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Seanad Éireann debate -
Wednesday, 13 Jun 2001

Vol. 167 No. 2

Cancer Treatment Services: Motion.

I move:

That Seanad Éireann calls upon the Minister for Health and Children to establish as a matter of urgency multi-disciplinary specialist breast units for the detection and treatment of breast cancer in all health board areas.

The Government side proposes an amendment which states:

That Seanad Éireann approves the Government's commitment to the continuing development of cancer services in line with the National Cancer Strategy; and welcomes the development of centres of excellence for the treatment of breast disease in line with the core recommendations of the Report of the Sub-Group to the National Cancer Forum entitled Development of Services for Symptomatic Breast Disease.

While I do not disagree with the Government parties approving the Government's commitment to cancer services, the purpose of the motion, supported by the Fine Gael Senators, is to highlight the urgent need to establish multi-disciplinary breast units because unless they are established in each health board women's health will be at risk. Two weeks ago the Minister for Health and Children provided the House with an up-date of developments regarding specialist breast units but I understood him to mean they would not be established everywhere and certainly not the Mid-Western Health Board region.

The report of the sub-group to the National Cancer Forum entitled Development of Services for Symptomatic Breast Disease is very detailed. It is the greatest fear of women, especially those presenting with breast symptoms, that they have cancer. In many cases the breast complaint is not due to cancer but there is great anxiety generated by the possibility that there is cancer. This requires that women with breast symptoms receive care in a sympathetic environment and that they have access to highly trained specialists and high quality facilities.

If we are serious about supporting women's anxieties there must be a firm diagnosis of a benign or instant condition without delay so that the patient is reassured. That is the most important aspect. When the patient has cancer the diagnosis and treatment must be carried out in a systematic fashion and must conform with very high standards of care.

There are 650 deaths from cancer in women each year and breast cancer is the most common fatal cancer. Although it is rare in women under the age of 30, all age groups can be affected and it is responsible for a high number of premature deaths. Sadly, according to the report of the sub-group to the National Cancer Forum, despite the research carried out in many areas of women's health, the causes of breast cancer are still unknown. However, we know – it has been stressed repeatedly – that if there is early diagnosis it is most likely that patients will have a favourable outlook. While high quality mammography is not infallible it can lead to identification of breast cancers when they are very small. This means that the possibility of a cure after treatment can be very high.

I am concerned that women in the Limerick area do not have access to BreastCheck despite the fact that its services are broadcast regularly on radio. We in the mid-west region feel disadvantaged with regard to the available facilities. According to Cuidiú, within the Limerick area there is a an urgent need for the provision of radiotherapy facilities. Phase two of a specialist breast unit and BreastCheck is also required. In the meantime women must travel to avail of these services.

It is no harm to consider what is happening in Europe. Last year I attended a conference at St. Bartholomew's Hospital in London which has a dedicated multi-disciplinary unit. The facilities are superb and being a public hospital they are open to all public patients. I wish similar facilities were available in Ireland. Europa Donna, to which I have links in Dublin, attended the conference, which made recommendations to other EU countries to have these multi-disciplinary clinics established, to provide breast cancer screening, quality assurance in breast cancer research, risk assessment, including genetic testing, treatment tailoring and participation in clinical trials. A number of Irish doctors, specialist breast care nurses and breast cancer activists attended the conference, which was the second one attended by a delegation from Europa Donna to discuss progress. All are agreed on what should be done.

Two organisations apart from Europa Donna have come together and will continue to work to stimulate cancer research, to improve the standard of cancer treatment, enhance communication and encourage breast cancer advocacy. The question of advocacy was also debated earlier today on Committee Stage of the Mental Health Bill.

In the context of our membership of the EU there must be an exchange of up to date information to ensure a more uniform method in the diagnosis and treatment of beast cancer. Sadly, matters are not uniform, as I am sure Senator Taylor-Quinn would agree. We in the mid-west feel we have been disregarded in connection with the establishment of a multi-disciplinary unit which has been advocated by all professionals dealing with cancer.

During a Seanad debate on the 29 March 2001 on the report of the sub-group to the National Cancer Forum, the Minister for Health and Children used aspirational language and I detected little sense of urgency about the establishment of multi-disciplinary breast clinics. He said he "accepted the broad thrust of the report". This suggests that the details of the report are not acceptable. It is regrettable the Minister is not present because I would have asked him to outline the aspects of the report he does not accept.

I wish to mention points raised by others in submissions to the 2001 health strategy. There is more to dealing with cancer than multi-disciplinary clinics, although they are central to the recommendations. In relation to the experience of women who reported breast lumps, as Senator Taylor-Quinn will agree, there is very uneven access to services for women with symptomatic breast disease. The further one is from the capital or centre of population, the less one is likely to be able to avail of any facility.

There are unacceptable waiting times for mammograms and appointments with consultants for many women, particularly public patients. This is sad. Many public patients are seen by junior doctors and not by a consultant. These facts were given to me and I do not dispute them because they are accurate. The services appear to be worse outside the main cities but even there, the services vary greatly from one hospital to another. There is no doubt that those attending specialist breast clinics appear to have the best experience because they have the support of specialist breast cancer nurses.

Regarding facilities for nurses who wish to become experts in oncology and breast cancer services, there is a course in UCD but I ask the Minister to clarify whether nurses must undertake it at their own expense if they want to develop further expertise in this much needed area. In Britain, if one leaves one's place of work to undertake such a course, one is paid one's salary while one is gaining further expertise. In most cases, the certification is degree level. I am particularly concerned about this matter because if the Minister is serious about setting up these multi-disciplinary clinics, he must realise they do not only involve consultants. The teams will include nurses who ultimately may have to come from other countries because such nurses are not available in Ireland. If the Minister wanted to set up the clinics tomorrow, the dedicated teams would not be available.

Why is the Minister suggesting these clinics will happen if we know the experts are not available? It is said that money is being thrown at the health services but planning is required. Perhaps this is why the Minister made a vague reference in this regard; perhaps he knows it will not be possible to establish the clinics. If he set up clinics without personnel, they would be only aspirational. I do not like to be negative but if existing breast clinics are under-resourced to varying degrees, I shudder to think how the recommended multi-disciplinary specialist breast units can be created. The bottom line is that women will not have equal access to high quality care. I often wonder if that is because we are women and, in the main, breast cancer affects women. The point is that if breast cancer is detected in time, women's lives can be saved.

The House discussed the Health Insurance (Amendment) Bill and women with private health insurance often have shorter times between surgery and subsequent treatment. There is less delay for such women in having surgery and adjuvant treatment in the same centre. It is sad that women in the public sector are worse off in that regard. Insufficient psychological support is available for patients and their families in what is a testing time. In the mid-west in particular, women must travel long distances for radiotherapy at enormous expense to them. It also involves enormous stress for them and their families. Many of the problems could be resolved by adequately resourcing multi-disciplinary breast clinics.

A plan to develop all 13 units proposed in the report on the symptomatic services over the next five years should be put in place now. We are not interested in hearing that it will happen next year or the year after. It should be put in place now by the Department of Health and Children in co-operation with health boards. Radiotherapy services and screening pro grammes for older women should be extended nationwide. A health promotion programme should be developed to inform people that cancer is a survivable illness, particularly if it is detected early, although we shy away from it. I hope the Minister will have some answers to the points I raised in the motion.

I second the motion. There are three medical experts on the other side of the House and I am sure they fully support and agree with everything Senator Jackman said. This is a serious issue. It is of huge importance to women because the statistical rate of fatalities from breast cancer in this country is high in comparison to other countries. The facilities under the health service leave an enormous amount to be desired. The former Minister for Health, Deputy Noonan, requested a report in 1995. Following the presentation of the national cancer strategy report, a sub-committee was established. However, it is extraordinary that the group in carrying out its report did not consult existing services outside the Dublin area. This is condemnable.

My constituency of Clare was one of the first to put in place a mammography unit in the general hospital in Ennis. A radiologist returned from one of the top hospitals in England under the impression that the Mid-Western Health Board was to put in place a state of the art centre in Ennis at that time. He and his team have done wonderful work over the years, but when the report was being compiled, it appeared that if one was outside the Pale, one was not deemed worthy of consideration or even asked one's views on the issue. Everything is focused on the Dublin area; it is as if the rest of the country does not exist. This is totally condemnable.

The bureaucrats and supposed "experts" who pulled together the report were paid a large amount of money from the public purse to get a balanced view of all parts of the country from people involved in this area. From that perspective, I am cynical and sceptical about the report. The group reported without getting a clear picture or clear views from the medics directly involved in providing the service. The Minister should bear this aspect in mind when he is attempting to put in place a better service throughout the country.

Detection is vital and I support the idea of maintaining existing units throughout the country and putting mobile units in place. Mobile units will make services more accessible to many people in a similar way to the TB detection units in the past. In that case, vans travelled around the country and people were X-rayed on site in various towns. The units were extremely helpful in getting rid of tuberculosis in its time. In this instance, the mobile units could be extremely helpful in detecting breast cancer in women at an early stage. However, it should only be an ancillary service to fixed services in various hospitals throughout the country.

The entire west deserves specific consideration because there is a dearth of such services from Donegal to west Cork. I am sure this applies to Cavan, Monaghan and other peripheral areas. They must receive specific attention. An attempt should be made in each general hospital in each county to establish a detection facility and a mammography unit. These services should be put in place in each county hospital.

I also support the idea of centres of excellence because there are certain problems. Detection is one thing, specific treatment and subsequent dealing with the problem can become in some instances quite a challenge. There is a need for centres of excellence where unusual cases are dealt with. In a number of health board areas some of the finest consultants are being drawn into the centre and their services and skills are being diverted into the regional hospitals at the centre of the health board area. This is happening in Limerick where good people are being taken out of Clare and diverted to Limerick. I have evidence that it is happening in Galway, where good people in Castlebar, the Minister's own constituency, are being diverted to Galway. This is not fair practice nor is it a commendable development.

The Minister of State is a former practising doctor with direct contact with the people and medical professionals of the area and would fully recognise the importance of the provision of service in rural areas. We must never underestimate the difficulty of travelling in rural areas. People who do not have private health insurance and are public patients find it particularly difficult to arrange transportation to the facility. The nearer the facility, the better for them and they are better served by having local units rather than everything centralised in large regional hospitals. Detection of disease is more efficient when the facility is easily accessible to patients. What is vitally important is that women's health is properly attended to. Early detection is vital and will mean that there is less pressure and demand on the centres of excellence from those with advanced illness.

The staff in the service are excellent and do commendable work often in trying and difficult circumstances. Senator Jackman has referred to the difficulty in the provision of staff. The fundamental issue is to provide skilled and professionally trained staff at all levels within the service and to put them in place in the hospitals. There have been thousands of bed closures due to the lack of professional staff, particularly nursing staff. The attitude towards nurses and their pay rates must be examined. It is an issue that must be addressed if a proper health service is to be provided into the future. Young people are not interested in applying for nursing training because nurses are not being properly remunerated for their skilled and professional work. The provision of personnel, their proper remuneration and the provision of facilities for training staff, are vitally important in the overall strategy.

I move amendment No. 1:

To delete all words after "Seanad Éireann" and substitute the following:

"approves the Government's commitment to the continuing development of cancer services in line with the National Cancer Strategy; and welcomes the development of centres of excellence for the treatment of breast disease in line with the core recommendations of the Report of the Sub-Group to the National Cancer Forum entitled Development of Services for Symptomatic Breast Disease.".

We have been talking about health all day today, about mental health and now breast disease. The one thing that has been neglected is the cultural dimension to mental health. Most of us here are old enough to remember when the person with mental health problems was pushed to one side. I am old enough and long enough in medical practice to know that women and men left it too late to come to any doctor when they were faced with problems in the genital area. I am referring to cancer of the ovaries, the womb, the breast and the prostate. That attitude will only be changed through education. Before any money is expended on systems for showing up any form of cancer, people must first be educated and their family history of cancer must be recorded. The family history is the bottom line for any doctor.

An interesting book written some years ago by McCormack and Skrabanek questioned the basis for screening and other modern trends in medicine. This is a short book, about 150 pages, and should be read by anyone interested in health matters. It examines the facts as they are and as they were in the past.

It is not regarded as politically correct to state that one is not in favour of overall screening, but I am more in favour of targeted screening. Any patient with a family history of the disease should be fast-tracked into screening. The discussion tonight is concentrating on blanket screening and the whole GDP of this country could be devoted to that without ever treating anybody. That cannot happen and the screening must be targeted and focused—

It is Government policy.

—and the service must be put in place. I agree with the other speakers who say that there is a need for it. Senator Henry, the Minister and I have been around long enough to know that, in the past, people only consulted a doctor when they were sick; now people visit a doctor to find out if they will be sick in the future. That is the way things have changed in medicine. Some screening programmes need to be implemented and not so much screening, but rather treatment programmes. A person who presents with breast cancer or a lump in the breast must be fast-tracked.

I do not wish to be parochial but there is a BreastCheck unit in the Mater Hospital in Eccles Street. There is a cervical screening programme in the Mid-Western Health Board area which is state of the art. The Mid-Western Health Board is a leader in this area, thanks to the Senators and the members of the Mid-Western Health Board who lobbied for it. The members of the Mid-Western Health Board—


Yes, they prioritise. No matter what the Minister says in Dublin, what the local health board says is what happens. The Minister provides the money and it is up to the health boards to provide the focus. This is what will happen in the future.

There has been a cultural element in people's reaction to genital cancers. I know of some horrific cases where people delayed far too long in going to seek medical help, possibly through fear or shame, or were cúthail, as they say in Irish. I am glad that those days are going.

The most important aspect of this debate is not that we can achieve anything concrete tomorrow, but we may be a means of educating people to take preventative action where their health is concerned and go for check-ups.

Senator Fitzpatrick has given some very practical and sensible advice. I understand Senators Jackman's and Taylor-Quinn's concerns following the recent report on the survival rates from cancer. It was profoundly depressing. The Minister, coming from the west, would be worried at the black belt down the west in regard to the survival rates from cancer and that so many more women had mastectomies there who would not have had them had they had been in other parts of the country.

Senator Fitzpatrick made a sensible contribution about screening and targeted screening. Unfortunately, breast cancer is so common that it would almost be impossible to find a sufficient number of people without a first degree relative who did not have it to make it worthwhile to look at targeted groups. It appears from the genetics that only 6% of those develop breast cancer who have those genes which are specific to breast cancer. It may be useful to use this genetic screening and genetic counselling to deal with people who may develop ovarian cancer because that has the same genetic background.

I am pleased to inform the Seanad, and the Cathaoirleach in particular, that I am going to attend the round table on genetic screening and on patentability of genes, etc., in Brussels next week. I would hope to bring back a considerable amount of useful information to the House. While we are in the forefront of scientific development in this area, we in this establishment do not get involved rapidly enough to say what we can do to encourage progress. For example, one part of the meeting in Brussels is about the patentability of genes. This is an issue in which we need to take a close interest because while it may be useful for the pharmaceutical companies here, is it of benefit to the citizen at large? I hope to have further information for the House in this area.

It is disappointing that Dr. Jane Buttimer is no longer leading the BreastCheck campaign. She has done incredible work. In the areas where it has been set up it is excellent. As I have told the House before, a close friend of mine was one of those who was positive and was picked up on the screening. Even the best of GPs would not have found the lump.

Senator Fitzpatrick stressed the need for education in this area, education of doctors and patients. It is disappointing that the significance of smoking has not got through to women. It has been clear for a long time that smokers have a higher level of breast cancer because nicotine is involved in fragmenting the DNA within any cells in the body. Those who smoke will have higher levels of cancer. Why has it not been possible to get this message across? All of us have to play a part in it, not just the Department of Health and Children. I applaud the programme on smoking which the Department of Health and Children has brought forward but we need to involve the general public more. Obesity which is one of our modern plagues is a factor. There is scientific evidence from Holland that obesity may be an important factor in altering the amount of oestrogen produced. This is not pointed out sufficiently. Young women are much heavier and fatter than they were even a generation ago. This is of concern and we may have to have a national fitness campaign and, if so, I am sure Senators would lead the way.

I suggest the programme of prevention has to be wider than screening. Of course I would like to see BreastCheck extended all over the country. However, before doing so more attention will have to be paid to the implementation of services, otherwise there will be screening in areas where there are no services. It is outrageous that Galway has had no radiotherapy unit, although I understand it is coming in October. Even with that and a new medical oncologist appointed, the oncologist has no beds. Given that the population is scattered we should not try to spread radiotherapy units all over the place. The oncologist will have to be given beds. I am aware from my colleagues in the west that there is a delay in the treatment of people in hospital because the CAT scan in Galway University Hospital must be working 24 hours a day. There is an inability to get patients screened to see if they have secondaries. Given the difficulty in getting CAT scans, patients who do not need to be in hospital are kept in hospital for days and there is delay.

Senator Taylor-Quinn referred to the shortage of nurses. This is one of the main problems. Nurses who deal with chemotherapy have a considerable amount of training. We have to look at how we can encourage people to go into these stressful areas. I cannot understand how the nurses in St. Luke's manage to keep going. I would find it difficult to keep up the esprit de corps they have when dealing with patients who are having a rough time. The way in which they encourage patients is remarkable.

We have a big problem regarding the shortage of radiographers. This affects the breast screening programme badly. In England they do not have such specialised training for radiographers who are to deal mainly with mammography. Could we consider doing that here? Could the matter be discussed with the radiographers organisations to see if this would be possible? BreastCheck has looked internationally for more radiographers, including Africa and Australia, but has not managed to get them. This is always the problem here. We always appear to be behind in training manpower for some specialist problem.

Professor O'Higgins suggested there should be 13 specialist units in the country for breast treatment. There should not be one more. Would every one of us do everything in our power to stop small groups trying to start specialist units which cannot be supported? It was worrying to note from the cancer figures that some surgeons were doing only about ten cases of breast cancer per year. Anyone who does anything practical will know that one needs to keep up a certain amount of expertise. This would not do.

I was dismayed at the recent decision by the North Eastern Health Board to send the breast specialist unit to Navan. This will mean trying to get oncologists and radiotherapists there all the time. For better results it would be more logical to put it in the most major centre. We need not have the situation we have now but we will have to wait for better results. The ICA is a sensible organisation. Such groups will have to be enlisted more. Navan paid for a mammography unit ten or 12 years ago but that would be obsolete now and that will have to be explained to patients. It is bad enough to have obsolete equipment in centres which are supposed to be centres of excellence without trying to send people to areas where the equipment is not the best. There is a great need to upgrade the facilities in Cork. While cash is allocated now and then, there is little in the way of planning. We should try to move ahead as fast as possible with developing the centres of excellence and explain to the population why it is being done because it is the best way to reduce the sad mortality rate.

We are all singing from the same hymn sheet. The message I have got from the speakers so far is that we have to proceed as fast as possible with the implementation of the recommendations in the report on the development of services for symptomatic breast disease.

If we are talking about specialised units in relation to centres of excellence, the involvement of a multi-disciplinary team is the most effective and caring way of dealing with the issue. I disagree with Senator Taylor-Quinn who said that every general hospital should have its own mammography machine. That is probably contrary to the recommendations for the establishment of specialised centres of excellence to deal with breast disease.

The multi-disciplinary approach involves not only the surgeons but also radiologists, radiotherapists, breast care nurses, psychologists and social workers. Co-ordination of this programme is critical and if it is resourced and co-ordinated properly, it should lead to early detection, early intervention and most importantly a greater prognosis. If we can implement these recommendations in the multi-disciplinary approach, we can quickly improve the prognosis of women who develop breast disease and in particular breast cancer.

I come from a nursing background and believe in the continuity of care delivered by the same personnel from the initial assessment right through the whole process of treatment and care. When a person is admitted to a hospital ward, a bond and a relationship develop between the patient and the nurse which can determine whether they have a positive or negative opinion of both the treatment and the other medical staff they will meet during their stay. Where there is a possibility that an individual has breast cancer, the rapport that that patient develops with the nurse is probably the most important relationship that an individual can identify with regardless of the treatment and the prognosis. The key to a multi-disciplinary team is having the personnel from the beginning who go through the experience with an individual and can empathise with her. There needs to be an holistic approach to dealing with both the individual and her family members.

While I have great respect for all the medical personnel, all the "ologists" as I call them, the oncologist, radiologist, etc., I feel that nurses are taken for granted. However, the back-up support that the breast care nurses can give to this programme cannot be underestimated not just for the patient but also for the family. The most important aspect of this programme will be the number of breast care nurses who are trained.

Senator Jackman said that there seemed to be very slow progress in putting these multi-disciplinary teams and centres of excellence in place. Senator Henry referred to the North Eastern Health Board. The bones of a centre are already in existence in Drogheda and I was particularly disappointed to hear that the board wanted to transfer it to Navan. It will come before the next health board meeting in July and I hope that sense will prevail and the existing service that needs to be upgraded will be maintained in Drogheda. There is also the need for secondary services or outreach services in other parts of a region, particularly in large geographical areas. Even though it is not in this plan, I support the idea of a main centre in Drogheda and an outreach centre in somewhere like Cavan.

The North Eastern Health Board also plans to have a project manager to oversee the implementation of this programme. I have had some difficulty with programme managers in the past because I am fearful that somebody who is used to providing reports, strategies and draft plans is not appropriate. What is needed is somebody who has worked at the coalface and dealt with patients. As a nurse, I have seen patients from the beginning of their assessment, coming through their treatment and out at the end. It is important to have people who understand what individuals are going through. In dealing with illness and particularly cancer, we must be extremely careful to put in people who really know what they are talking about.

When a woman is diagnosed with breast disease, the initial feelings include fear of death, separation from one's family, the treatment and the loss of hair, image and body organs. The centres of excellence can go the whole way with an individual and that should be the goal. I have no problem with secondary centres but we must look towards centres of excellence. In Northern Ireland, there is such a service available where there are multi-disciplinary teams and also individuals who go to the various centres and are involved in discussions about patients. That is the route we need to go.

The BreastCheck centre is operational in Dublin. From all the correspondence I have had with individuals there, it is clear they are particularly helpful to a public representative like me, representing women who are very fearful of the unknown and of illness. Their attitude to the patients and the guidance they have given has been second to none.

I wholeheartedly welcome the Minister's commitment to the development of the services for symptomatic breast disease. Other Senators spoke of the difficulty of having qualified personnel to carry out the service. This is not something that can happen overnight, but we should move as fast as we can. Early detection is the key to dealing with cancer in general. These recommendations are very useful and if we implement them we will improve the prognosis of breast cancer.

I listened very carefully to Senator Fitzpatrick and was very interested in what he had to say. I also listened to Senators Henry and Leonard. I do not disagree with anything that any of my esteemed colleagues said. I do not see much difference between the provision of multi-disciplinary breast specialist units and centres of excellence. What is a centre of excellence? It is all about access to services that will alleviate the dread and fear referred to by Senator Leonard. The fear and terror is appalling. Most of us have probably had family members touched by it. Any centre of excellence or multi-disciplinary facility should include the services of cancer counsellors. While the problem is obviously a medical one and often requires surgery, a positive mental attitude is important and some people seem to have a better ability to recover than others, because of the support services which they get.

Only four or five years ago, women in my own area of Clondalkin had the unfortunate experience of being collected by mini-bus and brought to the doors of St. Luke's Hospital, only to be sent home without any treatment. In most cases, the problem was that the machine had broken down. That was not a very reassuring experience for women who were already ill and quite terrified.

Tomorrow, I will attend the funeral of a close friend who died of this dreadful illness. Even as a private patient, she could not get an appointment for two weeks although her condition was obviously critical, so God help the poor misfortunate public patients. Added to that, she could not get a date for chemotherapy, because the books were already full. She did eventuaIly get her appointments but it was too late. I am not suggesting that the outcome might have been different but nobody should have to endure the stress and terror of waiting for very necessary medical assistance and reassurance.

Many general medical practices, with perhaps three or four doctors, now include health centres which can carry out most examinations pertaining to women's health, particularly in relation to cervical and breast cancer. A centre of excellence undoubtedly serves a useful purpose, but I suggest that a more local facility, involving GPs, would be less intimidating and would provide more immediate assistance and reassurance. It would also mean that people would not have to wait a month or more for an appointment and then endure long delay and overcrowding at a hospital-based centre.

It is not right that people who are already suffering should have to endure such additional hardship and stress. I strongly support the idea of locally based facilities. I fully agree with Senator Leonard's comments. While a patient obviously sees the specialist for surgery and other relevant procedures, her ongoing relationship is with her own doctor and nurse. It is at that level that the best support can be provided. On that basis, I strongly support this motion. The objective must be to ensure that a woman is not left without support at a time of great personal trauma.

It is difficult to imagine anything more distressing than the disappointment of having a hospital appointment cancelled at short notice for surgery for such a dreadful illness as cancer, after one has already packed and psyched oneself up for the event. It is of little consolation that one's hospital bed may have been reallocated to somebody with a greater need. We should do everything possible to facilitate patients at primary and preliminary level, through the services of GPs and nurses at women's health centres. Development in that direction is greatly facilitated by the present trend towards group practices involving a number of GPs, a nurse and a women's health specialist. That system can save long delays for patients and a great deal of trekking from one hospital to another.

I appreciate that the Minister of State at the Department of Finance does not have direct responsibility in matters of health policy. I have often been impressed by his use of words, even when taking a dig at my own party. However, that is par for the course.

I always put it in the nicest possible way.

The Minister of State may have spoken very nicely, but without saying very nice things. I have no doubt that he is as concerned as anyone else in this House to see what can be done to allay the dread – and that is probably the right word – which people feel in the situations which I have described. However, I am disappointed that we are not getting support from the Government side of the House.

I support the Government amendment to the motion in this very important debate. In discussing breast cancer services, it is unfortunate that some of the statistical material is a few years old. However, it is clear that the figures are increasing substantially. The overall figure of over 20,000 new cancer cases in a single year certainly emphasises the scale of the problem and the need to tackle it effectively, with particular reference to those types of cancer which are most amenable to treatment. Considering the level of expenditure and the proportion of hospital resources associated with cancer caused by smoking, it is reasonable to suggest that if this problem had been addressed more effectively, greater resources would now be available to deal with breast cancer.

It is estimated that early detection of breast cancer, through the screening process, can reduce the death rate by up to 30%. I understand that there are approximately 1,600 new cases of breast cancer in Ireland each year and, unfortunately, over 600 deaths. While there is evidence that breast cancer screening can cut the death rate, the full benefit will not be achieved unless the screening programme is of top quality. If it is not of the highest quality, there will be too many false tests. Many women, who do not have cancer, would be unnecessarily recalled for further tests, causing them anxiety. That is a disaster for any screening programme and caused the closure of some in other countries.

High quality requires a proper population register and what we have is not ideal. The national breast cancer screening programme, BreastCheck, relies on VHI, BUPA and the Department of Social, Community and Family Affairs for a database of 90% of the women in the age group. All women should receive an invi tation to come for screening. Specially trained, sub-specialist staff must work in multi-disciplinary teams and quality must be audited.

The development of services in the regions is important. We see the increase in symptomatic breast disease and people want development on a regional basis. My region spent two years on the board playing politics and fighting over the location of a centre of excellence instead of moving ahead with it. It is estimated that a viable centre of excellence requires a population of 250,000. Public representatives on health boards should look at the bigger picture and at the best service that can be provided by a centre of excellence in whatever location. It should be located quickly where it is appropriate. Women, nationally and in the regions, must be properly looked after. Whether we like it or not, people played politics with it, which was wrong.

Recently I saw a story in the newspapers that women had breasts needlessly removed. That was a disturbing, worrying report. Every effort must be made to ensure that care is of the best so that women, worried about problems, will be at ease attending doctors and hospitals. Much of that report is not factual. It is unnecessarily worrying. Women are concerned that breasts were removed without cause. I hope that the Department of Health and Children ensures that women, going for tests, can have confidence in the system.

More nursing specialists in the field of cancer care are needed. There are a few highly trained and efficient nurses specialising in cancer care in hospitals. People leaving hospital after treatment need nurses specialising in cancer care in the community. That must be a priority. I referred to the number who died. We must look at research. Last summer when my board visited Boston I saw the great advances in research there. We should learn from their experience so as to reduce substantially the number of deaths annually. That can be done, and more money made available, if people being treated for other forms of cancer took the necessary steps, such as stopped smoking, so as to free resources.

This is an important motion and speakers made important contributions. We commend the Department for the money it spent, and continues to spend, on cancer control, research and developing services. The advisory group recommended the development of services for symptomatic breast cancer at a regional level and this should be heeded because it considered what was best for the patients. As politicians and members of health boards, with the Department of Health and Children, we must take on board its views and provide the services in recommended locations. It may not be politically suitable for some because the developments are in another county but we should forget the county and consider the region and what is best for patient care. If that is done over the next few years and money spent wisely on patient care, we will be able to say that we took the right decisions and ensured the best care for those with cancer, particularly breast cancer. This is an important motion and I look forward to the Minister's reply.

I commend Senator Jackman and her colleagues for proposing this motion. I am glad to have the opportunity to speak on it. I do not disagree with what was said. I take particular cognisance of the views of, what we might call, the expert speakers who have medical backgrounds or direct experience of how the health services work on the ground, like Senators Leonard, Henry and others.

I would like to take up two points mentioned by Senator Moylan, one of which is lung cancer and smoking related illnesses and deaths, particularly among women. Senator Moylan also referred to a recent newspaper report on the delivery of health services in relation to breast cancer as contained in two reports recently made available to the Government and both of which have been referred to this evening.

I know we are specifically looking at breast cancer but it is in the context of an increased awareness of and discussion on issues surrounding women's health. There have been a number of studies and reports dating back over the last ten to 15 years, in particular, on the need to address specific health matters relating to women and obviously breast cancer and cervical cancer have been much discussed. One has to say that considerable advances have been made, although there are, particularly at the moment, severe problems in regard to the delivery of the service for the patient.

I would like to refer to a point in the context of women's health and smoking related cancers because I am currently sitting on a small sub-committee of the Oireachtas Joint Committee on Health and Children, as is Senator Jackman. We are looking specifically at issues relating to cigarette smoking. The statistics are frightening, particularly in relation to women. The figure of 600 deaths per year from breast cancer was mentioned but to give a comparison, there are 7,000 deaths per year from smoking, as the Minister will know. Some 90% of lung cancers are preventable. We do not know what causes breast cancer or why we have such a high rate but we know why we have such a high rate of deaths from lung cancer – it is because of the high incidence of smoking.

In terms of deaths among women from lung cancer, there has been more than a five-fold increase in deaths in the years 1970 to 1990. There is a very frightening trend among teenage girls in terms of the incidence of smoking which is now considerably higher than among their male counterparts. The incidence of smoking among young women in low income groups is between 44% to 45% compared to 31% among the population generally. I simply raise this issue in relation to women's health because we are right to concentrate on and to raise the awareness of issues such as breast cancer. I may use an oppor tunity in the future to raise the issue of women's health and smoking and the increase in deaths among women from smoking related illnesses and in the population generally. It is something that will have to be addressed in a far more aggressive fashion.

I thank Senator Jackman for raising this issue of breast cancer because we all know women and families who have been affected by it. One cannot help but think about it at the moment with the South Tipperary by-election. We lost a great woman to cancer, the late Deputy Theresa Ahearn, and that brought it home to us. We all probably know of somebody at the moment who is suffering. I know a woman in her forties, the mother of two children, who is as we speak at the end stage of breast cancer. One wonders about the incidence of it.

Senator Moylan referred to a report in last Sunday's The Sunday Tribune, to which I would like to refer, a report which has been made available to the Department and of which the Minister will be aware on the incidence of breast removals among women. The document was given to the National Cancer Forum last month and has highlighted a number of issues of major concern in this area. The findings made available to the National Cancer Forum are contained in an independent study drawn up by the department of community health and general practice in Trinity College looking at the statistics surrounding the treatment of breast and colorectal cancer in the country between 1994 and 1998 which, incidentally, are the years for which the most recent data are available.

Three issues are raised in this study entitled, A Report of the Variations in Cancer Treatment and Referral Practices in Ireland. Using that data the three issues identified included the suggestion that hundreds of women may have had breasts removed unnecessarily due to a lack of facilities in the public health services; second, it highlighted the fact that in this period 1994 to 1998, many older people with cancer were inadequately investigated and treated during the period concerned and, third – this is very disturbing – there is a regional variation in the kind and level of service delivered to the public. These are very important issues and I hope the Minister will refer to them because, as we know, there is a major concern about the delivery of the health services generally. However, when it comes to cancer, because it is a terror inducing issue and because we all know people who are and have suffered hugely, we need reassurance on the kind and level of treatment. We need to know it is available to everybody and that there is no regional variation in terms of the delivery of services.

The second report, which has been referred to by a number of speakers already, was compiled by the Symptomatic Breast Cancer Services Review Body under the chairmanship of Niall O'Higgins, professor of surgery at UCD in St. Vincent's Hospital, which was submitted to the Minister, who will be very familiar with it, in April last year. My information comes from the media and I would be interested in the Minister's response. A number of issues have been referred to by other speakers, including what Mr. O'Higgins describes in the report as serious and significant deficiencies in the treatment of women with breast cancer in some locations around the country. I do not intend to go over all of this as it has been referred to by other speakers but we could all relay stories of women who have come to our offices and who have approached us as public representatives on their experiences of going to St. Vincent's Hospital – this was referred to by Senator Ridge – and being left waiting for hours, maybe from 8 a.m. until well into the afternoon, to be seen in a situation where stress and anxiety levels are extremely high. One finds it hard to believe that in this day and age there is still a system of block booking for a particular time. Women diagnosed with breast cancer and women being treated for various conditions are forced to spend hours on end waiting to be treated.

I know of and have heard reports of the high level of expertise, the care and the diligence of the staff not only in St. Vincent's but right around the country and in Portlaoise as well. As Portlaoise is the nearest centre to my area of North Tipperary, I know of a number of women who have attended Portlaoise and the reports that have come back have been nothing but good in terms of the approach by the experts and staff at all levels from nursing right up to consultants. We know there are deficiencies in the service and that we have a long way to go, particularly in filling the vacancies among the specialists.

In relation to cervical cancer, I recognise a screening programme is up and running in the Mid-Western Health Board area. I hope the rest of the country will follow suit on the BreastCheck programme, as was pointed out by Senator Jackman. That programme needs to be extended to cover the country as it is the only effective way of ensuring the early detection of breast cancer. As Senator Leonard and others pointed out, it is only through early detection that the high incidence of deaths due to breast cancer can be reduced. Much more remains to be done and we are all at one in our determination to make sure it is done.

In terms of the delivery of the service, there is a long way to go, particularly in the management of programmes on the ground and of who is put in charge of running them as there are variations from one health board area to another depending on who is managing the programme. We are talking about patients and their families and many of them have children. Our first priority must be to ensure the service is excellent and meets the public's high expectation of this programme and of all levels of the public health service. The Minister is very well aware of this service and it is presenting a major challenge to him or to anyone else who might be in his shoes.

I commend the motion to the House. I am happy to support it and I welcome the full debate on it.

I apologise for my inability to be here for a large part of the debate. I had to present Estimates to an Oireachtas committee and between then and now I launched an all-Ireland report on mortality, the first one completed since 1921. The report was compiled by the Institute of Public Health, a North-South body. The Minister for Health, Ms Bairbre De Brún, came down from the North and jointly launched the report with me.

The report is of some relevance to this debate given that cancer is one of the major causes of death here. The contrast between the report just completed which examines mortality from 1989 to 1998 and the last such report in 1921 – which is another story about how we are compiling reports – is fascinating. The 1921 data show that the critical issue in terms of disease, death and illness was infectious diseases. I was struck by the number who died then from measles, diphtheria and even influenza. Tuberculosis was a major killer then. Many of the major killers of 1921 have gone and we are faced with three major killers today – cardio-vascular disease, cancer and accidents and injuries.

I recommend the report to Members of the House because there are some striking statistics in terms of occupational class and socio-economic status determining the time one dies. There is a clear correlation between people dying young and their socio-economic status. The other major factor is gender with men having far higher rates of death than women in a range of areas including assault, car accidents, cardio-vascular disease,etc.

I welcome the opportunity to brief the Seanad on developments in the area of cancer care and treatment here. There was also a debate on this issue last month. I am particularly pleased to inform the Members of the Seanad that multi-disciplinary centres of excellence for the treatment of symptomatic breast disease are currently being developed in a number of health board areas throughout the country. I record the significant resources in terms of infrastructure, personnel and services which the Government has put in place for cancer patients since the publication of the national cancer strategy and this is reflected in the Government amendment.

The 1994 health strategy, Sharing a Healthier Future, set out a framework for the reorientation of our health care system. The reorganisation of our cancer treatment services was an integral part of this strategy and targets were set for reducing the mortality from cancer in the under 65 year old age group by 15% in the period 1994 to 2004. Health care services were to be focused on improvements in health status and quality of life and increased emphasis was to be placed on the provision of the most appropriate care for patients.

Cancer was identified as one of the major sources of premature mortality in Ireland. The effect of cancer on health status here is striking. There was a clear need to address this and the national cancer strategy emerged as an evidence based initiative to enable high quality cancer services to be developed throughout the country. The two principal objectives of the national cancer strategy are to take all measures possible to reduce rates of illness and death from cancer, in line with the targets established in Shaping a Healthier Future, and to ensure that those who develop cancer receive the most effective care and treatment and that their quality of life is enhanced to the greatest extent possible.

There are specific objectives in relation to key elements of the cancer strategy concerning such areas as prevention of cancers for which a cause is known or suspected; access to equitable, effective, quality services throughout the country; improved quality of life for patients; appropriate multi-disciplinary treatment administered safely and in accordance with best practice guidelines; greater co-ordination of cancer treatment services from primary care to hospital care through to rehabilitation and palliative care; promotion of arrangements for appropriate research and education for those providing cancer services and there should be a co-ordinated approach by all those involved in the care and treatment of patients with cancer to ensure that all services are provided in a cost effective manner.

As the Senators will be aware, a range of support structures were put in place to co-ordinate and take a lead role in the implementation of the national cancer strategy. The first National Cancer Forum, under the chairmanship of Professor James Fennelly, was established. The forum, a multi-disciplinary body, proved to be extremely useful and advised on many issues central to the implementation of the strategy. The term of office of the first forum expired last year and I subsequently appointed Professor Paul Redmond as the chairman of the second National Cancer Forum. The forum is currently examining a number of issues of tremendous importance to the effective progression of the development of cancer services here. Areas such as guidelines and protocols for the care and treatment of cancer patients, information requirements and audit and evaluation of our services are all important component parts of the appropriate future development of cancer services and the forum, as the established expert advisory body, will report to me on these issues. Recent media coverage might lead one to believe that these issues were not being considered at national level whereas in fact they are being discussed and actively considered by this advisory group of experts, the National Cancer Forum. A report in The Sunday Tribune last week relates to the 1994 to 1998 period, in particular 1994 to 1997, and there are lessons to be learned from that and applied. There will have to be an evaluation of the period from 1997 to the end of 2001.

Regional directors of cancer services were appointed in each health board area to oversee and co-ordinate the development of cancer services in their respective areas in conjunction with the chief executive officers of the health boards. I reappointed regional directors of cancer services in each health board area last year and these posts are proving to be of great benefit in assisting in the development of appropriate future cancer services.

I am pleased to be able to report to the Seanad this evening that there has been considerable and tangible progress to date under the national cancer strategy. The strategy has been progressed far beyond the original commitments made in the action plan for its implementation. I will brief the Seanad on these.

The implementation of the national cancer strategy was estimated to cost £25 million when it was launched. The sum allocated for the strategy in 1997 budget was £6 million. Since then, the Government has invested £54 million in cancer prevention, treatment and care services. This involved investing £11 million last year and almost £19 million this year in these services. All of the commitments made in the action plan for the implementation of the strategy have been fully funded and are implemented or are in the course of implementation. The main implementation elements of the strategy included the areas of cancer prevention, early detection and screening, additional consultant appointments in key areas of cancer treatment and care, and cancer research.

Cancers occur as a result of the interplay between genetic and environmental factors. Risk of cancer depends on age, sex, genetic make-up, where and how people live. To some extent, certain aspects of cancer risk are within our own control. There is strong evidence that lifestyle and environmental factors play an important role in the development of cancer. The use of tobacco, the excessive consumption of alcohol and unhealthy diet all contribute to increasing the risk of developing cancer.

It is important that the public are made aware of the scope for preventing many cancers by making appropriate lifestyle changes. To this end, the health promotion unit of the Department supports an extensive range of initiatives that have an impact on the levels of knowledge and awareness of the risk factors associated with many cancers. These include mass media campaigns on anti-smoking, alcohol awareness and healthy eating. The unit also provides funding to the Irish Cancer Society in support of cancer prevention initiatives, including the yearly Europe Against Cancer campaign.

BreastCheck, the national breast screening programme, commenced in February 2000. Phase one of the programme covers the Eastern Regional Health Authority area and the North Eastern and Midland Health Board areas. Screening is being offered free of charge to all women in the target age group of 50 to 64 years of age on an area by area basis. In the period January to March 2001 approximately 2,700 women per month were screened at the BreastCheck units and approximately 700 women per month were screened on the mobile unit. Less than 1% of those screened are admitted to hospital for further management.

The board of BreastCheck has reviewed progress to date and informed me that they are pleased with the uptake of women in the areas screened so far, with uptake having virtually reached its target level of 70%, while meeting the quality parameters set and providing evidence of a significant level of screen detected cancers. The successful roll out of the programme is dependent on a number of factors, including the availability of appropriately trained staff. BreastCheck offers suitably skilled radiographers the opportunity of working in state of the art facilities as well as an attractive employment package. The board has taken a number of initiatives to address the current shortage of suitably skilled radiographers, including an international advertising programme. We suffer here from a historical lack of planning in terms of school, the provision of radiographers and so on, which is a key factor in regard to the current operation of the existing BreastCheck and the roll out throughout the country.

BreastCheck in conjunction with the school of diagnostic imaging at the faculty of medicine, UCD, have also set up a post-graduate diploma in mammographic imaging, the first of its kind in Ireland. This joint initiative aims to increase levels of mammographic trained radiographers in Ireland and share the experiences of BreastCheck with other mammography services. The board of BreastCheck plans to carry out a feasibility study nationally on the availability of skilled staff for the programme and this is expected to be complete in a number of months. They expect to have a recommendation to me later this year regarding the extension of the programme to the rest of the country.

Senators and Members of the other House have consistently asked for the extension of the programme. Coming from an area where the programme is not available, I share such enthusiasm and desire. However, it is important to caution that this is not about optics but about real services on the ground. We must ensure the backup services are in place to meet the protocols, guidelines and procedures outlined in the charter that underpins BreastCheck. Subject to availability of radiographers, it would be relatively easy to roll out screening throughout the country but it would be grossly irresponsible to do so in the absence of backup facilities to treat women detected to be treated and so on. We must get this programme right and it must be good quality from day one. So far progress is being made on that front. However, I have repeatedly said to the board that as soon as they come back to me in terms of the roll out of this programme, I will be anxious to pursue it nationwide.

Breast screening has a significant part to play in reducing morbidity and mortality from breast cancer in the country. I am committed to the extension of BreastCheck to ensure that women throughout the country have the highest quality breast screening services available to them. This involves not just screening but the availability of quality symptomatic services so that an equally high standard of hospital care is available for those who may require it following a screening detected cancer.

BreastCheck is providing an excellent, intensely quality assured service for screened women who believe they are healthy and for the treatment of the women who, through screening, are discovered to have breast cancer. It is essential that this service is matched by an equally excellent service for those with symptomatic breast disease. As the plans for the commencement of BreastCheck progressed, it soon became apparent that the symptomatic breast cancer services in this country were not provided in the manner which would or should lead to the best outcomes for women. International experience tells us that women who are treated in a multi-disciplinary centre, where all the relevant medical expertise is on one site and where there is a minimum number of patients with similar disease treated by the same team, have a greater chance of long-term survival and have less of a chance of their disease recurring than those treated in smaller centres.

Having regard to these concerns, my predecessor, Minister Cowen, requested the National Cancer Forum to review symptomatic breast disease services nationally. The forum established a sub-group to undertake this task. The report on the development of services for symptomatic breast disease was presented to me in April last year. I accepted the broad thrust of the report and established an advisory group to meet with all the health boards to advise and assist in formulating regional plans for the implementation of the report. It must be recognised that there were concerns raised in many areas because of a perceived notion that certain smaller hospitals around the country would be downgraded if they did not maintain their mammography services. I must stress to the House that this report was not about the downgrading or closure of any hospital or service. The report is about the reorganisation and development of breast disease services in centres of excellence to ensure every effort is made to reduce the number of women in this country who die from breast cancer every year.

Many politicians were involved in campaigns throughout the country. Unacceptable fears were whipped up which did not allow us to present to the people the real rationale and motivation behind what we are doing which is about better outcomes for women. I have provided £4 million in this year's Estimate for the development of seven centres in approximately six health board areas, for example, two centres in the Eastern Regional Health Authority, one in the Midland Health Board area, one in the North Eastern Health Board area, one in the South Eastern Health Board, one in the Southern Health Board and one in the Western Health Board. Funding was provided to these health boards because of their state of readiness. We examined if we gave money to health boards whether their plans were sufficiently advanced to spend it in 2001.

I wish to put on the record that I am not happy with the entire development of the services throughout the country. Some health boards have moved faster than others and some have been too slow. It is now six months since I provided the funding and progress is patchy throughout the country. The Eastern Regional Health Authority had consultations with the five hospitals named in the report and they are now apparently preparing a submission for me. Substantial funding has already been allocated in the 2001 Estimate for the provision of services. Health boards will have the capacity to spend some of the money in terms of infrastructure and so on.

The Midland Health Board has been given funding but it has not yet developed the services. The North Eastern Health Board is still considering the issue even though it was given substantial funding. Initially the health board indicated that Drogheda was the preferred location. However, a vote took place two weeks ago and it was decided that Navan would be the location but that is a matter for the health board. In any event, money has been made available to that health board since last December. The South Eastern Health Board is well advanced, is in a position to draw down the money and has had consultant appointments sanctioned and so on. It was one of the first health boards out of the traps in this regard which is one of the reasons it was selected. The Southern Health Board had no difficulty accepting the broad thrust of the National Cancer Forum report, therefore, we did not have to deal with the same issues as in other health boards. I am advised it is also in a position to draw down the funding. It has drawn up plans in the different units. The Western Health Board recently submitted a plan in regard to the £1 million allocated to it. Like other Members, I am impatient to get these centres up and running. It is only by establishing these centres of excellence and getting them up and running that people will realise the rationale behind them.

Phase one of the national cervical screening programme commenced in the Mid-Western Health Board in October 2000. Under the programme, in the region of 67,000 women aged 25 to 60 years of age will be screened, free of charge, at minimum intervals of five years. The question of extending this programme to the rest of the country is currently under consideration. This is being done in conjunction with the chief executive officers of the health boards and the expert advisory group on cervical screening. I will revert to the House at a later date in relation to the role of the cervical screening programme nationally.

As the Seanad will be aware, there were a number of key consultant appointments committed to under the national cancer strategy. There have been 55 additional appointments since the strategy. At this stage, all of the commitments made in the action plan have been met and additional appointments were made in the areas of medical oncology, histopathology, haematology and palliative care.

New consultant medical oncology appointments have been made or approved in the following areas – the Eastern Regional Health Authority, the Midland Health Board, the Mid-Western Health Board, the North Eastern Health Board, the North Western Health Board, the South Eastern Health Board, the Southern Health Board and the Western Health Board. New consultant haematology appointments have also been made or approved in the following major health board areas – the Midland Health Board, the Mid-Western Health Board, the North Eastern Health Board, the North Western Health Board, the South Eastern Health Board, the Southern Health Board and the Western Health Board. In addition I have provided funding of £2 million this year to the Eastern Regional Health Authority for the further development of oncology and haematology services.

New consultant histopathology appointments have been made or approved in the following areas – the Eastern Regional Health Authority, the Mid-Western Health Board, the North Eastern Health Board, the North Western Health Board, the South Eastern Health Board, the Southern Health Board and the Western Health Board. New consultant appointments in the areas of palliative care have also been made or approved in the following areas – the Eastern Regional Health Authority, the Mid-Western Health Board, the North Eastern Health Board, the North Western Health Board, the South Eastern Health Board and the Western Health Board. In addition, funding has been provided to the Midland Health Board for a palliative care consultant.

In relation to the specialist palliative care services, the National Cancer Forum advised that as these important services were at an early stage of development in this country, it would be appropriate to obtain detailed advice on their further development. The Government's action programme for the millennium contained a commitment to develop a national palliative care plan. In this context, a national review of palliative care services was undertaken under the chairmanship of Dr. Tony O'Brien, and a report has been prepared which will be published in the near future.

In addition to the aforementioned consultant appointments, there have been additional consultant appointments resulting from the national cancer strategy as follows – two new consultant posts approved in the speciality of radiation/ clinical oncology at St. Luke's Hospital, Dublin, and additional consultant surgeon appointments with special interest in breast disease and gastro intestinal disease in various locations throughout the country. All of these posts have been sanctioned as a result of an identified need and in a strategic manner. Most of the posts have been filled or are at an advanced stage in the process.

Statistics available from the national cancer registry show that the number of primary treatments for cancer have increased significantly year on year since 1994. In 1994, there were 12,682 primary surgery treatments for cancer. By 1998, this had increased to 16,470. The number of patients receiving chemotherapy/hormone treatment has also increased significantly from 3,796 in 1994 to 4,974 in 1998. These figures refer only to treatments given for the initial disease and not for any recurrence or for palliative purposes. HIPE data shows that the total number of treatments for cancer has increased from 36,442 in 1997 to 50,063 in 1999. Over that two year period alone it goes from 36,000 treatments to 50,000 treatments. That is a clear indication that we are providing more treatments and that people are now getting treatments that they did not get before. This increase is indicative of the fact that more specialist consultants were treating cancer patients and reflects a more active and aggressive approach to the management of cancer.

A substantial increase in drug costs has resulted from the more complex treatment options offered to patients. This was not envisaged when the strategy commenced and following consultation with the chief executives and regional directors of cancer services I have made additional funding of £6 million alone this year for this specific purpose.

Radiotherapy is a highly specialised and capital intensive service, requiring specialist personnel including, for example, therapeutic radiographers, nurses with training in oncology and technical and engineering support staff. A minimum throughput of patients is required in order to maintain and develop the specialist skills required for the service. Because of these considerations and the complexity of radiotherapy services, the national cancer strategy recommended that radiotherapy services should be provided from two supra regional centres. The two centres currently providing radiotherapy services to cancer patients are St. Luke's Hospital, Dublin, and Cork University Hospital.

The strategy recommended that the case for providing a radiotherapy service from a third supra regional centre at Galway should be kept under review. I am pleased to report that the Government acted quickly on this. My predecessor, Deputy Cowen, did this in assessing the case and took the decision to provide a service at Galway at an estimated cost of £10 million. The radiotherapy service there will be provided as part of the overall phase two development at the hospital. This is currently under way.

In addition to this major investment in new radiotherapy facilities, the existing services available have also been benefiting from a major injection of resources. I announced an important investment in radiotherapy and other cancer services in Cork University Hospital, with the allocation of £12.5 million for this purpose. The development will include a chemotherapy day unit, two state of the art linear accelerators and advanced CT simulation facilities. Together with approval for the appointment of two consultant medical oncologists, the improvements will ensure that the service for cancer patients in this area is in line with the best available internationally.

The State's largest radiotherapy centre at St. Luke's and St. Anne's Hospitals opened in June 1998, having undergone a major redevelopment funded by a capital investment of over £20 million. Last year, two additional consultant radiotherapists were appointed to the hospital as part of the ongoing process of developing services there.

I established an expert working group with the National Cancer Forum to examine the future requirements of radiotherapy services nationally. The work of this group is at an advanced stage and I expect to receive its recommendations in the coming months. That is one of the remaining key issues that has to be determined. It can be seen from the background of the strategy three or four years ago that no more than two or three were envisaged. Now the sub-group has been established to look at cover for other regions across the country and how they might link in to the supra regional structure.

In terms of research, the effective management of cancer requires a fuller understanding of its causes and in this context cancer strategy funding was provided to the Health Research Board to co-ordinate cancer research projects. The signing of the NCI all-Ireland memorandum of understanding in Belfast in October 1999 by the National Cancer Institute of the United States, Northern Ireland and the Republic of Ireland gave cancer research and international co-operation in the area of cancer further impetus. This tripartite agreement facilitates the sharing of information on cancer treatment between the countries involved with particular emphasis on epidemiology and cancer registries, scholar exchange and clinical trials. The recently launched all-Ireland cancer statistics is a joint report on the incidence of and mortality from cancer on the island of Ireland and is part of this initiative. I am pleased to inform the House that I have provided funding of some £500,000 this year to enable these developments commence. This initiative will contribute in a significant way to the understanding of cancer and thus to its effective management.

As previously mentioned, the second National Cancer Forum established last year is currently examining a number of areas for priority development including the establishment of evidence based guidelines and care pathways for the management of patients with cancer. This will ultimately lead to uniformity in cancer care through out the country which will result in a reduction in mortality and the delivery of more effective and efficient cancer services.

Seanad Éireann will gather that I am well aware of the need for further investment in cancer services and will continue to identify this as a priority. The national cancer strategy has to date achieved a widespread enhancement of the range and quality of cancer services available and a major improvement in equity of access to these services. We must continue to look ahead, however, and to examine ways of building on the success to date by continual improvement and investment. It is also important that cancer needs will be addressed in the context of the ongoing bed capacity review and the impending new health strategy.

I cannot over-emphasise my commitment to the further development of cancer services in this country. Cancer is a scourge on this society as it is in societies the world over. While it must be recognised that significant progress has been made in the development of our infrastructure and services for the treatment and prevention of this disease, I am equally aware of the need for the continued concerted effort in this area. It is my intention to continue to work with the National Cancer Forum and health agencies to ensure that those people requiring cancer treatment services will have available to them a high quality, equitable service that matches the best available anywhere in the world.

I welcome the Minister to the House. It is obvious to anyone who read through what he has said that there is a genuine commitment by the Government, and this Minister in particular, to address the issue of cancer in an effort to ensure that the principles underlining our cancer strategy are fulfilled. We have given adequate resources to the cancer strategy area. We see improved quality of life as one of the key principles and equality of access as another. We see greater co-ordination between all of the services provided as an added key principle.

I wish to comment particularly on the work that has been one of the most successful initiatives – the appointment of the cancer liaison nurses throughout the country. Anybody who looks at the work these nurses do on a daily basis, in terms of working with patients with cancer and with families trying to live with a patient with cancer, has to accept that these nurses do a job that can never be adequately paid. Their commitment and dedication to service and their love of their work is something society is lucky to have. I do not believe there is anything like it in any other part of the world.

Moving on to oncology services, it is absolutely super that the Minister has recognised the importance of providing the necessary funding to support the cost of drugs needed for oncology treatment. I am not as familiar as the Minister with the various consultants and the work they do. Aggressive and innovative treatment has been introduced to Ireland in various centres of excellence, which has made the whole country a centre of excellence. If we match that with funding for continually developing research, we will lead the way as regards cancer treatment services.

The Minister pointed out the huge increase in the numbers of those receiving treatment in the last two years. People are getting treatment which has never before been available and they are surviving cancer to a greater extent than ever. A diagnosis of cancer from a doctor is no longer a harbinger of coffins and funerals. We are learning to live quality lives despite cancer. We are beginning to look after our children and older people.

I wish to take a moment to compliment some people. On an evening like this, it is very important to recognise the fine voluntary work done to raise funds for various cancer strategies. Given this evening's discussion, I think particularly of the national breast cancer research unit based in Galway which works under the direction of Professor Fred Given. A superb fund-raising team has, on many occasions, provided funding for various initiatives when it could not be attracted from the Department of Health and Children. One initiative I was delighted to see was a minimally invasive breast surgery treatment machine, the first such machine in Ireland and the second or third in these islands. If this group had not raised funds for the people of the Western Health Board region, the machine might not have arrived until time had passed and funding arrived from the Department. The work of this group deserves to be recognised.

I am glad the Minister mentioned bed capacity for oncology services as it shows he is on top of this issue. Continuing investment in chemotherapy and radiotherapy is challenging hospitals as extra beds are needed. The effectiveness of oncology services is taking up extra beds that were previously used in other areas. Better treatment and quality of life for patients mean more resources are being used for a shorter period of time, which is a challenge for hospitals. Other areas of hospitals are being affected, which is why the review of bed capacity is badly needed. I hope the 450 beds in the Western Health Board area which have been applied for will be provided.

I recognise and compliment the hard work of the former Minister for Health and Children, Deputy Cowen, in relation to the radiotherapy unit in University College Hospital, Galway. It is vitally important that the work be completed. I spent the afternoon with someone from Galway who has been receiving radiotherapy in Dublin from Monday to Friday for each of the last six weeks. It is wonderful that the west will have a radiotherapy unit soon. As everyone knows, those affected by breast cancer are often mothers, the stable force at home. Women are getting breast cancer younger than ever and sufferers often have young children. If a patient is in Dublin for four or five days each week, who stays at home to look after the children, to cook meals or to look after the house? We need to bear this in mind at all times when looking at breast cancer strategy and overall cancer strategy and I know the Minister does.

Unfortunately, Galway Corporation recently rejected plans for a new private hospital which was to have wonderful features made available to both private and public patients, according to doctors. A new application has been sent to the planning authority and has been recommended by the manager. I hope that the go-ahead will be given on this occasion. I would welcome a greater relationship between public and private hospitals so that if diagnostic services or other expertise are available in a private hospital, they will be shared for the benefit of public patients in the surrounding area. I understand that such a commitment has been made in relation to ongoing developments in these areas.

The Minister would be disappointed if I concluded without mentioning the development of Merlin Park Hospital, although I admit it is not related to the cancer strategy.

Is the Senator referring to orthopaedic services?

This is very close to the cancer strategy. As oncology services in UCHG are developing so well, one of the challenges in Galway is to ensure that medical work is done in the central hospital and that elective work can be done in a suitable area in a hospital that is not from the dark ages. I appreciated the Minister's visit to Galway. I hope we can convince whoever needs to be convinced that particular investment is needed in the Merlin Park facility. I thank the Minister for his time and for the effort he has put into this strategy. It is obvious from his comments this evening that we are doing our best to strengthen the cancer strategy. Nobody will ever say that enough is being done, but we are doing our best.

I accept the Minister's apology. Senators would like to have been to the book launch and I am sure the book makes interesting reading as regards mortality rates. It is unfortunate that the Minister did not hear what I had to say earlier, but I will summarise quickly. I want to underline two key words in relation to this strategy – management and planning. I accept the Minister's commitment to the strategy and I know he is keen to get multi-disciplinary clinics up and running. The plan is very ambitious and will be monitored carefully. It is being done in the context of the Florence statement.

I contacted Europa Donna and saw a super service in St. Bartholomew's Hospital, which is a public multi-disciplinary hospital. The consultants in the hospital were as accessible to the patients as the nurses. The team was integrated totally and was working wonderfully in the heart of London. I was fired with enthusiasm at the time, having seen a multi-disciplinary team and facilities in action. We are in line with our European neigh bours, following the Florence statement that all women should have access to fully equipped, dedicated breast units. I know the Minister agrees with the statement, as a result of which European guidelines regarding a multi-disciplinary approach and multi-professionalism emerged. The statement demanded that national Governments establish and accredit breast units in accordance with guidelines, an aim I know the Minister shares.

I was a little perturbed by the Minister's comments two weeks ago regarding the women's health strategy. He stated that he accepts the broad thrust of the systematic services report, which suggests to me that he may not agree with some of its detail. I wondered whether there were aspects of it that the Minister did not accept or whether it was just a question of the language.

I was referring to the broad thrust.

I understand that.

Obviously at local level there will be some detail.

Sometimes that suggests that there is some difficulty in the detail. I am glad the Minister has clarified that.

I am concerned about the cost. There is no doubt that this will be a very costly project. For equipment alone it will be £280,000. This refers to a basic level of equipment for one unit, and it does not include personnel. I calculate that this is .25% of the cost of Stadium Ireland. I cannot help but be political and say that if the equipment is .25% of the overall costs of Stadium Ireland, I would urge the Minister to put the money—

We are putting money in.

Not when one thinks in terms of what could be done if we had access to the sort of funding that will go into Stadium Ireland. There is no doubt that the Minister would not have to push so hard. This will be very expensive. The core personnel alone include clinicians, breast surgeons, radiologists, pathologists, clinic nurses, medical oncologists, radiation oncologists, radiographers, clerical staff and administrative officers. To those must be added essential personnel, including plastic surgeons, clinical psychologists, palliative care, physiotherapists, occupational therapists, clinical geneticists and pharmacists. This is ambitious and will involve huge numbers of personnel.

When the Minister says consultant appointments have been made or approved, I worry about the term "approved" and about the timespan. This issue must be prioritised to an enormous degree. The mid-west has been left out. Understandably, the Minister has dealt with areas where the regional directors are proactive and the health boards are more able than in others. However, I am concerned – I am sure the Mini ster is too but he cannot interfere because it is a health board issue – about the North Eastern Health Board where everything was signed, sealed and delivered and then, out of the blue, the report was recommended for approval and it was decided that the centre would move to Navan. I hope this will not be replicated in other regions.

To take the Mid-Western Health Board as an example, I can understand why it would want a mammography unit in Ennis. I see no problem with having existing services there. However, we need a strong information campaign not just for personnel to explain the reasoning behind the recommendations, and not just for the general public, but for health board members. We really need to do a tremendous public relations job on what these centres will do. Given the mortality rates of women with breast cancer, health board members have to be made aware that the basic line is health, and that they cannot be parochial. The Minister might ask me how I would feel if it happened in the Mid-Western Health Board area. I am not on the health board, but that does not mean I would opt out. I hope there will be no prevarication and no politicking with what I believe is the most important issue facing the Minister in dealing with a killer disease.

On the question of how women feel, there is still tremendous reticence. I go to women's group meetings and advocate that they should have smear tests, breast checks and all the rest, but I would not be first in. We are not talking about socio-economic groups. All women have this awful fear and they cannot wait two or three days for a result, whether positive or negative. It is a situation of horror and shock not just for themselves but for members of their immediate families. It is extremely important that we should have the centres up and running as fast as possible.

I wish the Minister well in what he is trying to do. I hope he and the Senators on the Government side who spoke tonight will be actively involved in pushing the Minister for Finance to ensure that this is not put aside, because it is an ambitious project. There are 13 areas where multi-disciplinary centres will be established, and they are saving lives. There are other areas of health where that cannot be done, for example in the case of lung cancer because one is so far gone. Early detection is so important – one can actually save a life because of the availability of screening. We do not have it in the mid-west, nor do we have breast check facilities or radiotherapy. It is shocking that we have to travel so far. They are all deterrents.

Although I feel very strongly about this, I do not intend calling a vote because we agree in principle with the amendment. The Fine Gael group will be monitoring the pathway by which the Minister follows on what he has said here. We want action. We want planning and management, and we want to see the centres up and running as fast as possible.

Amendment agreed to.
Motion, as amended, agreed to.