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.