Seanad Éireann debate -
Wednesday, 13 Jul 2011

Vol. 209 No. 8

Adjournment Matters

Hospital Services

Senator David Cullinane

I welcome the Minister of State at the Department of Health, Deputy Kathleen Lynch. The previous Government made an explicit commitment to provide an oncology unit on the grounds of Waterford Regional Hospital. In 2007, the former Taoiseach, Mr. Bertie Ahern, and former Minister from Waterford, Mr. Martin Cullen, made an unequivocal statement to this effect to the people of Waterford.

The Minister of State may be aware that for more than ten years a campaign has been fought to bring an integrated multi-disciplinary cancer service to the south-east region. This campaign sought to establish a centre of excellence and an oncology unit that can provide all the modalities of cancer care, including chemotherapy, radiotherapy and surgery, on one integrated site because international best practice demonstrates this approach results in better outcomes for patients. Despite the fact that land was made available on the site of Waterford Regional Hospital, it appears the capital funding is no longer available or else the proposed oncology unit is not part of the current capital programme. This issue causes serious concern for patients in the south east. The region has a population of 450,000 and the hospital in Waterford covers Counties Waterford, south County Tipperary and County Wexford, as well as providing cancer services for patients in counties Carlow and Kilkenny. It is vital, therefore, that the oncology unit is built.

I recently joined my Labour Party colleague, Deputy Ciara Conway, and other Government Members in meeting the local hospice movement, which expressed concern about the delay in constructing the oncology unit and the 20-bed palliative care unit which was to be attached to it. At present, an integrated service with three consultants is based at the hospital but only two inpatient beds are available for a region comprising 450,000 people. There are four community home care specialist palliative care teams with consultant leads but, while these teams do fantastic work, they need in-house facilities for those who cannot be cared for at home. In Cork and Kerry the population is 510,000 but the area has 24 specialist palliative care beds. The south east, with a population of 463,000, has access to two inpatient beds. Some 1,300 patients in the south east per year are seen by the specialist community team, with 850 patients seen in acute hospitals. The estimated cost of the oncology unit which could provide the proper centre of excellence, with integrated care and all modalities on site and which would be part of international best practice in giving patients best outcome, would be approximately €70 million. It may be even less now because of the downturn.

The local hospice movement has provided €2.5 million which is ready to be spent. The money has been raised through hard work and the movement needs to have the unit built. The primary objective is the oncology unit with a palliative care section but if that is not an option, another plan to find an independent palliative care unit should be explored.

There are times when people play politics with very serious health issues. The commitments given by the previous Government were not carried out but my party also gave commitments, as did local Fine Gael and Labour Party candidates. The leaders of Fine Gael and the Labour Party, Deputies Enda Kenny and Eamon Gilmore, gave very clear commitments that if they were in government, they would deliver on the promise of delivering an oncology unit. I hope the Minister of State will be able to ease some of the fears of patients in the south east. I am being told that the unit is not part of the capital programme and if that is the case we should get the facility on the capital programme in order that we can expedite the issue.

Minister of State at the Departments of Health and Children and Community, Equality and Gaeltacht Affairs (Deputy Kathleen Lynch)

I thank the Senator for raising this issue as it provides me with an opportunity to reaffirm the Government's commitment to developing palliative care services. Government policy for palliative care is based on the report of the national advisory committee on palliative care from 2001. Palliative care is primarily concerned with quality of life.

The Government's objective of the continued development of palliative care services is reflected in the funding of these services in recent times. In 2009 in the region of €79 million was made available, with approximately €66.5 million of this being provided to the main voluntary organisations. It is accepted that these organisations do an extraordinary job. The overall budget provision in 2010 was €76 million and €74 million was provided in 2011. The HSE reports that specialist palliative care is provided to 3,600 people each month, and it is understood that the admission rates — waiting times — to palliative care beds over all regions is 90% to 100% within seven days of active referral.

A palliative care services medium-term development framework was published by the HSE. This sets national priorities, which have been agreed by all stakeholders. In line with recommendations of the framework, the HSE established in July 2010 the national steering group on palliative care services to monitor progress on the implementation of the framework at national and regional level. As the Senator is aware, the Health Act 2004 provides the Health Service Executive with responsibility for the management and delivery of health and personal social services. As a statutory body the provision of these services, including progressing palliative care services at local level, is therefore an operational matter for the executive.

There are a number of developments ongoing in the south east with regard to palliative care services. In the south east, including Waterford, specialist palliative care is delivered through hospital and community-based consultant-led multidisciplinary teams. These teams consist of consultants, non-consultant hospital doctors, senior occupational therapists and a principal social worker. Acute and primary care services in the south east have access to specialist palliative care teams 24 hours a day, seven days a week.

The Irish Hospice Foundation established a national programme to mainstream hospice principles in hospital practice. It focuses on four key themes generated from a pilot project: integrated care; communication; dignity and design; and patient autonomy. Waterford Regional Hospital is participating in this programme.

The management team at St. Luke's General Hospital in Kilkenny continues to work with the Susie Long Hospice voluntary group on the plans to develop outreach inpatient palliative care beds for Kilkenny. In liaison with the Susie Long Hospice Group it is planned, during 2011, to upgrade ward areas to provide improved accommodation for patients currently in receipt of palliative care and other related services.

The integrated oncology unit and 20-bed palliative care unit at Waterford Regional Hospital to which the Deputy refers, like all potential capital projects, must be submitted through the HSE's capital steering committees for approval to be included in the HSE multiannual capital programme. I must inform the Senator that this project has not been included in the draft HSE capital plan 2011-2015, so it will not be considered for progress in the current plan. I understand the HSE has just appointed a project team to design a business case for the development.

The estimated total cost of all potential projects is always greater than the capital funding available. Health care is a labour intensive activity and hospices are one of the most labour intensive services. Therefore, sufficient revenue and current funding to staff and operate new facilities is one of a number of critical factors considered in such a project's appraisal. Given the level of contractual commitments already in place, there is limited funding available for new contracts before 2014. The executive is required to prioritise capital infrastructure projects within its overall capital funding allocation and within the multiannual commitment thresholds notified by the Department of Public Expenditure and Reform.

I reiterate the strong and real commitment of the Government to progressing the highest possible standards of palliative care nationally. However, all future developments, including capital projects, must be considered within overall budgetary and economic constraints. I know Cork has a very good and accessible palliative care programme so I understand fully where the Senator is coming from and why it would be a significant addition to the region. There is no dispute in that manner and it is an incredible service to be available to everyone. Unfortunately, I am sure the Senator understands the country's Government does not have the money to progress the project. If he continues with pressure, it will eventually come about.

Senator David Cullinane

I thank the Minister of State for her response in reiterating the Government's commitment to palliative care, which is very important. The funding could and must be provided for. Despite the downturn, there is still money available for the Government and cancer care and provision of cancer treatment services is very important. A private facility has been built in Waterford, the Whitfield Clinic, which provides some form of radiotherapy. It is important in terms of international best practice that all modalities of treatment be provided on one site. For this to happen we need an oncology unit and the 20-bed palliative care unit.

As the Minister of State indicated, the local hospice movement has campaigned and raised funds for this project. I know the HSE is designing a brief now so I hope that when it is submitted, it will have the Department's full attention. I hope that at some point the Government will be in a position to allocate capital funding to deliver on this very important project.

Smoking Ban

Senator John Crown

I will take about 20 seconds of the four minutes allocated to me to state I am very supportive of Senator Cullinane's Adjournment matter. There is an extraordinary team of doctors working in oncology in Waterford Regional Hospital, and it has three of the hardest working oncologists. Those women are incredibly well trained and have done a wonderful job with routine care and the involvement of the Waterford hospital in the national research initiative. I express my great appreciation for the work of Dr. Horgan, Dr. O'Connor and Dr. Calvert.

I have not been in a position to follow today's news stories, but I understand there have been further disclosures of child abuse. I would like to talk about another form of child abuse, which takes place in our country every day. We are all aware of it and decreasingly tolerant of it. We need legislation to ban the exposure of young children to cigarette smoke, which contains harmful chemicals, in small enclosed spaces. When we are stuck at traffic lights every day, we often see one or more adults smoking in other cars even though children are strapped in with them. It should be possible to enforce a smoking ban in cars. This is not a crazy form of the nanny state or an attempt to heap further misery on hassled mothers and fathers who may be addled as they ferry their children around each morning. If they have addiction thinking, they might think their stress levels will be reduced if they have a cigarette.

There are unanswerable reasons to legislate definitively to ban smoking by adults in cars when children are present. One could go further and argue that smoking should be banned in front of children in any enclosed space, including rooms in people's own homes. Children are more vulnerable than adults to the effects of cigarette smoke for two reasons. First, they breathe more quickly. The respiratory rate of a young child is faster than the respiratory rate of an averagely fit adult. As a result, there is a greater exchange of chemicals into a child's system per minute than would be the case with an adult. Second, their weight is smaller and therefore they have a higher amount of exposure per kilogram of body weight. The relative impact of the potentially noxious chemicals in cigarette smoke on a young child is far greater than the impact on an average-sized adult. The issue of choice arises as well. An adult who is a non-smoker can choose to be in the company of smokers or to ask them to stop. Children often do not have that choice. Infants, by definition, never have that choice.

When a cigarette is lit in a car with the windows closed, within a minute the measurable occupational level of toxic emissions is 30 times higher than the level at which the US Environmental Protection Agency advises people to flee the streets, go into their homes and close their windows. If it is 30 times higher than the level that is considered dangerous, it is extraordinarily dangerous for children to be exposed to it. What does it actually do? Is this a vague theoretical concern or do we have quantifiable data? The data based on literature are very clear. Diseases like asthma, lower and upper respiratory infections, bronchitis, otitis or ear infections, meningitis and, chillingly, sudden infant death syndrome are more common in children who are exposed passively to second-hand smoke. The British Medical Association has suggested the data would indicate there is an increased risk of childhood cancers — not respiratory cancers, but lymphomas and tumours involving the nervous system — among children who are exposed to second-hand cigarette smoke. I have seen some data to suggest that people who grew up in a house where they were regularly exposed to second-hand cigarette smoke as children have a higher risk of developing lung cancer as adults, even if they do not have a smoking history themselves.

Ireland would not be the first country in the world to attempt to legislate for a ban on smoking in cars. As I have said, we could go further by banning smoking in all enclosed spaces. Many individual states in the US and many countries around the world have already activated the process of introducing protective legislation of this nature. I believe we should give serious thought to extending the current regulations to ban smoking completely within the confines of Leinster House, but that is a different day's work. I ask the Minister of State to bring the urgency of this matter to the attention of the Minister, Deputy Reilly. This is different from the mobile phone question we considered earlier, which continues to be the subject of genuine controversy. We should provide for some kind of warning about the potential, but as yet unproven, risks associated with mobile phones. This is different because we know there is a risk. Every adult who lights a cigarette, a cigar or a pipe in an enclosed area when a child is present is engaging in a form of child abuse.

Deputy Kathleen Lynch

I am responding on behalf of the Minister, Deputy Reilly. I am aware that this matter was raised by Senator Crown yesterday during the debate on the Public Health (Tobacco) (Amendment) Bill 2001. As a result of the introduction of the smoke-free at work legislation in 2004, and other tobacco control measures since then, awareness of the risks of smoking and exposure to second-hand tobacco smoke has increased significantly. It is recognised that smoking in the car exposes all the occupants to harmful environmental tobacco smoke, which is a carcinogen that contains cancer causing substances and toxic agents that are inhaled by the smoker. There is no safe level of exposure to environmental tobacco smoke. Exposure to cigarette smoke is particularly dangerous in enclosed spaces such as cars. Parents and others with responsibility for the welfare of children have a particular responsibility to ensure such exposure does not take place.

Legislative measures have been introduced in a small number of countries to prohibit or discourage smoking in cars when children are present. The nature of the measures and of the accompanying compliance and enforcement arrangements have been variable and far from consistent. In some jurisdictions, smoking in cars is treated as a driving offence. Other jurisdictions have introduced an education tool aimed at highlighting the dangers of smoking in cars. Any proposal to introduce a ban on smoking in cars must be based on evidence, such as data on the extent to which it occurs and the risks to public health it poses. Consideration will need to be given to the extent to which it may be appropriate to deal with this question as a road safety and a public health issue.

The successful introduction of measures with regard to smoking in cars would benefit from the roll-out of a public information and education campaign to mobilise public support. A similar approach proved successful when the smoke-free at work initiative and subsequent tobacco control initiatives were introduced. These provisions were underpinned by a clear evidence base and good planning. Public opinion was mobilised through a public education and information campaign. Simple, clear and enforceable legislation was introduced. Proposals relating to smoking in cars are being considered in the context of the tobacco policy review that is under way in the Department of Health. The review is expected to be completed and submitted to the Minister for Health within months. The Minister, Deputy Reilly, has signalled that he is in favour of legislating in this area. However, he would like a public information and education campaign to highlight the dangers associated with exposure to environmental tobacco smoke in cars and to mobilise public support in advance of the introduction of legislation. I think the Senator is pushing an open door.

Senator John Crown

I understand how legislative priorities can vary. Any delay in this regard would lead to real and quantifiable health problems for individuals. I suggested the other day that it would be easy to amend the original 2002 Act by including two one-line paragraphs. The first paragraph would ban smoking in vehicles in the presence of children, which is the conservative position. The second paragraph would ban smoking in any enclosed area in the presence of children. I believe it could be done with universal cross-party support. It could be enacted very quickly. The Minister of State said that a public information campaign would be essential. I suggest we would be pushing an open door with the public because there is overwhelming support for this measure. There would be no opposition to be overcome. We must remember that the tipping point for the original legislation, as introduced by the former Minister, Deputy Martin, was the exposure of people to carcinogens in a work environment over which they had no control. People did not think they should leave their jobs because others were smoking. The problem is far greater in this case because it affects young children. If the original ban was necessary in the interests of adults who could voluntarily leave their jobs, we should introduce this ban urgently in the interests of young infants, who are not aware of the problem or are unable to articulate it, and of older children, whose relationships with their parents may mean they are not in a position to say what should or should not be done.

The Seanad adjourned at 6.30 p.m. until 10.30 a.m. on Thursday, 14 July 2011.