Dáil Éireann díospóireacht -
Tuesday, 8 May 2001

Vol. 535 No. 4

Private Members' Business. - Cancer Services: Motion.

Mr. G. Mitchell

I move:

"That Dáil Éireann condemns the Government for placing patients' lives at risk by its failure to implement and reach the targets set in the 1996 National Cancer Strategy and particularly for its recent unprecedented failure to provide adequate services to deliver essential medical treatment and care to patients with cancer."

With the permission of the House, I intend to take about 20 minutes of my time and, I hope to give about ten minutes to Deputy Neville and five minutes each to Deputies Naughten and Connaughton.

An Ceann Comhairle

Agreed.

Mr. G. Mitchell

Of all those who die in Ireland aged under 65, one third die from cancer. We have the third highest death rate from cancer in Europe and many of those who die are awaiting so-called elective treatment.

The Chief Medical Officer of the Department of Health and Children informed us in his 1999 annual report that one third of all cancers are preventable, and one third are potentially curable. He also stated that good palliative care can provide significant improvements in quality of life.

The appalling reality is that in a society awash with money, this Government has failed to give the priority to cancer services which could see more people survive cancer and enjoy many more years with their loved ones.

At the launch of Daffodil Day last year, a consultant radiotherapist at St. Luke's Hospital, Dublin painted a very unacceptable picture regarding the availability of radiotherapy services in Ireland. He pointed out that, on average, only 16% of cancer patients are receiving radiotherapy despite the fact that up to 50% of patients could benefit from it. It was pointed out that up to 1,000 people are dying because of inadequate treatment. Whereas 16% of Irish cancer patients receive radiotherapy, an average of 66% of patients receive such treatment in the EU.

An eminent oncologist, Dr. John Crown, writing in the Irish Medical News in February last, stated:

The National Cancer Strategy which emerged . . . undoubtedly led to service improvements. However, by the time the civil servants were finished with it, it contained some awful clangers, principally its total failure to address the hopelessly fractioned Dublin set-up, and its determination that Galway would become the world's only radiotherapy-less comprehensive cancer centre.

He continued: "In truth, what was the worst cancer treatment system in Europe is better, but is still the worst cancer treatment system in Europe". They are his words, not mine.

The verdict of professionals such as these, and the fact that two major hospitals in Dublin recently confirmed that they had to postpone potentially life saving treatments for cancer patients to make way for non-cancer emergency admissions at a time of unprecedented wealth, huge budget surpluses and unprecedented amounts of taxpayers' money being made available by Dáil Éireann to the Minister for Health and Children, give rise to the concerns expressed in the motion before the House tonight.

One mother who needed chemotherapy for a cancerous lump on her neck said recently she had her life saving treatment cancelled each day for almost two weeks. She is reported as saying that the stress was so great, she telephoned twice daily but every day the queue was getting longer. The Minister is quoted as describing these developments as "unacceptable", as if he were some how a disinterested and unconnected commentator. We have all of this despite the launching of a National Strategy on Cancer in 1996 and an implementation strategy announced in 1997.

The effect of cancer on society in Ireland is now devastating. One third of all deaths in those aged under 65 means that, on average, 7,500 persons per year die from cancer in Ireland. This constitutes one quarter of all deaths every year and this figure has remained at that level for almost ten years. In 1995, the numbers of persons dying from ischaemic heart disease was 7,926 and this figure declined in 1999 to 6,876. There was no such decline in cancer deaths in the same period.

An average of 18,000 new cases of cancer are recorded annually in Ireland and on the basis of epidemiological data available, there are regional disparities in both the death rate and incidence, that is, the new cases of cancer, even after taking differences of age profile into account. Death rates from cancer are significantly higher in the Eastern Regional Health Authority area than in the rest of the country. Death rates from cancer are significantly lower in the Southern, Western and North-Western Health Board areas. Death rates for the major types of cancer show statistically significant variation between regions but that has not given rise to strategies to combat those variations.

There are about 1.3 million new cases of cancer every year in the European Union and more than 840,000 deaths from the disease in Europe. The number of new cases each year is rising and it is anticipated that overall mortality rate in the EU will increase significantly up to 2010 in the absence of effective strategies for prevention and treatment. Ireland's mortality rate from cancer compares unfavourably with that of the EU average. While our death rate from cancer has declined by almost 10% in the under 65 age group since 1970, it is still above the EU average and our mortality rate for the overall population, that is, including those aged over 65, has been rising significantly since the late 1970s.

There is strong evidence that lifestyle and environmental factors play an important role. It is estimated that tobacco, alcohol and diet, the three major lifestyle risk factors, contribute to two thirds of all cancers in Europe.

More than 6,000 deaths each year in Ireland from cancer and other diseases are directly attributable to smoking. Smoking is a major causative factor in almost 90% of the 1,500 deaths from lung cancer which occur each year. Smoking is also a risk factor in cancers of the mouth, head and neck, throat, oesophagus, bladder, pancreas, kidneys and cervix. An increasing proportion of cancer deaths among women is due to lung cancer. Passive smoking is now recognised as a proven lung carcinogen in humans.

There is substantial evidence of an increase in cancer risk to the mouth, pharynx, oesophagus, larynx and stomach due to regular alcohol consumption. The combined consumption of tobacco and alcohol considerably increases the risk of upper respiratory and alimentary tract cancer by a factor of ten to 100 in heavy smokers and drinkers. While the percentage of smokers in the Irish population has fallen from 43% in the 1970s to around 27% today, the figure is much higher within certain sub-groups of the population.

In the National Cancer Strategy it is stated that "Ireland will continue to press for an EU-wide approach to banning of advertising of tobacco products". This is the same EU which cannot agree to vote for the banning of tobacco advertising at the World Health Organisation. Despite the fact that Richard Peto's research, Mortalities from Smoking in Developed Countries 1950-2000, shows that the estimated numbers of deaths from smoking as a percentage of total deaths in EU countries in 1995 is as follows: Austria, 12%; Belgium, 16%; Denmark, 21%; Finland, 10%; France, 12%; Germany, 13%; Greece, 13%; Ireland, 20%; Italy, 16%; Luxembourg, 15%; Netherlands, 19%; Portugal, 8%; Spain, 14%; Sweden, 8%; and the United Kingdom, 21%, what has Ireland's Minister for Health done to reverse the obscenity of disagreement within the European Union on support for World Health Organisation initiatives?

One in ten people will develop skin cancer at some point in their lives and there is evidence to suggest that this figure continues to rise at a rate of 4% per annum. Why, with all this dreadful evidence, is the United States, not Europe, and certainly not Ireland, the best place to receive treatment for breast cancer? Why do we not yet have a national high quality screening programme matched by an equally high quality arrangement for women with symptomatic breast disease? At present, breast screening refers to the investigation by mammography of women who have no symptoms, that is, those who believe themselves to be free of disease, whereas symptomatic patients are women who have a breast complaint and fear that they may have cancer. Why do we not have high quality services for both, given that breast cancer is the second highest cancer killer of women in Ireland?

I welcome the development of the BreastCheck screening programme and encourage all the women invited for screening to take up the offer. I regret that the screening service is not available nationwide. I also regret that the medical manpower and infrastructure is as yet unavailable to extend the BreastCheck service.

Despite this welcome development, are we not in danger of being dazzled by the success of the new screening scheme and missing the gross inadequacy of investment in the current service for symptomatic breast disease? Women who present for breast screening under BreastCheck are rightly guaranteed timeframes within which they will receive treatment should they require it. Despite the best efforts of the medical and nursing staff at breast disease clinics in many of our major hospitals, women who already have breast disease symptoms can receive no such service guarantees. The BreastCheck service shows what can be done with proper resources. The long queues at the out-patient clinics of the under-resourced breast clinics of major hospitals tell a different tale. This under-resourcing is a scandal which could cost lives.

The professor of surgery at St. Vincent's Hospital, Dublin, Dr. Niall O'Higgins, informed a conference on women and cancer in Dublin that 43% of Irish women who develop breast cancer will die compared with an EU average of 37%. It should be noted that some EU countries have a breast cancer mortality rate of less than 30%. Still, the Minister has not bitten the bullet on the need for rationalisation of breast cancer services.

Mr. Martin

We have done so.

Mr. G. Mitchell

Like everything else the Minister has referred the report of one committee to another committee to examine.

Mr. Martin

Wrong.

Mr. G. Mitchell

The real problem is that this Minister has no plan. Everything is done on an ad hoc basis. There are so many advisory groups, steering committees, reviews, commissions and inquiries under this Minister that a parliamentary question put down to him on 27 March last inquiring about the number of such bodies and their terms of reference has not yet been answered, though we are now in the month of May. Most questions of this kind are answered in three sitting days. I suspect the Minister does not want to answer the question because he is embarrassed about the number of reviews which are ongoing and the number of matters he has submitted to committees at the drop of a hat instead of taking strategic decisions about the running of the health service.

Mr. Martin

The question to which the Deputy refers relates to matters involving the Department since the foundation of the State.

Mr. G. Mitchell

The Government launches reports, initiatives and studies with great fanfares, but where is the follow through? For example, in the Building Healthier Hearts document endorsed by the Government it was proposed that tobacco be removed from the consumer price index to avoid the situation where increases in the price of cigarettes, necessary from a public health point of view, are vetoed because of their potential impact on the inflation figures. The Minister for Health and Children, Deputy Martin, advocates this change but his colleagues the Minister for Finance and the Taoiseach veto it. So much for discouraging smoking. Instead of real action we have sponsorship of snooker tournaments out of Department of Health funds.

Not only does the Minister not have a plan for the health service into which a cancer policy would dovetail, he has presided over an Irish health care system which spends well below the EU average. In 1980 Ireland spent 8.7% of GDP on health. By 2000 its spend had dropped to 5.1% of GDP, 6.05% on a GNP basis which is probably a fairer measure. Ireland is 22nd in a list of 29 OECD countries in terms of health spending. From a low base in the early 1990s, health spending has more than doubled but it remains far behind the European average of over 8% of GDP.

Of course those who can pay for themselves suffer less. The percentage of the population covered by private health insurance has more than doubled in the past 20 years with almost 45% of the population now covered by private insurance. However, as the ESRI research for Irish men aged 55 to 64 points out, the poor die younger. Higher professionals have a death rate of 13 per 1,000 for semi-skilled this rose to 22 per 1,000 and for unskilled manual groups to 32 per 1,000, that is, the mortality rate was almost three times higher among lower income groups than better paid professional groups.

Fine Gael has published comprehensive health policy proposals, including extensive proposals for preventative care and health checks so as to tackle the horrors of cancer and similar serious illnesses. The Minister now pretends he will publish a policy after a hurried six to eight week consultation period and that he will do this in July next, that is, it will be published in this Government's fifth year in office.

Who can take the Minister seriously? He has abused the trust placed in him by this House by consistently appointing large numbers of people from his bailiwick to sensitive health positions. This included appointments to the board of the Irish Blood Transfusion Service, a most sensitive service. He has refused to answer questions in this House and released the information outside the House in a controlled and distorted way, a gross discourtesy to Parliament. Worse than that, he has refused to answer a question put down to him on 27 March inquiring about the precise numbers of advisory groups he has established. According to an independent report the Minister left the managerial system in the Department of Education and Science in a total mess but managed to come out smelling of roses. His ad hoc sticking plaster approach to the health service and his manipulation of the media with daily leaks and reactive announcements is typical of a style which will do little to strategically reorient the health services in general and to tackle specific issues such as cancer in particular.

I have set out my proposals for health reform and I challenge the Minister to say why he has not set out his. I would go further, however, particularly in relation to cancer and cancer related issues. Mortalities from Smoking in Developed Countries 1950-2000, from which I already quoted, states that an estimated 20% of deaths, that is, 5,881, in 1995 in Ireland were due to smoking. In the United States, the tobacco industry settled with the individual states for a total amount of $347 billion. This money is to be paid to the individual states simply to compensate them for the cost of the health services used in treating those who have suffered cancer and other related diseases from smoking tobacco. Individuals seeking compensation are now taking class actions. The US has a population of approximately 250 million people while Ireland has a population of approximately 4 million. Ireland should, therefore, receive compensation of the order of $6 billion from the same companies. Legal advice I have received indicates that this level of payment can be obtained from the tobacco industry if the Government follows on the US precedent. Why should we not do this? Should not the Government pursue the tobacco industry and use the money recovered from them in a ring-fenced fund to help give Ireland the best cancer treatment system in Europe?

Given the relationship between smoking, alcohol and cancer is it not time to ban the advertising of alcohol? Why is Guinness, for example, allowed to continue to sponsor the national game of hurling? Why, given the relationship between smoking and drinking and cancer, and the proven connection of lung carcinogen in humans from passive smoking, has the Government not moved to ban smoking in most parts of public houses? Should those who wish to smoke and drink be confined to a small part of a public house? I believe there is a case for doing this. Why do we not compel public houses to have proper and adequate air extraction and renewal systems? Is it not time we had a health ombudsman to whom the citizen, particularly the poor citizen, can go to defend his or her rights when he or she is treated to such an appalling health service and when life saving treatments, such as for those who suffer from cancer, are, without precedent, withdrawn?

Perhaps it is time we gave consideration to the appointment of a surgeon general. The chief medical officer of the Department of Health and Children does well, but he suffers from being an officer of a Department. The Comptroller and Auditor General is effective because he is appointed by and answers to Dáil Éireann. A surgeon general who would report directly to the Dáil and who is appointed by the Dáil could give us an independent overall view of the health service and its constituent parts, such as cancer treatment. He or she would force us to give this issue the attention it deserves. We have the resources and we must now have the courage and the commitment. Regrettably, I do not see any evidence of this from the Minister.

People in Ireland will collectively live 13 million years less than a comparable population of just under four million people in France. Why? It is time for a more professional approach to the management of our health services and to health strategy. The religious orders and medical people of the past gave us excellent service. Much of their dedication kept the services together. Furthermore, in times gone by we spent approximately 8% of GNP on the medical services which meant we were spending figures comparable to those of the EU average. However, those who gave generously of themselves in the past did not have or pass on the type of professional and managerial skills which a modern medical service needs today. Nothing short of a major reform of the strategic leadership and management of the medical services will bring about the type of change we need. Why should we not aspire to live as long as French people, for example? Why should we not live longer? Why should we not live healthier and longer lives? Why should the poor die younger? Should they not also live longer and healthier lives? If we are to do this, we must abandon the ad hoc behaviour and the downright mischievous political meddling with the health services of the nation which are the hallmark of the Minister's administration. I commend the motion to the House.

Mr. Neville

I am glad to have the opportunity to second this motion. Cancer is a disease we all dread. It is the plague of the 20th and 21st centuries and it is the tuberculosis of earlier generations. Everything possible must be done to defeat the curse of this disease. Extensive expenditure in research is required and maximum use of available cures and treatment controls must be made. Sufferers must not be spared treatment. Counselling services must be made available for those who suffer and for the families of patients. The Minister's efforts are severely lacking in all these areas. There is an immediate need to inject urgency into the service. A person suffering from cancer should not have to wait one minute longer than necessary for treatment. The most up-to-date treatment method must be made available. The deliverers of the service must be facilitated to keep them fully abreast of all new procedures and treatments for the disease. However, that is not happening.

This disease accounts for approximately one third of all deaths in those aged under 65. This means cancer is the cause of approximately 7,500 deaths in Ireland each year. Every year, an average of 18,000 new cases of cancer are recorded in Ireland and each year there are approximately 50,000 hospital cases of cancer. Ireland has a higher mortality rate from cancer than the average for other EU countries.

It is unacceptable and a scandal that people who suffer from the dreaded disease of cancer do not have adequate treatment facilities. No one should have to accept the excuse that the problem of bed shortages in the public hospital sector is so acute it is forcing cancellations of such services as chemotherapy for cancer patients. It is a nightmare for a person to be informed that he or she suffers from cancer. It is then frustrating, frightening, annoying and unfair if the patient cannot get treatment when he or she needs it. All doctors agree that time is of the essence when it comes to the treatment of cancer. A patient has a better chance of being cured if the condition is diag nosed early and the treatment is delivered at the appropriate time. There cannot be any excuse or reason for delaying treatment in such circumstances. The Minister and the Government stand indicted for doing so.

Approximately 20,000 people in Ireland are diagnosed with cancer annually. There is an urgent need for these people to obtain full and timely treatment. Experts believe that at the present level of service improvements it will take more than five, and perhaps ten years, before the service can cope. By that stage demographics will mean that the demand for cancer services will be significantly higher. In the meantime there are many surgeons and drugs and money to buy them, but there are not enough beds, radiotherapy units or personnel and there is a scarcity of nurses. There are too few specialists concentrating on one type of cancer, long waiting lists in some hospitals and few, if any, support services.

As we debate this issue, there are people who need to be treated as a matter of urgency. They need to have their treatment on schedule as that is their best chance of cure. The problem with beds has been there for a long time. Inadequate planning by the Minister and his Department to ensure this difficulty is overcome has caused a crisis. Consultants are competing with each other to get beds. Two years ago an eminent consultant in Cork University Hospital claimed that up to 1,000 cancer patients per year were dying because of inadequate treatment facilities, particularly radiotherapy. The consultant still stands over his claim that this is the case. Radiotherapy is one field where there are serious deficiencies. The Minister should take immediate action to overcome this difficulty. There are not enough radiotherapists. Of the 1,580 consultants in the country, only four or five radiotherapists operate in the public service. This is not good enough for a disease that affects one third of patients, 50% of whom need radiotherapy. There should be 40 radiotherapists for the Irish population.

The head of the UK cancer research campaign, Professor Gordon McVie, recently compared British waiting lists for colonoscopy with the Dutch scenario where a test is available within days. He said that "nowhere else in the civilised world are cancer patients treated so badly". He is incorrect as the Irish experience is more uncivilised. We need proper resources for research. Recently the director of the National Cancer Registry, Dr. Harry Comer, called for more resources to be made available to investigate why rates of bowel cancer are higher in Ireland compared to Europe. The key message from a new all Ireland report on the incidence of cancer is that it is a call to action to investigate the variations in cancer incidents and mortality in Ireland and Europe. Dr. Comer said they had identified in some cases quite a major difference between North and South and urban and rural Ireland and the rest of Europe. The Minister should immediately introduce a research programme into the high incidence of bowel cancer, as the medical profession does not know why this is the case. Bowel cancer is more common in Ireland than in the rest of Europe. This must be examined as a matter of urgency.

The prevention of lung cancer also needs to be addressed because all attempts at prevention to date have failed. There is an urgency to introduce a national prostate screening programme. Prostate cancer is the most commonly diagnosed cancer in Ireland after skin cancer. Earlier this month the Department of Health and Children stated there were not any plans to introduce such a screening programme. If left untreated or if it is not diagnosed early, the cancer will gradually spread to surrounding tissues, such as the lymph nodes, the bones and then usually the spine and the ribs. While there is no cure for it, there are many treatments available. The earlier the cancer is detected, the greater the likelihood that treatment will stop it from spreading. Figures from the National Cancer Registry show that approximately 1,100 men are diagnosed with prostate cancer every year.

The Minister must, as a matter or urgency, implement the recommendations of the report on the development of services for symptomatic breast cancer and specify the plans for the development of proposed breast units. Access to services for women with symptomatic breast disease is uneven, according to Europa Donna. It states that women treated in the type of multi-disciplinary breast units recommended in the report have better survival rates. Women must have equal access to high quality care, regardless of their income or where they live. The group states that there is an unacceptable waiting time for mammograms, for consultant appointments and for chemotherapy, particularly among public patients. I ask the Minister to respond to the submission of Europa Donna which was recently made to his Department. Earlier this year Mr. Michael Moriarty, consultant radiotherapist at St. Luke's Hospital painted a grim picture regarding the availability of radiotherapy services in Ireland. He stated that on average only 16% of cancer patients are receiving radiotherapy, despite the fact that up to 50% of patients could benefit from it.

The Government has made much play of the increased expenditure on health care. However, Irish expenditure on health care is well below the EU average and health outcomes are disappointing according to the Irish Pharmaceutical Healthcare Association. Compared to other EU members, Ireland has the lowest health expenditure as a percentage of GDP, standing at 6.3% compared to the EU average of 8.1%. Not alone are the services under pressure but services are being withdrawn because of shortages of facilities. In late last year a breast cancer clinic in the North-Eastern Health Board area was forced to suspend operations due to staff shortages. The North-Eastern Health Board mammography services at Our Lady's Hospital in Navan were suspended due to the turnover of staff and the diffi culties the board were encountering recruiting certain grades of staff. The nursing services manager of the hospital described this as very regrettable. This is not acceptable and should not be tolerated.

The Minister must immediately make available the facilities to prevent cancers for which a cause is known or suspected and to increase awareness and promote knowledge of the causes of cancer among professionals and the public to provide patients and their families with clear information on all treatment options available. The Minister must provide screening services of proven value in prevention and early detection. He must ensure that all patients have access to an equitable, effective service with uniform high quality care wherever patients live and he must ensure that treatments are provided appropriately and administered safely in accordance with established best practice. Treatments must be aimed at cure where possible and, failing this, at effective disease control and palliation. The patient should be cared for in a comprehensive way. This involves carrying out appropriate clinical and other investigations, providing care for complications arising from the disease and its treatment and offering appropriate emotional, social and psychological support. I commend the motion to the House.

Mr. Naughten

Our health system is in a shambles. It is a system which favours the rich. Money talks. If one can afford it, one gets the services one needs but if one cannot, one waits. Ireland has the lowest number of hospital beds per capita within the EU. Chemotherapy is cancelled due to the lack of beds. This inequality in access to health care is a fundamental problem within our system. This is supported by the fact that there are more people buying health insurance as waiting lists increase. Time is the crucial element that can secure treatment and survival for a patient with cancer.

The Minister will tell the House of the millions of pounds he is spending on our clapped out health service. It is allegedly a priority of this Government, yet in its term of office the percentage of funding for the health service has not increased. We are still below the EU average in relation to GDP investment in our health service. People should expect to receive equal medical services no matter what part of the country they live in. However, waiting lists can vary dramatically in different health board areas. Instead of one health service, there are ten health services. We need to decentralise our health services. We need to bring services back to communities where that is feasible. With the development of information technology these services are now feasible in rural towns and rural hospitals, not only in Dublin.

It is sad that public representatives must plead with consultants to get treatment for people. That should not happen. It is no wonder that we have the worst cancer treatment in Europe. As Deputy Neville said, 1,000 people are dying each year because of lack of treatment. That is a damning indictment of our health services and cancer treatment. Cancer patients must queue to get treatment and to get a bed. Each year the number of people diagnosed with cancer is increasing. Each year under this Government people wait longer and longer for treatment and for beds. Young women with families waiting for breast cancer treatment are in a crisis. Panic sets in for many of these women as they wait for treatment. There is still no national screening service for breast cancer. In Ireland a woman with breast cancer is more likely to die than in any other EU country.

Given the high level of awareness of cancer among women and the associated screening which is being put into operation, why are men left out? Apparently, it is not an issue of funding as there is no shortage of money, given that a sum of £1 billion is to be spent on the new "Bertie Bowl". Overall, the incidence of cancer is 30% higher in men than in women. There is a one in three chance of developing cancer by the age of 74 and a one in four chance if skin cancer is excluded. There are still no plans to introduce a national prostate cancer screening programme according to the Department of Health and Children, yet prostate cancer is one of the most commonly diagnosed cancers in men after skin cancer. According to the Department, the question of introducing screening programmes for different types of cancer is under review. How long will the matter be under review? How long must we wait before those screening services are put in place? Will the Minister give a date when those services will be provided? Every year, 1,100 men are diagnosed with prostate cancer. The earlier that disease is detected the greater the likelihood of survival, yet we still ignore the issue of cancer in men. This is despite the fact that men are less likely to visit their GP if they have a problem or concern.

Our health system is crumbling. The Minister has invested money, but this has not worked and it is now time to ask questions. What about the management and the manager? Sadly, the Minister has done a bad job at that. I commend the motion to the House.

Mr. Connaughton

I was in the constituency of the Minister of State at the Department of Health and Children, Deputy Moffatt, last week when I listened to Mr. Joe Duffy's "Liveline" programme on the radio and I have never known people as shocked as when a woman caller to the programme told listeners that she had cancer and was waiting for chemotherapy, yet could not get a hospital bed. One after another, callers expressed their shock. I have no idea of the politics of the callers but all said it was a shame and a disaster that such a situation could arise. If this motion does nothing else but spur the Minister to tackle this problem, it will have served a useful purpose.

There is talk of decentralising the various services, a need highlighted by the situation of a 77 year old man from east Galway who recently had to spend seven weeks receiving treatment at St. Luke's Hospital where he was extremely well treated. However, he had to stay in bed and breakfast accommodation from Monday to Friday for the seven weeks. The hospital could not take him as they had no places. The treatment took just ten minutes every day. The man had no relatives in Dublin and only occasional visitors from home over his period of treatment. Given the cloud hanging over him, it is difficult to imagine the fear such an elderly person would have in those circumstances. He received excellent treatment from the hospital, but for the other 23 hours of each day one can only imagine the problems that man experienced.

Mr. Martin

We are putting screening services in place in Galway.

Mr. Connaughton

The Minister should not expect a rosette for that. If the Minister's retort, which surprises me, is a reflection of his attitude to these patients, God help them.

Minister for Health and Children (Mr. Martin)

I move amendment No. 1:

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

"approves the Government's continuing and sustained commitment to implementing the National Cancer Strategy and welcomes the significant investment which the Government has made in enhancing patient care and in improving cancer-related services generally.".

I reject the motivation behind this Fine Gael motion which is clearly opportunistic and calculated to cause concern among a most vulnerable patient group. However, it provides me with the opportunity to put on record the significant resources in terms of infrastructure, personnel and services which this Government has put in place for cancer patients since the publication of the national cancer strategy.

This motion has been prompted by recent publicity concerning access to treatment by a patient in the Mater Hospital. It is not my intention to discuss the details of an individual patient's treatment as the provision of such treatment is a matter for the individual consultant and hospital concerned. It is unacceptable as a general principle for a patient's treatment to be disrupted and I know that Mater Hospital management has taken steps to ensure that the most immediate issues are addressed. I have already indicated that if there are resource issues to be addressed, I am willing to sympathetically consider any proposals I receive in the matter from the Eastern Regional Health Authority, the agency responsible for planning service needs in the area.

I am pleased to be given the opportunity tonight to outline the developments to date under the national cancer strategy and to brief the House on the areas of cancer services identified as priority areas for future development. The 1994 health strategy, Shaping a Healthier Future, set out a framework for the reorientation of our health care system. The reorganisation of our cancer treatment services was an integral part of this strategy and targets were set for reducing the mortality from cancer in the under-65 year age group by 15% in the period 1994 to 2004. Health care services were to be focused on improvements in health status and quality of life and increased emphasis was to be placed on the provision of the most appropriate care for patients.

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

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

Deputies will be aware that a range of support structures was put in place to co-ordinate and take a lead role in the implementation of the national cancer strategy. The first National Cancer Forum was established under the chairmanship of Professor James Fennelly. The forum, a multidisciplinary body, proved to be extremely useful and advised on many issues central to the successful implementation of the strategy. The term of office of the first forum expired last year and I subsequently appointed Professor Paul Redmond as the chairman of the second National Cancer Forum. The forum is currently examining a number of issues of tremendous importance to the effective progression of the development of cancer services in this country. Areas such as protocols for the care and treatment of cancer patients, information requirements, audit and evaluation of our services are all important com ponent parts of the appropriate future development of cancer services and the forum, as the established expert advisory body, will report to me on these issues.

Regional directors of cancer services were appointed in each health board area to oversee and co-ordinate the development of cancer services in their respective areas in conjunction with the chief executive officers of the health boards. I appointed regional directors of cancer services in each health board area last year and these posts are proving to be of great benefit in assisting in the development of appropriate future cancer services. I am pleased to report that considerable and tangible progress has been made to date under the national cancer strategy which has progressed beyond the original commitments made in the action plan for its implementation about which I will brief the House.

The implementation of the national cancer strategy was estimated to cost £25 million when it was launched. The sum allocated for the strategy in 1997 was £6 million. Since then, the Government has invested some £60 million in cancer prevention, treatment and care services, with £11 million being invested last year and almost £19 million being invested this year in such services. All of the commitments made in the action plan for the implementation of the strategy have been fully funded and have either been implemented or are in the course of implementation. The main implementation elements of the strategy included the areas of cancer prevention, early detection and screening, additional consultant appointments in key areas of cancer treatment and care and cancer research.

Cancers occur as a result of the interplay between genetic and environmental factors. Risk of cancer depends on age, sex, genetic make-up and where and how people live. To some extent, certain aspects of cancer risk are within our own control. There is strong evidence that lifestyle and environmental factors play an important role in the development of cancer. The use of tobacco, the excessive consumption of alcohol and unhealthy diet all contribute to increasing the risk of developing cancer. In spite of the fact that the EU directive on the banning of tobacco advertising was struck down, I successfully introduced legislation to ban the advertisement of tobacco in Irish newspapers and magazines. Contrary to Deputy Mitchell's assertion, the Minister for Finance is also keen to remove the cost of tobacco from the CPI but this matter is not within the Government's decision-making jurisdiction. Independent agencies must call for that. I am currently progressing this issue as it is a key factor in this country in the context of tobacco and alcohol alike.

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

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

The board of BreastCheck has reviewed progress to date and has informed me it is pleased with the level of uptake in the areas screened to date. Uptake levels have virtually reached their target of 70%, while meeting the quality parameters set and providing evidence of a significant level of screen detected cancers. The successful roll-out of the programme is dependent on a number of factors, including the availability of appropriately trained staff. BreastCheck offers suitably skilled radiographers the opportunity to work in state of the art facilities in addition to an attractive employment package and the board has taken a number of initiatives, including an international advertising programme, to address the current shortage of suitably skilled radiographers.

BreastCheck, in conjunction with the school of diagnostic imaging at the Faculty of Medicine, UCD has also set up a post-graduate diploma in mammographic imaging, the first of its kind in Ireland. This joint initiative aims to increase levels of mammographic trained radiographers in Ireland and share the experiences of BreastCheck with other mammography services. The board of BreastCheck plans to carry out a national feasibility study on the availability of skilled staff for the programme and this is expected to be completed in a number of months. The board expects to provide me with recommendations regarding the extension of the programme to the rest of the country later this year. This is an area in which I am keenly interested but we must avoid rhetoric on this issue. We must not continue rolling out a campaign which is not appropriately backed up in terms of treatment centres etc. as to do so would be reckless and irresponsible.

There is a great deal of rationale behind the manner in which we are now progressing the BreastCheck programme. We are doing so on a proper professional basis so as to obtain the best results for the women of this country. I am committed to the extension of BreastCheck to ensure that women throughout the country have the highest quality breast screening services available to them. This involves, not only screening services, but also the availability of quality symptomatic services so that an equally high standard of hospital care is available for those who may require it following a screening detected cancer.

BreastCheck is providing an excellent, intensely quality-assured service for screened women who believe that they are healthy and for the treatment of women who, through screening, are discovered to have breast cancer. It is essential that this service be matched by an equally excellent service for those with symptomatic breast disease. As the plans for the commencement of BreastCheck progressed, it soon became apparent that the symptomatic breast cancer services in this country were not provided in the manner which would or should lead to the best outcomes for women. International experience tells us that women who are treated in a multidisciplinary centre, where all the relevant medical expertise is on one site and where there is a minimum number of patients with similar disease treated by the same team, have a greater chance of long-term survival and have less chance of their disease recurring than those treated in smaller centres. Having regard to these concerns, my predecessor Deputy Cowen, requested the National Cancer Forum to review symptomatic breast disease services nationally. The forum established a sub-group to undertake this task. The report on the Development of Services for Symptomatic Breast Disease was presented to me in April of last year. I accepted the broad thrust of this report and established an advisory group to meet with all the health boards to advise and assist in formulating regional plans for its implementation.

Concerns were raised in many areas because of a perceived notion that certain smaller hospitals around the country would be downgraded if they did not maintain their mammography services. I would like to stress to the House that this report was not about the downgrading or closure of any hospital. It is about the reorganisation and development of breast disease services in centres of excellence to ensure that every effort is made to reduce the number of women in this country who die from breast cancer every year. I want to assure Deputy Mitchell that I have bitten the bullet regarding this report and its recommendations despite the efforts of his senior colleagues who tried to sabotage the implementation of this report by scare tactics in localities across the country which did no service to the work of the sub-group regarding the centres of excellence. Nonetheless, I pressed ahead and have provided funding of more than £4 million this year to enable a number of agencies to commence the development of seven centres of excellence for the treatment of symptomatic breast disease. It is my intention to proceed with the remaining six centres in the Estimates for 2002. We are awaiting proposals from the health boards in that regard.

Phase One of the national cervical screening programme commenced in the Mid-Western Health Board in October 2000. Under the programme, in the region of 67,000 women of between 25 and 60 years of age will be screened, free of charge, at minimum intervals of five years. The question of extending the programme to the rest of the country is currently under consideration by my Department in conjunction with the chief executive officers of the health boards and the expert advisory group on cervical screening. A number of key consultant appointments were committed to under the National Cancer Strategy. All of the commitments made in the Action Plan have been met at this stage and additional appointments were made in the areas of medical oncology, histopathology, haematology and palliative care.

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

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

In addition to the appointment of palliative care consultants in the areas mentioned, the National Cancer Forum advised that as these important services were at an early stage of development in this country, it would be appropriate to obtain detailed advice on their further development. This Government's Action Programme for the Millennium contained a commitment to develop a national palliative care plan. In this context, a national review of palliative care services was undertaken under the chairmanship of Dr. Tony O'Brien, a report of which will be published in the near future. That in itself out lines a very significant degree of necessary investment.

In addition to the aforementioned consultant appointments, there have been additional consultant appointments resulting from the National Cancer Strategy as follows: two new consultant posts approved in the specialty of radiation clinical oncology at St. Luke's Hospital, Dublin and additional consultant surgeon appointments with special interest in breast disease and gastrointestinal disease in various locations throughout the country. More than 55 posts have been sanctioned since the Government took office as a result of an identified need and in a strategic manner. Everything we are doing under the cancer strategy is strategic by nature; it is not ad hoc, we are not filling in gaps as Deputy Mitchell suggested. It is strategic in terms of how we are rolling out the services, taking on the expert advice and providing the funding.

Mr. G. Mitchell

If that is the case, why is the Minister only now developing a plan?

An Ceann Comhairle

The Minister, without interruption, please.

Mr. Martin

With respect to the Opposition, we are reaping the negative results of a very poor lifestyle 20 or 25 years ago. That is why we are an unhealthy country today. It is ridiculous for Opposition spokespersons to attack a current Minister for factors which go back 20 or 25 years in terms of how we lived.

Mr. G. Mitchell

The Minister should tell that to the 30,000 people on the waiting lists.

Mr. Martin

Our mistakes in the past have led to the fact that Ireland is very high up the league table in the European Union in relation to cancer. That is not acceptable. It is something we need to move on.

Mr. G. Mitchell

We used to spend more than 8% of GNP on health.

An Ceann Comhairle

The Minister, without interruption, please.

Mr. Martin

Statistics available from the national cancer registry show that the number of primary treatments for cancer have increased significantly year on year since 1994. That is a very important point. In 1994, there were 12,682 primary surgery treatments for cancer. By 1998, this had increased to 16,470. The number of patients receiving chemotherapy/hormone treatment has also increased significantly from 3,796 in 1994 to 4,974 in 1998. These figures refer only to treatments given for the initial disease and not for any recurrence or for palliative purposes. HIPE data shows that the total number of treatments for cancer has increased from 36,442 in 1997 to 50,063 in 1999. That is a very significant increase in a short number of years and is indicative of the fact that more specialist consultants were treating cancer patients and reflects a more active and aggressive approach to the management of cancer. A substantial increase in drug costs has resulted from the more complex treatment options offered to patients. This was not envisaged when the strategy commenced and following consultation with the chief executives and regional directors of cancer services I have made additional funding of £6 million available to health agencies this year for this purpose. We are far more generous than other jurisdictions in terms of allowing for a whole range of treatments.

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

The strategy recommended that the case for providing a radiotherapy service from a third supra-regional centre at Galway should be kept under review. I am pleased to report that this Government acted quickly in assessing that case and took the decision to provide a service at Galway at an estimated cost of £10 million. That is what I was referring to when I interrupted Deputy Connaughton. We have taken action to provide those services in the regions.

Mr. Connaughton

And rightly so.

Mr. Martin

We have now established a sub-group. The radiotherapy service there will be provided as part of the overall phase two development at the hospital. This is currently under way. In addition to this major investment in new radiotherapy facilities, the existing services available have also been benefiting from a major injection of resources. I announced an important investment in radiotherapy and other cancer services in Cork University Hospital, with the allocation of £12.5 million for this purpose. The development will include a chemotherapy day unit, two state of the art linear accelerators and advanced CT simulation facilities. Together with approval for the appointment of two consultant medical oncologists, the improvements will ensure that the service for cancer patients in this area is in line with the best available internationally.

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

On the advice of the National Cancer Forum, I established an expert working group to examine the future requirements of radiotherapy services nationally. I was anxious that the group would produce results as quickly as possible. It is taking a strategic and evidence-based approach to this issue. The work of this group is at an advanced stage and I expect to receive its recommendations in the coming months. The group will deal with the issue of geographic coverage.

The effective management of cancer services requires a fuller understanding of its causes and in this context cancer strategy funding was provided to the Health Research Board to co-ordinate cancer research projects. The signing of the NCI all-Ireland memorandum of understanding in Belfast in October 1999 by the National Cancer Institutes of the United States, Northern Ireland and the Republic of Ireland gave further impetus to cancer research and international co-operation in the area of cancer.

This tripartite agreement facilitates the sharing of information on cancer treatment between the countries involved, with particular emphasis on epidemiology and cancer registries, scholar exchange and clinical trials. The recently launched all-Ireland cancer statistics is a joint report on the incidence of, and mortality from, cancer on the island of Ireland and is part of this initiative. I am pleased to inform the House that I have provided £500,000 this year to enable these developments to commence. This initiative will significantly contribute to the understanding of cancer and, thus, to its effective management.

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

The House will gather from the breadth and scale of the investment I have described that I am well aware of the need for further investment in cancer services and will continue to identify this as a priority. The national cancer strategy has achieved a widespread enhancement of the range and quality of cancer services available and a major improvement in equity of access to these services. However, we must continue to look ahead and to examine ways of building on the success to date by continual improvement and investment. It is also important that cancer needs are addressed in the context of the ongoing bed capacity review which will shortly come before Government and the impending new health strategy. It is time for a strategic look at health services but I disagree with Deputy Mitchell's obser vations on what that strategy involves. Seven years after the previous strategy is an opportune time to look forward in terms of a new strategy.

Mr. G. Mitchell

It is opportune because of the election.

Mr. Martin

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

I wish to share my time with Deputy Hanafin.

Minister of State at the Department of Health and Children (Ms Hanafin)

I was surprised by Deputy Mitchell's motion which criticises the Government, particularly in light of the fact that, in a recent radio programme in which he treated us to his choice of music, Deputy Noonan stated that it is only since Deputy Martin took over as Minister that a further advance is being made in the treatment of cancer. When one receives such recognition from the Leader of the Opposition one is surprised by a motion such as this which does not take cognisance of what is happening regarding the provision of cancer services.

Mr. G. Mitchell

The devil quoting scripture.

Ms Hanafin

I am saddened that Deputy Mitchell would use a topic as serious as cancer as an opportunity to talk about appointments to boards and that he would make political points about something which has nothing to do with this subject. Cancer hits at the core of every family. Every Member has been affected by cancer by way of family or friends and we have lost Members to cancer. It is sad that Deputy Mitchell would abuse this situation when most Members are genuinely interested in this topic.

The Minister has drawn attention to the wide range of efforts involved in the implementation of the national cancer strategy. This strategy is far-reaching and is continually expanding now that greater needs are being identified. The additional investment, increased staffing and the provision of services throughout the country can only, one hopes, lead to better statistics than those cited in this debate.

Reorganising cancer treatment services will ensure a patient focus and equity of access. I too am aware that people have to drive home after chemotherapy treatment. However, do people receiving only ten minutes of chemotherapy need a bed? Medical advances are such that people can now access medical treatment on a day-patient basis, which is to be welcomed. However, the development of the centre of excellence in Galway which will provide chemotherapy and radiotherapy treatment will be of great benefit to people who have to travel from the west.

I particularly welcome the resources allocated for screening and early detection programmes. These programmes are of proven value and those concerning cervical and breast cancer are of interest to all women. The Minister cited the encouraging statistics regarding the uptake of the breast screening programme. However, I wish the 70% take-up rate would grow to 90% or 100%. Most Members have come across women who say they will not bother going for screening as the mammogram is painful. However, it is not half as painful as cancer and we should all do our bit to encourage women to avail of the opportunity of screening.

The development of the strategy also involves the promotion of a healthy lifestyle. Deputy Naughten accused the Government of ignoring men's health. However, it is men who ignore men's health. They are the worst culprits in terms of looking after their own health. The fact that the Government is providing resources and facilities cannot compensate for people who do not look after their own health. This is also true of women and children.

Skin cancer is one of the cancers not referred to so far in this debate. However, after only three days of sun people are showing the effects of sunburn. We might be excited by the sun but we are careless of its long-term effects on health. The same is true of women who speak about availing of the service while they never have a smear test or check for a lump. I visited the breast clinic at St. Vincent's Hospital and saw hundreds of women, and the only thing these women had in common was that they were waiting for the results of tests. I welcome the fact that St. Vincent's is now a centre which provides the best service and top-class diagnostic facilities.

The Minister referred to the important development of specialist palliative care services as it facilitates greater co-ordination of cancer research. Members are aware of the European code against cancer and research throughout the EU. However, research is only of use if people follow its findings. These findings include the manner in which healthy lifestyles assist people and the effects of smoking. Statistics indicate that at least 1,500, perhaps 2,000, people die of lung cancer each year. Of these cases, 95% are caused by smoking. The Government can play its part by way of tobacco legislation but people must shoulder the greatest responsibility for this situation.

The treatment of cancer demands much input and financial investment. The centres of excellence have been identified as the way forward. The cancer strategy is aimed at developing these centres of excellence and concentrated expertise so we can achieve a multidisciplinary approach. It is natural and politically unfortunate that counties which will not have a centre of excellence are demanding a small local service. Patients want what is best and, not being politicians, patients will want to go to a centre of excellence because they have a throughput of people and can recognise, quickly diagnose and treat cancer.

The centres of excellence are bringing services closer to people's homes, thus ensuring access and a high-quality service. Great progress has been made by the national cancer strategy since 1997. However, even as the health service has developed, health boards have identified a range of additional needs with regard to surgery, radiotherapy, cancer nurses, drug costs and palliative care. These areas will continue to demand further funding and the Government is committed to providing it. It is also committed to supporting counselling, other support services and nurse education. This issue was highlighted recently when I launched Daffodil Day with the Leas-Cheann Comhairle's son. The support services for patients provided by voluntary organisations and funded by the Department mean—

Mr. G. Mitchell

The Minister of State is no tulip.

Ms Hanafin

I am not a comedian either. This is a serious topic. This area is being tackled. The Government has demonstrated its commitment to it and it will continue to support it.

Ms McManus

It is now four years since the Government took office. The Taoiseach and his Government were elected on a programme to deliver on priorities in health care, to create a customer focused health care service and to target key health care areas for special attention. He promised to tackle the crisis in hospital waiting lists, but four years later the failure of both he and his Government is painfully evident. Waiting lists are still chronically long, waiting times for certain specialties have increased and the health service is overstretched and understaffed as patients suffer and even die as they wait for treatment they need. Nowhere are the deficiencies in the Government record more acute than in cancer treatment services. While the Government claims an increased spend on health, the experience of cancer patients tells a different and terrible story.

One cancer patient who attended hospital for chemotherapy recently was prevented from completing a course of treatment for weeks because no bed was available for her. Another cancer patient, a man who had already had surgery once, found that further surgery he needed was repeatedly postponed because of a shortage of beds. He presented himself at the hospital seven times and it was only on the eighth occasion that he was able to access the surgery he so desperately needed. Another woman telephoned me recently and told me that her specialist is concerned that symptoms she is displaying may be caused by cervical cancer. She has been told that it will take three months for the results of her cervical smear test to be delivered to her specialist. I asked an oncology specialist if such experiences were exceptional. He assured me that these were common events for many cancer patients and were not exceptional.

In The Sunday Tribune last Sunday, Dr. Des Carney, a consultant medical oncologist in the Mater Hospital, said:

There are people who need to be treated as a matter of urgency. They need to have their treatment on schedule; that is their best chance of a cure. The problem with beds has been there a long time, and it is an extremely frustrating one. Consultants are competing with each other to get beds. We are also competing with casualty to get beds and this is wrong.

It should be remembered that when the Government came into power, a national cancer strategy had already been prepared. The Minister, Deputy Martin, and the Minister of State, Deputy Hanafin, are generous people. It is an indication of how defensive they are feeling that they did not credit the origin of the national cancer strategy.

Mr. Martin

I mentioned it in my contribution.

Ms McManus

I did not catch that; it did not penetrate very far in terms of the Minister's references to the cancer strategy. Our strategy was well thought out and targeted a particular need. It seized an initiative and it is a model for how the Government could have strategically dealt with developing a new and better health service. If it had been adopted, the health service would be in a much better state now.

As other speakers noted, the prevalence of cancer is high in Ireland, particularly among women. The rate of breast cancer is high, but the screening programme which is effective and particularly helpful for women over the age of 50 years is being developed at a slow pace. Women in my county of Wicklow have still to be called by BreastCheck. I have received calls from constituents who want to know why they have not been called. They are as much at risk from breast cancer as any other woman in any other part of the Eastern Regional Health Authority area. What is the position regarding the women who make up the 50% of the population who live outside the areas that have been targeted? Are their lives somehow less in need of the protection that this screening programme offers? If, as the organisers of BreastCheck believe, deaths from breast cancer can be reduced by 20%, why are women whose lives could be saved being effectively condemned to die because they live in the wrong parts of Ireland? There is a need to deliver a genuine national screening programme that reaches all parts of the country at the same time.

Cervical screening has proved to be an even more effective way of saving women's lives yet no national screening programme is in place. Most shamefully, women on the GMS must pay for this service if they wish to have a routine cervical smear test, something all women are exhorted to have done. I take issue with the Minister of State, Deputy Hanafin. Women want to access screening programmes; that is not the problem. There is no need to encourage women. The problem is that the service is not being fully delivered to them. Cervical cancer is a preventable disease and screening is a most effective way of detecting it.

The same applies to testicular cancer, which is the most common cause of cancer in young men. A national screening programme could make a significant difference in detecting this disease but there is no sign of such a programme being instituted. If detected early enough, this cancer is 90% curable. This raises issues about the delivery of services in terms of general practice primary care and particularly the GMS. Screening on an ongoing basis is not part of the GMS. Services such as vaccination are taken as special items and the natural area in which screening could take place at primary care level is not being properly exploited and developed. It is impossible for a proper screening programme to be delivered in this way as long as patients are not registered with general practitioners.

Another example is bowel cancer. It runs in families and it is now becoming possible to test for a genetic predisposition to it. However, these genetic techniques are not being considered or included in the Department's measures. Increasingly, pharmogenetics will play a central role in tackling certain cancers but they do not appear to have impinged on Government policy. The use of genetics in health care and its delivery is a huge challenge facing the Government. However, it appears it cannot see the elephant.

Although it was handed a strategy on cancer, the Government has not moved with any great sense of urgency. There have been some welcome improvements in hospitals, but the service to cancer patients is at best patchy and uneven across the country. It is being directly damaged in Dublin in particular by bed and staff shortages. The expert view and recommendation of Professor Niall O'Higgins is that there should be 13 hospital cancer centres across the country. I welcome the Minister's commitment in this regard and I hope he follows it up. As an election draws closer, questions will be asked about whether the Government, instead of securing the kind of excellence of service that is required to meet the needs of cancer patients, funks the issue when faced with local opposition. People will ask what is more important to the Government – the delivery of high quality cancer care, inevitably centralised to an extent throughout the country, or pacifying local interests.

Local communities are committed to maintaining their local hospitals. I support this good commitment and the Government, despite all its limitations, should be able to provide a good future for local hospitals. However, this must be done in a way that does not put patient care at risk. This challenge needs to be discussed and real policies need to be put forward because there is an important role for the local hospital in terms of the delivery of quality care that is appropriate to its size and capability. However, on the basis of its track record, the Government has ducked difficult questions rather than face up to the changing nature of health care.

When it comes to overall health care, it is obvious that the Government has no idea what to do about the health service. It is spending a great deal of money – although it is probably not enough – but it does not have a coherent plan on how to provide a quality health service to everyone who needs it. The Minister's statement at the launch of the health strategy's national consultative forum is dispiriting if not illuminating. It is dispiriting because it shows the Government has no strategy for health care. After lurching from one health crisis to the other the Government now wants to know what it should have been doing over the past four years. It is illuminating because the public has realised this is one last effort by Fianna Fáil to get a lifeline on health policy before the next general election.

At the launch the Minister asked many questions, including should we move to a rights based approach to access to health care? How can we achieve fair access for all based on medical need? What are the pros and cons of moving away from the current tax based system of funding health care? How do we compare with other developed countries? What impact does the public/private mix have on the effective use of resources? What level of funding is needed to achieve a more people centred, equitable and high quality health service? Many other questions were posed by the Minister, who is a member of a Government that has been in charge of the health services for the past four years.

Will the Minister indicate why he is only asking these questions now? Why did he and his predecessor not ask them four years ago when they made these commitments to the public? Why did he not get answers from the fine and large Department he runs? The Government was elected to deliver on health care as a priority. Coming towards the end of its term it has yet to decide what are its priorities in this regard.

In our proposals, outlined in the document, Curing our Ills, the Labour Party sets out its priorities. We seem to have set the agenda for the Government. The elimination of a two tier health service and the provision of free GP care form the central planks of our policy. When we articulated them a year ago they were new and controversial and they were considered to be radical. Today there is widespread support for our objectives from within the medical profession and the public. We set the agenda while the Minister still poses the questions.

The record of the Taoiseach has been less than impressive. When he speaks about health, which is rarely, he generally refers to money. While the Government has spent a lot more money on health, it has much more to spend. The Taoiseach has a different priority, for Abbotstown, which is likely to cost at least £1 billion. Nobody would argue that we should not invest in sports facilities. Even on health grounds it is worthwhile. Many argue that investment should be made in local sports facilities, such as football pitches, swimming pools, running tracks or boxing clubs while others support the grand project at Abbotstown. Regardless of what side of the argument one favours there is unanimity among the public that cancer patients should not come second to the development of a range of sports facilities, whether at Abbotstown or elsewhere.

I agree with the Minister of State, Deputy Hanafin, that every family has been touched by cancer and they want the best possible care for those who suffer from it. I suspect that every family knows they have been sold short by the Government. What shocks people most is the lesser priority it is giving to the health service. People know the Government must make choices about its priorities and they know the kind of dedication of resources, including the strategic planning of management resources, going into the Abbotstown project could and should have been directed towards the transformation of the hospital service.

Even long standing members of Fianna Fáil are disturbed by the poor state of the health service and the lack of attention it is receiving by the Taoiseach. In the past Seán Lemass delivered economic growth, Donogh O'Malley delivered free second level education and Erskine Childers delivered a quality general medical scheme for the poor. These men understood the hardship people had to endure and responded to their needs. Their legacy lives after them, not in bricks and mortar but in the transformed lives and opportunities of citizens. That kind of outlook is needed now. Regrettably, this Government is deficient of any vision or ambition to transform society and to meet the needs of today's citizens.

The health service is riven with inequality in a society where inequality is being made worse by the Government's policies. We could have a great health service, a wonderful education system, a comprehensive child care programme, an effective transport network and a high quality clean environment. However, we have none of these things because we have a bad Government, even though it is in power in good times.

A Seán Lemass or a Donogh O'Malley would have delivered a world class health service accessible to all who need it but the Taoiseach comes from a more recent tradition in Fianna Fáil. He wants to leave another kind of legacy. The former Taoiseach, Charles Haughey, led Fianna Fáil in a very different manner from his predecessors. The extent of that difference is being revealed to us daily through the work of the tribunals. We know Charles Haughey liked to leave physical monuments behind, including Temple Bar, the IFSC and Government Buildings. His loyal lieutenant, the Taoiseach, shares the same desire. Deputy Bertie Ahern is not in the Seán Lemass or Donogh O'Malley mould. At Abbotstown he is seeking to leave a legacy that is even more extravagant and costly than Charles Haughey could dream of. In the meantime the health service is creaking from a lack of focus, direction and leadership. The Minister is making the best job he can of it. When he cannot make a good job of promoting his views he apportions blame to the hospitals when things do not work out.

When he spoke of health promotion and cancer research, the Minister did not mention the issue of poverty, yet it is clear from the research undertaken on a North-South basis that poverty is a significant factor in terms of ensuring an improved health status for the population. Jane Wilde made a similar point recently in The Irish Times. She pointed out that countries with a narrow gap between the rich and the poor, where there is more equality, generally have a better health status. However, the Minister for Finance advises us to party while his financial policies deepen the chasm between the better off and the poor. No wonder the Minister for Health and Children is silent.

The Minister is right to talk about lifestyle, smoking and drinking but over the past four years the problems stored up will create a worse situation. Young people are drinking, smoking and taking drugs to a much greater extent. It is not as if the problems go back a long time, it is that they are getting significantly worse.

I hoped when the Government took up office it knew what it was doing. It is clear that is not the case. Any future health strategy must have meaning and clear objectives. We must learn from the past in terms of devising strategies. The cancer strategy devised by the former Minister for Health, Deputy Noonan, has stood up to the test of time although it can always be improved. The Government is deficient in that kind of thinking. More than anything the health service needs strategic planning and leadership from the Taoiseach. The loss of this is creating many problems for cancer and other patients who are desperate to access and avail of services at a time of such plenty.

I forgot to mention earlier that I wish to share my time with Deputy Upton tomorrow night.

An Leas-Cheann Comhairle

Is that agreed? Agreed. There will be ten minutes remaining tomorrow evening.

Ms McManus

I point out to the Chair that the clock in the Chamber is wrong.

An Leas-Cheann Comhairle

I can only see the clock in front of me.

Ms McManus

It is helpful when the two clocks coincide.

Ms Hanafin

The Deputy cannot think of anything else to criticise.

Debate adjourned.