Cancer Services: Motion.

Senator Paddy Burke

I move:

"That Seanad Éireann, noting:

the announcement of a National Cancer Strategy;

the proposal to develop eight centres of excellence at various locations around the country;

the intention to provide every patient with the best medical care and clinical attention;

the absence of a Centre of Excellence north of a line from Dublin to Galway and conscious specifically of the geographical challenge and population distribution of the West/North West region; and

the proposed closures at University College Hospital Galway, where the Centre of Excellence is to be located, for the month of August this year due to severe budgetary constraints;

calls on the Government to:

proceed immediately with the provision of Centres of Excellence, based on an adequate and ring-fenced budget;

proceed immediately with the provision of a satellite unit at Letterkenny General Hospital and under the responsibility of the Galway Centre of Excellence;

retain existing safe, high quality cancer services as at Mayo General Hospital and Sligo General Hospital as satellite units under the responsibility of the Galway Centre of Excellence;

ensure that all Centres of Excellence and satellite units are the subject of an annual HIQA audit; and

continue to work closely with the authorities in Northern Ireland on the development of cancer services.".

I welcome the Minister back to the House. She is a great attender here for debates on motions on health matters. I am delighted she is here to take this important motion.

I thank the Labour Party for joining Fine Gael in tabling this motion. It is a very important motion dealing with the provision of cancer services, particularly in the west and north west. The motion will afford the Minister and the Government an opportunity to reverse the decisions that she has taken, or at least to put them on hold, until the centre in Galway, in our case, is fully operational.

This motion is the same as that which was debated in the Dáil some weeks ago. I am delighted that something positive has emerged from tabling it. The Government amendment to the motion is different from that to the motion on this matter in the Dáil. I welcome some aspects of the Government amendment, particularly where it is stated that "seasonal arrangements for summer months at University College Hospital Galway do not impact on key specialties, including cancer specialties". I would like the Minister to explain that aspect because the word is out that cancer services and operational services will close in University College Hospital Galway during the summer months, particularly for the month of August. I am delighted this provision is included in the amendment and welcome the intent of it, but I would still like the Minister to explain it.

The Minister needs to clarify a number of issues regarding statements she made concerning cancer services in the west and north west in the context of the number of hospital procedures carried out. What figures did she use to support her statement that women had a better chance of survival if the treatments were carried out on the east coast versus the west coast? She made that statement some weeks ago. Can she explain the differences between the figures she gave for breast cancer procedures carried out at Mayo General Hospital and Sligo General Hospital and those given by the surgeons and those hospitals? I would like the Minister to explain the discrepancy in those sets of figures.

The Minister is doing a disservice to Mr. Barry in the case of Castlebar and Mr. O'Hanrahan in the case of Sligo because they know the number of procedures they carried out. She has cast aspersions on them by saying they have not carried out the number of procedures that they have carried out and by saying that there is a better chance of survival if treatments are carried out on the east coast rather than on the west coast and in the south. Those two issues in question are dear to the hearts of those surgeons and I hope the Minister will take this opportunity to clarify them.

The Minister also said that the people were voting with their feet and were leaving Castlebar, other parts of Mayo, Sligo and the north west and going elsewhere to have their procedures carried out. I do not find this is the case on the ground. Thousands of people marched on this issue in Sligo and 7,000 people marched in Castlebar. The women who had procedures carried out in the centres in Castlebar and in Mayo led the campaign. Those seven brave women know what has happened in their cases. They have the highest respect for Mr. Barry and his multidisciplinary team in the case of Castlebar and Mr. O'Hanrahan and his multidisciplinary team in the case of Sligo. I do know of any cases, particularly in Castlebar and elsewhere in Mayo, where people are not going to the centres in Castlebar or Galway. The Minister said people were voting with their feet already and going elsewhere to obtain breast cancer services or have procedures carried out, but I do not find that to be the case.

I do not know from where the Minister got the figures to support her claim that people have a better chance of survival if treatments are carried out on the east coast than if they are carried out on the west coast. The centres in Castlebar and Sligo are only in operation since 2000. The first five-year survival rates are coming on stream. The survival rates in the centres in Castlebar and Sligo are more than 88%, which compares favourably with any centre in the world. That is why I hope the Minister will use this opportunity to apologise to those surgeons and to clarify the position. That would be welcome.

There is also the matter of funding. I acknowledge that the Government amendment refers to arrangements during the summer months. There is chaos in Galway. There are procedures that need to be carried out other than breast cancer services.

For parathyroidectomy there is a waiting list of almost 40 patients for Galway. That hospital can carry out only three operations per week. In effect, there is a waiting period of more than six months in Galway for this procedure. This is a life threatening disease for which procedures have to be carried out urgently for the patients involved but due to pressure on theatres these procedures are not being carried out. We now have a situation where people from Mayo, Sligo, south Donegal, Leitrim and north Roscommon will descend on University College Hospital Galway after September when Mr. Barry and his team move to Galway. This is unprecedented. Can one imagine Mr. Barry and his multi-disciplinary team leaving Castlebar and travelling one and a half hours to and from Galway one day per week when he could look after patients in Castlebar because he will meet only patients from Mayo in Galway? It is a Mayo clinic within University College Hospital Galway.

I am not sure whether there will be a Sligo, Roscommon, or south Donegal clinic in University College Hospital Galway. Two beds are available for the Mayo clinic within the Galway hospital which has ten beds. These beds are operating at full capacity. That a top class surgeon and his team will travel one and a half hours each way, one day per week, to Galway from Castlebar to meet patients from Mayo when he and his team could meet them in Castlebar every week is ridiculous. Some 30 to 50 people will travel from Mayo to Galway when they could be seen in Castlebar. That makes no sense.

I wish to draw the Minister's attention to an article in the Irish Medical Times of 28 May 2008 on the Beacon centre which reads:

A new breast cancer surgery service will open in six weeks' time at Dublin's Beacon Hospital. . .

The breast surgery service will augment a "comprehensive cancer care services" which has been operating at Beacon for the last year . . .

Delivery of an outreach service is envisaged under the Government's cancer plan. University of Pittsburgh Medical Centre (UPMC), which manages Beacon, runs a cancer facility in Pittsburgh, which is outpatient-oriented and operates in conjunction with 43 satellite centres. Service Level Agreements for cancer were reached for UPMC's joint venture Whitfield Clinic in Waterford in February last year and for the Beacon Hospital in January 2008. The beds in Beacon's oncology day unit can be turned around more than once daily. . .

In Western Pennsylvania, 90 per cent of patients get cancer care close to their homes, through a network of 23 centres. Ninety five per cent of our patients can get care at locations less than 20 minutes from where they live.

That is all we are asking for in Castlebar and Sligo. We are seeking an outreach and a satellite of University College Hospital Galway. We understand that and we are fully in agreement with the centre of excellence in Galway.

The Minister has an opportunity to at least delay the removal of services from Castlebar until Galway proves itself. She has said in the past that these centres will provide a better service to patients than at present. The people of Mayo, Sligo and the north west will not get a better service in Galway at present than they get in Castlebar or Sligo.

I ask the Minister to examine this issue closely and delay the removal of services to Galway. I hope she will avail of the opportunity to clarify the issues I have raised in regard to the number of procedures and the shadow she has cast over the work of some of the finest surgeons in the country.

Senator Fidelma Healy Eames

I second the motion in the name of my colleague, Senator Paddy Burke.

I welcome the Minister to the House. I take this opportunity to look at Galway and how it can serve the whole region of the north west. In that regard I will point out pluses and minuses in regard to the centre of excellence. We need an assurance that the minuses will be addressed, otherwise an adequate service cannot be delivered to the people of Galway or to the people of Sligo and Mayo. I accept it is great to have centres of excellence in health because in the area of breast cancer outcomes matter. To achieve the best outcomes, high volume and throughput count. I do not say this because the Minister has said it. It is a fact.

Galway has some excellent fundamentals in place. I will give a balanced contribution having done my research locally around the pluses and minuses. We can be proud of Galway in that, according to the national cancer control programme, more than 60% of women presenting with breast cancer do not need a mastectomy; a lobectomy will suffice. Also, more than 50% of women presenting with a mastectomy undergo immediate breast reconstruction at the same time, which is the highest rate in the country. All plaudits go to Galway.

There are aspects of Galway that appear to be ready to cope with the transition of breast cancer care from Sligo and Mayo but there are a number of aspects that are not adequate, even for Galway's hinterland. In regard to outpatient care, I am delighted with the new symptomatic outpatient unit, which opened on 16 June and which is working well. I understand there is adequate physical space there to cope with increased population. However, it is lacking in terms of staffing arising from increased patient case loads predicted from Sligo and Mayo. Extra patient caseloads from these areas will require the following staff to provide essential care: two to three outpatient nurses, one breast cancer care nurse, one radiographer, one receptionist-clerical officer and one backroom secretarial person. I did not make up those figures, they come from the unit. This staffing level will be needed to run the clinics. In addition, three consultants are needed if we are to cope adequately with the transition. In light of the staffing embargo and the ongoing cutbacks will the Minister outline her commitment to these specific staffing resources?

There is a need for dedicated beds because there is still a problem with access to beds. The care is good, the outcomes are great but the access is not good. There are no dedicated or protected beds specifically for breast cancer care in University College Hospital Galway. A centre of excellence for Galway and its hinterland, not to mention the expanded area of Mayo and Sligo, needs its own protected dedicated space, not a bed here and there.

Two new operating theatres are due to open in October 2008. We need a commitment that staffing will be provided for those theatres. These are the questions coming from the practitioners in the field in Galway.

I support my colleague, Senator Paddy Burke, on the notion of network solutions and outreach centres. Last autumn, when speaking to the main surgeon in Galway, he envisaged Galway as a centre of excellence but with network satellite centres in Sligo, Castlebar and Letterkenny to create a network solution to best serve patients' needs locally where that was possible. Like my colleague, I look forward to the Minister's response on that issue. It is critical that no centre should be closed until the new resources are provided. I seek an assurance that adequate capacity and staffing are in place before local facilities are removed, not only for the women of Galway but for those in the entire north west. That is only fair. Otherwise it will make a joke of the philosophy of centres of excellence.

I am concerned about the capacity of the laboratory in University College Hospital, Galway, to cope with cervical smear testing volumes. I am most disappointed with what has happened there. The Minister is aware that there has not been investment in the laboratories in UCHG to help it achieve accreditation. I accept, however, that it is on a list for that purpose. Last autumn, due to inadequate levels of staffing to meet the volumes of cervical smear tests in UCHG, smear samples from around the country were refused. I saw the letter myself from a professor. The laboratory needed only two extra staff to cope with the increased volume of smear tests. Instead, the Minister chose to outsource that work to private laboratories that had only 80% to 85% reliability compared with 95% in Galway. The laboratory's only failing was that the Minister did not invest to upgrade it. If the Minister is committed to Galway as a centre of excellence for breast cancer care, she should tie in other aspects of women's health in order that it can be a centre of excellence for cervical smear testing also.

My final point relates to the important area of broader transport infrastructure to support UCHG as a centre of excellence. I do not know whether the Minister is aware that traffic-wise, Galway is a bottleneck. The Galway Independent is a local newspaper that profiles an important person in Galway every week. People are asked what are the best and worst things about Galway and each week it is reported that the worst thing is the traffic. I received a significant number of representations about the need for a right-turning arrow to allow people to turn into UCHG. On several occasions I have waited in my car for up to three changes of traffic light to gain access to the hospital. One can imagine what that is like for sick patients in their cars and the inconvenience caused to families visiting patients, sometimes from a long distance away. I question whether there is joined up thinking between the Departments of Health and Children and the Environment, Heritage and Local Government to make Galway a true centre of excellence capable of serving the entire area. I look forward to the Minister’s reply as it is important to people in Galway and to women across the north-west region.

Senator Geraldine Feeney

I move amendment No. 1:

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

"—strongly endorses the National Strategy for Cancer Control in Ireland;

welcomes the HSE's National Cancer Control Programme and the designation of eight specialist centres;

notes that the Programme was developed on the basis of extensive international evidence which shows that cancer survival rates are greatly increased when patients are treated by teams of experts in dedicated centres that deal with a high volume of cases;

endorses the approach taken in the Programme that cancer survival must be the priority in treating patients;

notes that under the Programme patients will usually only require a single visit to the specialist centre for their initial diagnosis and a second visit for their surgery, and will continue, as at present, to receive follow-up chemotherapy treatment at their local hospital, such as Sligo General;

emphasises that the priority now is to implement the Programme fully and accordingly, supports the work of Professor Tom Keane of the HSE and his team of clinical leaders in so doing;

is satisfied that Professor Keane is making significant progress on the development of the designated centres and that adequate funding has been assigned for this purpose;

notes that the designated centres will be subject to regular audit;

welcomes the support of leading cancer specialists and non-Governmental organisations, including the Irish Cancer Society, the Marie Keating Foundation and Europa Donna in the development and implementation of the Programme;

notes that seasonal arrangements for the summer months at University College Hospital Galway do not impact on key specialties, including cancer specialties;

notes that on an exceptional basis arrangements have been made for the provision of breast cancer services at Letterkenny General Hospital, due to the unique geographical circumstances applying to Donegal; and

urges all concerned to work closely with the authorities in Northern Ireland on the development of cancer services serving the population in border counties."

I, too, welcome the Minister, Deputy Harney, and thank her for making herself so accessible to us in the Seanad.

The national cancer programme was rolled out last September. It was announced that there would be eight centres of excellence; four in Dublin and one each in Cork, Waterford, Limerick and Galway. It is not new to say that the people of the north west, especially Sligo where I live, were most disappointed that Sligo General Hospital was not on the list. Together with my Fianna Fáil Oireachtas colleagues I immediately set about working to try to change that. We met with the Taoiseach, the Minister, Deputy Harney, and Professor Keane. We hoped something good would come from the process. We were seeking a satellite unit for Sligo General Hospital. During last February and March, Mr. Kevin Barry, on behalf of Mayo General Hospital, announced that the hospital wanted to be part of the programme that is to be rolled out in Galway. That announcement dealt a severe blow to our political efforts. The last hope of Oireachtas Members in Sligo was to approach the then Taoiseach, Deputy Bertie Ahern, who was leaving office, and ask him to speak to Professor Keane on our behalf. He reported back to us in April that no exception would be made for Sligo General Hospital or anywhere else.

Acting Chairman (Senator Feargal Quinn)

Senator Feeney should be allowed to speak without interruption, please.

Senator Paddy Burke

It is a fact.

Senator Geraldine Feeney

Professor Keane is one of the best international experts in the world.

Senator Fidelma Healy Eames

Just like Professor Drumm.

Senator Geraldine Feeney

Professor Keane has addressed all the political parties in recent months. He did not spare himself with anybody. I am sure the Fine Gael Party, the Labour Party, the Green Party, the Progressive Democrats, and whoever else met him were equally impressed with his presentation as we were when he addressed the Fianna Fáil Party.

Sligo will lose its assessment and surgical units but it will maintain its chemotherapy service. The plan that has been rolled out for Sligo is that we will have a Sligo clinic in Galway or if a Sligo patient opts not to go to Galway, he or she can choose to go to any of the four centres in Dublin. Sligo patients will have dedicated beds, a dedicated theatre and dedicated clinic times in Galway.

Senator Fidelma Healy Eames

They are not in place at the moment.

Acting Chairman

Senator Feeney should be allowed to speak without interruption, please.

Senator Geraldine Feeney

If medical personnel in Sligo sign up to the strategy, as medical experts in Mayo have done, they would travel to Galway one day a week and look after Sligo patients who will return to Sligo for the rest of their treatment.

It is worth pointing out that only one out of every 15 women who are screened for breast cancer will be diagnosed with breast cancer. That means 14 out of 15 women will have to make only one visit to a breast care clinic. Professor Keane indicated that the fact we are transferring surgery to a cancer service is no criticism of surgeons in regional hospitals but the evidence is striking that the best way to provide a service is to concentrate resources.

If a woman has a mastectomy she should be offered reconstruction surgery. Sadly, in Sligo General Hospital there is no facility to offer reconstruction surgery because we do not have plastic surgeons. I can speak only for my area but I think the same is true of Castlebar. When the breast surgery unit is moved from Sligo to Galway, I urge the Minister to ensure the move is as smooth as possible bearing in mind patients' interests and safety and making sure they are to the fore. We all have a part to play in rolling out the cancer programme. Not only politicians but also doctors must come on board. They cannot let personal interests stand in the way of best practice and patient care. Politicians and doctors have a role to ensure patients in this country have the same chance as patients in the rest of the developed world. It was interesting to hear Professor Keane talk about the rise in lung cancer incidence that is expected in coming years, especially in young women. He feels that breast cancer is now under control and breast cancer services will be rolled out in the eight units. The cancer control programme will then try to bring prostate cancer under control. Rare cancers will be treated in two of the units here in Dublin.

I ask the Minister to ensure everything will be ready in Galway when the time comes to move services. I know there will be two ring-fenced beds. Women, particularly those presenting with breast cancer, have the best chance of survival and achieve the best possible outcomes if treated in a dedicated unit. Paediatric cancers are dealt with under one roof. Women need to be treated by dedicated breast cancer surgeons who are dealing with all sorts of surgeries and know what to look out for. Mr. Tim O'Hanrahan is an excellent surgeon and we are very proud to have him in Sligo. However, if something happened to him in the morning — God forbid — there would be no one to replace him because he is a general surgeon with an interest in breast surgery. When he goes on holidays I am sure no one is there to take over the vital work he does. Therefore it is important for us to move our unit. I commend the Minister's work and that of the national cancer control programme, which I fully support.

Senator Joe O’Toole

I am delighted to welcome the Minister to the House. In my 21 years in Leinster House I have never learnt anything in political debates on the health area. Anything I learn about the health service I learn through talking to people working in the service or through listening to experts on the radio. I find it very difficult ever to find that middle line and I tend not to involve myself in such debates. I believe this is the first one to which I have contributed in approximately two years. I wish to place on the record of the House that I feel the Minister is doing a job above and beyond what might be expected of her. That may be an unusual comment to make in these Houses in these times. However, that is my view on the matter. She has taken on an almost impossible task and I feel a huge sense of sympathy in how to get it done.

One of the biggest problems people like me have in trying to take a middle line on the matter is that we have nothing by which to measure it. At the beginning of a year I would like to have a very clear understanding of the objectives for the year, the key performance indicators and how we would assess them at the end of the year. That would allow me to say this was the objective we set out to achieve and this is how far we got in areas such as waiting lists, the number of operations performed, diagnoses or whatever. That is the information I need. I have found it very difficult over the past two years with the various things that happened in the hospitals, including misreading of X-rays etc. Given that we are talking about the running of a business with a management structure, I should be able to ask for the risk register for that particular institution, wherever it may be. I would be able to inform the Minister within one hour where responsibility lay or if someone was responsible. That is a major issue for me. I would like the risk registers of hospitals to be available. There is no reason for them not to be public documents and readily accessible. Over the course of the year the assessment of those documents should also be available.

The radio interview with Nuala O'Faolain, who, sadly, has died since, impacted on us all. In the middle of that interview she talked about the way she was treated in a New York hospital. I am sure we all listened to it in different ways. I listened to it on the basis of all we have heard about the Irish health service. We are supposed to be aspiring towards the system that is available in the United States. Even though she had adequate health cover, she was allowed to lie on a hospital trolley or some such without any counselling. Someone stuck his head in the door and told her she had terminal cancer. That is as bad a story as I have ever heard of the Irish health service.

The terms of the Fine Gael motion are not unreasonable and I look forward to hearing how the Minister responds to it. Intuitively like everyone in the House, I find it difficult to live with the fact that there is no centre of excellence in the northern half of the country. The Fine Gael motion accepts much of what already exists and seeks something which should not be beyond practical response. On the issues of travel and quality and how they relate to each other, there is no contest. It would be an abrogation of the Minister's responsibility were she to agree to establish a centre of excellence in a place where the scale, experience or amount of work being done did not reach the threshold to ensure quality. While I completely agree with the point, I do not know the figures. However, I certainly agree with that basis of making a decision.

I will give an example of what I am talking about. I spoke to a woman who was about to have minor heart surgery — some people would say there is no such thing as minor heart surgery. As she had full health insurance cover she went to a specialist in a hospital in Dublin. It was an unusual operation that involved inserting some sort of electrical impulse. Senator Quinn and I would be attracted to this. The specialist told her that the hospital had a 92% success rate, which is greater than nine out of ten. He advised her that a hospital in Bordeaux — the best hospital in Europe for the procedure — had a 99% success rate. Knowing her own situation and having received advice from the surgeon, she went home and made a decision with a full armoury of facts. In the event she decided to have the operation in Ireland, which, thankfully, was successful. That is the kind of benchmarking or quantitative detail that is not normally associated with the health service. As an Independent Senator I need more of those kinds of data to make an honest assessment.

Is the same level of scale needed in the four areas of diagnoses, surgery, chemotherapy and radiotherapy to make every centre of excellence effective? Could the surgery be in Galway and the treatment in Castlebar, for example? If we are moving, is it required to move everything?

The Fine Gael motion refers to "the proposed closures at University College Hospital Galway, where the Centre of Excellence is to be located, for the month of August this year due to severe budgetary constraints", which is utterly unacceptable. I cannot find any justification for establishing a centre of excellence and closing it down in August. The Minister has spoken previously about the comfort of people who need to travel long distances. There is no point in dealing with it in a way that politicians then complain about how much it cost us to send people in taxis in the previous year. I have no difficulty sending people in taxis during a year if they are sick and need that kind of cover, we can justify the expense and it is done on a properly tendered basis. I saw the Minister writing when I first mentioned benchmarks and I will finish by saying it again. What people like me need are the benchmarks to assess progress so at the end of a year we can say whether we have made progress towards the key performance indicators and quantify it. That would be very helpful.

Senator Dan Boyle

Recently Professor Tom Keane, who has been appointed to implement the national cancer strategy, met the Green Party parliamentary party as part of his ongoing consultation around the country. I found him a very impressive individual. He has come, with his experience and background, from British Columbia. The benefit of that experience is meant to be directly applicable here. British Columbia is a region of Canada that has a population similar to the island of Ireland and it implemented a similar type of regional cancer strategy. Interestingly, it chose to have eight centres, although British Columbia is geographically many times size the island of Ireland. The geographical distances between those centres are far larger than that between any of the proposed centres here.

Professor Keane made a few interesting points, the first being about the nature of reforming and changing a health service. Additional resources were made available in the cancer care services of British Columbia by altering the types of expenditure. The number of beds was reduced and rather than putting that saving back into the general fund, it was reallocated into diagnostic services, community care and after care services. We have not used this approach enough in reforming our own health services. Having someone like that in the Irish health service gave me great confidence that we might be heading along a direction we have not had an opportunity to go in the past.

Another point Professor Keane made, and this has not been communicated strongly enough, is that while we refer to the eight centres as "centres of excellence", he thinks that is not the most appropriate term. He is talking more about centres of specialist care in cancer treatment. Using the word "excellence" creates an expectation that wherever the centre is located has something super-duper, so to speak, and way in excess of anything available. In making that point he stressed that what does not seem to be getting across is that these centres will have the entire range of services that need to be available for cancer care, including all the diagnostic aids, continuing care, after care and surgery, which is the most important element of what will happen in the centres. That does not mean parts of those elements will not exist in the rest of the country. The surgery will take place solely in the eight designated centres but elements of the diagnostic, continuing and after care will continue to take place in the various parts of the country where they now happen. While much of the debate focuses on the eight centres, it continues to be a national strategy because all elements of cancer care will be provided somewhere, somehow in all parts of the country.

The implementation of this strategy is at the heart of the motion. Part of my family background is in the north west. My father was an islander from Donegal. He passed away of cancer eight years ago. He received all his treatment in Cork and was fortunate to do so. He had three incidents of cancer over a 20-year period and the incident that led to his passing away occurred while he was holidaying on the island. The manner of his passing indicated to me the degree to which there tends to be a regional imbalance in health care services. It is more difficult in a remote area such as an island. When my father passed away the island's ambulance was not in operation. He was carried from one part of the island to another on the back of a trailer with hay and was taken off the island by the lifeboat. He was then transported 30 miles from Burtonport to Letterkenny General Hospital. Fortunately for him he was in a coma during all this but it somewhat lessened the dignity of his passing away and represented to me an illustration of the need to have high quality health services wherever we are on this island. This was eight years ago and things have improved; we have a better ambulance service. However finely tuned the health service is in dealing with areas of low population and remoteness, it will be difficult to provide a high level of service.

This is at the heart of the national cancer strategy. We have to ensure that wherever people live they get the treatment they need how and when they need it and that the questions of geography and dignity are properly addressed. A fair attempt is being made to do that. There is a lacuna in the north west. Not only is it a remote part of the country, the population of the area is smaller than in other regions. Those factors have to be assessed in deciding which locations are best. I would like to think the cancer strategy is being structured with a Letterkenny node and that the possibility of increased links between the health services in the Republic and the North of Ireland would offer opportunities, especially with Altnagelvin Hospital in Derry. This makes perfect sense in the context of a holistic approach to health care on the island. If there is a medium-term strategy that could put this in place, it will address the gap that remains because of the remoteness and the population size in that part of the country. Thought is being given to that. It is difficult to marry our health system with the National Health Service in Northern Ireland but we are talking about cross-Border bodies and wherever such synergies can be achieved, we should work towards doing so.

I have a personal reservation on the application of the eight centres from the current, more diverse approach to cancer care service distribution. In the south west, Cork has been identified as the regional centre and moves are taking place to move cancer care services from Tralee to Cork. There is a logic in that. Cork has been designated and Tralee is part of the south west region. I find it difficult to understand the logic of the fact that the Cork regional centre is to be located in one campus in Cork University Hospital, CUH. This means some services currently being provided to a very high standard in the South Infirmary-Victoria Hospital, which already seems to have a liaison with the construction of the BreastCheck facility which is located next to it, will be moved across the city to CUH. If someone can explain to me why that has to take place and in the given time span, it would make more sense to the people of Cork. I understand Cork is the regional centre but I am not necessarily convinced that means location in one building. This is just a localised example of how the cancer strategy is being implemented. I accept this will cause difficulties when the regional centres are being moved from A to B.

I appreciate the opportunity of supporting the Government amendment and of asking some of the questions. We all wish to see the best cancer treatment system in the country and it is our collective intention in this House to work towards that.

Senator Phil Prendergast

I welcome the Minister. She is the Minister whom I have had the opportunity to meet most often in this House. That is a measure of the level of need to have her here regarding the health services and her commitment to coming here and giving at least an ear to what has to be said. It is very difficult to remove the emotive aspect of cancer services from the equation. I am aware that many people have suffered the loss or the diagnosis of close family members, which is difficult to deal with. The statistics on the prevalence of the different types of cancer are horrific. While I will not go into detail, it appears the very prevalence of cancer makes it seem as if it is not so horrific for the person hearing that diagnosis. This can cause another aspect of emotional loss and grieving that is probably not factored into the relationship with the diagnosis of cancer and its treatment, the therapies and the location where the best care can be given.

I take the point on when a child becomes ill. I worked mostly with very young children and babies and I know that when a child becomes ill, one would cross the world to get best service. I must acknowledge this, which is not to take from any case being made.

The strategy for cancer control in Ireland proposes to put in place a system which will see a reduction in the incidence, morbidity and mortality of cancer in comparison with the other European countries by 2015. It is a very good target to have set. We will see the establishment of eight centres of excellence which will deal with the diagnosis and treatment of the more common forms of cancer, with each centre serving an average of 500,000 of the population. There will also be a comprehensive provision for the treatment of rarer cancers in specific locations. I am fully supportive of this strategy in the context of developing and advancing expertise in the diagnosis and treatment of cancer. It would be unfair of me not to acknowledge this, having worked in the health service for so long.

While the provision of centres of excellence based on population works very well in the southern half of Ireland, this should not be the sole consideration in deciding the location of such a centre. In the northern half of the country, due to the lower population density, clients are sometimes hugely disadvantaged by the distance they have to travel to avail of treatment. A special case surely must be made in this area to make treatment more accessible to service users and to reduce the discomfort and disruption to very ill patients in need of regular treatment.

I take issue with the manner in which the eight centres of excellence were chosen. It seems that in the four HSE areas these centres will be located on the site of the existing regional hospital, which is not a particularly sensible approach. Most of these hospitals are in coastal locations and less accessible than would have been the case had they been located some distance inland. During the protracted situation in regard to the divided services in Clonmel and Cashel and the regional services in Waterford, on one occasion I was caught out when the bridge was up and I had to get to the hospital quickly because there was an emergency to be dealt with. I had to hope that the bridge would be back in place soon, which was a discomfort to me as a professional. I can only imagine the situation of the woman in premature labour, but we got there in time and everything was fine, thank God.

For service users to have to negotiate towns and cities that are already choked with traffic is another dimension when one needs to get to a hospital desperately, or when there is a concern about keeping an appointment and whether one will lose one's place in the queue. There is much to be said for having a new facility on a greenfield site. There is no reason a hospital has to be located in a town or city and it may be easier to access one on a greenfield site, both in routine and emergency situations, once the area is well serviced by roads. I accept this is not a small detail.

In the past, cancer care and treatment was provided at a local level by skilful and dedicated consultants. While Professor Tom Keane had issues with the provision of cancer care in smaller hospitals, I commend the consultants who managed to do so very successfully for many years. Thousands of people throughout Ireland were very well treated and can thank their local medical personnel for the fact they survived and got great treatment and care in smaller hospitals.

There is a valid point in regard to the consequences of a lack of experience in diagnosing cancer due to a low turnover of patients. We have seen the impact of such a systems failure on the women of the midlands caught up in the recent situation. One must not underestimate the stress and trauma caused to these women who had to undergo revision of their test results and to their families. I hope that with the provision of care through centres of excellence we will never see such a situation arise again. Awareness is a major factor in this regard. Quality audits should be in place and they should be put in place sporadically so all staff are subject to unannounced audit and should have no fear of that. I would have no fear of it.

In my own constituency, we have already seen the transfer of an excellent breast cancer care service from South Tipperary General Hospital to Waterford. It is essential that adequate groundwork has taken place to ensure the hospital has both the infrastructure and staffing levels in place to service the additional area of expertise. While the Health Service Executive denies it has a continuing embargo on staff recruitment, I am concerned that the directive in place indicating that staff may be hired within financial constraints does and will have implications for the setting up and maintenance of any new service.

Underpinning the centres of excellence, we clearly need to extend the screening process for treatable cancers, including widening the range and age groups for these tests. For example, in the case of breast cancer, it is expected that the 2,000 cancers treated annually will be reduced once BreastCheck, the national breast cancer screening programme, is fully rolled out. However, as BreastCheck encompasses only women in the 50 to 65 year old age group, it will have no impact on the 67% of cancers which were diagnosed in the over 65s. The Minister agreed this was to be extended to the age of 69 at a previous meeting of the Joint Committee on Health and Children and I hope this might be addressed in her response to this debate. The age group serviced by BreastCheck needs to be widened to include these women to ensure early diagnosis and treatment and, ultimately, a better prognosis.

In conjunction with extending the range of available tests, I acknowledge the importance of the front-line role of the general practitioner in the early diagnosis of cancer through the identification of symptoms during physical examinations and the provision of routine screening for cancers such as prostate cancer and cervical cancer in the surgery setting.

I am disappointed to note that despite the reservations voiced by me, among others, about the possible granting of the cervical screening contract, the Minister has signed the contract with Quest Diagnostics. This was ill advised considering the misgivings raised about the company's practices. On a more significant note, this decision will have long-term implications for cytologists and pathologists in Ireland who will have reduced access to the reading and screening of cervical smears. They will be completely deskilled in reading these.

I thank the Minister for coming to the House and I thank the Acting Chairman for allowing me to contribute.

Senator Marc MacSharry

I welcome the Minister to the House and I also welcome those in the Visitors Gallery and thank them for taking the time to come to listen to the debate.

I will be opposing the motion. To clarify that, since September last I have probably been the most consistent speaker on this issue. I have had two motions on the Adjournment on the issue which have been specific to Sligo and that region. I am a supporter of the Government strategy in general in the context of developing specialist centres throughout our nation and I acknowledge Professor Keane's expertise in that regard. I obviously differ, as the Minister well knows, on a variety of points, to some of which I will refer during my contribution.

A strategy for cancer control in Ireland states: "Ireland will have a network of equitably accessible state-of-the-art cancer treatment facilities and we will become an internationally recognised location for education and research into all aspects of cancer." I am holding a map of Ireland which apparently shows a network of equitably accessible facilities. It speaks for itself. North of a line from Dublin to Galway, there will be no centre of excellence. That is simply unacceptable to the people of the north-west region. There is no situation in which we can call no representation in the northern half of the country equitably accessible. It is unacceptable to me that any aspiration would exist to have the National Health Service supply the health service to the north west of this country.

There are a number of reasons the debate over the past year has taken a number of different turns. I do not accept there is no case based on facts. This is not some local politician interested in having a rant on behalf of some glorified local nursing home in the north west. I consider myself a citizen of the north west and I believe the north west is entitled to representation in the provision of equitably accessible services. This is based on fact, not on aspiration or any political situation because this is an issue of human importance. There is a human aspect to this which must be considered.

I fully support the concept of specialist centres because they will lead to better outcomes in due course. However, if we are to purport to design a programme which acknowledges this is the case, then we must examine the statistics, even if those statistics come from the HSE, laundered through public relations companies or otherwise. Based on the national cancer registry from 1994 to 2001, cancer sufferers in the north west region had a 25% lower chance of survival. However, that is an incorrect statement. When one examines the figures more closely, one sees that the figure is 123% less 100%, which is actually 23%. In the western health board region, which includes Galway where the proposed centre of excellence will be located, the figure is 26%. The north western region was no worse than the west. However, an interesting fact to which I have never heard anyone in the HSE refer is that, according to the same document, when the fully adjusted model is taken into account, survival rates in the north west are only 7% lower than those in the eastern region. At the same time, in the western region, including Galway, the figure is 26%.

Those figures are completely out of date, as we all well know. They predate the development of Sligo Regional Hospital, based in Sligo, which is a gateway centre under the national spatial strategy and the largest urban centre in that part of the country, north of the line from Dublin to Galway. They also predate the appointment of a medical oncologist, an excellent surgeon, Dr. Tim O'Hanrahan and a multidisciplinary team in 2001, as advocated under the report of 2000 by Professor Niall O'Higgins. Nobody from the HSE is prepared to engage with the professionals on the ground until they are, in their words, prepared to "submit" and at that point, Professor Keane has told the authorities in the regional hospital representing the north west——

I will finish now and I thank the Chair for his indulgence. To date, no one in the HSE has produced evidence to show that the outcomes for patients from the north west region attending Sligo General Hospital will be improved by moving their care from a hospital that has outcomes that are better than, or at least comparable to, the best in the United States, which is the benchmark country for the entire world.

I will support the amendment to the motion. I have made it clear on many occasions in the past that I believe it is highly disingenuous of Fine Gael to come up with a motion purporting to be all things to all geographical parts. There is a case for an adjustment for one location in the north west region and that is the reason I will vote against the motion.

Senator Paddy Burke

The Senator should table his own motion, in that case.

Senator Marc MacSharry

I tabled two motions, six months ago.

Senator Paddy Burke

The Senator should table a motion, not an item for an adjournment debate.

Senator Frances Fitzgerald

It did not sound like Senator MacSharry was opposing our motion.

Senator Nicky McFadden

I welcome the Minister to the House and thank her for taking the time to be here.

I fully support centres of excellence and I particularly support my colleagues, Senators Burke and Healy Eames in calling for the retention of existing high quality services at Mayo General Hospital and Sligo General Hospital, as satellite units. I urge the Minister to ensure the centre of excellence at Galway is able to cope with the increased volume of patients. In that context, I question the notion of closing the University College Hospital in Galway for a month. How in God's name can one close a centre of excellence for a month? I ask the Minister to clarify the situation in that regard.

There have been many fatal cutbacks in the health service. Wards have been closed, operations have been cancelled and there have been enormous increases in the number of patients on trolleys. Senator O'Toole mentioned Ms Nuala O'Faolain but there are many people like Ms O'Faolain. We should never forget the story that was documented on RTE, although I cannot mention the lady's name, about the length of time she had to wait to undergo a colonoscopy — seven months. We should also not forget the people to whom Senator Prendergast referred who were misdiagnosed in Portlaoise. I hope we never see this in our health service again. It is worth noting that the situation in Portlaoise arose less than a year ago.

I reiterate that I support centres of excellence. The Minister was present during my first debate in the House. I was accused of being parochial and colloquial when I protested at the closure of services in the Midland Regional Hospital in Mullingar but I make no apology for the concern I had for my constituents and the people of the midlands generally. At the same time, I agree with the need for centres of excellence. Unfortunately, however, people are not being cared for in the way they should be. People from the midlands region must travel to St. James's Hospital in Dublin and some who are attending Portiuncula Hospital are now being told they must attend the University College Hospital in Galway, the site of the proposed centre of excellence.

I repeat that centres of excellence are the way forward because there must be a sufficient volume of cases to guarantee better outcomes. There must be accessibility and staff. How can one deliver the service that is needed if there is an embargo on staff?

I spoke in the first debate about people travelling from the midlands to Dublin, having to get the train at ungodly hours and having to get off it to be sick. This situation has not changed. There are people in Ireland who have no cars and no means of transport. During the initial debate, I asked the Minister to put a dedicated medical transport system in place. There should be joined-up thinking between the HSE, the Department of Health and Children, which we should not forget, and the Department of Transport and a central fund should be ring-fenced for comfortable transport for victims of cancer.

It has been rumoured, and the Acting Chairman will have an input into this, that there will be a transfer of services from Roscommon County Hospital and that people will be helicoptered to a centre of excellence. I am not sure whether this centre will be Galway. Can the Minister clarify that because rumours are rife?

The Minister told me that Athlone is very well-serviced bearing in mind that we have no hospital. However, 40% of the people of Athlone, the population of which is about 25,000, attend Portiuncula Hospital. There is no longer a mammography service at Portiuncula Hospital which means that 40% of the patients from the Athlone area who have cancer or a query or need even a routine mammogram must go to Galway to which they are being transferred from Portiuncula Hospital. This is a significant number of people.

I commend the oncology service at Portiuncula Hospital and hope that it will not be removed. There is an excellent chemotherapy treatment at the hospital in conjunction with an advanced nurse practitioner. I applaud the staff who provide a 24-hour treatment facility. It is way beyond the call of duty. Due to the staff embargo, staff at this hospital are under serious strain and provide great relief to cancer services in the midlands and Galway area.

In respect of cytology, my colleague, Senator Fidelma Healy Eames, referred to the fact that laboratories are unable to cope with the volumes. To me, a centre of excellence is a place where one can get a diagnosis, prognosis, surgery and palliative care under the one roof. Is that correct? In respect of cytology and people who want to get the results of smear tests, this, to me, is diagnosis and should be provided under the one roof. As a centre of excellence, the laboratory should be able to deal with smear tests. Smear tests are no longer being reported or dealt with in Portiuncula Hospital but are being sent to Antrim at huge cost. I believe that funding must be provided in University College Hospital Galway as the centre for excellence for smear tests and the reporting of such tests.

I fully support the motion, particularly the position taken by my Mayo and Galway colleagues because I am concerned about the volume, access and egress to University College Hospital Galway where there is no car parking. This very basic issue needs to be addressed to deal with cancer services and a centre of excellence.

Senator John Ellis

I welcome the opportunity to express some views in the debate here today. We must accept that the Minister has endeavoured to provide the best possible care to people throughout the country. Nothing is being done from sinister motives or to attack or downgrade any hospital. I come from an area that, along with the people of Donegal, has probably the greatest gripe regarding the fact that there is no local service available.

The first thing to which any of us looks when a member of our families or our friends become sick is where the best possible diagnostic care and treatment can take place. This is why it is accepted across the House that centres of excellence are probably the best possible way of moving forward with regard to cancer treatment.

I did not interrupt the Senator. She was the one who drew the fire so she should take it when she draws it.

People in this country are entitled to the best diagnostic service and treatment. If this can be delivered through centres of excellence, we must accept it. However, there is a role for hospitals like those in Sligo, Castlebar and Letterkenny when it comes to the further treatment and monitoring of patients after diagnosis and initial treatment, which should be pursued.

I cannot understand why some people say that it is now impossible for somebody to get to and from Dublin. I agree with Senator McFadden that there are people who do not have cars but services are being provided by the HSE in all areas. In the area I represent, the HSE will bend over backwards to ensure that somebody gets the service to get them to and from Dublin. I do not know what the story is in respect of the area covered by the former Western Health Board. I can only speak for the one with which I mainly dealt, namely, the former North Western Health Board area which still provides an excellent service to patients going to and from hospitals.

What annoys me is the fact that certain people shout for local hospitals but when it comes to treatment, they go to either the Blackrock Clinic or some of the other private hospitals in the country. This is something about which none of us wants to be hypocritical. I, like many people, pay VHI but if people do this, they will use it to the full. It is imperative that those who do not have the benefit of VHI cover get the same level of care as those who pay for private health insurance. If this is by means of the provision of centres of excellence, then that is the way we should go.

What also annoys me is the fact that some of the people who are most vocal in some of these protests have first-class VHI cover and, in many cases, will not use the local hospital. We all know that. Some believe that those who do not have health insurance should have a lesser service than those who can afford to pay for it. This is not the way the HSE or others operate. Let nobody try to tell me that we should have a three-tier system because that is what some people would like to see. I want to see the best diagnostics and surgical treatment provided to patients. If the local hospitals are in a position to do the monitoring work as people's treatment progresses, then that is the role they must play. That will not please many people but if we are to have perfection, one must have continuous work in the field in which one works and this is what the centres of excellence will do. I pay tribute to the surgeons in regional hospitals who do excellent work. It is unfair to expect them to perform across every discipline, from cancer to other surgical work. That is why there should be specialist surgery.

There are a certain number of hospitals that will carry out cardiac surgery. Everyone is happy with that because they know that going to see the senior cardiac surgeons means they will get a service that is second to none. Oncology should be the same. While people may feel aggrieved, they must consider who must be looked after most, the patient. If a family member was ill in the morning, we would be prepared to go to the end of the world to ensure the best possible treatment. That is why we have a role to play as politicians to ensure people get the best service. It might not be the most convenient service but we want the best possible service.

On radio yesterday, the famous professor made it quite clear that there were sufficient funds in the health service of this country. In some cases he felt there was waste on some treatments and the amount of professional time used by surgeons to monitor people who could be monitored as well by the local general practitioner or cancer nurses. These are the people who are being dragged back to clinics on a regular basis after full treatment and cure. They are taking up consultants' time. I felt both for and against this because if someone has been seriously ill he or she would like to continue to see whatever doctor dealt with the illness.

Many of the motions before this House are not aimed at the patient but at making political capital. This is not in the best interest of patients or the communities we serve.

Senator Paddy Burke

This motion is about the patient.

Senator John Ellis

This issue is about the patient and ensuring that patients get the best possible service and that they have access to the service on a regular, clear-cut basis, with immediate effect.

Senator David Norris

I propose to share time with Senator Hannigan. I welcome the Minister, who is very good in the way she attends the House. She cannot always be pleasant because there is usually a good dose of criticism.

I have always agreed with the idea of centres of excellence. There is a problem politically because people are subjected to intense pressure in their local areas to keep the local hospital despite best practice. Centres of excellence are important.

The question of transport must be examined but in a country this size the best treatment is the most important factor even though there are great inconveniences with regard to transport.

Educating the public and self-diagnosis is important. Professor Keane made the point that cancers which affect the throat and so on are particularly nasty. Sometimes they can be detected during oral hygiene and visits to the dentist. Unfortunately, many of the people who develop this kind of cancer do not go pay frequent visits to the dentist. There is a question of diagnosing and identifying so that it is not given inappropriate treatment.

I refer to the question of certification. There have been a series of problematic areas, including the midlands, where there was difficulty with proper diagnosis, understanding of medical scans and treatment. In the Canadian system, there is a certification process every year. The senior consultant or a higher authority issues a certificate for all doctors underneath him or her. This states that the doctor is fit to practice, has had no accidents or problematic areas and can continue for another year. That is excellent and we should do that, which would lead to greater patient safety.

If one wants to find out what works, one should examine the way people practice. I am interested in evidence that is a partly anecdotal but partly verifiable, namely, that doctors send their families to centres of excellence. Then, for political reasons, they will bellyache about the closing of the local cottage hospital. That is as immoral and wrong as politicians mixing it.

My final point relates to Roscommon. I voted "No" in the Lisbon treaty referendum and campaigned for a "No" vote. I was clear about the reasons for this, namely, bullying, opportunism, lack of democracy and the infractions in neutrality. I remember the people of Roscommon but that is not a reason to vote "No". It is the lowest form of politics to base one's campaign on some other issue.

Senator Dominic Hannigan

I join with Fine Gael in an effort to ensure these centres of excellence are maintained and not affected by potential savings that the Government may be considering. We need to see the guarantee of centres of excellence around the country.

I want to defend a current centre of excellence that people are worried will be closed by the HSE and the Department of Health and Children. The Dóchas breast cancer unit in Drogheda has made a massive impact on the lives of the women it has served and the families that have been affected by its service. Louth maybe the smallest county in Ireland but it has clocked up one of the largest number of cancer diagnoses of all counties.

If the Minister needs to make a phone call I am quite happy to wait.

Deputy Mary Harney

I am listening, I am sorry.

Senator Dominic Hannigan

Dóchas was opened in 2004 as a dedicated centre for breast cancer care and it very quickly became popular in the area. It serves patients from across the north east, from Cavan, Monaghan, Meath and Louth. It provides an efficient service for treatment and after-care with dedicated staff who get to know the patients personally. If the centre closes it will dramatically affect the lives of a great many people across the north east.

Dóchas has seen a constant increase in the numbers of patients it treats over the past few years. In 2002, it was treating 72 patients but by 2006 this had increased to 136. Initially Dóchas was told that 100 new patients per year was a requirement to remain open. This increased to 150 patients per year in order to remain open. The number of patients in treatment by Dóchas in 2007 dropped to 115. It appears that the reduction was partly because GPs were referring patients directly to hospitals in Dublin to depress the number of users of Dóchas.

In the months of January to March this year, Dóchas treated over 130 women. Inevitably more patients will be referred during the summer and in the run up to Christmas. This centre does not need to be cut. It is essential for a growing number of breast cancer patients in the north east. In one place, patients can avail of a mammogram, an ultrasound and a biopsy.

The journey for many cancer patients to and from Dublin can be an arduous one. Many may have to travel from Monaghan or Slane to Dublin, where they are totally removed from their family, making it difficult for visitors. It is an arduous journey if one is ill.

I spoke to one ex-patient of Dóchas who described the comfort of knowing her husband and family were in close proximity and could visit on a regular basis. That may not be the case if this centre of excellence closes down. Every person I have spoken to regarding their experience in Dóchas has been positive. They have nothing but praise for the treatment and staff attention they receive. People describe it as an incredible service. The quality of aftercare could not be better. It is a centre of excellence for breast cancer services in the north-east. It treats a growing number of women with every week that passes. It provides a convenient and quality service for many people in the north east. The closure of the service would be a betrayal of these people who are asking for nothing other than the best treatment for their illness. We must retain existing centres of excellence such as Dóchas.

Minister for Health and Children (Deputy Mary Harney)

I thank the House for providing me with an opportunity to speak about the cancer control plan. I will try to answer as many of the issues raised by Senators as I can.

The cancer control plan is about one thing and one thing only and that is patient survival. Ireland comes 18th out of 23 European countries in terms of survival from cancer. The only area of cancer where we are top of the class is children's cancer. Why are we at the top with regard to children's cancer? Why do we compare favourably with Europe and the US with regard to children's cancer? It is because children's cancer services are centralised in Crumlin where diagnosis and initial surgery takes place. Much of the follow-up chemotherapy takes place in 15 other hospitals. I strongly believe if the trade-off is between survival and travel, few patients and their families would not travel in order to survive or would put the local area before better survival rates.

Places in the world which have the best survival rates include British Colombia, which has the same population as Ireland and which has four centres in the southern part of the province. Senator Boyle earlier stated it has eight. I visited them because we were so impressed with their results. It is a publicly funded system. People travel thousands of miles to obtain the best treatment in Canada and so it is that it has one of the best outcomes in the world.

We are discussing eight designated centres, not eight centres of excellence. Every health service should be a centre of excellence whether it is a general practitioner's surgery or a local hospital performing minor and elective work. We are discussing having eight designated centres where all of the surgical and diagnostic specialists will work together in multi-disciplinary teams.

Medicine used to be organised on the basis that we had general surgeons. We have moved well away from this. Most surgery has begun to specialise. We want to aspire in Ireland to what they have in British Colombia, Europe, the United States and Australia which are the countries which perform best. They have breast surgeons, brain surgeons for cancer and lung surgeons. They do not have general surgeons who might do a bit of breast surgery.

This is not about the skills of any individual. No service can be organised on the basis of any individual's skill or personal commitment. We cannot have a service organised around one or two people. As somebody stated, if this person is sick or on leave we do not have a service at all. Given the population of Ireland we cannot justify more than eight centres. Some people have stated this is four too many and we should have only four centres.

Senator Paddy Burke

There are four in Dublin.

Deputy Mary Harney

However, 23 people were put together, 17 of whom were doctors and six were non-medics. These 23 people recommended to the Government that we should have eight centres and stated where those centres should be. If we take the two hospitals mentioned, namely in Sligo and Mayo, a person with brain, lung or pancreatic cancer in Sligo or Mayo already travels. A total of 52% of all the lung cancers in the country are dealt with in St. James's Hospital.

In 2007, 7,014 surgical procedures were carried out in Sligo. We are discussing moving 79 of these, which happen to be breast cancer. In Mayo, 4,816 surgical procedures took place and we are discussing moving 58 of these. We are being accused of running down the hospitals. In 2006 in County Sligo, 477 people were diagnosed with cancer. Of these, 106 were not treated in Sligo. They were treated in other places, presumably because the specialist activity did not happen there. People had various cancers which required surgery.

Patients are already travelling from Sligo and Mayo for cancer treatment — many of them to places in Dublin — heart bypasses and many other procedures. The reason people must travel is because we cannot provide multi-disciplinary specialists and by this I mean more than one individual in a specialist area. One cannot have a designated cancer centre with one surgeon in a particular specialty. It is not adequate to provide the level of cover, expertise and service warranted to justify it being a cancer centre.

We already have many people working in these centres but they are working in a fragmented way. Until recently, breast cancer was performed in more than 30 hospitals in Ireland. In some cases, only one or two procedures were carried out each year. I do not know many women who would want to be operated on by a doctor who only did one or two surgeries a year. I do not believe any woman could be convinced, notwithstanding the data which I will deal with in a moment, that this would deliver a good outcome.

Approximately one third of breast cancers lead to mastectomies. Many women having a mastectomy want to have reconstructive surgery. This is particularly the case with regard to young women but not exclusively young women. They can have this in centres with a plastic surgeon. They cannot have it in Mayo or Sligo. A woman in Mayo or Sligo who has a mastectomy and wants to have reconstruction must have a second bout of surgery. This is not good international practice and not recommended. One should only have surgery when it is essential to do so.

No matter what small group of data we take, it cannot put to one side the data from throughout the world. More than 250 medical publications support the view with regard to breast and other cancers that volume equals quality. Unless one deals with 150 new cases a year and a surgeon performs at least one new case a week, one will not get a good outcome. Recently, I was asked a parliamentary question about this data. I referred to a website which contains it. I recommend people to check it out. It continues for pages and pages and includes data from the world's best surgeons and scientists in the best organised cancer services in the world.

I would not be worthy of the job of Minister for Health and Children if I were to set this aside, take a chance and state to the women of Mayo or Sligo that they will be second best and that we will take a chance it just might be all right when we know all of the evidence states that by having a designated centre with multi-disciplinary teams their chances are so much better. What are the chances? If one is treated in a centre with a low volume where four women survive, five will survive in a specialist centre. We are telling one woman who might die that if we treat her in a specialist centre she might be the one to survive. I do not believe any health system should take this type of chance.

When the strategy was recommended, seven patient organisations recommended, notwithstanding the inconvenience to some people which we acknowledge, that we should implement it. These organisations included the Irish Cancer Society, Europa Donna, Arc, the Marie Keating Foundation and the Irish Patients Association. It also included local cancer organisations. These organisations did not recommend that we proceed as quickly as we could for any reason other than that they knew it would deliver the best results and outcomes for women.

Last autumn, Senator Fitzgerald stated that we have the guidelines and demanded that they be implemented. She asked that the eight centres be put in place and for me to show leadership. This is what she encouraged me to do. When one shows leadership and gets on with it one is accused of ignoring certain matters. In Ireland, approximately 22,000 new cancers diagnoses are made every year and approximately 7,750 people die from cancer. We have approximately 2,500 cases of breast cancer. To provide the service that deliver the outcomes achieved in places such as British Columbia, we need to reorganise, eradicate fragmentation and make sure screening, diagnosis, surgery, chemotherapy, counselling and so on are integrated.

It is proposed that initial diagnosis and surgery will take place in the designated centre and the follow-up treatment will be carried out in the hospitals in Sligo, Mayo, Mullingar and the other locations mentioned in accordance with protocols that will be devised at the specialist centre. That is best practice and it delivers good results. Out of every 100 women who travel to Galway from Mayo or Sligo, 95 will not need to return but if the five who may be diagnosed with cancer and need surgery are not given the best chance at the start, the process cannot be undone. One can never recover down the line with chemotherapy if the diagnosis and initial surgery is not correct. That is what all the experts tell us and there is a compelling argument for us to take on board the best expertise available to the Government and the health service and put that into effect.

I was asked about resources for Galway University Hospital, which has 2,500 staff. From time to time, 100 beds are occupied by patients awaiting medical or radiation oncology treatment. That is not best practice because most of the treatment should be provided on a day case basis. That is why Professor Keane is reorganising the service. The issue is reorganising the manner in which the service is provided to make sure it is focused on delivering the best result for patients and not on more beds or staff. The 100 beds occupied in GUH are not necessary and fewer hospital beds are required for such patients. St. Luke's Hospital in Dublin has 300 beds for radiation oncology while the hospital in British Columbia, which caters for the same population, has approximately 60 inpatient beds.

We are spending a great deal of money but, unfortunately, it has not been put in the right direction. Recently, the Government advertised for 120 new consultants for the health care system, more than 20 of whom will be cancer specialists in the eight centres of excellence. Additional specialist breast surgeons will not be appointed to centres that are not designated because it does not make sense to do so. When doctors work in a critical mass environment dealing with cancer, significant positives flow from that.

Senator O'Toole referred to performance indicators and survival rate is the one that matters in the context of cancer services. In the first instance, we must organise around volumes of 150, for example, for breast cancer while there will probably be only one centre for both prostate and brain cancer, one or two centres for oesophageal cancer and perhaps only one centre for lung cancer because the volume of patients to achieve good results only warrants these numbers. That will mean patients travelling but if it improves the chances of these patients having a positive outcome by 20% or 25%, many of them will do that.

I fully accept the need for modern transport that meets the needs of patients and that is why the Irish Cancer Society is involved in a new transport initiative. Only yesterday I met Mr. John McCormack, chief executive of the society, which will provide in conjunction with cancer centres, similar to its counterparts in many other countries, resources for the provision of transport where a bus service would not make sense and where individuals want to make their own arrangements through a family member, neighbour or another form of private transport. The ICS is also developing a volunteer effort, which works well in Canada and other European countries. I have witnessed this working well elsewhere and people might like to contribute to this effort.

Recently, at the request of Senator Feeney, I made an allocation to Sligo hospital to provide a new bus for patients who must travel to Galway for radiation oncology treatment because she brought to my attention the substandard nature of the current bus. More dedicated transport initiatives are needed to meet the highest transport standard.

Two additional beds will be provided for breast cancer patients from counties Mayo and Sligo in GUH. I am often criticised because there is 90% to 100% occupancy in hospitals, which people say is dangerous. It is normal practice for hospitals such as GUH to reduce activity during August for maintenance and refurbishment work and other reasons. That does not affect cancer or other specialist services or the accident and emergency department. That is normal practice around the world. Many elective hospitals that do not deal with emergencies, cancer or other specialties in Europe close during August. I assure Senators it will have no affect on the availability of capacity.

Professor Keane did this job in British Columbia and we are lucky to have his medical expertise and people's skills in putting this plan into effect in Ireland. He is ahead of the target set, which was to make a 90% transition from the current system to the new arrangements over two years. By the end of this year, all breast surgery will move to the designated centres. He is moving on to prostate and lung cancer services and he expects to complete their transition during 2009. By any standard, that is a major outcome in a short period and it is a performance indicator.

Many Members feel strongly about the issue but I appeal to them not to confuse the local with the best outcome. If I were to take a chance and leave the service as it is, I would not be able to live with myself when I know the evidence worldwide is so compelling. The countries that have done this achieve the best results and Ireland has the capacity to achieve similar results. Every cancer patient, regardless of where he or she is from, should be given the same chance of survival as the patients from Dublin, Galway or Cork.

Senator Joe O’Reilly

I wish to share time with Senators Twomey and Doherty.

I also welcome the Minister to the House. Contrary to what she just stated, health services should be delivered locally, where possible. This is critically important, as people want to remain in their locality because they respond best in that environment. That should be our guiding principle and we should only opt for an alternative when the evidence is compelling. The burden of proof should be to establish a patient should not be cared for locally rather than the reverse. The Minister has made a compelling case for centres of excellence and empirical evidence suggests they should be provided but it is not right that, north of a line between Dublin and Galway, a centre of excellence will not be provided. That is active discrimination against a significant proportion of our population and it is unacceptable.

I am not convinced and I do not have sufficient evidence that there is budgetary provision for the centres of excellence and the necessary ancillary facilities. How will next week's announcements impinge on resources? We were told in 2007 there would be no cutbacks but there has been a plethora of cutbacks since then. How do we know the resources will be available to provide the centres of excellence? If we are not convinced of that now, why proceed with dismantling existing facilities before the centres of excellence are in place?

Take the example of primary care. There are not enough general practitioners to implement primary care. The concept of primary care is great but there are no resources. There is also the example of Monaghan hospital, which is now effectively closed. There were 3,000 admissions per year to that hospital while Cavan hospital has 5,000 admissions per year. The total is 8,000 and that number will now be loaded onto Cavan hospital, but there is no evidence that it has adequate resources to cope with it. In fact, one of the wards in Cavan hospital has no staff resources. While the philosophy and the grand statements are fine, there is no evidence of resources to support them. That has been the case with primary care and in a range of services and hospitals throughout the country.

Acting Chairman (Senator John Ellis)

There are four minutes left and these are to be divided between the Senator's two colleagues.

Senator Joe O’Reilly

I will finish with a compelling point, and if the Minister can dispute it I will be happy for her do so. I understand that before attending the centre of excellence in Galway, the patients will be seen by the same personnel of oncologist, radiologist, pathologist and surgeon in Letterkenny and Mayo as will see them in Galway. What is the logic of that? In what way will it enhance the welfare of those patients to be seen by the same personnel in Galway? The logic of that escapes me. Where possible, we should keep services local.

Finally, although it is not germane to this debate, it is an abomination that the Minister is proceeding with the co-location plan. It is wrong to put a two tier health system in place and to give public hospital grounds for private hospitals to create a system for the rich, famous and powerful. The location of private hospitals on the same grounds as public hospitals will mean the public hospitals will ultimately become the slums of hospital care because money dictates these things. That is wrong. It is also wrong to have a grand plan for cancer services without a statement of specific resources to match it.

Senator Pearse Doherty

I am sorry I do not have enough time to go through the issues. However, I reject the Minister's efforts and those of Professor Drumm and other Ministers and colleagues. They are trying to induce a guilt trip in public representatives and local communities when they suggest we are irresponsible in seeking the retention of services at Sligo and Mayo. In the motion we are calling for safe facilities and services and satellite units linked to the Galway centre.

However, this is nothing new from the Minister and this Government. They have consistently argued for centralisation of hospital care and have implemented it in a number of cases. This is far removed from reality. When there is centralisation, people die or they accept inferior treatment because they and their families have to travel shorter distances. The Minister talks about Professor Keane as if he is a person who knows everything but Professor Keane is only implementing——

Acting Chairman

I am sorry, Senator. We had the problem earlier of Senators mentioning people when they should not.

Senator Pearse Doherty

Okay, but the Minister referred to him many times.

Senator Frances Fitzgerald

He is mentioned in the motion.

Senator Pearse Doherty

He is implementing a Government strategy. That strategy calls for eight centres of excellence. Nobody is arguing for radio-oncology and everything that goes with it in all these centres but eight centres is too few.

I attended a public meeting on this which was packed with cancer patients and people who have gone through the system. They are demanding that these centres are kept open. I urge Members on the Government side of the House to support the patients in the north west and the people who are asking us to do the right thing tonight.

Senator Liam Twomey

I also know doctors who work in British Columbia. Some of them came back to work in Ireland. They tell me that the regional hospitals in Ireland are not a patch on the smaller hospitals in Canada. That is the reality. There is neither the number of consultants nor the equipment in the hospitals in this country to do what the Minister has described. No matter what high notions the Minister might have about saving people's lives, she has not put the resources into it. Until she does, she will not save those lives.

It would be far more appropriate for the Minister to put the funding into the eight centres now and, when we return to this in 12 or 24 months, the Minister can show us the comparisons between the resources those eight centres have and what she wants to take away now. We see what has happened in the north east where the Minister's Cabinet colleague has confirmed that there is no money for a new hospital there. If the same thing happens in this case, there will be no money for cancer services to treat patients. In the meantime, however, the Minister will have closed down the services that are already available to patients in hospitals throughout the country on the basis of something she calls reform. The Minister should first build up the services in the eight centres and when we debate this again in 12 or 24 months we will make the comparisons the Minister mentions. At present, however, it is a phoney war. The Minister is not putting the resources into this and she will not save people's lives.

Senator Cecilia Keaveney

The Minister has a very difficult job and has had to make very difficult decisions. This issue was unclear for many people until they met the man who cannot be named, Mr. Keane, and listened to him. It is one thing for a politician to say something, it is another for a clinician to say it. Almost ten years ago I was asked by Europa Donna to go to London for a meeting with clinicians. The clinicians made it clear that they realised politicians would want their local service to remain as close to home as possible. In three major cancer hospitals in London, however, the clinicians pleaded with us not to fight a parochial battle for a local hospital but to fight for the multidisciplinary team that will deliver best results for patients. Patients must come first. This has been a difficult issue for the Minister and for many public representatives throughout the country.

——her approach to this issue. I also ask Senators from all sides to support the motion.

Deputy Mary Harney

The main centre has 2,500 units.

Amendment put.

The Seanad divided: Tá, 27; Níl, 23.

Tá

Boyle, Dan.
Brady, Martin.
Butler, Larry.
Cannon, Ciaran.
Carty, John.
Cassidy, Donie.
Corrigan, Maria.
Daly, Mark.
Ellis, John.
Feeney, Geraldine.
Glynn, Camillus.
Hanafin, John.
Keaveney, Cecilia.
Leyden, Terry.
MacSharry, Marc.
McDonald, Lisa.
Ó Domhnaill, Brian.
Ó Murchú, Labhrás.
O’Brien, Francis.
O’Donovan, Denis.
O’Malley, Fiona.
O’Sullivan, Ned.
Ormonde, Ann.
Phelan, Kieran.
Walsh, Jim.
White, Mary M.
Wilson, Diarmuid.

Níl

Bacik, Ivana.
Bradford, Paul.
Burke, Paddy.
Buttimer, Jerry.
Coffey, Paudie.
Coghlan, Paul.
Cummins, Maurice.
Doherty, Pearse.
Donohoe, Paschal.
Fitzgerald, Frances.
Hannigan, Dominic.
Healy Eames, Fidelma.
Kelly, Alan.
McFadden, Nicky.
Mullen, Rónán.
Norris, David.
O’Reilly, Joe.
Phelan, John Paul.
Prendergast, Phil.
Ross, Shane.
Ryan, Brendan.
Twomey, Liam.
White, Alex.

Tellers: Tá, Senators Fiona O’Malley and Diarmuid Wilson; Níl, Senators Maurice Cummins and Phil Prendergast.

Amendment declared carried.

Question put: "That the motion, as amended, be agreed to."

The Seanad divided: Tá, 27; Níl, 23.

Tá

Boyle, Dan.
Brady, Martin.
Butler, Larry.
Cannon, Ciaran.
Carty, John.
Cassidy, Donie.
Corrigan, Maria.
Daly, Mark.
Ellis, John.
Feeney, Geraldine.
Glynn, Camillus.
Hanafin, John.
Keaveney, Cecilia.
Leyden, Terry.
MacSharry, Marc.
McDonald, Lisa.
Ó Domhnaill, Brian.
Ó Murchú, Labhrás.
O’Brien, Francis.
O’Donovan, Denis.
O’Malley, Fiona.
O’Sullivan, Ned.
Ormonde, Ann.
Phelan, Kieran.
Walsh, Jim.
White, Mary M.
Wilson, Diarmuid.

Níl

Bacik, Ivana.
Bradford, Paul.
Burke, Paddy.
Buttimer, Jerry.
Coffey, Paudie.
Coghlan, Paul.
Cummins, Maurice.
Doherty, Pearse.
Donohoe, Paschal.
Fitzgerald, Frances.
Hannigan, Dominic.
Healy Eames, Fidelma.
Kelly, Alan.
McFadden, Nicky.
Mullen, Rónán.
Norris, David.
O’Reilly, Joe.
Phelan, John Paul.
Prendergast, Phil.
Ross, Shane.
Ryan, Brendan.
Twomey, Liam.
White, Alex.

Tellers: Tá, Senators Fiona O’Malley and Diarmuid Wilson; Níl, Senators Maurice Cummins and Phil Prendergast.

Question declared carried.

An Cathaoirleach

When is it proposed to sit again?

Senator Donie Cassidy

Tomorrow at 10.30 a.m.

Seanad Éireann debate - Wednesday, 2 Jul 2008

Cancer Services: Motion.

Tá

Níl

Tá

Níl

Seanad Éireann debate -
Wednesday, 2 Jul 2008