, we are still hearing that people have to do so. I will refer to the national cancer strategy to underline how important it is. It contains a target to reduce the number of people who go through emergency departments to less than 20% if they are on active treatment. Sadly, that metric or key performance indicator, KPI, expired in 2018, which demonstrates that the national cancer strategy is the blueprint for what we need to do in cancer services. When it is not implemented, sad experiences, such as the Deputy described from his personal situation, continue to happen. We are talking a great deal about statistics today and the high percentages of people who are not receiving the care they need. An oncologist told us recently that statistics are people with the tears wiped away. That is something we often reflect on. When we talk about these percentages, 20%, 40% and so on, they show that high numbers of people are having an inferior experience in the Irish health system.

Deputy Gino Kenny

In alluding to the National Cancer Registry Ireland report published about inequalities in cancer care, Ms Power, by and large, answered my next question. As long as we have inequality in our health system, we will continue to have inequalities, particularly in diagnostic care. If people have access to better healthcare because of their financial circumstances, they will be diagnosed quicker than people who have fewer resources. There is no doubt that this is a complicated issue and there are no simple answers but it is alarming that people in less affluent areas have a 28% higher risk of cancer. A number of factors are involved but one of the main factors is accessibility. It makes sense. If people get tests, diagnoses or MRI scans, sometimes years before people in the public health system, it will save their lives. There is no doubt about that. I ask Ms Power to comment on the report published today by the NCRI.

Ms Averil Power

Sadly, today's report is not news to us as it has long been established that those inequalities exist. Ms Morrogh mentioned, for example, that it is much more likely that people from disadvantaged areas will have their cancer picked up in an emergency department. I also mentioned that there are higher rates of smoking in disadvantaged areas. Some 25% of lung cancers are picked up in emergency departments and it is often people from poorer backgrounds who are being diagnosed with a hard to treat stage 3 or stage 4 lung cancer that will almost certainly take their lives. The prognosis is not good when it is picked up that late.

As Ms Morrogh said, we can desensitise these issues but it is horrifying to think that in 2023, in one of the most well-off countries in the world, people are dying of cancer just because they are poor. Statistics have been published to show that people are three times more likely to get and die of cancer in Mulhuddart than they are in Castleknock. Those two areas are side by side but people have radically different outcomes, primarily because of their income and, as the Deputy said, access to diagnostics. It is not good enough. We are also deeply worried that today's figures relate to 2018. We have no doubt that the differential, that 28% higher mortality rate in 2018, is much higher now because of what we have picked up about the widening inequality due to the impact of Covid-19.

Our services are much more difficult for everybody to access right now, but this is especially true for those in disadvantaged communities. We are very worried it is actually much worse than the picture painted in the report.

Ms Rachel Morrogh

One of our frustrations is that we have been highlighting the inequity in healthcare, specifically in the area of cancer and cancer outcomes, for as long as I can remember. Members of the committee have highlighted it as well. When we consider the health inequalities highlighted in this report, the authors are saying that there has been no change in the gap between the most well off and the least well off in the past decade. The most startling finding for the Irish Cancer Society is that despite everything we know about health inequalities, there has been no progress. That is highly disheartening and worrying.

Deputy Róisín Shortall

It is damning.

Ms Rachel Morrogh

Indeed.

Deputy Gino Kenny

I thank the witnesses.

Chairman

Deputy Durkan is the last contributor. I will give priority to other members the next time.

Deputy Bernard J. Durkan

The last shall be first and the first last. Is that not true? I seem to recall that was the wording. I welcome the witnesses. There are some very startling and worrying aspects. It is wrong to give an impression that people who are less affluent are in greater risk. Whatever happens, that must be dealt with. Whatever it is, that should apply in all aspects of the health service. It is used all the time but it is now creating a myth that the person who is less affluent will not get proper or adequate treatment on time. That applies across the board, not just in cancer services. It is important we restore confidence in the system and ensure that people who are deemed less likely to get adequate treatment are provided with a level of service that gives them equal and timely access. Otherwise, public confidence in the health system will disappear and we need the public to have confidence in it.

The other matter is up-to-date data and the extent to which they are not available. Why is this? Are we still suffering from the Covid pandemic? If so, have the data not been prepared as a result? Are there any other reasons they have not been prepared in this area? It was remarked that when the Department of Health was in charge of cancer treatment services, etc., there was a better response than there has been since the HSE took them over. Our guests might elaborate on that.

Ms Rachel Morrogh

The Deputy said there is a myth people who are not well off do not get timely access to care. Our view in the Irish Cancer Society is underscored by the findings of the report and it is also our experience that people who are less well off are not getting timely access to care. We see that in particular in the case of radiology waiting times. There are 150,000 people who have been waiting longer than three months for a radiology appointment. Radiology is a key diagnostic tool when it comes to cancer. For those with private health insurance, the waiting times, if there are any, are much lower, so there is a disparity when it comes to people who can afford private health insurance and those who cannot. That is an inequity and it means timely care is not provided for those people who, in addition, do not have a medical team advocating for them because they do not have a diagnosis. They are sitting on radiotherapy-----

Deputy Bernard J. Durkan

What do we need to do about that? What is the answer to that question? Why does that have to be? Is it because it has gradually become the cause of the problem? What is the cause of the problem and how do we deal with it now?

Ms Rachel Morrogh

The Deputy asked why does it have to be. It does not have to be. That is a key message we want to get across to members and I am certain they are very aware of it. We need facilities such as diagnostic centres so that services are not being delivered side by side with acute care. We know the pressures the acute system faces but if we had diagnostic centres people could get a diagnosis quicker. Ms Power also mentioned that, thankfully, GPs now have good direct access to diagnostic tests and referrals. We need to ensure that continues.

Deputy Bernard J. Durkan

Why does it not work?

Ms Rachel Morrogh

We do not have the-----

Deputy Bernard J. Durkan

It is obviously not working, even though backup is available. One possibility is a lack of up-to-date data but why is it not working? With technology almost at its zenith, we should not have problems of this nature. How do we reach those people who are not getting services on time and diagnosis when they should?

Ms Rachel Morrogh

A key part of it-----

Deputy Bernard J. Durkan

What is the Irish Cancer Society asking us to do to address that now?

Ms Rachel Morrogh

We are asking members to highlight the crisis in diagnosing cancer, specifically the crisis that it is.

Deputy Bernard J. Durkan

Does Ms Morrogh mean the various forms of cancer, rather than one particular form of cancer?

Ms Rachel Morrogh

Yes. Ms Power mentioned the rapid-access clinics for breast, prostate and lung cancer. They are not meeting the KPIs that have been set for them. Then there are the cancers for which there are no rapid-access clinics. Potential sufferers of those are the ones sitting on radiology waiting lists. For somebody who has a typical symptom easily identifiable as a possible symptom of cancer will get faster access. I was speaking to a radiologist recently and there was a woman who just had back pain as her symptom. She was on a radiology waiting list for nine months and she was diagnosed with metastatic cancer. We need to ensure everybody gets access to diagnostics. It is the key. It is the central pathway into timely care and treatment and we need to focus more on it. It needs to be on the agenda of every political party at every parliamentary party meeting. It needs to be on the agenda of Cabinet every week until it is solved.

Deputy Bernard J. Durkan

I agree with Ms Morrogh. The nub of the issue has to be dealt in early days.

On ovarian cancer, the prognosis at stage 1 is 83% and only 15% at stage 5. There is a statistic. Would our guests like to elaborate further? That is from the opening statement.

Ms Averil Power

As I said earlier, it is typical of many cancers that if they are diagnosed at stage 1, the prognosis is 80%, 90% or 95% but at stage 4 that drops to 10% in some cases, or 15% or 20%. That is why we are underscoring the need for earlier access to diagnostics. The earlier cancer is caught, the easier it is to treat. We want to be catching all tumours before they have spread. We want to be catching breast cancer before it has become metastatic breast cancer when it is easier to remove the tumour and the procedure is less invasive. People who go through less invasive treatments have much less harsh side effects afterwards and a better quality of life. They have a better chance of both surviving the disease and having a decent life afterwards, including getting back to work and, we hope, to normal life.

Our goal should be to stop people getting cancer in the first place and do more on prevention for the four out of ten cancers that are caused by lifestyle factors. It should be to educate, empower and support people to reduce their modifiable cancer risk. We should invest more in screening to catch problems at a precancerous stage as CervicalCheck does. We have called for screening to be expanded to lung cancer and other areas where there is good international evidence that screening for healthy people without cancer symptoms can catch cases. People might not have symptoms and do not yet know they have an issue but screening them can pick up cancers either at a very early stage of cancer or at a precancerous stage before it has even gone on to cause cancer. It is about prevention and screening and catching people in that way. It is also about ensuring people who have symptoms can get into their GP.

Again, there are big disparities. There are parts of Dublin that are massively under-resourced, where we just do not have enough GPs. We have far fewer GPs per capita than other countries so even when people have symptoms, they cannot get in to a GP. Others, as Ms Morrogh said, cannot afford it. The €50, €60 or €70 it costs to go to a GP means those people will not get picked up because they are having to make choices about whether to pay their heating bill, buy shoes for their kids or say something does not feel right and pay to see a GP. Some of us take that for granted. For others, they just cannot afford it. It is all of that.

We need all of cancer care to work, from prevention to early detection, treatment and proper survivor support, so people have a decent quality of life and, as Deputy Gino Kenny mentioned, a decent quality of death. We should have dignity in death so people with terminal diagnoses get the palliative care they need and their final days are not painful, so they are being looked after, are as comfortable as they can be and pass away with some dignity. Right now, none of that is working as well as it should be. That is simply not acceptable.

I know all of the members know this. All of them have advocated on these issues for us and for cancer patients who have reached out to them to share their family's heartbreak and personal experience of what is happening. We are just asking to please keep that up. We cannot do this without them. Cancer patients cannot do it. It is awful that we put the burden on patients who are sick. Family members who are distraught from looking after their sick loved ones have to go out and advocate for themselves. They have to become researchers to try to find out if there is a better treatment or if there are trials available elsewhere that they could get on. They are researchers and advocates who are navigating the welfare maze to get medical cards. Nobody should have to do any of that. People should be able to rely on the services. As Ms Morrogh said, we have the information. We know what best practice looks like from other countries. It is about time we actually implemented that and gave people the best chance - the chance they deserve - of surviving cancer in Ireland.

Deputy Bernard J. Durkan

What is wrong with our system at the moment? Ms Power pointed out the lack of GPs and the graduates who are leaving the country, which incidentally cannot continue. A means has to be found to ensure that, having achieved their success in terms of graduation or qualification, their first job is in the country. We live in free times with freedom of travel, freedom of choice and so forth. However, if it means we have an inferior health service as a result of a combination of these factors, I think we have to deal with it. Previously, we had a better result when the Department of Health had direct responsibility for cancer services, as opposed to the HSE. That is an old-----

Chairman

Deputy Durkan, you need to come to an end.

Deputy Bernard J. Durkan

I know. That is an old issue of mine, anyway. I am not gone over yet. Despite the article in the newspaper last weekend, my demise has not been heralded to that extent. What do we do now? Do we do an advertising campaign drawing public attention to the deficiencies so we will know more acutely what we have to do in the short term?

Ms Rachel Morrogh

As regards what needs to be done, we have an excellent national cancer strategy. It needs to be implemented. There is no point in wringing our hands and saying we do not know what to do next because we do know, so let us just do it.

Chairman

I apologise to members. There is just not enough time. I would have liked to contribute too. I am bursting with loads of questions but hopefully all members will get to speak next time. In the next session I will try to prioritise those who did not contribute in this session. This meeting was very useful. We touched on a lot of issues. I personally think the two-tier system is at fault. Ms Power is correct that if someone is from a poorer background, it is more likely they are not going to get a scan. If someone has money they can go and get that scan but if they are from a poorer background and they have access to a medical card, it is almost impossible to get a doctor to take them on. It is similar with dentists. Dentists identify a lot of cancers in the mouth and so on but many of them are not taking on medical card patients. The system is stacked against people who are poor, unfortunately. We need to collectively look at that.

I appreciate the witnesses coming in. It was useful and I hope to see them again very shortly. Many of the issues they raised around digitalisation and so on are part of the ongoing work of the committee. We will bring in the Secretary General of the Department to discuss that issue in the coming weeks. I appreciate the witnesses' input in the meeting this morning.

Sitting suspended at 10.56 a.m. and resumed at 11.05 a.m.

Chairman

I welcome our witnesses. From the HSE, we are joined by Professor Risteárd Ó Laoide, national director of the national cancer control programme; Professor Arnold Hill, surgical oncology clinical adviser at the national cancer control programme and consultant breast cancer surgeon; Dr. Clare Faul, radiation oncology clinical adviser at the national cancer control programme and consultant radiation oncologist; and Mr. Robert Kidd, assistant national director of acute operations at the HSE. I invite Professor Ó Laoide to make his opening remarks on behalf of the HSE.

Professor Risteárd Ó Laoide

A Chathaoirligh agus comhalta an choiste, míle buíochas as ucht bhur gcuireadh anseo ar maidin, Lá Fhéile Bríde. As the Chair stated, I am joined by my colleagues Professor Hill, Dr. Faul and Mr. Kidd. I thank the clinicians for taking time out of their busy schedules to join us.

In this statement I will provide an overview of cancer services in Ireland and outline the various approaches to improving services and outcomes, as well as the challenges facing cancer services. I begin by thanking everyone working in cancer services in hospitals and community services across the country, who have continued to provide quality care to their patients through difficult circumstances in the past three years. I also thank those involved in the charitable and voluntary sector who support people living with cancer. Our partnership approach with these organisations, as well as with our colleagues in the HSE, the Department of Health, the National Cancer Registry and a broad range of stakeholders across research, education and service delivery, only strengthens our collective ability to face the challenges presented by cancer in Ireland.

The National Cancer Registry predicts that one in two people in Ireland will develop cancer at some stage in their life. Cancer prevention, diagnosis and treatment present major healthcare challenges. More than 35,000 invasive cancers are diagnosed each year in Ireland. As with many other health conditions, the absolute number of people diagnosed with cancer is increasing, primarily because the population is growing and the number of people who are 65 years or older is rising. We see the impact of this on services, with an increase of more than 20% in annual new attendances at the urgent rapid access assessment services for suspected breast, lung and prostate cancer in recent years.

Encouragingly, mortality rates are falling for the four major cancers of prostate, breast, lung and colorectal, which account for more than half of all malignant cancers. This fall in mortality rates is likely attributable to a combination of reduced incidence that is partly due to success of tobacco control efforts, earlier detection, including through screening, and better treatments. As between 30% and 50% of all cancer cases are preventable through changes to lifestyle and environmental factors, we must redouble our efforts to support the population to address these modifiable factors.

Early detection involves diagnosing cancer as early as possible, before it has grown bigger or spread to other parts of the body. For most types of cancer, diagnosing it early is a critical step in achieving higher survival rates, reducing treatment severity and improving quality of life.

National Cancer Registry data show that five-year survival for people diagnosed with cancer in Ireland averaged 65% for patients diagnosed between 2014 and 2018, which is a substantial improvement from 42% 20 years previously and is a testament to improved detection and treatments.

There are more than 200,000 people living with or after cancer in Ireland. The cancer strategy’s particular focus on quality of life has led to targeted investment in survivorship and psycho-oncology services and other supports for these people. The cancer service has clear policy direction through the three national cancer strategies, published in 1996, 2006 and 2017. Funding of €20 million in 2021 and again in 2022 has helped to address historical deficits in the cancer service and support implementation of the cancer strategy. This investment has allowed us to allocate more than 400 new front-line positions across all disciplines in the cancer services. However, it is crucial that multi-annual funding is sustained in order to implement the cancer strategy.

The HSE national cancer control programme was established in 2007 as a result of the cancer strategy of 2006. The NCCP works with service providers to prevent cancer, treat cancer, and increase survival and quality of life for those who develop cancer, by converting the knowledge gained through research, surveillance and outcome evaluation into strategies and actions. International research published in Lancet Oncology in 2022 highlighted the association between cancer policy consistency and improved cancer survival. Ireland scored above average compared to our international colleagues for policy consistency, and also demonstrated substantial improvements in survival for most cancers. The paper highlighted the likely impact of centralisation of lung, pancreas, rectal and oesophageal cancer services on improvements in survival for these tumour types in Ireland. An important feature of the work of the NCCP is the engagement of clinicians, in a voluntary capacity, in the development of cancer services. Across all disciplines, countless front-line providers contribute significantly to the work of the NCCP on top of their own busy clinical commitments. In addition, patients and their advocates also contribute significantly to the work of the NCCP at multiple levels. I would like to thank them for their continued contribution.

The cancer service is facing considerable challenges. While cancer care was prioritised by the Department of Health and the HSE during the Covid-19 pandemic, there remains an ongoing impact. We will not fully understand this impact for a number of years. The most recent estimate from the National Cancer Registry of Ireland is that 10% to 11% fewer cancers were diagnosed in 2020 compared to expected numbers. We do not yet have clear data on the impact on staging of cancer, but there are anecdotal reports of later stage presentations. Awareness campaigns continue to operate through the HSE, as well as through various voluntary and charitable partners, to encourage people to recognise the signs of cancer and to visit their GP without delay. Another key challenge facing the cancer service is the recruitment and retention of staff across almost all disciplines. This is a major challenge to sustained provision of services. The availability of appropriate infrastructure is critical to ensuring that we can provide care to cancer patients in the most appropriate setting. This includes dedicated facilities for cancer care and the provision of theatres, beds, day wards and radiotherapy facilities. While these challenges are common to many health systems around the world, any impact on individuals in Ireland facing cancer is regrettable. Cancer service staff around the country are working to minimise those impacts.

Despite the challenges of the past three years, great progress has been made in the development of cancer services. In line with the cancer strategy, we are implementing models of care for systemic anti-cancer therapy, psycho-oncology and child, adolescent and young adult cancers. We have published numerous national clinical guidelines, pathways and treatment protocols to support efficient front-line care. We have implemented the acute oncology nursing programme, through which experienced cancer nurses assess cancer patients requiring care, so that attendance by cancer patients at emergency departments is minimised. Through investment, we have been able to improve patient access to advanced treatments through the repatriation of chimeric antigen receptor T-cell, CAR-T, therapy and peptide receptor targeted radionuclide therapy, PRRT, and the implementation of stereotactic ablative radiotherapy, SABR. We have provided access to new cancer drugs and we are implementing the national cancer information system. Collectively, these new initiatives have improved access to quality cancer care in the State and enhanced patient experience.

As we look towards the remaining years of the cancer strategy, we are focused on addressing the challenges outlined above. This includes completing the process of centralisation in designated cancer centres and developing comprehensive networks of care that align with the regional health areas and deliver on the principles of Sláintecare. We want to put in place a transparent process of accreditation of these networks so that we can continue to deliver quality cancer services to the people of Ireland. This concludes my opening statement. Míle buíochas as ucht bhur n-aird is bhur bhfoighne.

Chairman

I will kick off. The format is that members have ten minutes each for questions and answers. I will try to bring in people who were not able to contribute to the last session. We will start with Deputy Colm Burke.

Deputy Colm Burke

I thank the witnesses for the presentation. It was stated that 65% of patients diagnosed between 2014 and 2018 survived longer than five years, so there is a 65% survival rate. How does that compare to other jurisdictions, such as the UK or other European jurisdictions?

Professor Risteárd Ó Laoide

As I said in my opening statement, the most recent study was published in 2022. That showed that the Irish survival figures were above average for a number of cancer tumours. It stated that the survival rates for some tumours were above average and some were below average.

Deputy Colm Burke

What tumours have survival rates that are below average, and what do we need to do in order to get them above average?

Professor Risteárd Ó Laoide

One that we are addressing, in particular, is ovarian cancer. Ireland has the lowest survival rate for that in international comparisons.

Deputy Colm Burke

Is there a particular reason that is the case?

Professor Risteárd Ó Laoide

The bandwidth between the survival figures is not enormous. There is around 10% difference between the best and the worst, with Sweden being the best. The reason for that is that we need to centralise. We are working on centralising ovarian cancer services, particularly high-end ovarian cancer services. I guess the figures we have are from around 2014 to 2018. There have been significant improvements since then.

Deputy Colm Burke

Besides ovarian cancer, what other cancer has survival rates that are below the norm?

Professor Risteárd Ó Laoide

I would have to come back to the Deputy on that. Perhaps Professor Hill has some information on that.

Professor Arnold Hill

I do not, but I know that the breast cancer figures are certainly very acceptable and on a par with other countries.

Deputy Colm Burke

I know it is great to be on a par with other countries, but the issue in healthcare is to try to be ahead. What do we need to do to make sure that people get diagnosed early, get the best quality care and are able to survive? What do we need to do to ensure that we are above average rather than being on a par with others or below average? What additional work do we need to do in these areas?

Dr. Clare Faul

I can add to what Professor Ó Laoide said. Some of the larger and more difficult cancers in the community include lung cancer and even cervical cancer, but in the last five years that has significantly improved. For example, we were below target in lung cancer. It is a difficult population because we are talking about people from disadvantaged communities. Rapid access into services has opened up in the last five years and we expect access to respiratory diagnostics, including bronchoscopy etc., to increase. In most of the acute hospitals there is a new pathway for rapid access diagnosis, so that will improve. However, we will not see that improvement for another few years, because obviously people need to go through the system and get the results post treatment.

Deputy Colm Burke

On the areas where survival rates are below average, is there a major campaign to make sure that we can improve the service and that people who require treatment can access it?

Dr. Clare Faul

Obviously, there is the campaign to stop smoking. It is about education and ensuring that the population is aware. We must ensure that GP access into the rapid access clinics is available across the country. That is improving and the survival rates will be reflected in that. They are already improving.

Professor Risteárd Ó Laoide

The most recent EU comparative study is the CONCORD-3 study, for the years 2010 to 2014. For 14 out of 18 tumour types, Ireland ranked in the top half of the countries surveyed for five-year survival. For all four tumour types where Ireland did not rank in the top half, survival rates have significantly improved.

Deputy Colm Burke

Okay. I want to move onto the issue of getting information out there. I want to focus, in particular, on lung cancer and prostate cancer. I am not convinced that there is enough information out there to ensure that people can go to their GP and then on for further checking at an earlier stage than is happening currently. Is there a plan as regards getting more information out there? Dr. Faul mentioned the lower-income groups. How do we focus on getting information out in order that people can access healthcare in a timely manner?

Professor Risteárd Ó Laoide

I will take that question.

We are working with the Sláintecare healthy communities programme which is targeting the most deprived areas in 19 community care areas in the country to help to address the factors that lead to the higher risks in more deprived areas. We also have a Think Lung campaign which raises awareness of the signs and symptoms of lung cancer in disadvantaged areas. Last year, we did a survey on cancer awareness and attitudes and this year we are targeting specific groups in the population, commencing with the Traveller community, to try to assess their awareness of cancer risk factors and symptoms, particularly high-mortality cancers like lung cancer, and to assess their barriers to access.

Deputy Colm Burke

We have done a national programme in relation to breast cancer. Is there any proposal to do something similar in relation to prostate cancer, for example?

Professor Arnold Hill

The Deputy mentioned lung and prostate cancer. I will talk about lung cancer and the potential for screening in that area. There is a very exciting initiative, supported by the Irish Cancer Society with Professor Naidoo, looking at people who have a history of smoking, as identified from their GP records, and bringing them in for a diagnostic screening CT scan. This means that if they do have lung cancer, we are picking it up at an early stage. This is being done in other countries and has proven to be effective. It will be the start of screening for lung cancer in this country, which will enhance survival rates.

Deputy Colm Burke

Unfortunately, a member of my family died from lung cancer in the last seven days so-----

Professor Arnold Hill

I am sorry to hear that.

Deputy Colm Burke

-----I am very much aware of the challenges of the disease. This was a person who did not smoke. We also need to get the message across that lung cancer can affect people who never smoked. This is important because people who have a cough might ignore thinking it could not be lung cancer because they have never smoked in their lives. We need to get that message out there as well.

Professor Arnold Hill

Yes, that is an important message. Over the last number of years, with the development of the rapid-access clinics for lung cancer, the service has been really enhanced and we can prioritise those who need to be seen quickly to get diagnosed.

Deputy Colm Burke

How many clinics do we have with that service?

Professor Arnold Hill

In the cancer centres it works very effectively. GPs are aware of that process. If their patients have symptoms suggestive of lung cancer, they can get rapid access.

Deputy Colm Burke

We have eight of those centres around the country. Is that correct?

Professor Arnold Hill

Yes, that is correct.

Deputy Colm Burke

Are people aware of that? I am not sure members of the public are aware that they can get access rapidly.

Professor Arnold Hill

The GPs are certainly aware and those with symptoms are appropriately referred in.

Deputy Colm Burke

What is proposed on prostate cancer with regard to getting information out there so that people who have symptoms of prostate cancer would go to their GP? Is there enough information out there on that whole area?

Professor Arnold Hill

It can always be improved. The test to screen for prostate cancer is more tolerable as it is a blood test. The management of that, with the rapid access clinics, has resulted in significant improvements. We try to triage in and identify those who need to be seen early and get them treated. The whole area of prostate cancer has changed rapidly over the last five years. The surgery is robotic and is very sophisticated now.. Early detection and treatment with surgery can be very effective.

Deputy Colm Burke

We still need to make progress in this area. We have made a lot of progress already; I fully accept that but-----

Professor Arnold Hill

The Deputy is right. The education in this area is something that can always be improved.

Deputy Colm Burke

I want to go back to the issue of young people. About two months ago, two young people contacted me about housing issues. Both of them had major health problems. One person, who was only 24, had both lung and stomach cancer and the other person had had a bone marrow transplant. A lot of young people do not think cancer can affect them and yet I met two young people in one week from two different households who were affected. We need to get information out to young people about symptoms of cancer. I am not sure that we are doing enough in that whole area.

Professor Risteárd Ó Laoide

The NCCP is working on a schools programme to try to get information out to schools. As Professor Hill has said, there is no doubt that we can improve on that. The more information we get out there, the better. We do it through media campaigns, the schools and through GPs. It is key to educate the patients about the signs and symptoms and risk factors. We also have similar education modules for healthcare professionals on early symptoms and early diagnosis. There is a lot done already but more needs to be done, as the Deputy has said.

Deputy Colm Burke

New Zealand is introducing legislation to prohibit the sale of cigarettes to anyone born after a certain date. Would the witnesses be in favour of similar legislation being introduced in Ireland?

Professor Risteárd Ó Laoide

That is something for the Oireachtas to consider.

Deputy Colm Burke

If it was proposed, could it be helpful?

Professor Risteárd Ó Laoide

Yes, it could be helpful to reduce the incidence of cancer. The Deputy mentioned that some lung cancers are not caused by cigarettes but, in truth, eight out of ten lung cancers are caused by smoking. Lung cancer is the biggest cause of cancer mortality in Ireland in both men and women. Any actions that have been proven to reduce the incidence of smoking will reduce the incidence of lung cancer and the number of deaths from cancer in Ireland.

Chairman

On the screening for lung cancer, do we have any idea when that will be rolled out?

Professor Arnold Hill

The programme was just funded in early January and the hope is that it will be activated by the summer.

Chairman

On screening programmes, there seems to be some push-back with regard to screening for prostate cancer. Is there potential there in the near future?

Professor Risteárd Ó Laoide

Just to clarify, the screening programme for lung cancer is a pilot study that is being performed. It will involve an inner city area of north Dublin. Screening is not under the remit of the NCCP so I want to be careful about what I say here. We support the introduction of a pilot programme for lung cancer screening. It may also involved a rural community in Galway; we are looking at that possibility. The actual implementation of any screening programme in this country is under the remit of the national advisory group in the Department of Health, chaired by Professor Niall O'Higgins. There is no doubt that the information gleaned from something like a pilot programme will be invaluable in terms of how a screening programme might be rolled out. In terms of lungs, it is more about lung health than screening because there is also advice given in the models that are used internationally.

Similarly on prostate cancer, we are looking at a potential pilot programme starting in Ireland as part of a multinational EU-wide project that is being supported by the European Association of Urology and various other groups. Dr. David Galvin is leading a pilot programme in this country which will also help to inform any potential roll-out of screening in Ireland. That will obviously be in the hands of the national screening authorities.

Chairman

That is great. Senator Hoey is next.

Senator Annie Hoey

I thank the witnesses for coming in. I am sure they have seen the recent report highlighting that those with the financial means can access care while those without means cannot, and the different rates of cancer survival in different socioeconomic areas. I am astonished that in 2023 we are still in that situation. There is something really immoral about people not being able to access care. Even if one takes away the lifestyle factors linked to cancer, the fact is that people from certain areas are not able to access the care they need while people with money can access such care. The longer I am involved in politics, the more frustrating that becomes. As the report indicates, there are areas that touch each other and yet there are enormous disparities in access and outcomes.

Has the funding for the NCCP for 2023 been confirmed?

Professor Risteárd Ó Laoide

The national service plan is currently being finalised and the HSE is in discussions with the Department of Health on that. The funding for 2023 has not been finalised yet. I do know that we will be spending some money on cancer services in 2023 but we do not have any finality on that as yet.

Senator Annie Hoey

Would it not be more helpful to have that information? It is 1 February now. I am sure it would be useful for the NCCP to know.

Professor Risteárd Ó Laoide

Yes, but we have to await the outcome of the discussions between the HSE and the Department of Health. We look forward to that outcome.

Senator Annie Hoey

Okay.

Professor Risteárd Ó Laoide

On the issue of inequalities, the paper produced by the National Cancer Registry Ireland, NCRI, is a great piece of work and very important for us. I have not read it in detail yet because it was just published today.

Social equality affects not only cancer but all healthcare. It is a worldwide problem. Issues around education, employment and income are all important factors. It is a significant piece of work and we will be looking at it in the NCCP and helping to try to mitigate that problem in this country.

Senator Annie Hoey

The national cancer strategy has outlined that only four of the 23 key performance indicators were met. We know about staff retention, getting people into the system in the first place, infrastructure, waiting times and all of the things that, I presume, lead towards this. Why were only four key performance indicators met? Is it due to a lack of money or political will? In the past two years, President Joe Biden proudly declared that America would eradicate cancer. The merits or likelihood of that aside, are we lacking the same level of ambition? Are the witnesses not being empowered in the way they should be in order to get us to where we need to be?

Professor Risteárd Ó Laoide

The cancer strategy was rolled out in 2017. It is a ten-year programme to 2026. We have received significant funding in the past two years for that, which is appreciated and has done a lot to advance the cancer strategy. We in the NCCP work closely with the Department of Health in empowering us to implement elements of the cancer strategy. Some of the things that will be important for us are the Sláintecare developments, the issue around governance and making changes to services. This is a programmatic model for cancer care in Ireland. We work across the whole pathway from prevention right through to survivorship and end-of-life care. The fact that Sláintecare and regional health authorities will be introduced will allow us to create a new governance structure within the health services to impact on how we deliver outcomes for our cancer services.

Senator Annie Hoey

We have talked briefly about lung cancer screening, but it is a particular area of interest of mine. Some 25% of lung cancers are diagnosed in emergency departments. Is that a similar figure globally or is it quite specific to Ireland? In the case of a very loved family member of mine, while being prepped for surgery, having been in hospital for five weeks, there was a diagnosis. It seems to be a cancer that is sometimes caught by accident, which is distressing in and of itself. It is probably not the best way for someone to find out he or she has lung cancer, in particular when it is at a later stage such as stage 3 or 4.

The witnesses mentioned a pilot programme. The UK is rolling out a screening programme. It found that screening people at high risk of lung cancer saved lives from disease and that the benefits outweigh the harms. The pilot programme in the NHS will be along the lines of lung health, which will include screening for lung cancer. Do the witnesses envisage that we will, depending on the pilot programme or otherwise, go down the route of rolling out a lung cancer screening programme for people aged between 55 and 74 years who are smokers or are otherwise high-risk? There are similar programmes internationally. Is there an appetite for us to go down that road? We have to wait until the pilot programme in the UK is rolled out. International evidence seems to show that this is a reasonable cancer to screen for and that we should move towards a screening element.

Professor Risteárd Ó Laoide

This has to be done in a very structured and evidence-based manner. That was how it was originally done for breast screening. It involved international best practice and an evidence-based manner to ensure that we produced a quality screening programme with appropriate metrics and a reduction in mortality for patients.

The UK is rolling out programmes, which it is calling screening programmes even though they are more akin to the lung health we are now talking about. They have rolled out these programmes as pilots and are selecting different locations. There is an appetite among clinicians in this country to do this. The governance of it is through the national screening advisory group in the Department of Health. I suspect it would be very interested in the results of a pilot programme in this country.

Professor Arnold Hill

The most important thing to understand is that we are talking about screening specific populations. We are trying to identify those people who have been smoking for 20 years. They are far more likely to have lung cancer than a person who has never smoked. We are targeting a specific population to screen, rather than carrying out a population screening. It is a targeted screening programme. Previous efforts at doing CT screening of the entire population have been shown to be not effective. This is a much more targeted programme.

There are also new initiatives in this programme and unique ways we might be able to diagnose lung cancer more easily via a breath test. There is lots to learn from this pilot screening programme that will guide future pathways. We can always increase education. We would not have expected there to be the current level of smoking in 2023. That is where we support legislation to try to help reduce smoking among our population.

Senator Annie Hoey

I wish to discuss a much smaller group of people. I am aware of women who are at risk of having the BRCA gene. I have a trio of sisters whose GP is refusing to refer them for screening because they are too young. One of them is aged 38. They cannot get into another GP practice. It is a small area. Where do people like that go when they come up against a blockage? The older sister is starting to tear her hair out because at the age of 38 she is heading very close to a risk age. I do not know if the block involves not believing women or not taking them seriously, but I am sure this happens in other areas. How do people get where they need to be when they cannot access screening? It is an exceedingly specific example but where do these people go? How do they get screening if their GP does not believe them despite the fact that a number of family members have died?

Professor Risteárd Ó Laoide

That is an important question

Professor Arnold Hill

It is a very good question. The key issue is that we have a system for each individual to work out what his or her true risk is. We could take a detailed history and identify whether someone is high, medium or low risk. There are appropriate pathways of care for that. That is available to people. If a GP wanted to send the woman to a symptomatic breast unit, a triage process will work. The benefit of that is sometimes where people feel they have a very strong family history they can be reassured as to what their true risk profile is. Those pathways are in place and can be sought out. If the person concerned was referred to a symptomatic breast unit, that would be looked after for her.

Senator Annie Hoey

The GP is not even engaging with the referral process. Aunts both sides of the family have had breast cancer. The sisters do not know where to go or what to do. Is the advice to get a different GP, during this trying GP time?

Professor Arnold Hill

It is very hard to comment on a specific case.

Senator Annie Hoey

Of course. I understand. We are talking about screening-----

Professor Arnold Hill

In principle, the pathways are there to work out who is truly high, medium and low risk and treat them appropriately.

Senator Frances Black

I thank all of the witnesses for coming in today. I also thank all of the front-line workers in this area, as well as those working in NGOs. Everybody knows somebody who has cancer. We will have a family member who has had cancer. Two of my family members have passed away from cancer. It is a very important topic.

I am aware that there has been a lot of talk about cigarette smoking but there has not been much said about alcohol and alcohol-related cancers. Evidence has come out which shows that alcohol increases people's risk of several types of cancers, including mouth, throat and liver cancer. It is also responsible for one in eight breast cancers in Ireland. People do not have to be drinking in a harmful way to get breast cancer. That is an important point. Every year in Ireland, 900 people are diagnosed with alcohol-related cancers and around 500 people die from these diseases.

We know that for people who drink and smoke, their chances of getting cancer of the mouth, throat or oesophagus are also very high. There is no safe level of alcohol when it comes to cancer, but it is very well known that if you drink less, you lower your risk of developing alcohol-related cancers.

There has been public awareness on this issue, but should there be more talk about it? Even in our discussion this morning we talked a lot about smoking and the impact of it. That is great, but those results are quite shocking and there should be much more awareness about the impact of alcohol. I was very involved in the Public Health (Alcohol) Act 2018. I am also aware of the pressure that came on the Department and the HSE with regard to this issue, in particular from the alcohol industry. Do the witnesses think there should be a much higher level of public awareness campaign on the impact of alcohol harm and cancer?

Professor Risteárd Ó Laoide

I thank Senator Black very much for her question. That is a very important issue. Coming back to Deputy Burke's point about awareness generally of risk factors for cancer, I do not think we can do enough on that. When I come in here and Senator Black says we should be doing more, she is absolutely right. We should be doing more. We work with Healthy Ireland within the HSE on campaigns on all these issues. There is no doubt that, in many people's minds, cancer and cigarettes are much more intimately linked than alcohol and cancer. As Senator Black says, it results in a significant incidence of head, neck, stomach and liver cancers, as well as breast cancer. I certainly take her point that we should be doing more about that, and possibly doing more of it in schools, because that is where these habits begin. I fully take the point. I do not know if Professor Hill or Dr. Faul have anything to add to that.

Dr. Clare Faul

I agree. Starting early is probably the most important element, along with getting the message across to the entire population. The Irish Cancer Society has done a lot of work in this area as well. All of the cancer support bodies can help us in the voluntary sector, as well as through our own education roll out.

Professor Risteárd Ó Laoide

One of the other things I mentioned is the education of our healthcare professionals so that they can raise it with patients and relatives. The more the staff, GPs, and the public are aware, the more it helps in raising awareness. HSeLanD is the system we use within the HSE and it has an education programme for general practitioners, which has been very well received, for education on risk factors and early symptoms for a lot of these cancers.

Dr. Clare Faul

I was asked to go into my daughter's school to discuss some of the risk factors for cancer. The feedback is that having a diagrammatic way of getting the message across seemed to be one of the ways of doing that. We could have brochures and publications. Starting in the schools is probably the way to get the information out as early as possible. Students can influence their families as well. If a child tells a dad or mum that perhaps they should stop smoking, that is one way of making sure we try to get the message across to the entire family and population.

Senator Frances Black

I agree. I also think it is vital we get the warnings on alcohol. I tabled an amendment, which was accepted in 2018, on the fact it should be stated on the label that there is a direct link between alcohol and fatal cancers and liver disease as well as the danger of alcohol consumption when pregnant. The impact of alcohol does not roll off our tongue as much as smoking does. Everybody in the entire country is aware of the impact of smoking but not many people are as aware of the impact of alcohol. I sometimes think we are a nation in denial in that regard. It is vital we have a better public awareness campaign on the impact of alcohol.

It is shocking to think the likelihood is that it can be predicted that one in every two people will get cancer. It is vital we future-proof our services to manage this inevitable demand. Given that recruitment and retention of staff are a major barrier, what efforts are being made to improve staff retention in this area?

Professor Risteárd Ó Laoide

The retention of staff is a very broad subject because there are many issues outside the control of the HSE and the NCCP such as the cost of living in our city, the fact young people want to travel, and family reasons. There are many reasons it can be difficult to retain staff. We are doing a lot of workforce planning to ensure we have an appropriate number of people in training to take up posts as we expand. We try to give education and training opportunities to staff within our system so that they are working at the top of their licence. An example of that is our systemic anti-cancer therapy, SACT, competency framework which we introduced in the past year or two. It has been a great success. It is training people to give chemotherapy in the wards. Giving chemotherapy is a specialised task that nurses do. In the past year we put in place a framework where people can get trained at any point within our system. For example, it used to be that if you went into a cancer centre, you had to wait six or eight months before you could get trained and then you were working in a difficult scenario within the day ward. What we have done is to have created a structure whereby staff can get trained every month. Each of the cancer centres rotates and provides the training for the nursing staff so that they can get regular training and they get a passport, so that if they move from one centre to another, they are not told they cannot work in a daycare ward anymore because they are not trained in St. James's, for example, or wherever else. They can bring their passport with them and work.

There is that kind of training and competency for the nurses. They are also using their skills to maximum effect. I think that is what people want when they are working within the cancer system. We need to develop new roles like cancer support workers to relieve workers on the oncology ward so that they can do oncology work. We have put in clinical skills facilitators in nearly all of the cancer centres now. These people give training and development to the nursing staff within the institution. All of these things together can encourage people to work to the top of their licence, work in a system which values them and educates them, but there are other elements outside our control. For example, post Covid in radiography and in radiation therapy, typically, younger graduates within the system could not leave the country. Many of them want to go abroad, which is very good for the country, because they learn new skills abroad and, it is hoped, come back again. There was an egress from our system of a significant number. That caused difficulty in our healthcare system, but it is not something we can directly control. We do not want to stop that either.

We do workforce planning. We try to do education in the workplace. One of the other points that is very important and that we must address in this country is the conditions people have at work and the infrastructure that is in place, so that people are working in a safe, comfortable environment.

Senator Frances Black

That is a very important point. There is often burnout. One can imagine what it is like working with patients who have cancer and looking at their families. It must be very difficult, but if the conditions are not right within the work environment, there could be a lot of burnout and staff could be lost that way as well. That might be something that could be taken into consideration going forward.

Deputy Thomas Gould

I was reading through the HSE report and listened to its submission earlier. It highlighted how as a result of Covid-19 there were 10% to 11% fewer diagnoses in 2020. Are figures available for 2021 or 2022? Is there any way to calculate how many people lost their lives prematurely during Covid-19 or will do so as a result of restrictions and lockdowns as a result of Covid-19? There are people whose late diagnosis will have a negative knock-on effect on other patients down the road.

Professor Risteárd Ó Laoide

The latest figures we have are from 2020. They are from the National Cancer Registry Ireland, NCRI, the organisation that produces the statistics for incidence and staging of cancers in Ireland. The preliminary evidence is that the numbers increased in 2021 so the shortfall is nothing like it was in 2020 but we do not have the figures for that yet.

The Deputy asked a question about upstaging. That is where people present later in their cancer which obviously has an impact on survival and outcome. We do not have the evidence for that yet but work is ongoing. There is anecdotal evidence from clinicians, from the clinicians here, that some patients presented with more advanced cancers. Having said that and having discussed with the National Cancer Registry, preliminary reports suggest that in an area like breast cancer where there was a reduction in the number of people coming forward, those who were not diagnosed were the early cancers and not the later cancers. That would be a good thing. We do not have the final data on that yet. The national cancer control programme, the NCRI, the Royal College of Surgeons in Ireland and the Irish Cancer Society are looking at breast cancer, lung cancer and melanoma. We hope that later this year we will have the results on upstaging and its effect. Professor Hill might say something on breast cancer.

Professor Arnold Hill

With breast cancer during Covid, we managed to see the urgent patients throughout the pandemic. There certainly was a temporary reduction in March, April and May 2020 but after that it picked back up. The most significant thing that happened during Covid was that, correctly, we had to pause the national breast screening programme because of the risk profile of a well person coming in and their getting Covid. Therefore, the screening programme was paused. That definitely caused a delay in the pick up of breast cancers. The screening programme is in a catch-up phase to recover from that pause that happened during Covid. That is probably the most significant thing.

Deputy Thomas Gould

Have we caught up at this stage?

Professor Arnold Hill

I think we are in the process of catching up. You know you are fully caught up when everyone is getting their mammograms in a timely manner every two years in the appropriate age group. That is not back to speed yet. There are many factors for that, including having full numbers of staff. We are in the early stages of catch-up. I think it will happen, hopefully, this year.

Deputy Thomas Gould

That is concerning. The Irish Cancer Society was before the committee earlier and it outlined the issues with any delays in early detection. It said that when people are diagnosed at stage 1 they have a 95% success rate but that is less when it is later and that we have not caught up with screenings and diagnosis and what that means. The data should tell us that there is a certain number of cases in every category every year and that is something we can plan for. The HSE submission here states there was a 20% increase. If we have a 20% increase in annual new attendances-----

Professor Risteárd Ó Laoide

My apologies if I crossed the Deputy. The screening service is under the remit of the National Screening Service. Ms Fiona Murphy is not here. The point the Deputy is making is a good one. We had a 20% increase in urgent attendances in urgent breast cancers in 2022 compared with 2019. That has led to a 10% increase in the number of cancers diagnosed above 2019.

Deputy Thomas Gould

Is that a direct consequence of not diagnosing in 2020?

Professor Arnold Hill

It is certainly part of the explanation.

Dr. Clare Faul

It is more complex than that. Some patients, even if they had an appointment, were afraid to go to the hospital. Take radiation and oncology. We provided a service all through Covid. I was clinical director at the time. I had to write a number of letters through the Irish Cancer Society and the Friends of St. Luke's asking people to attend. There was a fear. It was not just the provision of the services. We had to educate patients that it was safe to come in and provide them with the support. That is still out there. There are still patients who are fearful of coming into hospital. We have to encourage them. Everyone needs to encourage patients to attend when the services are available. It is more complex than just not having been through the screening programme.

Deputy Thomas Gould

I understand that and I respect the point Dr. Faul is making but it is unfortunate, whether we reduced services in 2020 or people had a fear factor. I think Covid is starting to fade into our memories but when we were at the heart of it, there was fear among people of going into any congregated setting. The HSE's figures show a 10% increase in diagnosis in 2022, so then it could be possible that it would be the same or even higher in 2023 and 2024 because of the delay. I hope I am wrong there.

Professor Risteárd Ó Laoide

The numbers of cancers were down 10% in 2020. Most of the people with cancer, if they are alive, will present with cancer. We are seeing an increase in cancers in our urgent rapid access clinics of 10% in 2022 compared with 2019. Some of that may be a demographic element. Obviously, the population has increased and people are getting older so there is an inexorable climb there anyway in the number of cancers that we are going to see. The preliminary data we are getting is that the extra cancers are more likely to be the early stage cancers, rather than the late stage. I hope we will verify that because that would be good news for us, the people of Ireland and for the patients.

Deputy Thomas Gould

The Irish Cancer Society made the point that in January 2023 research showed that three people in ten were put off going to their GP or hospital because of the pressure that hospitals were under in the last three months. Different hospitals have called on people not to present to hospitals or emergency departments because of the trolley crisis or staff shortages. That is very concerning.

Professor Risteárd Ó Laoide

Yes. It is a difficult balancing message when emergency departments are crowded. Mr. Kidd might comment on this. The message from the national cancer control programme is that anyone with symptoms of cancer needs to go to their primary care giver, that is, their general practitioner. The well known symptoms of cancer are something we try to get out there, and as members said, we need to do more on that. The general practitioners know that they can get access to the rapid access clinics that we have available for them.

Deputy Thomas Gould

The Chair made the point earlier to the Irish Cancer Society was that now our problem is that people cannot get access to GPs. There is a huge problem with GP services in the State. It is probably not for today's discussion but we know people who cannot even get an appointment with their GP and there are others who cannot even get a GP. One of the GP services in my constituency, in Blarney, closed down recently when the doctor retired. She said that had she had support and had been able to get holiday cover and sick cover, she would not have retired but she felt so stressed and under pressure that she had to walk away. We are losing good doctors like this.

I am watching the time. I have two points if the witnesses have an opportunity to respond to them. The Irish Cancer Society stated that one in four people is put off seeking medical advice because they cannot afford it. It also made the point that we have a cancer strategy. We need to fund it and implement it.

What does the Government and the HSE need to do to ensure the implementation of the cancer strategy? Please outline a wish list.

Professor Risteárd Ó Laoide

My wish list would include the development of infrastructure and getting staff recruitment and retention in order. Good cancer care can be delivered when you have good staff, are able to retain them and there is infrastructure

Chairman

Professor Hill made the point that treatment was ongoing during Covid. I am one of those people who received treatment for cancer during Covid, and staff turned up and the cancer care was very efficient. There are conspiracists who say negative things but I can vouch for the fact that there was ongoing treatment. Again, we congratulate the people who turned up for work every day during the epidemic and saved many lives. I call Deputy Shortall.

Deputy Róisín Shortall

I welcome the delegations and thank them for their presentations.

There has been a lot of talk about the impact of Covid on cancer services and the increasing numbers of undiagnosed cancers, which are concerning but also distort what is happening to a certain extent. I wish to discuss the pre-Covid period. We saw in the media today a report by the National Cancer Registry Ireland, NCRI, on what happened up to 2018. There were a lot of positives in the 2018 report in terms of incidence rates going down and survival rates improving. One of the most negative aspects from that report was the fact that progress does not seem to have been made with health inequalities. The report showed that low-income cohorts are 28% more likely to die from cancer than more affluent cohorts, which is a worrying figure. It seems that the figure has stuck at that level for some time and no progress has been made in respect of the disparity between people, based on how much they have in their pocket. What does the HSE believe are the main reasons for that? What is being done to address the issue?

Professor Risteárd Ó Laoide

The NCRI released its report today so I have not read it in detail. I completely agree with the Deputy that the "28% higher mortality risk" for this group is concerning. We welcome the NCRI report and we will study it. There are underlying factors such as education, employment and income, which can affect people's healthcare generally and have a similar impact in cancer care. Differences exist in the exposure to and knowledge of risk factors. Differences exist about the knowledge of access to screening services. Differences exist in funding, including the ability to go on transport to hospital or go to screening services. This needs much more targeted attention. As I said earlier, we are working with the Sláintecare healthcare communities project, which operates in 19 disadvantaged community areas and focuses on factors that lead to higher risk factors in those regions. We also did a Think Lung Cancer campaign in disadvantaged areas to raise awareness of lung cancer signs, symptoms and risk factors. Last year, we conducted a general attitudes study but this year we will conduct a targeted study among the Traveller community to ascertain their awareness of the risk factors and symptoms and hear from them the barriers to access to it.

I wish to point out that the rapid access clinics are open to everyone and GPs are aware of these clinics. There is a direct access to diagnostics, which is being rolled out to GPs and, again, that service is open to everyone. A policy decision has been made to continue with this important scheme.

Deputy Róisín Shortall

I want to discuss specifics. The report contains a lot of generalities and part of that is because we do not have good data. A lack of good data holds everybody back and is a major problem within the health service. Earlier I posed the same question to the Irish Cancer Society and was told that two standout issues affect low-income communities when it comes to cancer services: low uptake of screening and difficulty in accessing diagnostics. Notwithstanding what has been said about some improvements being made in that area, the reality is that there is a push within the health service to direct people into private diagnostics and thus skip the queue. Of course one must have the money to pay for private diagnostics. Does Professor Ó Laoide accept that both of those issues are significant in respect of the failure to address the disparity in cancer services based on income? What, if anything, is being done to tackle those two specific issues?

Professor Risteárd Ó Laoide

The short answer is, yes, I accept it. On screening, I do not run the screening programme. Ms Fiona Murphy is the CEO of the national screening service and I do not want to speak for her here. The screening service will have to tackle access to the screening programmes.

Deputy Róisín Shortall

Am I correct that the professor does not know about the uptake of screening services?

Professor Risteárd Ó Laoide

No. I am not the CEO of the national screening service so the implementation of increasing the uptake in disadvantaged communities is something that the screening programme will do.

Deputy Róisín Shortall

Is this not a key issue for the programme?

Professor Risteárd Ó Laoide

It certainly is for the screening programme, yes.

Deputy Róisín Shortall

Does anybody here know the uptake of screening based on socioeconomic profiles?

Professor Arnold Hill

This is always a challenge when implementing a national screening programme in that it needs to be ensured the uptake is at least 75% for an effective programme. It has always been a challenge to educate and raise awareness so that people turn up.

Deputy Róisín Shortall

I am keen to hear the data. How big is the gap in uptake based on socioeconomic situations?

Professor Arnold Hill

I have not read the NCRI report in detail as it was only released this morning. I do not have the exact figures but it is always going to take continuous effort to enhance the volume of people who turn up from disadvantaged areas.

Deputy Róisín Shortall

Is that not a little concerning given that the HSE officials present are responsible for the programme?

Professor Arnold Hill

Not for the screening programme.

Deputy Róisín Shortall

No, for the cancer programme and the NCRI's report only relates to the period up to 2018. Is this not an ongoing concern or issue that the HSE addresses within its programme? Surely the poor rates of uptake of screening is a priority for the delegation.

Professor Risteárd Ó Laoide

The national screening service is not in the cancer control programme. Poor uptake is an important issue for cancer. We will get back to the committee with the data on the disparity but we do not have it today.

Deputy Róisín Shortall

I thought the poor uptake of screening would be an issue with which the cancer control programme would concern itself.

Professor Risteárd Ó Laoide

Certainly the screening service concerns itself with the matter.

Deputy Róisín Shortall

I find it surprising that the national cancer control programme does not. I also raised the issue of access to diagnostics for people who cannot afford to pay privately.

Professor Risteárd Ó Laoide

Without doubt access to diagnostics is an international phenomenon because there is an increased number of patients and increased demographics.

Deputy Róisín Shortall

Does Professor Ó Laoide recognise as a major issue the fact that people in Ireland cannot get access to public diagnostics?

Professor Risteárd Ó Laoide

Yes.

Deputy Róisín Shortall

What is being done about that?

Professor Risteárd Ó Laoide

There is a primary care direct access programme, which is now in situ and gives primary care physicians access to any person who need diagnostics. There were 253,000 studies done in the past year through the programme. A study done by the Irish College of General Practitioners has shown that this reduced the number of outpatient attendances by 34% and ED attendances by 96%.

Deputy Róisín Shortall

What are the waiting lists like for cancer diagnostics?

Professor Risteárd Ó Laoide

On the diagnostics waiting list, I am aware that the Irish Cancer Society representatives mentioned a figure of 250,000 earlier. That relates to an undifferentiated waiting list for diagnostics. In other words, it relates not to cancer but to all diagnostics available in the system. As a radiologist, I know that if anyone is referred with the question of cancer, he or she does not go on a waiting list but into the diagnostic service. I do not know whether Mr. Kidd wants to talk about diagnostics generally, because that is where the waiting list figure is.

Deputy Róisín Shortall

I am concerned about cancer diagnostics.

Professor Arnold Hill

I deal with breast cancer. When I have patients with breast cancer, their tests are prioritised. I am referring to the staging tests, the CT scan and bone scan. These are done in a very timely fashion. If I wanted to operate within two weeks, I know the staging tests will be done in a timely fashion. That puts pressure on the system in that everything else waits, but cancer is absolutely prioritised. It is the same when a patient is referred. Those deemed most likely to have cancer on triage will get a mammogram first. If there is an excessive waiting list for mammograms for low-risk patients, we generally put in place systems to make sure they get done within a reasonable timeframe. One could argue that if one does not have cancer, one is discriminated against. That is a challenge.

Deputy Róisín Shortall

That is good news. It would be helpful if we had the figures across the board for different cancers.

Professor Arnold Hill

I do not have a staging list for staging breast cancer patients.

Deputy Róisín Shortall

Sure. That is in respect of breast cancer, which is very welcome, but it would be good to know about other cancers.

Professor Arnold Hill

In general, all cancers are prioritised in the cancer centres. Cancer patients are the first preference for admission and staging, and they do get prioritised.

Deputy Róisín Shortall

Do we have a figure for the cancer diagnostics waiting list?

Professor Arnold Hill

In my practice, I do not have a waiting list.

Deputy Róisín Shortall

Do we have a national figure?

Professor Risteárd Ó Laoide

All cancer patients are prioritised. The rapid-access clinics were developed so that if anybody has a symptom or sign of cancer, he or she can gain diagnostic access rapidly. The figure 250,000 relates to everything, from back and knee pain to osteoarthritis in the shoulder. It is broad. Clinically, what happens in the X-ray department, as I know as a practising radiologist, is that when someone expresses concern to us that a patient may have lung cancer, that patient gets the diagnostics.

Deputy Róisín Shortall

Obviously, many of those symptoms could relate to cancer. Could I ask about radiation therapists? We are told there is a 30% vacancy rate across the service. Is that the case? Is anything being done to ensure we address that?

Chairman

Earlier, it was stated three in ten patients were not seen within the recommended timeframe for therapy. Could the witnesses outline what is happening in regard to that also?

Dr. Clare Faul

To clarify, the radiation therapists work on the machines. Professor Ó Laoide mentioned that they comprise a core group of staff and are highly specialised. Coming out of Covid, they are now more mobile. We have done an exit survey and got information directly from the radiation therapists on why they are leaving. Certainly since Covid, there was a rate of 20% in some centres and of up to 30% in others. There are several reasons. One is that there is an overall worldwide shortage of radiation therapists.

Deputy Róisín Shortall

I am just asking about what is being done to address it.

Dr. Clare Faul

Absolutely. We asked the therapists the reasons they were leaving. The reasons were the cost of living-----

Deputy Róisín Shortall

I am sorry but I am out of time. What is actually being done about that?

Dr. Clare Faul

What we need to do is improve staff retention by ensuring we use more automation. We have many different ways of trying to ensure job satisfaction is as high as possible so staff are working at their highest level. We want the ability to promote the staff, so we are considering different ways of working for radiation therapists. We are investigating automation so we can relieve some of the burden on them. We want to attract radiation therapists from abroad, so we are considering recruitment internationally. However, the retention of our own staff is obviously our priority. It is about work practices, continuous recruitment, ensuring the staff are working at their highest level and having a promotional aspect to their jobs. We have considered this matter and are working on it within the NCCP.

Chairman

Dr. Faul might revert to us with a note expanding on that.

Dr. Clare Faul

Sure.

Senator Seán Kyne

I welcome the team from the HSE. Let me give the testimony of an individual I know. We will call him Paddy. He is not even 50. A number of years ago, he was not feeling well for about three months and eventually asked his partner to ring the doctor to make an appointment. She rang the doctor and the doctor said Paddy was no longer a member of the practice. She said Paddy was but the doctor responded that he had not attended in nearly 19 years. She responded that he therefore had not seen a doctor in 19 years. How important are regular checkups and getting blood works done, whether for prostate issues or other conditions? Is the message being lost? Is there a continuous need to focus on this and advise people to get regular checkups?

Professor Arnold Hill

Regular checkups are to be advised. There is no question about that. We are all improving in respect of having healthy lifestyles. We certainly know what we should be doing. That is the first part. Whether we are all actioning what we know should be done is a different matter. As the Senator mentioned, there are some challenges, including access to GPs, but the education of the population is improving and people are aware it is not great not to see a doctor for 20 years. That is unwise. Certainly, at the age the Senator mentioned, one should be getting checked. That is a very reasonable thing to do and should be encouraged.

Deputy Seán Kyne

Is there a difference between men and women? Anecdotally, men are less likely to get regular checkups? Is that in fact true? Is there a change or improvement?

Professor Arnold Hill

It is across both sexes. I do not know if I have any data on it, but it is said that men were slower to come forward traditionally. However, it is-----

Dr. Clare Faul

It relates even to checks for general chronic illness, such as checks for diabetes or blood pressure. It goes beyond cancer because we are talking about overall mortality. I believe there is an improvement. Everyone knows that once they have reached the age of 55, and certainly 60, they should be getting checked. GPs are very aware of that. The message is getting across. A range of checks need to be done, and they probably need to be done yearly.

We come back to education time and again. Education, awareness and understanding the benefits of attending for checks, both for cancer and other illnesses, are really important.

Deputy Seán Kyne

Reference was made to a welcome fall in the mortality rate, which is likely to be attributable to a combination of factors, including reduced incidence, earlier detection and better treatments. Reference was also made to the importance of tobacco controls. Is Dr. Faul concerned that this trend is reversing somewhat among younger people now? Are the controls declining in impact, even though we have plain packaging and anti-tobacco advertising? While there is more education on the impact of tobacco, is Dr. Faul concerned this may reverse at some stage?

Dr. Clare Faul

Having teenage children myself, I am concerned. Peer pressure and Internet influencing are a problem among that group. Peer pressure is really important in the teenage years, so we really need to get into the schools and get the message across. The teenagers are starting with vaping. Vaping is like a gateway to taking up smoking. That is becoming more of a problem among the teenage group, not to talk about access to alcohol and other substances. I would be concerned. Starting education earlier and influencing influencers to get the message across would be very welcome.

Deputy Seán Kyne

I am from Galway. The incidence of certain cancers is higher in the west than for the rest of the country, on average. Professor Michael Kerin and others have plans for a new cancer centre, with over 220 beds, on the grounds of University Hospital Galway as part of the national development plan.

I am sure the HSE is aware - I can see our guest nodding - of those plans, supports them and believes it is absolutely vital for the west that there is equality of service. We have fine and experienced consultants, but I refer to the standard of care and the outcomes that will prevail from that.

Professor Risteárd Ó Laoide

I want to congratulate Professor Kerin because he is a wonderful advocate for the west of Ireland and making sure that they get access to best quality care there. I support him 100% in that. He identified an infrastructural deficit, which is possibly something that is general in the country for cancer services. We need to work on our infrastructure, and it is particularly acute in Galway. They presented plans and we are aware of them. We are working with the acute hospitals division, the HSE estates and the office of the chief clinical officer, CCO, to help progress these plans. There is no doubt that there is an infrastructural deficit.

Dr. Clare Faul

There good news in respect of the new radiation centre, as I am sure the Senator is aware. The building is available and the machines are now being commissioned. We are hoping to start treatment in quarter 2 of this year. That is extra capacity and extra staffing. It is a great advance for the west of Ireland and Galway.

Senator Seán Kyne

I certainly welcome that the HSE is fully supportive of these plans. They have been talked about for a long time. It is important now they are advanced through the system in relation to the cost-benefit analysis and the planning applications, which are outside the control of circumstances or whatever. It is absolutely vital that there is equality across the country and, through the work of the HSE and consultants, we increase the survival rates of all types of cancer and provide better education. Certainly, no part of the country should be left behind, just as no demographic should be left behind either.

What best practice has the HSE learned from other countries in respect of what they are doing better than we are doing at the moment?

Professor Arnold Hill

Regarding best practice, we are always looking at what is happening elsewhere. Looking at our screening programmes, they always followed on from where it was proven in other countries. One thing we are looking at is standards of care and accreditation processes. We are learning from the European accreditation process as well and that will raise up the standards of cancer care delivered in this country. Does Professor Ó Laoide wish to speak to that?

Professor Risteárd Ó Laoide

We need to get best practice throughout our system and we need centres to learn from each other. In the NCCP, we are working on a network structure of cancer centres in this country. I am very supportive of the Sláintecare regional health area, RHA, delivery because that will allow us to network community care with individual patient care, primary care and our acute services. That is particularly important in the cancer continuum because we go from prevention right through to the most complex treatment. However, the organisation of services involves centralisation for highly complex surgery and for highly complex treatment such as bone marrow transplantation, CAR-T or PRRT, which I mentioned earlier. If we centralise, we need to say that the person in Belmullet has the same access as the person right next to that hospital, wherever it is. To do that properly, we need a network service. To do that well and efficiently, we need an accreditation system to show that we are doing that. We are involved in a European process that is looking at that through the Commission on how best we would accredit a network of cancer service in this country to make sure that the care, as the Senator said, the access to care and the outcomes for patients are the same all over the country.

I refer to infrastructure internationally. There is discussion now, particularly after the pandemic, on having dedicated infrastructure for cancer care. That is one of the difficulties that comes up when our cancer care is depending on emergency department activity and beds and getting access to beds. The system has worked well in this country in the sense that we have managed to overcome that, but the argument is whether we should have dedicated infrastructure, theatres, inpatient beds and diagnostics for cancer care – a dedicated front door to save vulnerable patients from getting respiratory disease, Covid or such. That is another area we are looking at.

Dr. Clare Faul

Certainly, the development and technology development in the cancer service is excellent. One area we need to look at is survivorship now that we have 65% to 70% long-term survivors. What impact does that have on their lives? That is of particular interest to us in radiation oncology, but also in general. We need to look at the impact on, for example, finance, jobs, psychology and family. That is an area we need to emphasise for the future. We are doing much better and improving our survival rates; now we need to make sure that the quality of life of our patients who survive cancer is optimised.

Professor Risteárd Ó Laoide

The cancer programme has put much investment in the past couple of years into survivorship and psycho-oncology. Hopefully, we will have a full complement of psycho-oncology multidisciplinary team, MDT, in each of our cancer centres this year. That has been a result of recent investment. We also put a significant number of people into the survivorship pathway. We are looking at things such as self-stratified managed follow-up of patients. These are patients where it is their will and decision that they will work with a nurse specialist and perhaps a cancer care worker so that they have an organised follow-up surveillance package, which shows them, for example, when they get their CAT scan follow-up and when they need their blood test. They do not need to be coming into hospital for this. This is all organised and they are told about their red flag signs so that they get immediate access if a red flag raises. It just means that they are not coming into outpatient departments to sit to meet a consultant or somebody. It is called self-stratified, managed follow-up. It is being rolled out for prostate cancer in the first half of this year and we hope to roll it out for the other cancers in the next 12 to 18 months.

Dr. Clare Faul

For example, in radiation oncology follow-up, there are the virtual clinics, which is one of the benefits of Covid. That was important. We doubled our access for patients into our outpatients and our "did not attend", DNA, rate reduced because we moved many of our routine follow-ups to virtual. These would be, for example, scan results impacting any symptoms. We could bring anybody concerned about them in for a face to face. We found that very beneficial. If somebody is in Donegal or west Galway and still needs to come to Galway or Dublin for an appointment, now they do not need to actually travel. That is a huge benefit and that is one of the pluses from Covid as to how we can use the technology advances in the future.

Chairman

That was a useful discussion. Some of the meeting was dominated by the report that was released in the news highlighting the inequalities in access to the system and so on. It is understandable that it dominated the meeting to some extent. The difficulty of people trying to access a GP was highlighted, which is normally at the centre. I mentioned even dental care, which, again, is the system. I think we would all agree that this is time sensitive. It is about screening, identifying the issue and then treatment. The frustrating thing that came out during the meeting is that where that system breaks down, people cannot get access to it.

It was sort of a bleak meeting to some extent. We did not really get into the important work ongoing during Covid and now. There is hugely positive work going on. We did not get into work on the new drugs that are coming through the system. We talked about the new technology – the virtual stuff – and that. There are many positive things.

I am aware that we all carry the cancer gene, it is just our immune system, and many people break it down so they do not get it. For those people who are out there and are worried, there is treatment and supports are available. We would encourage them to go and get tested. People know their own bodies and whether there is something wrong. That should be the message that we are sending out here. In addition, there is help.

There is life with cancer and there is life after cancer. People should not be afraid to go for advice.

I thank our guests for coming in this morning. More importantly, I thank all those who work in our cancer services and who are doing fantastic work in saving and transforming people's lives. We really appreciate that, particularly in the context of the sacrifices that were made during Covid, but not exclusively so. Sacrifices are still being made. We understand the pressure people are under and why some want to leave the service. This committee wants to try to improve services. If there is something our guests feel that we did not touch on today that could improve the service and they want our support in respect of it, I ask that they please write to us. We will certainly return to this issue. Once more, I thank the witnesses for their thoughtful insights. Apologies to members who did not get a chance to contribute, but we are out of time.

The joint committee adjourned at 12.01 p.m. until 4 p.m. on Tuesday, 7 February 2023.