JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Tuesday, 21 Oct 2008

Cancer Screening Services: Discussion with NCSS.

Chairman

I draw members' attention to the fact that while members of the committee have absolute privilege the same privilege does not extend to the delegation and, therefore, I remind the delegation that it should not make comments on, criticise or make charges against a person outside the Houses, or an official by name or in such a way as to make him or her identifiable. Will members ensure all mobile phones are turned off?

I welcome Mr. Tony O'Brien, chief executive officer, National Cancer Screening Service. We regret that on a previous occasion he waited three hours and yet we did not have the opportunity to hear from him. We look forward to his presentation and I am sure Members on all sides of the Houses will subsequently have questions to put.

Mr. Tony O’Brien

I thank the Chairman and members for the star billing on this occasion, which is appreciated. I will begin with a brief opening statement with background information, if that is in order.

BreastCheck was established in 1998 as a specialist agency with the sole remit of providing Ireland's first quality assured, population-based breast screening programme for women aged between 50 and 64 years.

Deputy Niall Blaney

Has this speech been circulated?

Chairman

Yes.

Mr. Tony O’Brien

The pioneering clinical-led model developed for the BreastCheck programme has been successful in minimising the risks associated with breast screening. The aim of BreastCheck is to detect breast cancer at the earliest possible stage. The programme is fully audited against a range of quality, client-centred criteria as set out in the BreastCheck women's charter, which is appended to the document circulated. We continually measure our performance against this charter to ensure the programme is performing at optimal level.

Governance of BreastCheck was transferred to the board of the National Cancer Screening Service, NCSS, on its establishment in January 2007. The establishment of the NCSS and its development is an integral element of the national cancer strategy and contributes to proof that a clinical-led, evidence-based approach to cancer screening can successfully reduce the incidence of and mortality from breast cancer in Ireland. BreastCheck has been extended to eight of the 13 counties in its expansion area and we have launched CervicalCheck, which is Ireland's first national cervical screening programme.

To date the BreastCheck programme has provided screening to more than 206,800 women with a quality-assured programme that is recognised as a world leader in the use of advanced digital mammography. The successful BreastCheck model has been used and adapted for CervicalCheck, the national cervical screening programme. CervicalCheck is Ireland's first free, quality-assured cervical screening programme. The overall aim of CervicalCheck is to reduce the incidence of and the death rate from cervical cancer in Ireland.

BreastCheck provides free mammograms to women aged between 50 and 64 years, sequentially, on an area-by-area basis in a two-yearly cycle. BreastCheck began offering free breast screening to women in that age range in the then Eastern Regional Health Authority and the North Eastern and Midland Health Board areas in February 2000. In 2003 approval was given for the extension of BreastCheck to counties Wexford, Kilkenny and Carlow. Screening commenced in Wexford in March 2004. Screening was extended to women in Carlow in 2005 and in Kilkenny in May 2006.

In December 2007, some ten months ago, construction was completed and screening began from two new screening units, namely, the BreastCheck western unit and BreastCheck southern unit in Cork to serve women in the southern and western regions. Screening commenced from both units in counties Cork and Galway in December 2007. These units, together with seven mobile digital units, will provide screening to in excess of 140,000 women in the south and west of the country. To date in the expansion area, the service has been extended to counties Roscommon, Galway, Mayo, Cork, Limerick, Waterford, Tipperary North, and in the coming weeks screening begins in Tipperary South. In addition, BreastCheck is currently, as of today, screening women in Monaghan, Meath, Cavan, Kilkenny, Kildare, Dublin, Wexford, Arklow, Tallaght, Gorey, Galway, Cork, Nenagh, Mayo, Dungarvan and Limerick.

On expansion, BreastCheck was clear that it would take in excess of 24 months to complete the first round of screening. Despite media and public reports to the contrary, I assure the committee that BreastCheck remains on schedule for the introduction of the programme to all women in the remaining counties. The BreastCheck programme is, and must remain, focused on quality assurance for the women we screen. The screening schedule is part of that quality assurance. It is this focus that has ensured that the women we screen can have confidence in the service they receive from BreastCheck.

BreastCheck will not, therefore, compromise on this quality remit to satisfy any political, with a small "p", or public demand for the introduction of the service. Our screening schedules are dictated by operational considerations alone and we will not be swayed in terms of sequencing.

I refer to some key statistics. The total number of mammogram examinations carried out from 2000 to the end of September 2008 is in excess of 442,000. This has resulted in the recall of some 16,390 women for further assessment. This has, in turn, resulted in the early diagnosis of breast cancer of some 2,717 women. The overall acceptance rate of women attending after invitation in that period is 78.8%.

In 2007 the target for timely admission to hospital, an important dimension of our programme since we cover primary treatment as well as diagnosis, was exceeded for the first time since with 94.4% of women diagnosed with breast cancer by BreastCheck admitted to hospital within 21 days or three weeks.

In its 2007 "Health at a Glance" survey, the OECD ranked BreastCheck fifth in the world for the percentage of women screened, ahead of long-established screening programmes in countries including the UK, USA, France and Australia. The Scandinavian countries came in ahead of Ireland in that survey.

In April 2008, state of the art digital imaging technology was introduced across the entire breast screening programme. BreastCheck is considered to be the first screening programme internationally to be converted entirely to digital mammography. BreastCheck developed a national radiographic training centre, known as Breastlmaging, to support mammography in both screening and symptomatic services. The first Breastlmaging students graduated in June 2008.

The NCSS has a remit to make particular efforts to encourage the uptake of screening by disadvantaged groups. Dublin's north inner city has been a traditionally challenging area for us. In the past, the average acceptance of invitation to screening was only 44%. Following an intensive, targeted screening promotion campaign in the area in 2007, the uptake rate for screening reached 71%, which is the highest acceptance rate achieved by BreastCheck in that area to date. This bodes very well for the future and is testament to the excellent work of our screening promotion team.

BreastCheck is currently preparing to complete expansion into the remaining counties in the west and south. Following the national expansion of the breast screening programme and in line with Government policy and the 2006 cancer control strategy, and subject to the provision of additional resources, the upper age limit for screening will be extended to 69 in accordance with the European Council's recommendation.

The board of the NCSS has commissioned an internal review to examine the evidence for reducing the lower screening age limit from 50 to 47 years. This proposal is under examination and no decision will be made until a thorough review is complete.

CervicalCheck, the national cervical screening programme will provide free smear tests to 1.1 million eligible women aged 25 to 60 living in Ireland. Over time, a successful national programme in Ireland has the potential to cut current mortality rates from cervical cancer by up to 80%. The programme will provide a free, complete, quality-assured programme of care. Women can choose a registered smear taker. Similarly to BreastCheck, the programme is auditable against a range of quality-led criteria as published in the CervicalCheck women's charter, which is appended to the notes provided to committee members.

The ultimate focus of the programme is on quality assurance and the NCSS was anxious to ensure a number of necessary elements were in place before embarking on a national programme. A national quality assurance group was established with specific sub-groups to address the following: quality standards in primary care and smear-taking; laboratory, cytology, histology; and colposcopy, gynae-oncology and primary treatment. As part of the preparation, new screening intervals were introduced, in line with international evidence. CervicalCheck will provide screening every three years for women aged 25 to 44 years and every five years for women aged 45 to 60 years. Prior to this, in the phase one programme, there was a single interval of five years.

An NCSS smear taker contract for medical practitioners was published following an extensive consultation period. Letters from a Member of the Oireachtas were published in newspapers today concerning this contract. I wish to make clear that the contract in question was not imposed on any party. The consultation period included the publishing of a draft contract, which produced significant feedback from potential smear takers and an extensive consultation process over several months with medical practitioners, key stakeholders and representative bodies.

Following an EU public procurement process, Quest Diagnostics Incorporated was named as the provider of cytology laboratory services to the CervicalCheck programme. Quest Diagnostics Incorporated operates to a range of quality-assured standards set by the NCSS. A review of colposcopy clinics in Ireland resulted in the establishment of a quality assurance structure for colposcopy. For the information of members, colposcopy is a secondary diagnostic tool which can provide a definitive diagnosis. The NCSS has identified 11 colposcopy clinics to initially support the programme. The NCSS is examining the feasibility of providing additional colposcopy services and is in the process of agreeing a further four locations to accept referrals from CervicalCheck. The NCSS has made significant investment in colposcopy services to ensure a standardised, quality-assured level of care is delivered, with timely access for all women, as specified in the charter.

A smear taker training unit was established to facilitate the accredited smear taker training programme that is delivered by the nursing division of the Royal College of Surgeons in Ireland, the Irish College of General Practitioners and National University of Ireland, Galway. A new brand identity was introduced and the programme was made available to women on 1 September 2008.

The governance of cytology services has been transferred from the HSE National Hospitals Office to the board of the NCSS. All smear test samples are examined twice by two separate cytotechnologists. Smear test results are being provided within ten days of receipt, with results available to women within four weeks of having their test taken. Approximately 2% to 5% of women screened will require access to a colposcopy service. Our aim is to guarantee that women with high-grade changes detected are provided with such access within four weeks and women with low-grade changes are guaranteed access within eight weeks.

It is important to remember that, on average, 180 new cases of cervical cancer are diagnosed in Ireland every year. Half of all new cases are in women aged under 46 years. On average, there are 73 deaths per year in Ireland and the average age at death from cervical cancer is 56.

CervicalCheck has now registered 3,842 smear takers in 1,416 locations throughout the State. While already substantial, that number can grow, if necessary. Since the programme commenced, 69,000 smear tests kits, including vials, brushes, transport boxes and so forth have been delivered to smear takers at their various locations. That will be an ongoing process.

The Minister for Health and Children has asked the board of the NCSS to explore a national colorectal cancer screening programme. One of the key advantages of a colorectal screening programme is that it can detect pre-cancerous adenomas and is therefore a preventative health measure. In April 2007, the NCSS established an expert group on colorectal screening to make recommendations on the development of a population-based colorectal screening programme in Ireland. This group, chaired by Professor Niall O'Higgins, has evaluated the clinical and operational requirements for the establishment of an effective, well organised and quality assured service. It has examined the population to be screened, the type of screening test required, the screening intervals and the potential impact on existing clinical services. The group presented its first interim report to the board of the NCSS in December 2007. An independent peer review of the report was sought from an international panel of experts on colorectal cancer screening and was completed in August 2008. This panel included Professor Wendy Atkin and Professor Robert Steele from the United Kingdom, Professor Jean Faivre from France and Professor Michael O'Brien, who is Irish but practises in the Unites States of America. The expert group took into account the recommendations of the validation panel and completed its second and final report in October 2008 which was been submitted to the board of NCSS last week. The expert group's clinical recommendations form the basis of a modern, best practice and quality-assured screening programme for colorectal cancer. The board of the NCSS is considering the report at the moment.

In response to a request from the NCSS, the Health Information and Quality Authority, HIQA, is currently undertaking a health technology assessment to examine the relative cost effectiveness and resource implications of different models of population-based colorectal cancer screening programmes. The board of the NCSS expects to publish its recommendations in the coming weeks.

Approximately 1,900 new cases of colorectal cancer are diagnosed in Ireland every year, with 900 deaths from colorectal cancer per annum. Ireland has the highest mortality for colorectal cancer in western Europe, the fourth highest mortality rate among men worldwide and the 15th highest mortality rate among women. England is currently introducing a population programme targeting 60 to 69 year old men and women, while Scotland is introducing a population programme targeting 50 to 74 year old people. Wales will introduce a population programme imminently, initially targeting 60 to 69 year old people and gradually extending to those aged 50 to 74. A national programme is being introduced in France, which is currently screening people aged between 50 and 74, while Finland offers screening to all those in the 50 to 74 year age range. Regional programmes are under way in Italy, Spain, Hungary, Bulgaria, Romania, Czech Republic and Australia. This brings us up to date on the three main remits of the NCSS.

I pay tribute to the board, management and staff of the National Cancer Screening Service. It is a testament to their efforts that a national cervical screening programme was launched to 1.1 million women in Ireland, within 21 months of the organisation being established and receiving its mandate. It is also significant that BreastCheck has become the first national screening service provider worldwide to offer a fully digital mammography service.

The National Cancer Screening Service has developed an organisation that is not subject to the traditional barriers and enmities that so often exist between clinicians and administrators and this is one of our key strengths. It contributes to the fact that the NCSS has never lost a day to industrial action and I firmly believe this is due to the cohesive working relationships fostered among staff regardless of discipline. Every member of the NCSS team is committed to our ultimate shared goal of reducing the incidence and mortality of cancer among women in Ireland and, we hope, among a large section of men.

Our organisation is one that can make a real difference and the commitment of our staff is what makes it work. We have had much success in our screening programmes to date and the model we have created clearly works. Everyone in the NCSS is committed to providing quality assured screening that women in Ireland can trust. The experience of what we have achieved forms a model for future screening and cancer care programmes. Quality assurance will continue to underpin every aspect of every programme undertaken by the National Cancer Screening Service.

Chairman

On behalf of the committee I congratulate Mr. O'Brien and his team on the lifesaving work in which they are engaged.

Senator Frances Fitzgerald

I thank Mr. O'Brien for his presentation today and for the description of the work being done by the screening service. Mr. O'Brien concluded by telling us how well it works in a number of areas and how it stands up internationally. In this context, I want to ask about the amalgamation of organisations recommended in last week's budget and the idea that the National Cancer Screening Service would be amalgamated into the HSE. Will Mr. O'Brien inform the committee at what stage is this decision? Will it go ahead? Does Mr. O'Brien have views on the impact of this amalgamation? Is there a timetable in place for it? This is a general inquiry into the future of the organisation and its relationship with the HSE.

Many of us have concerns about the organisation being brought into the HSE given the problems the HSE is experiencing at present. Many of us are disappointed that BreastCheck does not have coverage throughout the country given the excellence of the service. There have been no scandals or concerns raised about quality assurance levels in BreastCheck and it is important that women have confidence in it given the universal nature of the scheme. On this point, will Mr. O'Brien speak in a general way about the results? Have misdiagnoses occurred? We know every screening programme has false positives and negatives. Will Mr. O'Brien comment on this? My overall point is that there is confidence in the service.

Will Mr. O'Brien outline the timetable for the implementation of the service in other counties? He has stated that despite political and public demand the organisation will not compromise on quality. Of course, no politician would expect it to compromise on quality. What we are anxious to see is access to the service for every woman in every county. When will the upper and lower screening age limits be extended? It is happening in other countries and a key issue is to include women up to 69 years of age and from 47 years of age. I am aware that the age limits are under review.

Mr. O'Brien outlined developments in cervical and colorectal screening. Will he provide details on funding and timeliness of these screening programmes? Evidence exists with regard to rectal cancer screening but it has not been introduced. Progress has been made on cervical cancer screening and it is progressing. As work has begun on the cervical cancer screening programme will Mr. O'Brien inform the committee on its funding?

Deputy Kathleen Lynch

I welcome Mr. O'Brien and his team. I will not repeat how much I admire the work they do because Mr. O'Brien would blush. It is one of the success stories of the re-organisation of the health service in Ireland. For years in the south we campaigned for the introduction of BreastCheck because the positive effects it has on the health of women were obvious. I share Senator Fitzgerald's concerns that it has not been rolled out throughout the country. I support the call for this to happen. As a member of a group which campaigned for it for years and as someone who now sees its benefits, it is important that all women are covered by the service.

I have some questions for Mr. O'Brien. How many women in the southern area are seen per year? The number varies from area to area and the service has been in operation in the southern area since January 2007. I am not necessarily interested in how many women are recalled. The figure for how many can be seen in a year will change during the second round.

With regard to cervical testing, I hear that in Canada it is done by a blood test. If the virus does not exist in the blood it will not get to a point where it becomes problematic for several years. Are we headed in this direction or is there any value in it? If the organisation is testing for cervical cancer, surely it must make an argument in favour of the vaccine. It should not be one or the other and the combination should be sought.

With regard to amalgamation and the subsuming of the organisation into the HSE, I was glad to hear Mr. O'Brien finishing his contribution by telling us how well the organisation works and how effective it is. Many women will be grateful to the effectiveness of the organisation in delivering its service and the effectiveness of the programme and the professional way in which it was rolled out.

While many quangos in the country could do with being merged some organisations should not be. I have a major concern about a successful professional organisation which is delivering a service being subsumed into the HSE given the major problems facing it. I am not on a HSE-bashing exercise. I am concerned about the budget, administration, delivery of service and, most of all, about the follow up. Can we still be guaranteed that if the National Cancer Screening Service is brought under the auspices of the HSE the 21 day follow up and admission to hospital will continue? Will the budget, administration, ethos and delivery of triple assessment remain the same and continue? No matter what anyone says, the National Cancer Screening Service cannot remain separate and independent if it is taken into a much larger organisation. How does Mr. O'Brien feel about that? I have concerns about this issue as a woman and someone who has fought for this service, knowing there are other women waiting for the roll-out.

Deputy Niall Blaney

While I am very satisfied with how the National Cancer Screening Service is operating as a whole, I do not take the same view at constituency level. I take issue with Mr. O'Brien's statement that, contrary to reports, BreastCheck remains on schedule. In County Donegal, two dates for the roll-out have already been passed. At his last meeting with the committee, I was assured of a reply in writing of when BreastCheck would come to County Donegal. I am still waiting for it. If he cannot give it to me today, he could do so shortly.

The recent announcement on colonoscopy services at 11 national centres was the reason I requested this meeting. While I agree with the work of the service and its choice of centres, for geographical reasons I believe the north west, in particular Letterkenny General Hospital, deserve further merit and examination. Since the announcement, the service has been in consultation with Letterkenny General Hospital. The hospital gave a press release on positive meetings and a positive outcome. Trying to get information from the National Cancer Screening Service, however, has provided to be unsuccessful. While it says the press release is true, the service should not be circulating releases through a hospital. Will Mr. O'Brien clarify that the colonoscopy services is up and running at Letterkenny General Hospital? Is it to the satisfaction of the National Cancer Screening Service? The service had problems around the quality of the service provided and unnecessary procedures taking place.

Senator Phil Prendergast

I welcome the proposals announced by Mr. O'Brien. As the Labour Party's spokesperson for older people, I welcome the extension of breast screening for women 69 and over. When will BreastCheck be rolled out in Clonmel, County Tipperary? Where are the 11 colonoscopy clinics identified by the National Cancer Screening Service? St. Joseph's Hospital, Clonmel, has been providing a colonoscopy service for the south east for the past 25 years. The standards of the service were found to be excellent and extremely high. Does Mr. O'Brien have any comments on it?

It is a great reassurance to women that BreastCheck is being rolled out. The advertising campaign for the service has been effective resulting in a good uptake. I congratulate the National Cancer Screening Service on what is in place. I hope it continues to be a success and treat people in speedy and professional fashion with successful outcomes and associated lifelong benefits.

Deputy Margaret Conlon

Those who use the BreastCheck service in County Monaghan have every confidence in it. Senator Frances Fitzgerald raised the issue of recalls. Any service will have some level of recall for one reason or other. By and large, the women I have spoken to have every confidence in it. It is important, however, the service is made available to all parts of the country. Mr. O'Brien said the National Cancer Screening Service is preparing to complete expansion into the west and south. When can we expect it? Women from those regions are no more or no less important than those women throughout the rest of the country who receive it.

I welcome the roll-out of the cervical cancer screening programme and that it will be quality assured. One important element of the service is that women can choose the smear-taker. That will give them confidence if they would prefer to see a female doctor. On average, up to 180 new cases of cervical cancer are diagnosed every year. Out of that figure, how many are treated successfully? The earlier it is detected and people are treated, the greater the success rate. What is the position with the cervical cancer vaccine?

There was no mention of men's specific cancers in the presentation. What are the plans by the service to screen for testicular and prostate cancers? Again early detection in these cancers means successful treatment and greater life expectancy.

Deputy Rory O’Hanlon

What is the number of women whose first diagnosis for breast or cervical cancer is made through the screening programme? Will the colon-rectal cancer screening programme be implemented through specific hospitals or otherwise? Are there links between Professor Tom Keane and his team and the National Cancer Screening Service? What measures are in place for this service and others to provide integration of services, value for money and opportunities for synergy? In the event of being integrated with the Health Service Executive, what would Mr. O'Brien see as the requirements to ensure he will be able to maintain the high-quality service which no doubt would be the ambition of everybody, politicians and the Health Service Executive alike? Has he any views on that?

Deputy Jan O’Sullivan

My apologies for being late and for missing the presentations. I will ask brief questions in case I am repeating others.

I want to be parochial first in terms of the roll-out of BreastCheck. Limerick has now been included, but only a part of County Limerick has been included so far. If he could, I ask Mr. O'Brien to indicate when he expects breast screening to be provided in Limerick city. I have been asked by my colleagues in Clare, a little part of which is in my constituency, whether Mr. O'Brien can tell us when they can expect screening to begin there.

Quest Diagnostics obviously got the full contract. At the time we were told that it was a two-year contract and there would be an opportunity for Irish laboratories with the necessary quality assurance to tender. From speaking to people who work in laboratories, I understand that most of the Irish people who were doing cervical cytology screening are doing other work. Has Mr. O'Brien had discussions with the Department of Health and Children on how we could maintain the expertise that had been built up in this country and that is not being used because all of the screening is going to the United States? Has he had discussions with the Department about how Irish laboratories might be able to tender when the contract comes up for renewal?

Deputy Caoimhghín Ó Caoláin

I join in the welcome to Mr. O'Brien and Ms Byrne and wish them well in their responsibilities in the various cancer screening areas. I did not hear the presentation and I ask Mr. O'Brien to forgive me if he has addressed my questions already.

A global study report published in July indicated that Ireland had one of the worst survival rates for breast cancer. I wonder what comment Mr. O'Brien would make about that. What lessons can be learned from it? Have we done comparative studies? I am sure the answer must be in the affirmative in the case of neighbouring European countries where the survival rates are so much better, particularly Sweden and France. Why have we not yet scored better in terms of global comparisons? What is his expectation of improved figures on the roll-out of BreastCheck?

I understand there is a review currently under way which is examining the prospect of reducing the age for access to the BreastCheck service from 50 to 47 years. Would Mr. O'Brien indicate the status of that review and whether he expects there will be an extension of the age group for qualification from the current 50 to 64 years, back to 47 years of age? Can he indicate when that might occur?

While my interest is in BreastCheck, and the reduction of the age for qualifying from 50 to 47 and, hopefully lower in time, a number of women have raised the issue of not being included in the cervical screening programme because they are over 60 years of age. I represent a Border constituency, as other colleagues here do. The cervical screening programme north of the Border is for those up to 64 years whereas I understand ours is currently for those between the ages of 25 to 60.

A number of quite irate women have reflected their anger. Without looking at my notes, I believe none of them has previously had smear tests carried out. It is not that they have had one or two negative tests that might give some comfort, but that they have not been tested to date. My understanding is the medical card does not cover this procedure. That can be clarified. There is a real concern about this issue.

Is there any prospect of extending the higher age limit at least to 64, even in line with what is happening north of the Border, so we could have a universal all-island approach to this issue? We could defer looking at the arguments for an older age limit until another time. Let us try to move it at least to that age.

I would appreciate the Chair's indulgence. A week ago the budget announced a 2.1% increase in the health allocation. Given that health inflation up to the end of September was running at 6.3%, a 2.1% increase in the health budget for 2009 represents only one third of the inflation reality affecting health services, and there is a particular drop in the capital programme for 2009. Are there concerns within the National Cancer Screening Service for the roll-out of services such as BreastCheck, cervical screening etc.? There is a signalled reduction in funding for the health services in 2009. There is no other way to describe it. Are there concerns? Has Mr. O'Brien examined the detail to which we are not exposed in terms of what is intended in this reduced allocation for 2009? Will it have an impact? Has Mr. O'Brien been informed? Has he been consulted? What is the position? Should women and the wider society be concerned that his hopes and expectations for 2009 might not now be fully realised?

Deputy Bobby Aylward

I apologise for being late but I had to get a few statistics.

I welcome today's presentation. This service is one of the success stories within our health services. Fair play to those concerned. The women of Ireland must be very appreciative of what has been rolled out.

As usual, I have a parochial question. It is about Waterford, even though I am a Kilkenny man. There was a protest attended by 500 or 600 on Saturday last organised by a group called Women of Waterford. While the breast cancer service is provided in Dungarvan and in the county, it is not provided in Waterford city. When is it envisaged this service will come to Waterford city?

Chairman

I join with Members on all sides of the House in congratulating Mr. O'Brien on his work. I wish to revert to a point raised by Deputy Conlon, namely, men's health. Happily, there is a heightened degree of awareness among the female population of the importance of BreastCheck, smear tests, etc., but the figures for colorectal cancer Mr. O'Brien put before us are staggering — 900 deaths per annum and the fourth highest mortality rate among men worldwide. That would suggest that there is an urgent need to roll-out the proposed screening programme in that area.

Can Mr. O'Brien give an indication of the timescales involved? Can he also give an indication of what particular initiatives will be needed to communicate with the male population because I suspect they do not possess as strong a sense of the importance of their health as prevails among the female population?

Mr. Tony O’Brien

There was a wide range of questions. I will arrange them in groups and try to cover them all. If I miss any questions, the Chairman might give me an opportunity to return to it.

With regard to men and diseases such as prostate or testicular cancer, there is an absence of a test that is fit for population-based screening. While there is PSA testing it is not of a sufficiently well developed nature to make it appropriate to roll out on a population basis, due to the number of false positives it would generate and the resulting harm that could potentially be done. However, prostate cancer is an area that the national cancer control programme is focusing on from a symptomatic point of view. Similarly, in a wide range of other male health issues, there is an absence of an effective, population-based screening tool.

This links with the issue of how we determine what the age ranges are for our screening programmes. It is essentially based on a review of the available evidence on the efficacy and appropriateness of the test in different age populations. The reason BreastCheck was first rolled out for women aged 50 to 64, admittedly based on the technology on which it was originally rolled out, was very clear evidence that this was the age range that would benefit the greatest from that screening intervention. In addition, with X-ray based mammography there are significant issues for women below the age of 50, in other words those with pre-menopausal breast tissue, the effectiveness of screening, the frequency with which such screening would have to occur if it were to have any beneficial effect, and the balance between that effect and the resulting persistent exposure to X-ray level radiation doses.

Similarly, in the case of the higher age range, once all women aged 50 to 64 in all of the counties that have been mentioned have received their first round of screening from BreastCheck, the evidence shows that a significant benefit would be attained from increasing the age range to 69 or 70 years. It is an evidence-based trail.

The age of 50 to 64 is clearly the most appropriate age range to start with, 50 to 74 years after that has been achieved, and the issue of a downwards age range review is largely a potential that arises from the fact that we now have an exclusively digital screening modality, which offers some advantages for denser breast tissue. Again, however, the evidence is not unambiguous at this point so that is why it is being reviewed.

In terms of sequence, clearly the highest objective must be to deliver the first round of screening nationally to all women aged 50 to 64. It is already Government policy to extend it to the higher age range but that will involve a 35% increase, approximately, in screening activity, with some additional costs. Clearly there is a budgetary dimension to that decision when it is made at an operational level. We are only at the very early stages of looking at the evidence on 47 to 50 year olds, but that would clearly be implemented after 50 to 70 year olds have been included.

To deal with the budgetary issue, the NCSS falls within Vote 39, and at this point we have not been advised of the allocation for 2009. In the normal course of events I would not expect to be aware of that at this stage, so that is not unusual. We were asked for significant information on what the requirements would be for 2009 in terms of BreastCheck, CervicalCheck and in the event that the proposals relating to a colorectal screening programme could be progressed, bearing in mind that only very preliminary steps would be possible in 2009.

To answer the question of the likely modality of a colorectal screening programme if it were to be progressed, this would be based on a fecal immunology test. In essence this means we would need a central laboratory which would send out self-administered tests to every person in the designated age range, with clear instructions on how to use the test. People would post back the test and that would then be checked. A relatively small number would then be recalled for further assessment which would involve colonoscopy.

We would expect that this would take place at no more than four locations, and those locations would be consistent with the designated cancer control centres for colorectal cancer. It would make no sense to have them elsewhere. The level of activity that would be required to provide a seamless service would suggest a model not unlike the BreastCheck model, where there are specified facilities and a dedicated team who have cross-over appointments in other aspects of cancer care but who have a discrete period of time assigned to this work so we can accurately match the likely demand for the service with the capacity to provide it in a reasonable turnaround time.

There would be a significant health promotion or screening promotion dimension because this would be an entirely new experience for a large slice of the population, including men being exposed to cancer screening programmes for the first time. In many countries these programmes have struggled to get above a 50% uptake. A 50% uptake produces significant benefit but we would wish to target a 60% uptake. There have been some testing advances which make the self administration somewhat more acceptable. Where one of the tests we have examined has been trialled in parts of the Netherlands, a significant increase in uptake was achieved as a result of trying this new testing modality.

Deputy Kathleen Lynch

May I interrupt? I must leave the meeting as I must be in the Chair in the Dáil for 6 p.m. Could Mr. O'Brien address his replies to my questions to my colleagues? I would appreciate it.

Mr. Tony O’Brien

Certainly. One of the significant issues relating to the introduction of a colorectal screening programme is colonoscopy capacity. If we were to attempt to roll a programme out overnight, we would probably bring the colonoscopy services in the hospitals to a complete halt. There is a need to develop additional supplementary capacity to make it possible. It is a programme that would take some time to achieve.

If we assume a target population of approximately 700,000, we would expect approximately 11,340 colonoscopies to be required each year. About half of those would be normal, a little under half of them would detect polyps and approximately 1,134 would lead to cancer detection. Again, timing is something I cannot comment on at this stage.

Turning to BreastCheck and geographical issues, members who represent constituencies which have been served for a longer period of time by BreastCheck will be aware that the programme serves approximately half of its counties in a screening unit in one year and approximately half in the subsequent year. That establishes a pattern which is then repeated over time. With regard to the 13 counties in the western and southern expansion, we are in or have been in eight of those counties. Only one of them, Roscommon, has been completed so far. We have not yet provided screening in counties Donegal, Sligo, Leitrim, Kerry or Clare. In the case of Waterford, we have been in Dungarvan. That mobile unit is now moving to Clonmel and will move back to Waterford.

Deputy Bobby Aylward

How long will that take?

Mr. Tony O’Brien

It will be back by next year. I am aware of the demonstrations that have occurred. In Limerick we are now moving into Croom and will subsequently move into other areas of the county, including the city.

During the first round there is naturally a degree of tension about the sequence of screening, and that was the case in the east as well. It is understandable. Equally, however, we do not subscribe to the view that urban areas are more deserving than rural areas. I have had representations, not from Deputy Jan O'Sullivan, but from others, that we should have started in Limerick city. We do not accept that. We will move through the county in sequence and it will be a continuous process. Similarly, we will be back in Waterford city and it will be a continuous process in the Waterford and south Tipperary area.

Deputy Jan O’Sullivan

I wish to clarify something. Did Mr. O'Brien suggest that it takes two years to complete a county?

Mr. Tony O’Brien

No, two years to complete the screening round. Each county will take a different length of time, based on its screening population. A mobile unit will provide screening to an average of 40 women per day, depending on the number in attendance. Continuous screening takes different lengths of time depending on the population and the attendance rate. However, if one considers what is now happening in the east, one will note there are clearly counties screened in odd-numbered years and others screened in even-numbered years. They are straddled in some cases but a routine sequence is developed. Only at the first point of the delivery does the sequence become controversial because of the perception and the reality that some counties are dealt with in year one and others in year two.

Senator Frances Fitzgerald

What is the cause of the delay in reaching all the other counties? Is it caused by money or personnel? While quality assurance must be kept at a high level, can the programme be delivered more quickly to the remaining counties?

Mr. Tony O’Brien

In the context of a commencement date of December 2007, it is not our position that there is a delay. There was a delay prior to 2007 in the context of the approval to proceed. Many will be aware that announcements were made in 2003 implying that the expansion of BreastCheck had been approved at that time. I shared that impression but actual approval was issued in May 2005. We had always said in our business plan that it would take two to two and a half years to put in place the teams and infrastructure to enable us to commence. Exactly two and half years after approval we opened the doors to the western and southern screening units. We would expect a cycle of 24 months or more and do not expect to be in every county at the same time because we deploy mobile units sequentially. This has been the case in the east and will be the case in the west and south. At present, we are in Meath in one year and Louth in another or in Wicklow one year and Wexford in another. In Dublin, given its population density, screening would be carried out at all times, but at different times in different parts. Therefore, the same type of sequencing occurs.

Senator Frances Fitzgerald

Can we acquire more mobile units? What is preventing the deployment of extra staff in the counties not covered at present?

Mr. Tony O’Brien

If we were to screen everywhere in the first year, we would have nothing to do in the second year. One cannot screen more frequently than every second year.

Deputy Bobby Aylward

Is it physically possible to do it?

Mr. Tony O’Brien

It is theoretically possible and would require a very significant investment. There would be an insufficient number of qualified mammographers available to us to do it. If we could do it, we would screen the entire population in year one and there would not be a population left to screen in year two. If we were to do so, arguments would arise as to which counties should be screened in the first half of the year and which should be screened in the second.

Senator Phil Prendergast

When will the service be available in Clonmel? Have the people in south Tipperary been notified? There is obviously a process for informing them.

Mr. Tony O’Brien

I believe the mobile unit will arrive in Clonmel at the end of next week. The consent process has been engaged in and I expect that appointment letters will be issued this week or early next week.

Chairman

Senator Prendergast will tell them the service is coming.

Mr. Tony O’Brien

I have no doubt.

A very specific issue arises in the north west concerning a specific challenge regarding the recruitment of radiographers in the region. I am very pleased this challenge is being overcome in that we recently appointed our first mammographic personnel who are resident in the region. As sufficient numbers come on board, we will be enabled to be definite in regard to screening dates.

A general principle must be noted and it is particularly important now that there is such anxiety over symptomatic breast screening services. We generally never publish a screening schedule well in advance, for very good reasons. A huge surge in attendance could occur in the area from which the mobile is coming and, more important, it is a fact that women who may be experiencing symptoms today who believe the BreastCheck service will be available to them in three, four or six months will postpone going for a check-up until the service arrives. Six months makes the difference between life and death. We would not wish our impending arrival to deter any woman in the age range we cover, who may experience symptoms, from consulting a general practitioner who would refer her to a symptomatic service. We are aware this happens because women present and state they became concerned at Christmas but did not have a consultation because they knew the BreastCheck service would be returning the following May or June.

We choose not to publish our schedule well in advance as an avoidance measure. Sometimes when we write back in respect of representations stating we do not publish our schedule well in advance, it sounds like spin and evasion but there are very good and effective reasons therefor.

On the question on the north west, good progress is being made regarding the recruitment of radiographic personnel. We will commence in the north west in the early part of next year but I will not name a date for the reasons I have outlined. I assure the Members of the Oireachtas from the region that they will be made aware of it as soon as we know it. As I have often stated, public representatives, including Oireachtas Members, play a very important role in promoting the uptake of screening and raising awareness. We very much appreciate that and will seek to continue working with them on these issues.

Deputy Kathleen Lynch asked a specific question on the south that illustrates my point on the two-year cycle. Roughly speaking, there are 80,000 women in our southern region, which is not the same as the HSE's southern region. Our southern region includes Waterford, Cork, Tipperary South, Kerry and Limerick. This breaks down into approximately 40,000 women in each of the two years of the cycle. At an 80% uptake rate, which we hope to achieve although we would love to do better, 32,000 women will attend each year. Of this number, approximately 5% will be called for reassessment. Of the total population attending in a first round of screening, during which the cancer detection rate will be higher, we expect to diagnose cancer in approximately eight to 9.5 women per 1,000. In subsequent screenings, this figure should decrease significantly, to approximately five. It can take time to settle. Certainly by round three, the number should decrease to approximately 4.5 women per 1,000 screened.

The way we operate is such that we know the number of women we have to screen and the likely attendance. From the attendance rates, we can work out the exact demand on the various services. This gives us an advantage that mainstream health services simply do not have. We can match resources to demand and this enables us to achieve, in conjunction with our host hospitals, chartered standards in respect of hospital admissions. Sometimes the cancer detection rate can be higher than expected and this affects admission times. Our calculation of the exact demand represents a distinct advantage that other services do not enjoy.

On cervical cancer screening, a question was asked by Deputy Lynch about HPV testing. It can be done using the sample from the cervical test and does not require a separate blood test. Emerging evidence points to the benefits of follow-up treatment. If a patient is clear, she may not need to be followed up as regularly as others. We are examining this but, as yet, there is insufficient evidence for us to say it would be safe to defer follow-up smear tests at this point. As evidence emerges, we will integrate it into the programme.

On the vaccination programme, we were asked by the Minister to give our advice on the HPV vaccine. We commissioned HIQA to carry out the health technology assessment. Our board recommended a HPV vaccination programme and members will be aware that the Minister announced such a programme in the summer with a view to its implementation at the end of 2009. Its implementation is not part of our remit but will be part of the immunisation programmes administered by the HSE. There is obviously a financial dimension but, like the members, I am not sure how it has fared in the current budgetary process.

With regard to colposcopy, on 3 September, following an extensive audit process earlier in the year, we confirmed to 11 locations that they were the best placed to receive initial referrals from CervicalCheck. Those locations were in St. Munchin's Hospital — I believe that is the correct name; it is the maternity hospital — in Limerick; Galway University Hospital; St. Finbarr's in Cork, which is associated with the maternity hospital but not on the same site; the National Maternity Hospital, Holles Street; the Coombe Women and Infants University Hospital; the Rotunda Hospital; Tallaght; Clonmel; Wexford; Sligo; and Kerry. To answer the specific question about Clonmel, we were satisfied although, as in all these, there were some areas for potential improvement.

This assessment was based on straightforward criteria around the nature of the woman's experience, the accreditation of the staff involved, the quality assurance and recording processes in place, particularly with regard to the issue of tracking results and fail-safes, and the facilities in which the examination was to take place. Other locations were told that at this point they were not identified for initial referral but we provided them with a detailed list of the identified challenges they faced. These had all been signed off by the parties in each hospital at the time of the original visit, therefore, there was nothing new in any of this.

At this point, four locations have committed themselves to addressing the issues that were outstanding. Those are Waterford, Castlebar, Drogheda and Letterkenny. As those deficiencies are addressed, those centres will be included but I emphasise that our letter of 3 September, which was matched by a similar letter from the National Hospitals Office which had jurisdiction in this area at that time, did not have the effect of closing any of those services. They would all expect to receive ongoing referrals from the services that existed before CervicalCheck was implemented, and they will all have a follow-up workload. Nothing in our communications suggested or directed them to discontinue, although we drew their attention to our serious concerns.

Deputy Bobby Aylward

What are the deficiencies in the four Dr. O'Brien mentioned?

Dr. Tony O’Brien

They are in the categories I mentioned but it is a good principle of audit that the clinicians involved are given the space, support and the opportunity, together with their local management, to address those concerns without massive public exposure of the detailed list. It is sufficient to say that they were issues of such concern that there are no circumstances in which the cancer screening service board or I, as its chief executive, would countenance referring CervicalCheck patients, to whom we have made specific assurances in the charter, for colposcopy services. Equally, none of the deficiencies are ones that are so great that they cannot be addressed.

One of the advantages of our approach and our model is that issues that were not substantially different from those identified in earlier quality assurance visits, and which were outstanding as of 3 September, are now either being addressed or there are detailed plans to enable them to be addressed because of our move to what is known as a service level agreement approach whereby we will match funding to performance against specific quality assurance criteria. If services fail to comply with those criteria on an ongoing basis, we will cease referrals and cease funding. That creates what I would regard as a virtuous link between quality, policy and funding. That was not present previously but is increasingly present now and that will be the hallmark going forward.

Regarding our communications about it, the responsibility for addressing the issues in any place lie with the hospital management and the relevant people involved in the service provision. Until such time as those deficiencies are addressed, we will not take responsibility for those services. We should not issue press statements or updates because the people responsible locally are in the best placed position to do that. Neither have we issued detailed lists stating that this is a laundry list of the things we believe are not right because the people in question have those lists and are working their way through them. We are satisfied that this is a process that will produce a better outcome for women who will use those services at the end of the day.

The broad question of the announcement in the budget last week regarding quangos' amalgamation and so on has come up in a number of guises, as has the issue of synergies. The issue is not new and did not surface in the budget, in that at the time of the instigation of the national cancer control programme just over a year ago, which the national cancer screening service, NCSS, has played a significant part in facilitating and co-operating with, the Minister made it clear. Also, when Professor Keane and I were before this committee we also said that in light of the ongoing development of the cancer control programme, and as it achieves the organisational characteristics it wishes to achieve, it is a logical and appropriate step that the national cancer screening service should become part of the national cancer control programme in as much as a vibrant, well organised, highly efficient cancer control programme would be somewhat deficient if the cancer screening service were outside it. That would not be a model one would find replicated elsewhere.

In terms of synergies, the cancer screening service works extremely closely with the cancer control programme and has facilitated a number of its activities. In that sense, some of our core support services are shared with the cancer control programme.

In regard to our synergies in BreastCheck, for example, the teams we have appointed and who operate BreastCheck units, all of the consultants have cross appointments with the symptomatic services in those hospitals. The arrival of BreastCheck on those sites has been associated with a significant increase in the level of activity in those centres and a growing conformance of symptomatic breast services at those centres, with the same types of standard that BreastCheck adheres to. That has made a significant contribution.

In addition, a BreastCheck team was centrally involved in carrying out the patient focused review in the context of the Portlaoise review. The women whose films were reviewed were reviewed by a BreastCheck team and those who were recalled were recalled to a BreastCheck facility. It was heartening from our point of view to note the comments by Dr. John Fitzgerald in his review who commended the enormous work and the speed with which it was done by BreastCheck. Across several fronts there are important synergies between us and the host hospitals, and therefore with the Health Service Executive and the cancer control programme.

At Professor Keane's request, in addition to my substantive role — my employment, as it were — as chief executive officer with the National Cancer Screening Service, I am also the deputy director of the national cancer control programme in which capacity I have deputised for Professor Keane at various times and contributed to some of the management arrangements in regard to the cancer control programme.

Regarding the questions about concerns and so on, it should come as no surprise that in the context of the evolution of the cancer control programme as an entity that will hopefully have more or less all the same characteristics organisationally as the cancer screening service has today, that holds no particular fears for us. We have been advised that, notwithstanding the decision last year and the announcement last week that currently there is no timetable in place, our current board has a term of office which extends to the end of next year. From our point of view we hope that any change of this type will be well planned and well managed in terms of a NCCP which, over time, is emerging as a very well organised entity. That has been widely acknowledged.

In terms of what would be required, funding must be associated with designated outcomes in regard to the performance of the programmes, both in terms of activity and quality, across CervicalCheck and so on. That would have to encompass commitments to the charter. If all of those are intact, this need have no fears but we have had contacts from women, our clients, and from staff who had an emerging concern about the issues. There is no reason to believe that if it is taken forward in a well managed way and placed in the context of the national cancer control programme, the NCCS cannot continue as a business unit within the NCCP and thrive in the way I know everybody here would wish it to do. Timing and ethos are the critical issues.

With regard to timelines and funding, as already stated, we do not yet have our budget for next year. However, that is not unusual or unexpected. For this year, we had the full funding required for the cervical screening and breast screening programmes. We hope that this will be the position again next year. The business model for the cervical screening programme is extremely efficient from both a financial and organisational point of view. We expect that it can be successful. Funding relating to cytology and colposcopy which is currently in the control of the Health Service Executive will be transferred to the governance of the NCSS as part of that. This will affect our overall level of funding at a later stage.

Until we have made our policy submission in respect of colorectal screening, neither the Minister nor the Government can take a view on it. It would be somewhat previous to comment on timeline or funding issues before the submission is made. However, it would be some time — for operational and build-up reasons — before such a programme could become costly. There is a great deal of preparatory work required.

A question was posed in respect of breast cancer misdiagnosis. This is an issue of considerable concern to every woman who has ever had a mammogram or who is concerned that she may need one. Our programme, in common with others, is not foolproof. However, there is in place a significant range of checks and balances. The first of these is that there is a fully dedicated team of expert medical physicists who ensure the quality of our diagnostic imaging. We also have in place at each location a specialist team of three breast specialist radiologists. Every film is double and sometimes triple read to ensure that the potential for error is minimised. We employ radiologists, breast pathologists or histopathologists and specialist breast surgeons, all of whom have specialist experience in the area of the very small or non-palpable cancers that BreastCheck is designed to detect. Any case where there is cause for concern or where the two radiologists are not agreed that everything is all clear is submitted to a triple-assessment process.

We have the checks and balances in place. However, it is important to emphasise that having a breast mammogram carried out under any programme, including BreastCheck, does not confer immunity from cancer. There will be occult cancers which cannot be detected by BreastCheck but which become apparent in the intervening period. Interval cancers are a very real issue for screening programmes because not every cancer can be detected. Against that, in the eight years we have found more than 2,700 cancers. It is important that expectations of population-based screening are not overstated. They are not a guarantee and they confer no protection. They do, however, provide early detection and where cancers are found, early treatment is provided by specialist teams. They can do no more than that.

I was asked about survival rates in Ireland. We do not perform well by comparison with the EU 15 or internationally. I stand to be corrected — I do not have the relevant information with me — but I believe our breast cancer survival rate is in the third quartile. This must be taken in the context of five, ten and 20-year survival rates. The effect of having a national breast screening programme does not show up in those statistics and regard must be had to the time lag with which the Cancer Registry must work in order to have validated data. Bearing in mind that until last year approximately 45% of the population had not been covered by the breast screening programme has undoubtedly contributed to the position regarding survival rates here.

We subscribe to the view that the way in which breast cancer services were delivered was a significant contributory factor. Up to August of last year, no fewer than 33 hospitals claimed to have provided breast cancer surgery in the previous year. That is now being diminished and there is substantial evidence available of the benefits of the features I described in respect of BreastCheck — specialised multidisciplinary teams, significant caseload volumes, etc., — providing better diagnosis, better surgical treatment and optimal outcomes for women. I hope the combined influence of the BreastCheck programme and the substantial changes that are currently being put in place in respect of systematic breast cancer services will have a profound effect. However, we will not see the evidence of that effect for another ten years because that is how breast cancer survival is measured.

I was asked about cervical cytology and Quest Diagnostics. Deputy O'Sullivan inquired about training and asked whether discussions are ongoing with the Department of Health and Children in this regard. The answer is "Yes".

In respect of the contract, it was for a two-year period with an option to extend for two years. A view will have to be taken within the next year as to whether the conditions exist to resubmit that contract to tender. The cancer screening service will be obliged to deal with that matter at this time next year, particularly in view of the lag time relating to tendering processes, etc. It is early days as regards the contract. It went live in the mid-west on 1 August and nationally on 1 September. It is too soon for us to begin to take a view on the retendering exercise.

Deputy Jan O’Sullivan

When the NCSS is examining that matter, it will obviously consider the quality of the service being provided by Quest Diagnostics.

Mr. Tony O’Brien

Absolutely.

Deputy Jan O’Sullivan

Will it also be considering the quality of other services that are available in Ireland?

Mr. Tony O’Brien

We will be considering that possibility and also that of other international services. Quest Diagnostics is by no means the only major international provider of this type of service. There is another major international provider which also has a base in Ireland.

Chairman

I thank Mr. O'Brien. I will take a couple of brief supplementary questions and responses.

Deputy Niall Blaney

I must again take issue with Mr. O'Brien regarding the statement made on 3 September. The copy I received was very clear and it was followed up on by the general manager of Letterkenny hospital. It indicated that the Letterkenny service was closing down as and from that date. It also indicated that the patients already availing of the service would be dealt with, to the end of their treatment at Letterkenny hospital and, at that stage, the service would be closed down. It further indicated that all other patients would, from that day forward, be referred to Sligo General Hospital. I do not have the statement in my possession but I can obtain the information for Mr. O'Brien if he so desires.

I was interviewed on local radio and received over 500 representations from members of the public because I stood over what the NCSS is trying to do in respect of quality assurance and deficiencies in the services provided. According to Mr. O'Brien's statistics and my figures, approximately 500 people availed of the service at Letterkenny last year who should not have done so. That is why I stood over what the NCSS is trying to do. For those reasons, it is only correct that the people of Donegal should be provided with an answer. I accept that Mr. O'Brien cannot indicate a date by which the service will be operational. However, we at least want to know whether it will be within three, four, five or six months. Surely he can provide some indication of how the NCSS can deal with the deficiencies and lack of quality assurance that exist in the current service and state how the latter can be brought up to the expected standard.

Senator Phil Prendergast

I am concerned with regard to the merging of the NCSS and the HSE as announced in the budget. The HSE is going to face significant financial challenges in the coming years. It is considering a service reconfiguration and process improvement, limiting services to the funded level and eliminating non-pay growth through activity management and income maximisation strategies. My worry is that there will be a further deferral in the roll-out of the various screening programmes or that there will be a cutback in services. I cannot overstate the importance of the service currently provided. The service should remain a standalone one.

Deputy Caoimhghín Ó Caoláin

I thank Mr. O' Brien for his comprehensive response to all questions. However, he may have overlooked one. He should forgive me if I missed it in his replies. I asked a question about BreastCheck and the review under way on the lowering of the age threshold. Mr. O'Brien's response signalled the intent to extend the age on the upper side of the current threshold. I have been contacted by several women over 60 about the cervical screening programme who were deeply concerned because they had never been tested and, therefore, had no record of negative tests. They do not have access to the service because I understand the medical card does not cover it. Is Mr. O'Brien in a position to signal any intent on the extension of the cervical screening programme in the State that would leave it commensurate with the situation that currently obtains north of the Border? Two very different sets of access now apply to women who live a short distance from each other but who socialise together. Can Mr. O'Brien indicate the prospect of extending the higher age threshold to synchronise both programmes at age 64 at least?

Mr. Tony O’Brien

In regard to Deputy Blaney's questions, I cannot say for definite that nobody issued any statement in Letterkenny of the nature to which he referred. All I can say is that the national cancer screening service gave no directive. To my knowledge neither did the Health Service Executive give any directive that would have had that effect. I am aware the impression was given locally, for whatever reason, that the service in Letterkenny had ceased with immediate effect. I have been assured that is not the case in discussions with the general manager. My understanding is that the centre is open for business in terms of its current, pre-existing workload. Our communication with the hospital in Letterkenny, which I am happy to share with the committee, did not contain that type of information or directive. I know there are significant local anxieties about the issue and that at least two representative cancer groups have highlighted the issue to a significant extent. I am concerned that in its communications one of those groups, rather than supporting the notion of a quality assured colposcopy service, has tended to attack us for doing it.

We have had much discussion today about the relative roles of our organisation and the Health Service Executive. It is very important that when service providers, be it the national cancer screening service or the Health Service Executive, take what on the face of it are quite tough decisions that are designed to improve quality for the benefit of individuals that the advocacy groups should try to be more supportive and understanding of that. I have a simple choice, as does my board; we either endorse a service that we do not believe is appropriate from a quality assurance point of view or we send a very clear signal that there needs to be improvement and that we are serious about it. That is what we did in that instance and that improvement is coming about.

The timetable is, ultimately, a matter for the hospital but I am given to understand that all of the issues are capable of being resolved by Christmas. We will have ongoing dialogue and discussion. We have offered financial assistance to facilitate the resolution of some of those issues, because some of them are resource related. Our fundamental approach has been to take the concerns clinicians have had in local services, which they have raised over many years, and to put them at the top of the agenda and in the future to empower clinicians to do their best work. That has been the hallmark of BreastCheck and that will be the hallmark of our colposcopy service provision also. I accept that takes a bit of getting used to because it is not what clinicians or hospital management is used to. Initially people may not have understood our intent but in many of the centres the clinicians involved have grasped the opportunity with both hands and literally run with the ball. That is the kind of relationship we want to have. I have no doubt that at the end of the exercise things will be better in Letterkenny than they otherwise would have been.

Deputy Niall Blaney

Does Mr. O'Brien envisage that when Letterkenny reaches that standard it will be added on as an extra centre?

Mr. Tony O’Brien

Yes, absolutely. There is a significant requirement for a service in Letterkenny, or in Donegal at any rate. It makes sense to improve the standing service rather than to start from scratch, but if we had to we would start from scratch.

Deputy Ó Caoláin is absolutely correct, I only answered his question by implication not explicitly. I referred to the international evidence base we use. Policy in Ireland has been set as far back as 1996 in the blue book on cervical screening and there has not been significant evidence to promote a change in the position that the appropriate age range is 25 to 60. I am aware there are differences in policy across the Border. For example, in the area of breast screening, if one lives in Newry one will get screened every three years and if one lives in Dundalk one will get screened every two years. Until recently single view only has been available in the North and double view has been available in the South. There will be differences but in many instances those differences are to the benefit of quality of services in the South. In some instances they appear to be the benefit of eligibility in the North, but our approach must be based on the available evidence. If evidence emerges to show that the age range should be changed then we will promote that view and discuss with the Department a change in the age range, but for the moment I see no prospect of a change in the age range.

Deputy Caoimhghín Ó Caoláin

I will direct women who inquire to Mr. O'Brien's telephone number in future.

Mr. Tony O’Brien

The Deputy is more than welcome to do that.

Deputy Caoimhghín Ó Caoláin

I would rather he would deal with that than I.

Mr. Tony O’Brien

The service is answered in Limerick and I am based in Dublin so the Deputy is more than welcome to do that. Ultimately, Health Service Executive issues relate to Government policy and it is not for me to comment one way or another on the appropriateness of Government policy. I hear Deputy Ó Caoláin's concerns.

Chairman

On behalf of members I thank Mr. O'Brien, Ms Byrne and the entire team. He has been forthright and informative and we have all benefitted from hearing what he said.

The joint committee went into private session at 6.40 p.m and adjourned at 6.45 p.m. until 3 p.m. on Tuesday, 4 November 2008.