Seanad Éireann debate -
Wednesday, 16 Apr 2003

Vol. 172 No. 13

Cancer Treatment Services: Statements (Resumed).

Ms Feeney

I, too, welcome the Minister of State back to the House. I am touched at the nice tone of the debate today, which represents how we all feel about cancer and the treatment services provided for it. It is only right that we should all be singing from the one hymn sheet and it would we wonderful if we could focus our minds on the best possible results for patients suffering from the dreadful scourge of cancer.

I commend Members on the Opposition benches, people like Senator O'Meara and others who have chased the Minister for Health and Children, as we have. I like to think that we all do that for one simple reason, to get the best possible outcome. It saddens me when it becomes a political football, but I am glad that most Members contributing today are not using it as such, and that we all seem to be coming from the one side.

I agree with Senator Feighan that cancer is a very emotive issue. It is a horrible, aggressive illness that affects all our lives and the lives of our families. I commend Senator Feighan on the excellent presentation he made in this House today at a difficult time for him personally.

I am delighted that the Minister for Health and Children, Deputy Martin, has seen fit to extend the BreastCheck programme to the entire country. I am especially delighted that many areas in the west like Galway, Sligo, Roscommon, Donegal, Mayo and Leitrim are to have the facility of a mobile unit where screening can be carried out. I support Senator Henry when she talks about the unique nature of generic cancers and how there should be special accommodation made for people who find themselves in that position.

It is about six weeks since we had a debate on breast cancer, and I covered quite a lot in that debate. I will not reiterate that debate or what my colleague, Senator Glynn, has said. I will talk about the services available from the North-Western Health Board in my constituency and in particular what is available in Sligo town.

A year ago my constituency was fortunate enough to secure the appointment of a medical oncologist, Dr. Paul Donnellan, and the lives of hundreds of men, women and children in the area served by the North-Western Health Board have changed dramatically. It is a huge development in the delivery of cancer care, a huge improvement over the situation 18 or 24 months ago, and a fine service. The Minister of State spoke today about the focus on patient-centred treatment. The unit we have in Sligo is small but very effective. I say small because I know that in the near future more beds will be sought.

The North-Western Health Board region has the services of two oncologists, one in Letterkenny and one in Sligo. I recognise the fact that cancer treatments are better delivered in centres of excellence. Senator Feighan may have been misquoted by my colleague – he actually said in "centres" rather than in "areas". We get the best delivery of such treatment, a fact adverted to by the Minister of State when he said it is not realistic to expect delivery of such a service in 30 acute hospitals. Everybody recognises that.

Sligo now has chemotherapy services available for all types of cancers, and travel to Dublin is necessary only for radiotherapy. In the not too distant future it is to be hoped that patients from the north-western area may have to travel only as far as Galway for that treatment. I am glad the days are gone when people had to make that terrible journey from Sligo and stay overnight, being very ill and away from the loving comfort of their own families and homes. We never want to return to such stories, because we had them regularly in the media, and I am glad we have moved on and are now capable of delivering such excellent treatment in our own areas by multi-disciplinary teams, the best of professionals.

I have no hesitation in saying that what Dr. Paul Donnellan is delivering in Sligo for the North-Western Health Board would be on a par with what is delivered in London, Paris or New York. Five hundred new patients have been seen by the medical oncologist in just over a year since he was appointed. Before that, every two weeks an oncologist from St. Luke's Hospital travelled to Sligo and saw people on an out-patient basis. That situation was never acceptable and I am glad it does not have to be relied on now.

I am also delighted to tell the House of the appointment of an oncology-trained lady pharmacist in Sligo, the first of her kind in my neck of the woods. Such oncology-trained pharmacists are rare, and they are under immense pressure, and over-worked. I am delighted too to report on the excellent nursing staff in the area, and on the numbers of nursing staff in the oncology unit who have an oncology diploma. No doubt this is partly because it is much cheaper for nurses and professionals like them to live outside the capital city of Dublin. Sligo and other areas in rural Ireland have certainly benefited from this.

The Sligo unit is small, with 14 beds. I have visited it and have been hugely impressed by the high level of care and the excellent service provided by the multi-disciplinary team. Those of us from the area are certainly delighted with our day-ward, our in-patient ward which allows patients stay on an overnight basis, and with our oncology-trained pharmacist.

The Minister for State touched on the area of clinical trials, and I am glad to see investment in that area. In Sligo, sadly, we have not yet got that far, and we need a second oncologist, or perhaps another oncology-trained pharmacist before we can embark on that. The clinical trials investment is an excellent initiative.

The North-Western Health Board has spent €1.2 million on chemotherapy drugs last year. It is a service which is getting busier all the time, and I would ask the Minister of State to keep an eye on that area, and note that in order for an excellent service to be provided, it must be adequately funded.

Like Senator Feighan, I welcome the smoking ban that the Minister for Health and Children, Deputy Martin, has been talking about. I am not a smoker, but I know that when I frequent a public house, I wake up the next morning feeling absolutely terrible. The Leas-Chathaoirleach is smiling, but the feeling is not due to the effects of alcohol, it is due to the passive smoking I have to endure.

An Leas-Chathaoirleach

Is that fairly frequent?

Ms Feeney

Very infrequent. Like Senator Feighan I would like to commend and acknowledge the hard work of the hospice in the North-Western Health Board area.

Senator Henry spoke about young girls and women smoking, and the ageing effects it has on their skin. I am delighted she mentioned this, because as the mother of two teenage daughters, I abhor the fact that they both smoke. I turn a blind eye and do not allow them to smoke in front of me, but I can now go back and tell them the wonderful news Senator Henry has imparted.

Ms O'Meara

I thank the Leader, in her absence, for arranging this debate. I thank the Minister of State for coming before the House for the debate. As one of those Senators who requested this debate, I acknowledge the early response to that call. This is an issue on which all of us have strong feelings, both as public representatives and individual citizens, with regard to the pervasive frequency of illness and mortality from cancer. Like Senator Feeney, I welcome the broad range of the debate, particularly in relation to the causes of cancer and the issues of prevention and screening.

I differ from Senator Feeney as to whether we are all singing from the same hymn sheet because it is clear that this is not the case. On this side of the House, we do not believe enough is being done in relation to cancer care, particularly with regard to the inadequate provision of resources, despite the claims we hear every day. I totally reject the line which ran through the Minister of State's contribution and through that of the Minister for Health and Children, Deputy Martin, in the debate on cancer services in the Dáil last night. The message was that we cannot have a centre of excellence at every street corner, as if we were looking for an airport or, indeed, a centre of excellence in every village and town. Clearly, people are not seeking such provision.

Mr. B. Lenihan

Some people expect that.

Ms O'Meara

Absolutely not. As one who has campaigned for extension of the BreastCheck programme, I have been told on more than one occasion, for example, that there cannot be a centre of excellence at Nenagh General Hospital. That was never requested; what is being called for is an adequate level of service. People expect, as is their right, to have the best level of service which Ireland, as a wealthy country, can supply. People are at a complete loss to understand the reasons for reports on radio and television news bulletins which state that 150 beds are to be closed in the Mater Hospital and that there will be job cuts in the health services.

Although a huge amount of money has been spent on the health services in recent years, I was recently contacted – this is a true story – by a woman who was in a state of desperation following a call from St. Luke's Hospital, for the sixth week in succession, to inform her that her father, who was suffering from throat cancer, could not be admitted as there was no bed available. As a nurse, the woman in question could see a deterioration in her father's condition. Last Saturday, in Nenagh, a woman told me that, on the previous day, her father had been diagnosed in Nenagh General Hospital with a suspected brain tumour. Efforts to have him admitted to Cork Regional Hospital for a biopsy were unsuccessful, nor was there any indication as to when he could be admitted. Those are factual cases which demonstrate the reasons people are so angry that they are taking to the streets in protest.

A person from Nenagh would not expect to be treated in Nenagh for cancer of the throat or a suspected brain tumour. However, they would expect to be treated as soon as possible rather than being left waiting indefinitely without any indication as to when their parent will be treated. Although this is a wealthy country, we have not got our priorities right. The Minister of State referred to the national health strategy published approximately two years ago. However, the necessary funds are not being put into the implementation of that strategy. That is the factual position.

Let us give credit where it is due, however, specifically on the extension of the BreastCheck programme. I congratulate everyone who campaigned for the extension of that programme, thereby shaming the Government into extending it. I do not blame the Minister for Health and Children, Deputy Martin, for the non-extension of the BreastCheck programme, I blame the Minister for Finance and the Taoiseach for that failure. It was only a question of money. The plans were in place and everything was ready to roll out. All that was needed was the allocation of funds. Some 48 hours before a march in which I was privileged to take part – leading a women's group from North Tipperary which had campaigned on the issue – a Government announcement, clearly under pressure, was made.

As everybody knows, €27 million is a relatively small amount by comparison with what is being spent under other budget headings. People would point to sport, in particular. I do not begrudge expenditure on sport, but we must get our priorities right in that regard. In a previous debate on the need for breast cancer screening, I quoted a figure which the BreastCheck organisation had given me to the effect that in the 55 to 65 age group in North Tipperary alone, there are currently 45 undetected cancers. Accordingly, in the 22 months interval before the screening programme is rolled out, there will be 90 undetected cancers. I hope all of those will be detected by the screening programme. This indicates the urgency of the situation, the importance of screening and the value for money which it provides. Clearly, early detection of cancer will result in substantially less expenditure on medical care and expertise, quite apart from the personal, family and community trauma associated with the later detection of the condition at a stage when it could be fatal.

In the Dáil debate last night, Deputy Gormley quoted a WHO report which included a shocking prediction that, within the next 20 years, there will be a 50% increase in the incidence of cancer, largely due to environmental factors. It is well known that cancers occurring in the west are quite different to those which occur in China and Japan. This points directly to the conclusion that cancers are actually linked to environmental and lifestyle factors. That, in turn, raises the issue of prevention and lifestyle. We need to make greater investment and work much harder on prevention, not only in relation to smoking, although that is the more obvious issue.

I add my voice in strong support of the Government's initiative in relation to smoking in public houses and public places. That is an essential initiative, having regard to the number of deaths from smoking-related illnesses each year. I understand that a majority of patients in St. James's Hospital are there because of smoking-related illnesses. It is not good enough that we, as legislators, should allow a situation to continue whereby people's health is so seriously affected and, indeed, the public purse is adversely affected when we can do something about it. Let us do something about it.

As an ex-smoker, I share the growing concern about smoking among younger women, in particular, although I did not take up smoking in my teenage years. One might suggest I should have had more sense. However, I did, at least, give up the habit. Evidently, there is a certain glamour or culture surrounding cigarette smoking. That should be addressed in terms of advertising campaigns.

Mr. B. Lenihan

Senator Henry pointed out that it does not prolong a person's glamour for very long.

Ms O'Meara

Indeed, it does not. However, one does not believe that when one is 17, 18 or 21 years of age. When one starts to see wrinkles at the age of 32 years, one might start to think about it. The most powerful message to a smoker is received when someone he or she knows dies. Young people should be brought to places like St. James's Hospital to see people with emphysema dying from cigarette smoking in order that they make the connection between smoking and its end results. It is hard to get the message across to young people but great work is being done by groups such as ASH. Nonetheless, more needs to be done to de-glamourise cigarettes and alcohol. Merely printing "smoking kills" on the side of cigarette packets is not enough. We need to look at the bigger picture.

I will leave the detail of the issue of radiotherapy services in the Mid-Western Health Board area to Senator Finucane because he is so eloquent on the issue. As a public representative in the area, I receive regular correspondence on the issue from health board officials at the planning end, practitioners and senior medical personnel to tell me we should have radiotherapy services there. Therefore, if the Minister of State accuses me of localism in referring to the mid-western region, he is also accusing the entire medical infrastructure of the area. I am curious to hear his response to this.

While it is important that people receive the best level of service and many wish to attend the Mater Hospital or Beaumont Hospital, it can be a massive inconvenience for those who are ill and their families to negotiate Dublin's difficult traffic conditions. This underlines the issue of the concentration of services in particular parts of the country. There is a case to be made for a greater spread of such services, a point which I hope will be taken on board.

I also hope we will see the report on radiotherapy services soon, because the recent leaking of reports is an insidious practice. We have seen the drip-drip effect in the leaking of the strategic rail review and other reports, which causes an unhelpful level of anxiety in the community. We need to get the big picture. While it is helpful to employ experts to produce a report, when one is investing huge sums of public money in health, one must get it right rather than fumbling around on the edges. People need to know the reason decisions are being made. I agree with the Minister of State that we should have the best quality services in the best locations, whether they happen to be in Dublin, Cork or Limerick, but it is important to understand the rationale of the argument. The best way to do so is to get the reports published and widely disseminated to ensure the debate on the level of service continues.

Strategies and reports are good and important but if they are not backed up by funding, they are meaningless. They gather dust on a health board office shelf and may eventually be taken out to compare current circumstances. Most critical is the level of funding the Government is prepared to commit, not only to cancer services – although they are hugely important and what we are discussing – but also health services generally. The Minister of State referred to the importance of primary care in the cancer care area.

I commend those who work at every level in cancer services, from nurses to consultants. I agree with the Minister of State that there have been huge advances. One must pay tribute to the work of the hospice movement in humanising and putting care at the centre of terminal cancer services. An elderly man told me that he recalled his uncle being sent home from hospital many years ago dying with cancer. He lived in the adjoining house to his uncle's and, as a child, could hear him screaming in pain. People have horrendous memories of how things were in the past but those days are gone and should be replaced by an era in which we expect the best quality service. It will take some time to get there but we should see more progress and, in particular, more priority funding by the Government.

I thank all those who work in cancer care services, whether they are fund raisers or care givers, consultants or doctors because the quality of care provided on a one-to-one basis is truly exceptional. It makes such a difference to any family affected by this terrible affliction.

Dr. M. Hayes

I welcome the Minister of State and sympathise with him because he has an almost impossible task, particularly when dealing with a hugely emotive condition such as cancer.

Like Senator Feighan, I hope everyone will stand firm on the smoking ban in licensed premises. Like many other Senators it appears, I spent a good part of my youth working in pubs and although I have never smoked, I am waiting for it to catch up with me. Employers owe it to their employees and are obliged under health and safety at work regulations to give them a safe working environment – the strongest argument for the ban. When the Minister of State examines these risk areas, he might also examine the promiscuous use of sunbeds. Perhaps promiscuous is the wrong adverb to use because I refer only to the health effects of sunbeds, rather than any other effects.

Ms O'Meara

No one would need a sunbed on a day like today.

Dr. M. Hayes

I congratulate the Minister of State on the frankness of his contribution. As Senator O' Meara has underlined, it is important that we have an open debate on this matter and that people begin to understand the nature of a strategy and its basis. I hope he will stick to his strategy. It is easy to respond to pressure and distribute money and resources in penny packages around the place but if one has a strategy which is being unrolled and will ultimately cover the whole country, it is preferable. People should reflect on the fact that it is not just a question of money, it is a question of getting people to work the system within a timescale. One cannot pluck oncologists from the trees. They are scarce.

There is a tremendous dilemma in this form of health care, almost more than any other, of balancing access with quality and correcting for equity. Most would go for quality but there is also a need to understand the problems of people at a distance and try to make services such as mobile screening as accessible as possible.

There is a need to maintain a concentration of intensive phases of treatment. It is well noted in international literature that the two year and five year survival rates are much better where there is a concentration of people. It is not just a question of maintaining skills or the volume of work; the interaction between people in different disciplines is important. People are coming across new things all the time. This is particularly important when dealing with some of the more obscure or less commonly met forms of cancer.

The Minister of State might find it useful to take a look at the provision in relation to cervical screening, in particular among young women. A connection has been made between the increase in sexual activity among young women and some forms of cervical cancer. Given their age and the possibility of longer survival periods, it might be worthwhile looking at that area. We should take a hard-nosed look at all screening programmes from a health economics point of view. Some of them are more valuable than others. One can spend a great deal on identifying one single case but that simply diverts resources from other areas.

It is important to put in place good diagnostic infrastructure to ensure rapid results of tests and shorter waiting times for imaging and so on, particularly when dealing with a disease where early intervention is important. The stories of people having to wait for treatment sine die is soul destroying.

I would have liked to hear more reference to the hospice movement which is an important element of cancer services. People tend to think of the interventionist element of treatment but palliative care is also important. The primary care system in the North is delivered differently. My sister died of cancer last year. She died at home with dignity and in peace with a huge input from the palliative care services. It is so much better than having to wait around in hospitals.

People must realise the Minister of State will not be able to maintain more than a small number of centres. If he is lucky he will have three to start with, but he might never have more than seven or eight. People need to know the difference in survival rates in small centres and large ones. I am not much into league tables but I do think patients are entitled to this information. I am entitled to know whether I will get better care in hospital A than in hospital B. If those sorts of figures were known, people would tend to vote with their feet.

I am glad the North-South linkage has been referred to. People like Professor Johnson are doing important work in that regard. It might also be sensible to talk about more active liaison between hospitals in the North and the provision of services here in the north-west and north-east in particular. That might be of assistance to some people.

I was glad to hear Senator O'Meara speak about the support needed by people working in this area. That is also true of those working in the palliative care and terminal care areas. Those who work in intervention often see improvements in their patients' health, while others work with people who they know will die. Those carers need a great deal of help and support.

I am not particularly into passing the buck to the Minister for Finance for every shortcoming in the health service. It is facile to say more money would solve the problem. There is no point in prioritising unless one realises some things are not priorities. This issue is of sufficient priority to be ordered within the health service. It is a cop-out to say we must get more money to enable us to do this. It is an important service which deeply affects the lives of so many people, families and communities. There will never be easy answers. There will always be trade-offs between excess and quality of service. The best we can do is ensure people have access to high quality services. That is a price worth paying. I wish the Minister of State well and thank him for coming to the House today.

Mr. Finucane

I wish to share time with Senator Brian Hayes.

Acting Chairman (Mr. Leyden)

Is that agreed? Agreed.

Mr. Finucane

I am glad to renew acquaintance with the Minister of State. I raised the issue of radiotherapy with him last November and again this February in an Adjournment debate. I know he is aware of my concerns in relation to the absence of such a service in the mid-west region.

The leaking of the contents of the expert review group report, which has been anticipated for the past two years, did not surprise anyone in the mid-west region. It has been leaked that the three radiotherapy centres are to be located in Dublin, Cork and Galway. I know strong attempts were made by Waterford and Limerick to secure the location of such a facility in their areas. A deputation from the Mid-Western Health Board, including officials and members of the board, was due to meet with the Minister yesterday. The deputation was to be accompanied by people from the Oireachtas and I am sure this issue would have been high on the agenda of that meeting. The meeting has been deferred because the Minister for Health and Children was busy in the Dáil and could not meet them.

Senator Maurice Hayes said the provision of services comes down to money in many cases. That is true. What is being put forward in the mid-western area is what has been advocated by the Government for some time, the public-private partnership concept. We have a population of approximately 350,000 in the mid-west region. The Minister of State will be aware of the Caiman-Hyde report prepared in 1995 which said that a population base of more than 300,000 should have two linear accelerators and a radiotherapy facility. In this case, planning permission has been granted on the campus beside the oncology unit at the regional hospital.

We are fortunate to have the Mid-Western Hospital Development Trust, a trust organisation which provides a great deal of funding for developments in the mid-western region, including the regional hospital. In this case, it was prepared to provide up to €2 million for capital equipment. What then would the Department be required to pay?

It has been quantified by the Mid-Western Health Board that the staffing resource to run this unit would cost €1.5 million, if it were to be granted now to run for a year, based on current trends. In the scale of spending, that would not appear excessive when compared with the costs incurred both as a result of many people in the Mid-Western Health Board area having to travel to Dublin, a distance in many cases of 150 or 160 miles, and by St. Luke's Hospital which at times has problems providing its great services. In many cases the people from the region I represent receive treatment between 5 p.m. and 9 p.m.

It is completely contradictory to all aspects of palliative care that a person with such an illness should have to travel a long distance. In many cases these people have families and must farm out their children while they are absent in Dublin for treatment, which often takes only a few minutes. There is a need to look at the logic of that and ask whether it is desirable that this should happen. In many cases people refuse to undergo a lumpectomy in Dublin, and instead undergo a full mastectomy in the Limerick Regional Hospital rather than have to travel to Dublin for further treatment. That is regrettable.

I can give case histories, which have been given to me by the Mid-Western Health Board, encompassing young people as well as older people with different forms of cancer. In those cases there is a considerable delay before radiotherapy treatment starts, often four to six months. Where a person who has cancer was probably receiving chemotherapy initially, to be followed by radiotherapy, can we imagine the uncertainty that must prevail in their mind because of the long delay involved?

This is a new millennium and Ireland has advanced, and it is about time we recognised that the most important issue is health. When I see the liberal dispensing of funding, particularly lottery funding, I often wonder if somebody examines whether we are getting value for money or whether the importance of quality of life is factored in.

I want to read one telling statement from Cancer in Ireland 1994 to 1998 which will probably crystallise what I have been saying. On the treatment of cancer in Ireland, this states:

With one or two notable exceptions, differences in treatment patterns between the various health boards were not statistically significant . The most notable exception is the lower percentage of lung, breast and lymphoma patients receiving radiotherapy in the Western and Mid-Western Health Boards.

The position has not changed since. It is logical, on the basis of geography and everything else which stands for best practice, for a radiotherapy unit to be based in the mid-western region. It would be a retrograde step if the Government did not consider the rationale of the persuasive arguments which have been put forward. The Minister of State, Deputy Lenihan, already knows my sentiments in this regard and I have expressed them on many occasions. I feel very strongly about this issue and I will continue to highlight it.

Mr. B. Hayes

I welcome the Minister to the House and thank Senator Finucane for sharing time with me. This has been a very well-informed debate. I have been listening to it in my office and I have been very impressed by the contributions.

I want to make two interventions. The first is on the issue which Senator Finucane was discussing and which Senator Maurice Hayes raised. I am slightly at variance with my colleague and I suppose that is because the Seanad allows one to think in a more independent way than the constant party-political knockabout which takes place in the other House. The health services are decimated because of the appalling concentration we place on the issue of politics and geography in deciding how we spend money. Our primary objective in all of this, whether it is the provision of services for cancer treatment or other treatment, must be best practice and quality service to ensure we spend the money wisely.

There should be no difficulty bringing people to the kind of specialist services we provide for people today if there are good access and transport links. The dilemma is that every region wants the best possible service. That cannot happen in a country the size of Ireland. It is a dilemma which every Government must face because of the understandable lobbying which takes place in all the regions. The mid-west has a good case, particularly the Limerick region because of its population base, but not every region can have those services.

We as a country must move on. If we are serious about providing the quality services we need, we have to ensure not only that those services are spread throughout many parts of the country but also that they are specialist services and that there are good transport links to get people to those services, particularly in the case of oncology and radiotherapy services for cancer. We must disconnect medical politics from politics generally. Too often we devote too much time to the issue of politics and its connection with the best possible spend from our money, and that is a real problem which we must confront.

Second, I have long since held the view that the Government must launch a huge campaign on testicular cancer and prostate cancer. The Minister of State, Deputy Lenihan, will be aware that because of the problems of getting many older men to doctors, and of confronting them with the high incidence of prostate and testicular cancer, people are needlessly losing their lives. We have to move, first, to a screening process – I think a pilot screening process is already in place – which would ensure that we build up the capacity and the confidence of men to go early to get screened for these conditions. Second, we must embark on a massive advertising campaign to encourage men to get these tests done at an early stage. Too often these diseases are not caught early enough and if they were, much better outcomes could be achieved.

I agree with Senator Maurice Hayes's comments about the hospice service and the support it gives to families and people who are dying of cancer. It would be wrong in this debate not to refer to the wonderful work which takes place. I have seen it myself in my own family. I want to record my thanks to the people who do such a marvellous job in caring for people who will confront the ultimate test through this appalling disease. Our thanks and support should go from this House to those who do such tremendous work in this area.

Mr. Dooley

I join my colleagues in welcoming the Minister of State to the House and in recognising the excellent work which he, and the Minister, Deputy Martin, are doing in this area. There is no doubt that health generally, and particularly cancer, is an emotive area for very obvious reasons. When people are diagnosed, or presented with a terminal diagnosis, it can be quite difficult for them to accept the situation and therefore there is a recognition that this issue must be treated sensitively. Sometimes I suppose perception takes over from reality, and the Minister of State has addressed that in terms of what is happening with the strategy going forward.

Clearly there is a problem with cancer in this country. I think we all recognise that. Some 20,000 people develop cancer in Ireland each year and 7,500 people die from the disease each year. This is quite a horrifying thought but it is a reality of which the Government and the Minister are well aware. It is also true that we as a country have a higher proportion of cancer fatalities than a number of our near neighbours and this obviously creates some concerns for us. The statistics are quite a staggering, but I believe that the Government and the Minister are striving to remedy this problem at a much faster rate than many of their critics are giving them credit for. Therefore let us accept the fact that the system is not perfect. Nobody in this House believes that it could be rendered perfect overnight, and no doubt none of the countries in close proximity has a perfect system either.

What is really in question is the progress being made. There is no doubt that progress is being and has been made. The Minister and others have detailed a number of the initiatives which have been put in place over the years. Certainly this Government and the previous Government have not been found wanting in that regard, but it would seem that some people refuse to accept that this fantastic progress is being made on an ongoing basis.

Since the launch of national cancer strategy in 1996 considerable strides have been made in terms of the provision of cancer treatment services. Since 1997 approximately €400 million has been pumped into this area. This money has been invested by the Government. If this is put in perspective, it represents an increase of approximately 1250% on the £25 million that had been originally planned to be spent during that period. As the Minister of State indicated earlier, the Government has allocated a sum of €29 million, in this year alone.

Critics will say that we have spent a vast amount of extra funds but that we have failed to grasp the higher quality of drug treatments that are now being used by the health services. These higher quality treatments have the unfortunate drawback of costing more money, but the service being delivered and the results of that service are quite good. Much of the treatment available has enabled people to live or live longer even though a terminal diagnosis may have been given at an earlier stage. A substantial increase in this funding has facilitated the provision of some 80 additional consultants' posts along with all the necessary support staff that are required.

Eighty additional consultants in a country the size of Ireland is quite a staggering number. For this alone, the Government deserves the credit that has been forthcoming from all sides. We have had a reasonable debate and there is a consensus that a great deal is being done, although it is obvious that there is still a long way to go. There was a suggestion that the Government would have some difficulty in increasing the number of consultants to such a level, but it has done so and we need to recognise this. However, all politics is local, and I notice that the Mid-Western Health Board has only been provided with five extra consultants. I ask the Minister to consider the mid-west region if there is any additional consultants become available.

The increase in funding for various cancer treatment schemes has had a real impact on the number of people being treated in recent years. There was a 58% increase in the number receiving radiotherapy treatment between 1994 and 2000, with more than 3,800 people receiving such treatment per year. There was also a large increase in chemotherapy treatment, with a jump of up to 30% in the number of patients, from 2,694 in 1994 to 3,519 in 2000.

The Minister of State and the Minister, Deputy Martin, have played a key role in the implementation of BreastCheck, the national breast screening programme. Under phase one of this scheme, 83,000 women were screened in the eastern region, the midlands and the North Eastern Health Board area. There is no doubt that this will have a huge impact on society in the future. Many people have been identified as being at risk and, in many cases, their lives will have been saved as a result.

I note with some amusement that rather than praise the Government for the structures that have been put in place, there have been people, not necessarily in this House but in the Lower House, who have accused it of practising cancer apartheid. It would be foolhardy of any Government to roll out a scheme nationally if it had not been properly pilot-tested, did not have the necessary structures and infrastructure available for its implementation and did not have the necessary staff available to operate the service. This illustrates the importance of running a pilot programme. It allows the Government to ensure that when it comes to rolling out the scheme, the best possible service is provided.

If anything proves the practical and professional manner in which the Government has handled this aspect of the health service, it is BreastCheck. The Government made sure it had all the necessary elements in place before it committed to something that was simply not possible to implement before now. However, the Minister recently announced that the service is to be rolled out nationwide, so the whole country will be able to benefit from this excellent initiative in the very near future.

The Minister of State and Senator Brian Hayes both addressed the issue of having separate cancer treatment facilities scattered throughout the country. Since the Minister announced his intention of grouping cancer treatment units in order to allow a multidisciplinary approach, this has been found to have the best chance of treating and curing cancer. That is a fact. However, as the Minister tries to reverse the rise in cancer deaths, his efforts are being met with claims of apartheid from groups that are unhappy that a small local cancer treatment unit is not being located in their area or that there is no opportunity for the provision of an international-standard treatment unit there.

We need to consider how to proceed in the area of cancer treatment. We can either have small, ineffectual units scattered throughout the country, providing a limited level of treatment, or we can have a large, top-of-the-range facility that will act as a one-stop shop for all cancer treatment. We must consider this in terms of what the Minister has identified as the importance of an international best practice approach. We cannot have both. Ireland is a relatively small country and having 30 centres scattered throughout the country, one in each of our main hospitals, would be neither effective nor possible.

On a parochial level, I join Senator Finucane and others in supporting the imaginative proposal put forward through the Mid-Western Health Board together with the Mid-Western Hospital Development Trust for a radiotherapy unit in the mid-west region. The ingredients are there – the health board has a site and the trust is prepared to find the money. The expertise will come through a partnership with the Mater Private Hospital.

This proposal deserves to be considered – I am sure the Minister will do so – in light of the fact that it will be effectively paid for – both the building and the equipment – and that the expertise will be there. There are obvious concerns in terms of the necessity of having more than one machine in place, but that is something that can be overcome. When people come together, as is happening in the mid-west region, and deal with the health board, the hospital development trust and the local community in order to raise funds, we should encourage their efforts. There are difficulties in this case, but we need to encourage the community to assist in the provision of services. I thank the Minister of State for his attention and for the information he provided.

Mr. Quinn

I appreciate the sincerity and commitment of the Minister of State and the amount of work he has put into this. We have had a useful debate up to now. There have been suggestions, comments and criticisms, but they have been given from the point of view of recognising a challenge up to which we must face. We faced a similar challenge in 1948 in the form of TB. There was a national consensus that something had to be done, but one man, former Minister Noel Browne, grasped the nettle and stated that we had to solve the problem. It is amazing what can happen when a crusade such as this takes place. The Minister of State's heart is in the right place: the sincerity is there. We must make sure the nation is behind him and the Minister in order that we can actually do something about this.

There are some things over which the Government has no control. I met a very successful Japanese businessman some years ago. He impressed me and when I asked him how he succeeded when others did not, he said something I liked, namely, that "Whether you believe you can or you cannot, you are right". He was talking about business, but also about a game of tennis. He said that if one goes into something convinced one has no chance against the other side, one has not got a chance, but if one goes in believing one can win, one can win. All the evidence suggests that there is some link between one's commitment to succeed against something like cancer and one's success rate. Some people give up when they hear the bad news while others say they will beat it. I know a person who was diagnosed with cancer ten years ago. She lost her hair after going through chemotherapy, but she was determined to win and I believe that is why she succeeded. We do not know enough about medicine to know how this works – perhaps in ten or 100 years we will know a lot more – but there is a connection.

A publication from the Irish Cancer Society states that according to the most recent report of the National Cancer Registry, approximately 20,000 new cases of cancer are recorded annually in Ireland. The Minister of State disclosed that today. This means that one in three will develop cancer in the course of their lifetimes and one in four will die. The report also shows that the current survival rate in respect of cancer is only 43%. I know many people who assume that a diagnosis of cancer is the end. One of the jobs we can do in the House is to get across that this is not the case. There is a 43% survival rate. The Irish Cancer Registry says it is "only" 43%, but this is higher than many people expect. Very often a great deal of this is in the hands of individuals who say they can beat it. In other cases it is not.

The Irish Cancer Society further stated:

Despite these alarming statistics, there is still evidence that there are large numbers of patients, particularly elderly patients, with a cancer diagnosis who are not receiving appropriate cancer-directed treatment. There is also evidence that only 30% of people with cancer in Ireland receive radiotherapy as part of their treatment protocol, whereas the national average should be 50%.

This is a matter about which we can do something. This is not in the individuals' hands but in the hands of the State and the Minister. This is a time when the Mater Misericordiae Hospital is closing 120 beds under the watch of the present Government. I do not have an easy answer, but we should look at the national commitment to do something about it. We can win if we really believe in it.

Early detection is also an element on which we can do something. There is no information needed. As Senator Brian Hayes said, if we can encourage people to be seen early, they can get treatment and can do something about it. I met somebody this morning who told me her brother had just been diagnosed with cancer. She said that he was fortunate to have the money to go to the Blackrock Clinic to get a PET scan because if he had not the money he would not have got it. I do not know how true that is, but she was convinced that he was fortunate to be able to afford it. What sort of nation is this if survival depends on whether someone can afford to get treatment?

The Irish Cancer Society also talked about the stringent enforcement of tobacco and alcohol laws and this was mentioned by the Minister. While I do not know if sun beds are covered by any law, I did not realise the implications of using them and this information needs to be made available to the public.

Senator Maurice Hayes spoke of his experience in the North of Ireland. We keep hearing reports of certain parts of the country that have a greater incidence of cancer than others. Is this true? If so, we should carry out research into it. We keep hearing about higher incidence in counties Down and Louth and the east coast in general. Perhaps that has something to do with Sellafield. Can we not carry out research to verify that?

I read the Irish Cancer Society's submission to the Irish cancer forum, which highlighted preventive measures and awareness. Although there are some things about which we can do nothing, we can do more about those. The Minister has indicated what is happening and we are taking quite a few steps. However, we can do more.

We talked today about a massive advertising campaign to encourage people to seek information early. As part of early detection and screening, the BreastCheck service needs to be extended nationwide. While I know this is gradually happening, it needs to be done urgently. There need to be national guidelines on access. The Irish Cancer Society places strong emphasis on the need for clarity on the best practice of referring from the GP to the consultant. I gather there are different standards around the country and this needs to be addressed.

Different things can be done at individual, community and national levels. The Minister has shown his heart is in the right place and the Government is sincere and committed. We as a nation can do far more if we set our hearts to it. I got to know the Irish Cancer Society through its efforts on daffodil day a few years ago. Its work on disseminating information is only one step along the road. Having read that and identified the issue, I believe we can do more. Let us make sure we do.

Mr. Kenneally

I welcome the opportunity to make a brief contribution to this important debate. It will come as no great surprise to the Minister that my main focus will be on radiotherapy. As mentioned by other speakers, I realise we cannot have all the services everywhere. Last year we talked about putting a heart and lung transplant unit into one of the hospitals in Dublin. However it was decided not to do this because – I hope my figures are right – only 22 people required this procedure last year. I believe they were sent to the Freeman Hospital in Newcastle. If a procedure only needs to be performed once every fortnight, we will not have the expertise here to do that.

We have to give similar consideration to cancer. However, cancer is totally different because one in three people will be affected by cancer at some stage, making it probably the biggest health issue in the country. Forgetting about location for a moment, the radiotherapy services are not being provided for everybody at present. I do not denigrate St. Luke's Hospital in Dublin, which is doing a fantastic job. A very good friend of mine has spent time there and while he was lavish in his praise for the care and treatment he got, that is not enough.

We are all frustrated waiting for the report of Professor Hollywood on radiotherapy services. The Minister has been given completion dates, which have not been achieved. We are now told we will see that in the next few weeks. Although I do not know the contents of the report, there have been certain leaks.

All the oncologists at Waterford Regional Hospital tell me that the three strands of treatment available – chemotherapy, surgery and radiotherapy – must all be available at the one location. We lost an oncologist who moved to Cork because he was frustrated at not being able to treat his patients properly. I fear that will happen in other areas if we do not provide all the correct services. Everybody in the entire south-east region is at one in wanting a radiotherapy service in Waterford. That does not happen often as we are usually pulling against one another. The leaks seem to indicate this will not turn out the way we in the south-east want.

I have a difficulty with the fact that vested interests are involved in producing this report in that most of the people on the review group were located in Dublin, with a number from Cork also. I accept that is where the experts are located and we could not get them from anywhere else. However, they will look after their own patches to the detriment of the rest of the country.

It is also suggested this report will say that by about 2010 the south east region will have the population base to merit the provision of linear accelerators in the region. If that is the case, we should start working towards that now. We all know the decision about Galway was taken many years ago and it is still not there because of the huge lead in time to provide these services. Everybody accepts that if a decision was made to locate this in Waterford or Limerick it would take a number of years before everything would be in situ. There is no point in waiting to start planning until we reach the level of population necessary because it will take five to seven years after that. From the population projections we know the number of people who will be living in the region in future, so we should be working towards providing adequate services in accordance with those projections. That is only commonsense. If the Hollywood report does not recommend such a unit, then at the very least we should be working towards providing it in due course.

Minister of State at the Department of Health and Children (Mr. B. Lenihan)

I thank Senators for a constructive discussion on the causes, prevention and treatment of cancer. I am grateful for the universal welcome Senators have given to the proposal by the Minister for Health and Children to ban smoking in licensed premises and other such venues. I will report back to the Minister on that positive contribution from Seanad Éireann. Many Senators spoke of their experiences with passive smoking, including Senator Feeney, and when I entered public life I also developed a serious chest problem due to exposure to smoke in public places. Such serious problems need to be addressed.

Senator Glynn spoke about the right to smoke but the right he was looking for and did not identify was the right to clean air. I hope Seanad Éireann has played its part today in trying to secure that right for our population. All the Senators who contributed to the debate felt there should be a total ban on smoking in public places, including Senator Hayes and Senator Feighan, who began on a very constructive note, setting the tone for the debate. Opposition speakers have expressed legitimate criticisms about the health service, including bed provision, circumstances in particular hospitals and the requirements of different regions. These matters have been echoed on all sides of the House.

It is interesting to see how constructive a debate can become when it focuses on a particular aspect of the health service, such as the provision of cancer services, rather than the more generalised discussions we have had about health provision in general. Seanad Éireann is at its very best when it focuses on what we can do as a country to tackle serious medical conditions such as cancer.

Hard questions were posed and Senator Feighan kicked off on the first and fundamental question in this area which concerns the shortage of radiotherapists. It is the most difficult question that I have to address. Since 1997, two additional consultant radiotherapists have been appointed but I accept that is not sufficient given the need to develop radiotherapy services generally. The Minister established the expert review group in order to provide an effective plan for future developments. I accept that our radiotherapy services are not adequate at present to meet current and future requirements for radiotherapy treatment. As soon as the Minister receives the report, which is very close to finalisation, proposals will be developed for consideration by Government.

Senator Feighan contrasted the fact that we have eight radiotherapists in the State, while in Northern Ireland there are 12 in Belfast alone. I was taken by that fact because one of the key elements that was not mentioned in the debate concerns what the Northern Ireland authorities are proposing to do with regard to radiotherapy services. They are proposing that there should be only one radiotherapy centre in the North.

I understand that Senators have to press for particular regional claims, however. Senator O'Meara graphically described how all the general practitioners and health board staff in her area have made representations to her about the provision of radiotherapy services in the Mid-Western Health Board's area. Likewise, Senator Finucane made an eloquent plea for radiotherapy services in Limerick, and Senator Kenneally made a very legitimate claim for Waterford. In all those contributions, I was struck by the dislike all country people have for travelling to Dublin. The expert group, however, is not proposing that anybody should travel to Dublin – it is examining where these services should be located outside Dublin.

In recent years, a substantial investment has been made in Cork and Galway, as I outlined in my opening remarks. Senators, and the general public, have to look at what is happening on this island of ours. We are living in an era of North-South co-operation and in Northern Ireland it has been decided to centralise the radiotherapy services in one unit in Belfast. It is proposed to construct a comprehensive radiotherapy facility in Belfast to treat all cancer patients in Northern Ireland, which has a population of 1.7 million. Therefore, patients from Fermanagh, Derry and the Mournes will have to travel to Belfast to receive such treatment. I appreciate that, naturally, Opposition Senators will not fall over themselves to point this out to the public but I have to do so because it is relevant to the decisions we are making.

Senator Brian Hayes spoke about this subject in the course of the debate and, as someone who has been elected to represent a Dublin constituency, I feel strongly about this too. Of course we want patients to receive the very best service but that requires a centre of excellence that must not only have a critical throughput of patients but also connections with the other disciplines. That is the multidisciplinary approach that requires all the medical expertise to be concentrated in that unit to be made available to patients who require it.

In general, I welcome the quality of today's debate and I am sure the Minister for Health and Children will take into account what has been said. Many Senators expressed their great appreciation for the tremendous work undertaken by the hospice movement. In my opening remarks, I referred to the substantial State investment that has been made in palliative care in recent years. That investment can only work, however, if we have co-operation from the hospice movement, which has been forthcoming. I acknowledge the great work that has been done in that regard. I join with other Senators who paid tribute to the work of the hospice movement, which has helped the State so much.

Senator Glynn referred to psychiatric support services. The national cancer forum, under the chairmanship of Professor Redmond, is examining a new national cancer strategy to identify the key areas to be targeted, including psycho-oncology. The forum has identified a great need for this service due to the important role it can play not only for cancer patients but also for their families who are also affected when their loved ones contract such a condition.

Senator Henry cited statistics widely in her contribution, as well as raising a number of detailed matters. It was refreshing to hear her discussing men's health issues. Along with Senator Brian Hayes, she drew attention to the unwillingness of the male of the species to seek early diagnosis and treatment. That has been identified as a major problem in the development of fatal cancerous conditions. Senator Henry also expressed her concerns about the epidemic of lung cancer among women in their 50s. In fact, the Minister for Health and Children launched the SLÁN report on tobacco consumption today.

The good news is that overall cigarette smoking rates across virtually every demographic category have fallen since the first survey was carried out five years ago in 1998. I will share some of the statistics with the House because they bear public examination. The highest smoking rates are still among the younger adult population. Some 34% among those aged between 18 and 34 still smoke, which is a fall from the 39% rate in 1998, but the rate is still very high. That suggests why Senator Henry could confirm that we have the epidemic of lung cancer among middle aged women. The rate of cigarette smoking among those between the ages of 35 and 54 is 25%, which is a fall from the 30% rate in 1998. The rate among those aged 55 and upwards is 17%, which is a fall from the 20% rate in 1998. Among school-going children, 19% still report they are smokers in contrast to 21% in 1998.

Exposure to passive smoking has fallen in the workplace, at home and in public transport, but passive smoking in pubs and clubs affects 47.3% of men and 31.6% of women, another matter to which many Senators testified. There is some improvement in regard to the fall in the rates of cigarette smoking. I have no doubt that the great welcome the Seanad has given to the Minister's proposal to ban smoking in public places will give a decisive push forward on those figures and will set a tremendous public example in regard to cigarette smoking, which would help us to get those figures down even further.

There were many other points to which I would like to refer. I appreciate my time is short, but Members might bear with me.

Ms O'Rourke

The Minister of State can have another five minutes if that is agreeable.

Mr. B. Hayes

That is agreeable.

Mr. B. Lenihan

It is also important to note the matter of expenditure. Senator O'Meara raised the hard cases that exist in the health service and the great difficulties we have in this area. If we are to develop cancer services we need to invest money but we also need to be efficient in how we spend it. That is the way forward in the health services. It is not enough simply to propose new expenditures; we must engage in a critical examination of our existing expenditures.

I am glad to note from the report on surgical procedures that the cancer forum has examined oncology surgery between 1997 and 2002 in respect of a number of site specific causes, including lung, breast, pancreas and colon cancer. The forum concluded that there are too many hospitals, given the total number of procedures that are performed in our hospitals. We do not have the patient caseload to support the current organisation of oncological services. The forum has advised that the current organisation of services is not in line with international best practice. I outlined that to the House in my opening contribution and I am now giving Senators the details in greater specificity.

This report needs to be addressed at a number of levels in our health services. The medical profession must assess the report to ensure that, in a balanced way, we reform our arrangements for organising and delivering our health services. At the level of the individual health board, we will have to examine this report to benchmark each local hospital organisation against international best practice. The forum will reflect further on the data established in this report in developing the national cancer strategy.

There has been a great deal of examination in this area and much work has been done on prevention. We intend to continue the work on prevention in relation to smoking and there are other key causal factors. Senator Henry rightly raised the question of obesity as a further factor which is tending towards cancer conditions. In relation to hospital provision, there is scope for efficiencies and much scope for improvement.