JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Thursday, 5 Feb 2004

Radiation Oncology Services: Presentation.

Chairman

I welcome Mr. Donal Hollywood, professor of clinical oncology at St. Luke's Hospital, Dublin; Mr. Gordon Watson, consultant surgeon at Waterford Regional Hospital; Mr. Kevin Moran, consultant surgeon at Letterkenny General Hospital; Dr. Maccon Keane, consultant medical oncologist at University College Hospital, Galway; Dr. Ian Fraser, consultant oncologist at St. Luke's Hospital; and Dr. Seamas O'Cathail, consultant radiation oncologist at University College Hospital, Cork. I will ask Professor Hollywood to commence the presentation on the development of radiation oncology services in Ireland and I ask each of the witnesses to be as brief and concise as possible in their contributions, given that there are time constraints.

I draw the attention of witnesses to the fact that members of the committee have absolute privilege but that this does not apply to witnesses appearing before it. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name in such a way as to make him or her identifiable.

Professor Donal Hollywood

I thank the committee for the important opportunity to address it on the recently completed expert report on the development of radiation oncology services in Ireland. I thank and commend the other 22 members of the group for their significant contributions to the many discussions and challenges that presented to us in addressing our remit. I am confident the detailed proposals outlined in the expert report will provide the significant first phase of development of a national clinical network of radiation oncology services. This will, to the greatest degree possible, guarantee patients access to the highest level of care that is being developed or is envisaged in other western countries. Fundamentally, the report recognises and endorses the right of all cancer patients in Ireland to access the highest quality radiation oncology service.

In regard to the proposed development of radiation oncology services within Europe, Ireland stands at a unique crossroads of opportunities. We are in the unenviable position of having the weakest radiation oncology service in the European Union. This, nevertheless, presents us with a unique opportunity to learn from other jurisdictions and to develop what is best. At its simplest, we have the critical opportunity to get this right and we have an equal opportunity to get it wrong.

The committee should be aware the report, with its recommendations, has been subject to significant national and international scrutiny and has been endorsed subsequent to its publication by international and national authorities, which are outlined in the information pack. Unequivocal endorsements of the report have been provided by Professor Norman Coleman, director of the radiation oncology branch, National Cancer Institute, Washington, the largest cancer care agency in the world; Dr. Martin J. Murphy, Jr., a trustee of the American Cancer Society Foundation and director of the American Cancer Society; Professor Michael Baumann, president elect of the European Society for Therapeutic Radiology and Oncology and chairman of the European education and training committee, which speaks on behalf of more than 6,000 radiation oncologists in Europe; and Professor Tom Keane, provincial radiation therapy program leader, British Columbia Cancer Agency and professor, chair and head of the division of radiation oncology, University of British Columbia. Nationally, the report has been endorsed and supported by the board of the faculty of radiologists of the Royal College of Surgeons in Ireland and, importantly, by the medical board of St Luke's Hospital.

It is important to realise both the magnitude of the clinical problem that the expert group has addressed and, equally, the potential benefit to our patients of correctly structured radiation oncology services. The burden of cancer on our society and the need for modern state-of-the-art centres of excellence is abundantly clear when one considers our present position. One in three individuals in Ireland will develop cancer during their lifetime. With present treatments, one in four of the Irish population will die from cancer. There is significant evidence, from both north America and Europe, that this burden can be reduced by the delivery of multidisciplinary care, including radiation oncology, in the context of specialist comprehensive cancer centres. Ireland lies 13th of the 15 EU member states in terms of cancer mortality rates. Although the cause of this is multifactorial, it is highly likely that the existing underdevelopment of radiation oncology services contributes to this excess and early mortality. The most modern estimates suggest that between 55% and 60% of patients will require access to radiation oncology services during their cancer illness. In contrast, approximately 20% of cancer patients in Ireland have radiation therapy as part of their primary treatment.

The report recognises and details the profound underprovision of services currently. It provides a solution where the issue of patient access is not dominated by the present limitations of profound treatment undercapacity. The proposed model of care will provide a 150% increase in treatment capacity by 2008 and full capacity within a decade.

It is equally critical that we recognise and acknowledge the importance of the quality of radiation treatment delivered to patients and its impact on patient outcome. Unlike other forms of human illness and treatment, the initial quality of treatment is of paramount importance in maximising the chances of cure. The quality of the first course of treatment has a profound influence on the chances of cancer control and patient survival. This outcome cannot be corrected by a second opportunity or attempt to get it right. If the initial treatment is sub-optimal, the chance of cure for patients is invariably reduced.

It is implicit, therefore, that future service must guarantee excellence of care at the point of service delivery. The overwhelming majority of the expert group believes the recommendations set out in the report, developed in the first phase around the four centre model, will deliver this potential. It is equally important to acknowledge the report's recommendations will deliver on the expectations of patients who have recently had the unique experience of receiving radiation therapy. These include in order of patient priority the unequivocal provision of the highest level of patient care; the guarantee that patients be given information on their condition; the need to reduce waiting times for radiation treatment; and the improvement of communication between medical and other health care staff and between all health care staff and patients.

The expert group has recognised the potential problems associated with travelling to centres of excellence, and has provided detailed recommendations on facilitating prompt and appropriate access, particularly through dedicated accommodation for patients and families, innovative fast track transport arrangements for patients and extended working days at the treatment centres. It is the expert group's view and my own passionate belief that the initial service development of a backbone of four large clinical radiation oncology centres will fulfil this expectation and, equally, the cancer care requirements of this and future generations.

I reiterate in the last decade our colleagues in Northern Ireland have undertaken a similar process of radiation oncology service review. Through their independent analysis of the Calman-Hine report, the NHS cancer plan and the Campbell report, the Northern Ireland authorities have opted for the development of a single large radiation oncology centre located in Belfast. This centre will have ten linear accelerator treatment units and a full complement of multidisciplinary teams. This single centre will serve the entire Northern Ireland population of 1.7 million.

The report defines a realisable and cost effective implementation plan that will address the following deficits: first, the unenviable position, where Ireland has the lowest number of clinical specialists per million population in both the EU and all western countries examined and, second, it will rapidly address the fact that Ireland has the lowest provision of treatment equipment per head of population in the European Union.

The proposed model will also provide a framework that meets the following national and international standards: it will adhere most closely to the World Health Organisation, and US National Institutes of Health concept and "gold standard" of cancer treatment being delivered within the context of a comprehensive cancer centre model; it will enable the development of specialist clinical teams with both tumour-specific and technology specific expertise; it mandates the development of more extensive and integrated multidisciplinary care; it meets the stated and expected medical and para-medical training programmes and their associated national and international accreditation mechanisms; it facilitates the most rapid implementation of new radiation technologies particularly those with significant complexity, and expense; and, fundamentally, it will address the issue of access where a profound shortage of national treatment capacity no longer becomes the dominant limiting factor.

For those who remain uncertain about the issues, the need for quality that the report identifies and the proposed solution of rapidly developing large comprehensive cancer centres, it is worth noting the following: without exception, every western country has an existing national framework and backbone of large treatment centres and all consultant radiation oncologists and medical oncologists in Ireland have trained at equivalent large institutions in Europe and the US before returning to Ireland. Each one of us, in our professional capacity, has recognised that these centres provide the best training and the best care for patients. Why should we suggest anything different for our own patients?

The report's recommendations are based on a comprehensive analysis of authoritative national reports, the existing international models of care and a detailed study of the anticipated evolution of care pathways in radiation oncology. I would like to acknowledge the immensely valuable input from the independent patient study undertaken on behalf of the group by the

IPA/RCSI. Some of these patients were receiving end of life care at the time of the study and their conviction and contribution to our thoughts and decisions were irreplaceable.

I acknowledge the commitment of the Minister to deliver the implementation programme endorsed within the report. This decision is courageous and correct.

The expert report enshrines excellence and the belief that equity of access to the highest quality radiation oncology treatment is a right of all cancer patients in this country. Within the discipline of radiation oncology, highest quality care means the greatest chance of patient cure. The report equally endorses the need for a continued and informed review of future service development. At its heart the report identifies an immediate timetable and realisable investment programme that will deliver this excellence.

The report has the overwhelming support of the majority of members of the expert group and the independent authoritative endorsements from national, European, Canadian and US authorities. We stand at a crossroads in the provision of new radiation oncology services. The report endorses excellence of clinical care, not compromise or mediocrity. Our patients expect excellence. To deliver otherwise is indefensible.

Dr. Ian Fraser

I am a consultant in radiation oncology. I was appointed to care for the patients attending the Mater Misericordiae Hospital, Dublin, St. Luke's Hospital, Dublin and also to run clinics in Waterford, Wexford and Kilkenny for the patients in the South Eastern Health Board. Through the Mater Misericordiae Hospital, I see patients, not only from Dublin but also from the North Eastern Health Board and from other health boards. One in three people in Ireland are going to develop a cancer during their lifetime and one in six people will need radiation therapy. One in five people will die of cancer. The incidence of cancer is going to increase by 41% by the year 2015. It will continue to increase subsequently as the population ages. We currently have two consultant radiation oncologists per million of population. The next lowest in the European Union is Portugal, with four per million.

I do all my public outpatient clinics myself. I make a point of doing all my clinics in the peripheral hospitals because the decisions, which have to be made, require the presence of the consultant and decisions cannot be left to the next clinic because these are too far apart - some clinics are held on a monthly basis. There is also the matter of continuity of care. The patient must see the consultant and must feel that the consultant is making the decisions and is in charge of their management.

The clinic is also the time when consultant colleagues can come in and discuss difficult problems. My door is always open. There is no waiting list to attend the clinic. Every patient comes to the next clinic. The first action I did when taking over the Wexford and Kilkenny clinic was to ensure that a local person was put in charge of the secretarial aspect, so that they would inform me what was really going on with many of these patients. This is because patients will come in and tell one story when the reality may be completely different.

In Waterford, the clinic is run on a truly multidisciplinary basis and I think that this is a model which could be adopted elsewhere. The medical oncologist is on one side of a corridor and I share the other side with the palliative care consultant. The ENT consultants come down and we review old cases to discuss the follow-up. The patients and relatives are encouraged to participate in the discussion. Other clinicians such as pathology, radiology, haematology, gynaecology and general surgery also come into the clinic and the patient may be seen by up to five or six consultants at the same time. This means the management is truly open and the patients and their relatives can see the rationale behind the pathway of care. The surgery and medical oncology can take place locally, but the radiation must take place in Dublin at present and the model is Dublin, Cork and Galway. The patient will have to travel for their radiation therapy. I find that even when I try to persuade patients from west Waterford to go to Cork, they will insist on coming to Dublin. For the private patients this is a seamless process, with the Mater Private providing an excellent service, though from 1 January this year beds are not available. The delay for private beds in St. Luke's may be up to three or four months.

The simulation is the setting of the beams and taking measurements for the treatment plan. This may take four to six weeks to develop and then the patient returns for verification of this plan. The patient then goes on the bed list and will have to wait for a further couple of weeks before admission for radiation therapy. During this wait, which can be three to four months in the case of a public patient between the time he or she is seen in the clinic and the start of the treatment, the tumour does not stop growing. We have instances of patients having very significant advance in the development of their tumour with obvious consequences as regards their potential survival. The patient may then come to Dublin for a period of up to seven weeks to receive the radiation therapy and some of the patients will travel daily five days a week for up to seven weeks to get their treatment. The treatment takes five to ten minutes a day and, as one patient said to me, the two hours of treatment meant that she was away from her home for a total of 500 hours. The staff of St. Luke's Hospital is excellent at looking after patients, but the system as set up at present simply cannot respond to the urgency.

Cancer is now a multidisciplinary problem. In many common tumours such as rectal cancer the diagnosis is made and an immediate demand is made for pre-operative radiation. This needs to commence as soon as possible and needs to be delivered concurrently with chemotherapy so the patient will be seen in the general hospital at Waterford, Limerick or wherever. They need to start the radiation and chemotherapy at the same time, and they need to continue at the same time. On completion of that course of treatment the patient would be returned to the surgeon, who will operate as soon as the acute reaction settles down. This needs to be timed and everybody needs to know precisely what is going on with the individual patient. This gives the best potential survival and the best functional result.

We have one of the highest incidences in the world of cancer of the rectum and it is very hard to organise the co-ordination when one is doing this across a gap of 100 miles. We are finding it extremely difficult to co-ordinate the management of the surgery, radiation and chemotherapy. This rectal problem is not an isolated one. The same exists in cancer of the oesophagus, cervix, head, neck and breast. I recently had a young teacher with an eight centimetres cancer of the rectum in whom we got it absolutely right and it was wonderful, but the surgeon turned around to me and said that patient may be cured but we had another older gentleman who was waiting two months to start his treatment and his outcome was very much less certain.

Patients find travelling to Dublin very difficult. They talk of the nausea, of vomiting in the ambulance, of the pain travelling on bad roads, and of not being able to pass urine when stuck in traffic. I listen to the nurses who accompany them and see the look in the eyes of the ambulance men who must hang around. Ten minutes of treatment can take up to ten hours: three hours coming to Dublin, three or four hours hanging around and three or four hours going back.

One of the faults of the patients' survey at the end of the report is the fact that the really sick patients were not interviewed. Over half of the patients interviewed in this survey came from Dublin. The sick patients from the periphery either were considered too ill to attend Dublin, and we simply gave them more morphine and just did not give them the treatment, or they were brought to Dublin and were so ill that nobody asked for an opinion about travelling and they were simply sent home afterwards.

I have a patient who is travelling daily from Tramore to Dublin for radiation for seven weeks and his main concern is his alcoholic daughter at home in Tramore. Life goes on for these people. Cancer treatment is not an isolated incidence. Cancer treatment is part of life and the more normality that these people can have in their lives, the easier it is for them to cope with the cancer therapy.

I had a young woman patient yesterday who has had a baby. As her baby was delivered they noticed a swelling of her arm. She had metistatic breast cancer and she is now coping with a new baby and with multi-site metistatic breast cancer. She had to come to Dublin for treatment yesterday. She was away from her baby for six or eight hours while getting the therapy. Her anxiety was palpable. She does not want to make these journeys all round Ireland. These are not isolated instances. They happen each day of the week.

I live and work in Dublin. It would be much easier for me to say nothing. I am a Dublin consultant and I could stay here. To develop Cork and Dublin alone would be the wrong decision. We need big centres of treatment and multi-disciplinary levels of care, which can be developed across a web. I spoke with Professor Keane, about whom Professor Hollywood spoke. I asked him how he organised things in British Columbia. He said they have a central model in Vancouver and peripheral units in the Rockies and on Victoria Island where they simulate the patients, plan centrally and treat patients close to their home. It is not necessary for the patient to travel as one gets the information and the patient can be treated where he or she lives. This means one obviates transport and accommodation costs, which makes it much cheaper to give a higher standard of care.

There should be treatment facilities. I am not referring to a unit for every single hospital in Ireland, but a central structure. Units in Dublin, Cork and Galway are justified. According to the report, Cork was developed because it was difficult to co-ordinate the treatment with Dublin. The information can be transmitted if local facilities cannot cope. Treatment can then be delivered locally, which is a higher quality of care.

St. Luke's Hospital Dublin, is doing a great job. We have some of the busiest linear accelerators in western Europe. However, it is a poor hospital because it does not have surgery, medical oncology services or the back-up of a general hospital. It has very limited medical oncology services. We need to deliver in the periphery. In 1979, Cork would not have fulfilled the requirements laid down by the expert group. It has been a total success, as have the two private units in Dublin. There is no question as to the viability of the size of the private units. Patients are getting excellent care and are delighted with the standard of care. Why can such a standard not be delivered in the public service? There are economic pressures. The expert group planned a four linear accelerator unit of the minimum size. Construction costs €35 million, revenue €7.36 million and patient accommodation €2.3 million. The cost to the South Eastern Health Board is €1.8 million a year just to drive patients up and down. This amounts to €18 million over ten years. This cost can be eliminated. I have a quotation from a major supplier who said they can build a two linear accelerator unit for €8 million. This means that patients would attend out-patients.

In conclusion, on the grounds of improving the quality of care technically to co-ordinate radiation with the medical and surgical oncology, locally provided radiation, not in every hospital but in the major centres, is a better option. In terms of the social care of cancer patients, local management is better. In economic terms, significant sums of money will be saved by doing this. Patients deserve better than they are receiving at the moment. Above all, decisions must be made, and quickly. We cannot just sit on the fence. While we are discussing the matter, tumours are growing, patients are waiting and patients are dying. Action, not talk, is needed.

Chairman

I thank Dr. Fraser. Forgive me for noticing how both people sit so easily together with such differing views on the matter.

Mr. Gordon Watson

I am a consultant general surgeon at Waterford Regional Hospital. I have a special interest in breast and endocrine disease. In 1998, I was appointed regional director of the cancer services for the South Eastern Health Board. Currently my work is different from what specialist surgeons will become. I have a broad range of interest. Principally I am involved with the management of cancer patients, particularly patients with breast, colorectal and skin cancer. I was asked to be lead physician for the South Eastern Health Board symptomatic breast care group, which was opened by the Minister last year. I was a member of the radiotherapy review group.

We all agree with Professor Hollywood who, in his foreword to the report on the development of radiation oncology services in Ireland, states that a high quality radiation oncology service is one of the cornerstones of a modern treatment programme for cancer patients. Clearly for this to achieve maximum benefit for patients, it must be linked to a high quality specialist surgical service and to medical oncology, together with all the supporting disciplines. We are also in agreement that there is a considerable shortfall in radiation oncology services in Ireland at present and there is little doubt that, under current circumstances, there are major difficulties in developing and, indeed, delivering integrated cancer care incorporating the disciplines of surgery, medical and radiation oncology. It is well recognised that it is the way forward by which we will manage all the common cancers today, particularly my interest in breast cancer, rectal cancer, oesophageal cancer and some ENT and gynaecological cancers.

In future it is estimated that between 50% and 60% of cancer patients will require radiotherapy. This is a significant increase on what we can accomplish today. Furthermore, our population is set to rise to 4.3 million by 2015, when the population of over 60% of a high cancer group will amount to 18% overall. It is estimated that there will be a 41% increase in the number of cancers between 1994 and 2015, not counting non-melanoma skin cancers, while there will be a major increase in the common cancers which require radiation oncology, including breast, prostate, lung and non-melanoma skin cancers.

Currently there are radiation oncology facilities in Dublin and Cork and at centres under construction in Galway. There are three radiation oncology facilities in Dublin. One is in St. Luke's Hospital, with six linear accelerators, which is the delivery system for radiation oncology. The second is in the Mater Private Hospital, with two, and the third is in St. Vincent's Private Hospital, with two bunkers. The latter four linear accelerators were not emphasised in the review group's report. These bring the number of linear accelerators in Dublin to ten. Cork University Hospital has three linear accelerators and one cobalt unit. The population of the North of Ireland is estimated at 1.7 million. They currently have eight linear accelerators, centred in Belfast. It is hoped to increase the number to ten or 12. The population of greater Dublin, with 1.3 million, already has ten linear accelerators.

While I concur fully with the review group's report advising on an overall increase in linear accelerators throughout the country to 26 by 2008 and 35 by 2013, I have considerable concerns about their distribution, as I believe the current proposals lead to inequality of access. Yet the expert group acknowledged that cancer patients expect the provision of rapid access to the highest quality of care. Furthermore, the most recent report on cancer services, An Evaluation of Cancer Services in Ireland - A National Strategy 1996 by Deloitte & Touche on behalf of the National Cancer Forum, puts access on the top of its terms of reference in its introductory paragraph. At present, and with the proposed configuration of radiotherapy oncology for the future, I cannot be convinced that cancer patients from the south east, mid west and particularly anywhere north of Dublin or Galway, would have equality of access to radiation oncology services. It was on this point and the factors leading to it that Dr. Liam Grogan, a medical oncologist, and I, a general surgeon working predominantly with cancer patients, could not support the proposed model of service delivery as advised by the review group.

While we represented only a small minority of the overall group we were as significant in view of our representative positions in terms of cancer care and our non-alignment to radiation oncology or the Department of Health and Children. In general, we favoured a hub and spoke of a network type system with smaller units of radiation oncology delivery centred in Limerick, Waterford and a chosen site in the northwest similar to the existing site at the Mater Private and St. Vincent's Hospitals. I envisage such units as being service only, non-training units, consultant provided and hence in keeping with the current aims of the Department of Health and Children. They would network with larger units, a system which will be proposed in the forthcoming cancer strategy policy documents for cancer in general.

Finally, the findings of the radiotherapy focus group were unreliable and unscientific. The report was subject to considerable bias and patient selection and was not representative of cancer patients attending for radiation oncology treatment. For example, 51% of respondents came from Dublin or Cork and seven counties were not represented, including Galway. Some 68% of patients were out-patients and as such could either travel conveniently or were not particularly ill. There was no case mix data provided and we do not know the number of patients who might have attended for palliative radiotherapy. No patients excluded on clinical grounds from travelling were included. In my opinion, this study if sent to a peer review journal for publication would not have been accepted. I was surprised that the Minister, when questioned, was advised to rely so heavily on its findings.

If the Department of Health and Children cannot extend the remit of radiation oncology outside the three designated areas the people will take action to counter this perceived injustice. Action is already well advanced in Limerick and Waterford towards the establishment of private facilities for radiation oncology services. I look forward to a slightly different approach - the introduction of intra-operative radiotherapy, a technique of radiation delivery which can be administered in a standard operating theatre to breast cancer patients who can receive it during initial surgery. The technique is available to patients in the European Institute of Oncology in Milan where it has undergone rigorous introductory trials.

In terms of the management of cancer patients, radiation oncology is part of a multi-disciplinary process which usually commences with surgery and which also includes medical oncology and other disciplines. We in Ireland need an increase in the number of linear accelerators to deliver the process. As with all cancer care, such accelerators should be networked to super-regional and regional centres thereby ensuring all people with cancer can have equal access to this essential service.

Mr. Kevin Moran

I have been a surgeon in Letterkenny since 1991, almost 13 years. I will provide the committee with a brief prospectus from the periphery. In those 13 years I have treated patients with breast, head, neck and skin cancer. For the past number of years, I have had the luxury of specialising in neurological cancers.

In 1998, with the inception of the cancer strategy, I was appointed regional director of cancer services and have been involved in the planning and local organisation of cancer services. The national cancer strategy has been, from our point of view, a wonderful success in delivering two of the three treatment modalities in cancer management. It has been successful in terms of surgery and medical oncology. We now have teams working together in a multi-disciplinary way in a protocol driven manner with progressive audit. However, I am sad to report that the story is entirely different in terms of radiation oncology.

In the 13 years I have worked in the northwest, radiation oncology services have deteriorated. Initially we had consultants visiting Sligo and Letterkenny twice a month. Unfortunately, due to consultants' workload, they no longer visit the northwest. We are visited by registrars in Sligo and Letterkenny twice monthly. That is not quite the same as a consultant-delivered service. On how this translates into the service provided to our patients, currently women with beast cancer are opting to have radical surgery rather than more conservative surgery because of the difficulties in travelling to Dublin for radiation treatment. Patients with rectal cancer are waiting two to three months for radiation treatment before their surgery can proceed. Patients with prostate cancers are waiting three, four, five and six months before they can be treated. Patients with head and neck cancers are also waiting significant times for treatment.

The fact that only 24% of patients suitable for radiation oncology receive it in the northwest indicates that at least another 25% of patients with cancers are not being treated possibly because of the difficulty accessing the service. There is no equality of access for patients from the northwest to radiation oncology services. I pay tribute to the excellent work done by Professor Hollywood and his team in attempting to address the problem nationally for the future. The committee has heard a great deal already in terms of statistics so I will not repeat them.

I am not optimistic that the proposed services will improve our equality of access too dramatically. Currently Belfast has eight linear accelerators which are not adequate to service a population of 1.7 million. I am concerned that in the future it will not be able to deliver the service it is proposed it might deliver to the northwest. It is 70 miles from Malin Head to Letterkenny, from Letterkenny to Sligo is also 70 miles and I am not sure what the mileage is from Sligo to Galway but I am sure it is at least 80 miles. Without going into detail on logistical and demographic factors we have to consider in delivering services in the northwest, that provides a flavour of the picture.

The report includes an aspiration from the northwest that it should be permitted or encouraged to develop its own services locally. From my 13 years experience in the north-west and my experience as regional cancer director, I endorse that view.

Dr. Maccon Keane

I thank the committee for the opportunity to speak on what is one of the most important matters in health care today in Ireland. I am currently the only medical oncologist working in the Western Health Board and I see approximately 20 to 30 new cancer patients per week. Yesterday alone I saw seven new patients in Castlebar. I see much of the clinical load of patients from the western seaboard who require treatment for cancer.

The one area in which there has been agreement among everybody here this morning concerns the poor radiation oncology services in Ireland. The issue is not what we have but where we are going and what solutions we should implement in order to give the country first class quality care. There are three main problems as matters stand. We have inadequate access to radiation services. This inadequate access can be broken into several areas. There is a complete lack of adequate numbers of treatment machines and treatment is limited by the number of machines available. We all agree the number needs to be increased. In addition, we do not have the personnel to use these machines or the radiation oncologists to deliver the care and with respect to access we have the issue of geographic isolation. My practice, in particular, like Mr. Moran's, includes patients who are geographically isolated from the two sites where public radiation is currently available.

The second big issue, also addressed in the Hollywood report, is the isolation of radiation oncology services from other acute medical services. The major radiation oncology delivery site in the country is a standalone unit at St. Luke's Hospital. This is inadequate in terms of modern cancer care and in terms of the acute health care of cancer patients also suffering from other diseases such as diabetes or heart disease. In contrast, the facility in Cork is located on an acute hospital site.

The third area I see as being majorly deficient, and everybody here agrees, is that there is completely inadequate, up front, multi-disciplinary planning of patients' treatment for cancer. At the point of diagnosis not all the personnel required to make a plan for a patient's treatment are present on site to give the patient the best option in terms of his or her overall survival and potential cure from the disease.

The Hollywood report, the other suggestions from this board and Dr. Cowley's suggestions have all sought to address this problem in a variety of different ways. All have merit and all have problems. The remit of this committee should be to choose which is likely to provide the best solution for the country. Professor Hollywood went into this in detail in the background to his report. The solutions offered so far include the one in this report which is for the establishment of four major cancer centre sites, that from the Irish Society for Medical Oncology, which I presented to the National Cancer Forum, which recommends eight centres, that presented by Dr. Cowley and Mr. Watson's solution which seeks six centres.

The Hollywood report offers some major advantages the first of which is the matter of access. As outlined, it supplies a sufficient number of treating doctors and machines for patients with cancer to be treated in this country, considering the existing burden of disease. It also helps resolve the issue of the treatment of patients outside of Dublin where, as Mr. Watson eloquently outlined, there are three treatment sites and not one as is generally thought. This report, if properly implemented, can certainly succeed in delivering high quality radiation oncology and multi-disciplinary cancer care outside Dublin. Third, it will allow for the full multi-disciplinary management on site for all patients suffering from these diseases.

In addition - this is something which is not often considered - a major centre such as that described allows for the development of sub-specialisation, as is happening with the direction radiation and other facets of oncology are going, for a much higher quality of care and for the development of research within the country in a way that individual sites do not.

I have outlined the hazards of this report and of almost any of the plans put forward in the document I presented to the committee. The benefits of the plans, specifically this one, can only be seen if the hazards are avoided. The first hazard is the failure to fund this development in its entirety. Whether it is the Hollywood report or any other mechanism of delivery of radiation oncology care, a piecemeal approach to funding will leave patients untreated for their cancers. The capital and personnel costs of this or any of the plans are substantial. It is incumbent on the Government that a budget be allocated over the lifetime of the project of delivery of radiation. It needs to be allocated at the beginning and not through year on year funding which is routinely the way projects are funded by Department. Year on year funding is inadequate for the capital and ongoing costs of delivery of radiation oncology care.

The second hazard is the potential ongoing inequity of access. This plan is perceived, as Mr. Watson outlined clearly, as essentially a mechanism to deny radiation oncology services other than at the sites identified. In contrast, if this plan is fully implemented, radiation oncology services will be provided equitably to everybody in the country. The actual treatment may be delivered at the major centre, but with adequate personnel and proper multi-disciplinary planning, we can have the highest quality of care delivered even at very remote sites.

The other issue to which Mr. Watson also alluded is one of my single biggest concerns. If this or an equivalent plan is not implemented, we will see the development of sporadic radiation services throughout the country. This was alluded to in terms of private developments. Failure to rapidly institute this plan will lead to opportunities for independent radiation units to be developed on a non-integrated and largely ad hoc basis in various areas throughout the country. This development would certainly help deliver some radiation oncology services locally but it would not resolve the issue of the isolation of radiation therapy from complete cancer care and it would propagate the inadequate multi-disciplinary care of cancer patients. I feel strongly that this committee needs to act on this and resolve that whatever plan is instituted is moved forward promptly and completely.

I will exemplify some of the developments within the Western Health Board and will highlight some of the successes and problems. Galway was identified in the original cancer strategy document in 1996 as being the centre for super-regional services within the western area. Since that time the medical oncology services within the region have developed. We have developed a cancer centre structure for medical oncology within patient services and day ward services at UCHG and a day ward service has been developed at Mayo General Hospital and at Portiuncula Hospital. In addition, with the appointment of Dr. Paul Donnellan in a joint capacity to the North Western Health Board and the Western Health Board, the development of clinical and academic links have strengthened the delivery of care across the western seaboard. This hub and spoke structure has led to a relatively seamless, integrated medical oncology service over that geographic region, which contains some of the remotest areas in the country. It has been a relatively successful development in delivering high quality medical oncology care within the area.

In contrast, I will discuss some issues with respect to the development of the radiation oncology unit to service exactly the same area. Phase one of the radiation oncology unit for the western super-regional area has been built at UCHG. Unfortunately as yet, no in-patient beds have been provided for this service. It is vital that hospital beds required to care for these patients are provided at UCHG. It is not a geographical issue for patients who require an in-patient service but rather an issue of them being unwell during their care and requiring to be treated as in-patients. If there are no beds it will not be possible to treat those medically very ill patients.

While recruitment of staff to commission the unit has begun, there has been no additional wholetime equivalent staffing allocation made to the Western Health Board to staff this new service. The board is already under immense stress to deliver the level of service it provides in other areas. If it is to develop a whole new area, then it needs to be given the appropriate staffing. I do not mean just a financial allocation but also the wholetime equivalent slots. Public health service slots need to be increased to the Western Health Board. If the Oireachtas decides to do that, to supply the infrastructure, funding and staff necessary to the western super-regional cancer centres at UCHG, I am quite confident it will be capable of delivering the highest quality cancer care to the whole western super-regional area.

This Oireachtas has been given a plan, the current report, and others, which can deliver a world class national radiation service. I encourage the members of the committee to support this plan and specifically I encourage them to fund it because in my view it will reap the rewards in lives saved and suffering reduced for patients with cancer.

Chairman

Dr. O'Cathail, Dr. Fraser was of the opinion that everything was rosy in Cork and I am sure it is normally. Knowing you, I am sure you may have a different view.

Dr. Seamas O’Cathail

I thank the Chairman and the committee for the invitation to speak. My main purpose is to put at the committee's disposal my unrivalled and sometimes unenviable experience of running a single treatment unit, no treatment unit, one treatment unit, two treatment units and three treatment units within the State for public patients, so I have no illusions about the practicalities and problems of implementing some of these suggestions.

Chairman

I apologise to the speaker. There is a vote in the Dáil. The committee will suspend for approximately ten minutes. We will try to arrange a pairing arrangement with the Whips so that the committee will not be interrupted further if that is possible.

Sitting suspended at 10.45 a.m. and resumed at 11 a.m.

Chairman

I call on Dr. Ó Cathail to continue.

Dr. Ó Cathail

I thank the Chair. I will be brief, as I realise that we face time constraints. I am more than happy to advise the committee about my first-hand experience, over 17 years, of trying to run a service with no machine, one machine, two machines or three machines. I would like to start by giving some background detail.

I want to emphasise that when Deputy Martin became Minister for Health and Children, he became aware of a World Health Organisation report about the number of treatment units per head of population worldwide. The report placed each country in one of three categories. The top stream included most of Europe, America and Australia and the second category included eastern bloc countries and countries which aspire to being in this stream. Ireland was in the third category, along with countries with which we normally associate organisations like GOAL and Concern. I refer to countries where the main health care problems are starvation and infection. Nothing has changed. There has not been an increase in capacity, despite the increases in population and cancer incidence. I emphasise to the committee, therefore, the importance of acting on this report. It will not improve the lot of a single person in Ireland if it is not acted on.

I do not know of any radiotherapist who would gladly, willingly and electively have a course of radical radiotherapy at a stand-alone radiotherapy machine. Perhaps some such people exist, however. I cannot commend such a service to any of my patients. I emphasise that I have been running a service——

Deputy O. Mitchell

Could you repeat that?

Dr. Ó Cathail

As a radiotherapist, I would not have a course of radical radiotherapy at a stand-alone treatment machine which is geographically remote from services that may be needed in the event of a problem. Therefore, I would have great difficulties of conscience in saying that it is okay for some people but not for me.

I have heard a great deal about equality of access, which is a crucial issue. I have successfully provided services to Tralee, which is 75 miles away, for 17 years without any complaints of inadequacy of access from the large urban population there. The current structures deprive me, however, of the opportunity to provide services to Limerick, which is 60 miles away, and to Waterford, which is 80 miles away. The logic of the structures defies me. Those who are familiar with the road between Cork and Tralee will be aware that, for many years, it was one of the most primitive navigational channels in Ireland. It is not much better now. I question the remarks that have been made about equality of access.

I emphasise the importance of the expert report on the development of radiation oncology services in Ireland. I encourage the committee to ensure that action is taken as quickly as possible. Although many years have passed since the inception of the report, we are still debating it. My colleague and I have operated almost single-handed at Cork University hospital for 25 years. We have not benefited from an increase in staffing in that time. It is not earth-shatteringly difficult to grasp or to solve, but it has not been solved.

Chairman

I thank the witnesses for attending this meeting and for giving us such erudite, compelling and revealing presentations. I would like to raise two issues before I allow the members of the committee to speak. Most members want to ask questions. I feel that Professor Hollywood deserves an opportunity to respond to the description of his patient study as "unreliable and unscientific". There is a good deal of agreement among the delegations, for example regarding patient focus, ready access and equality of access. Perhaps Professor Hollywood will expand on these issues.

Professor Hollywood

I refute the suggestion that the patient study undertaken by the Institute of Public Administration was "unscientific" and, perhaps, biased. The IPA, which has independent authority, met the subgroup of the expert group to construct the detail of this study design. All consultant radiation oncologists in this country were invited to participate in the study, which was undertaken and analysed independently. The argument that the study does not stand up to peer review flies in the face of the facts. In the last 18 months, the study has been presented at three international meetings, which are subject to the highest standard of peer review. The article has been submitted to the Lancet for publication. I strongly refute the contention that the study is “unscientific”. This conjecture was raised in the latter part of the expert group’s meeting. The unequivocal view of the majority of the expert group was that the study is wholly scientific.

Chairman

I would like Professor Hollywood to speak about the issue of access.

Professor Hollywood

The issue of access has been the subject of strong arguments from everyone at this meeting. It has been linked, in some ways, to delays in treatment. The two matters are associated. Our access problem is primarily restricted by profound limitations in the numbers of treatment units and staff that can deliver treatment. The report states that we are functioning at about one quarter or one third of the capacity of our European and North American counterparts. It is impossible for us to deliver a modern standard of service while operating at such a level of deficit.

We have to ask some critical questions. How do we move forward? What is the best way to structure the system? How do we deliver the excellence expected by patients? There is clear international evidence that outcomes are supported and enhanced if patients receive care in large centres. This evidence emerged from the 1985 patterns of care study in the USA and has been repeated on several occasions, for example from the European School of Oncology, in recent times. It has been discussed in the National Cancer Forum in this country. An analysis of the outcomes of patients, in relation to the size of the centres in which they were receiving care, was recently undertaken by the National Cancer Registry. One's chances of success and cure can vary by 33%, depending on the size of the centre in which one receives one's care. There is a strong relation between one's chance of success and cure, on the one hand, and the size of one's centre and the caseload of one's consultant, on the other hand.

I would like to make a final point. References have been made to our Canadian colleagues. It has been argued that they have an advanced care system. I would like to draw the attention of the committee to a letter we received from Professor Tom Keane, who is the provincial leader of radiation oncology in British Columbia. Members of the committee who received an information pack have in front of them a copy of the letter, which relates to the British Columbia Cancer Agency. Professor Keane says in the letter that the Irish recommendation of four regional centres to achieve our goal is, essentially, what has been done in British Columbia, where four regional centres are managed under a single provincial programme. It is worth pointing out that British Columbia has a population of 4 million and a geographical area ten times that of Ireland. Professor Keane goes on to say that this model has been in place for nearly ten years and that its success is supported by the fact that almost all patients receive radiation therapy within four weeks. The utilisation of radiation therapy conforms closely to evidence-based standards. Critically, Professor Keane states, it should be noted that with this service model British Columbia has the lowest provincial cancer mortality rate in Canada. Case load, cancer centre size and outcome are inextricably linked. We must enshrine this in future service development. We cannot move away from the principle of excellence, the associated quality of care and the improved outcome which flows from that.

Deputy O. Mitchell

We are all slightly speechless after having heard the presentation. I thank all of the delegates. I read the review and was convinced by its recommendations although I do not automatically subscribe to the view that big is best. I was devastated to learn of the degree of under-provision highlighted in the report and I agreed with its recommendations, in the first instance at least. Having listened this morning to the arguments of those on the other side, I recognise how compelling they are also. I understand the deeply held views which motivated the visitors to attend the committee to make their arguments to us.

My question centres on the main reason the Hollywood report, if I can be excused for using that term, recommends four large centres, counting the two in Dublin. It is contended that big is best, that the level of expertise, specialisation, experience and throughput involved provide a better outcome and that this is evidence based. None of the other speakers addressed that point. Difficulty of access and, as is absolutely right, the huge distress involved were spoken about, but the better outcome which flows from larger centres was not. Is not this debate academic given that we do not have a single centre which provides a decent, adequate service at present? Is not that the real question? The longer the making of the decision is postponed, whether it is by this committee or the Minister, and the longer we talk about where a centre should be provided, the less movement will be made as to when it happens. That is the real problem. We talk about inequality of access which results from the lack of capacity anywhere to meet demand. While there are problems of geographical location, lack of awareness among some GPs of the value of radiation therapy and long waiting lists to see consultants for initial diagnoses which may be made too late to avail of therapy, we must first address the problem of overall capacity.

We all know how long it takes to accumulate the range of expertise required on multi-disciplinary teams. Galway is a case in point. I am not sure if the physical infrastructure is in place there, but the multi-disciplinary teams are not. It took four years to appoint the last consultant appointed in this country from the date the decision was made. The report before us has been in circulation for seven or eight months but very little has happened to provide one additional person with treatment.

Deputy McManus

I thank the witnesses for an excellent presentation. It is important to pay tribute to the work they and others working in radiation oncology do. Many people are highly dependent on the services provided. It was interesting to note in the report that the response of patients who were able to access care was very positive. Nevertheless, the report is deeply disturbing on two counts. We have fallen far behind other countries in terms of the provision of care and we have fallen behind in the capacity building project required by this report. This is apart from any arguments about location. This is a central issue. I am very concerned that even in Galway, where the Government continually trumpets a centre will be provided, there are real shortcomings. I would have thought the fact that there are no in-patient beds was a central issue. Would it be of assistance if the committee was to invite the Minister for Health and Children to tell us what exactly is happening with the investment programme required to underpin improvements in the service? We would also ask what he was doing to ensure real progress rather than the provision of a further report which can be quietly put on the back burner.

Everybody seems to be in favour of multi-disciplinary care, which I can understand and support fully. However, the report does not deal with the issue of St. Luke's Hospital. While the hospital is not part of a multi-disciplinary set up, Professor Hollywood does not say what should happen there. Nor does he say where the centres should be north and south of the River Liffey. It took a long time to produce this report which is why I find it remarkable recommendations on these matters were not made. They have now been sent back to the medical officer in the Department which leads one to question why he did not make the decision in the first place. What were the difficulties in this respect?

The issue of slowness of delivery has been addressed to an extent with regard to Galway. It is clear that the investment and planning is not in place to make sure the centre is up and running. The concerns I have relate to the fact that we are now seeing the development of private centres. Can Professor Hollywood comment on them? Does he think it is better to have a private centre than no centre at all? One is emerging in the Mid-Western Health Board area and there is a possibility that one will be developed in Waterford. Will it be the case that private patients will be able to access care close to home with no great concerns about standards of excellence because they can pay for it? Will that create further inequality in a system which is already unequal?

Another of my questions relates to access. In an ideal world everything can be got for everybody. If technology can provide safeguards and it will be necessary to invest in equipment and staff anyway, why is it not possible to locate equipment in acute hospitals which are closer to where people live? The result would be to get rid of the ghastly experience of people who have to travel long distances. Letterkenny Hospital in Donegal provides an excellent service and has a very large catchment area, yet people there are expected to travel to Dublin or Galway into the future.

With due respect to Professor Hollywood, I do not accept that the focus group method used provided him with a clear enough answer. According to the Mid-Western Health Board, 40% of people in that area are not accessing radiation therapy. Those people were not asked their views. The method was limited and based very much on the larger urban centres. While I am sure it was honest, it was not a convincing attempt to assess the true nature of the problem of access.

Professor Hollywood

I will respond first to Deputy Olivia Mitchell whose concern about the implementation process is recognisable. I have had the recent privilege of being appointed to chair the national radiation oncology co-ordinating group which is part of the implementation plan recognised in section 10 of the report. It is multi-disciplinary and represents each professional grouping and individuals in administration, medicine and nursing from different parts of the country. The group is convinced that this agency, which has a direct reporting function to the Department of Health and Children and the Minister, will oversee and advise on the implementation of the programme. While funds and capital funds are restricted in the present climate - I am not speaking for the Departments of Finance or Health and Children in this regard - there has already been investment in the western and southern seaboards to develop project teams at both sites with a view to scaling up the necessary services from their existing capacity to the capacity identified within the report by 2008.

A sum of €2.5 million has been given to Galway in this capital year with a view to appointing the necessary staff. The first new consultant radiation oncologist position was advertised last weekend and the financial approval for two additional consultants was given in the recent allocation. It is the prerogative of the national co-ordinating group to watch this closely. I have no doubt that we will make the Minister aware of any shortcomings in the speed of implementation of the report if they arise.

Let us consider Deputy McManus's comments on the lack of specificity regarding what should happen to St. Luke's Hospital. The group comprised 23 people and it took the discussion on the future of St. Luke's as far as it could. There are many sensitivities to be considered. The hospital is the mainstay of national treatment capacity at present and it has developed many technologies. It is important, in terms of the future phased expansion of services within the eastern seaboard, to capture all the expertise that exists within St. Luke's.

Two specific options were outlined that meet the international criteria of excellence of care. St. Luke's could become a large university teaching hospital with all the disciplines on site. I believe this is unlikely. It is also unlikely that in the present context we need another teaching hospital on the south side of Dublin. The report articulated the other option, namely, the transfer of St. Luke's in an appropriate phased manner, availing of all the competencies and expertise, to respective sites on the north and south sides of Dublin. Within our expert group, we did have competency and expertise which would have enabled us to consider the development of control plans of individual hospitals. This is an enormous undertaking and it simply would not have been in our terms of reference or our capacity to examine in detail the development of control plans at each teaching hospital in Dublin and to make a recommendation. The argument in the report that this decision would benefit from a focused study, conducted through the chief medical officer's office, with the additional input of external international pay review, is undoubtedly the most objective and transparent way of making a fair decision. I commend the Minister for supporting this and I am conscious that the process is under way.

The report acknowledges that there is an opportunity for public-private investment. However, what is important in constructing this service is that we have a clinical network that, in a co-ordinated fashion, meets the requirements in a logical and sequential manner leading through 2008 to 2013. I am certainly not convinced that the ad hoc, sporadic development of small private centres will meet the requirements. Most of the centres will operate on a business model and will not have the object or terms of reference to provide the totality of care to patients. One of the options we must copperfasten is that whatever service is developed should enable equity of care to all patients, independent of whether they are public or private. It is the precedent in other western countries, with the exception of the USA, which has a particular business model of medical practice, that the backbone of service comprises large, comprehensive cancer centres that function within the public domain. This should be the cornerstone of our future service.

I question the uncertainty about the validity of the patient study undertaken by the Institute of Public Administration. It was open to all consultants who treat patients with radiation therapy in Ireland. Each was approached as to whether he or she would permit and allow communication to be directed to his or her patients to participate in a study. There was no selection bias. A distribution of patients from around the country was invited to attend. We had to obtain their consent to attend and ultimately we recognised this consent. The people who answered and met the study conductors availed of the opportunity to have the study and analysis undertaken close to their homes, by telephone or by an agreed arrangement that suited them.

Deputy Cowley

Did many not take part because they believed the study was biased? Only 3% went more than 100 miles and therefore one wonders how it could have been a proper study.

Professor Hollywood

The study was conducted in such a way that bias was completely removed. We had an open invitation letter to patients coming through all consultants, with the exception of one. This is as far as we could take it in terms of trying to ensure we had a balance of patients, patient profile and the location in which they lived.

Dr. Fraser

Deputy Mitchell is correct that we need a critical mass of accumulations to create a proper cancer centre. We need multi-disciplinary care. Radiation should not be taken in isolation because it is part of cancer care. When I went into St. Luke's we worked on the basis that the doctors went to patients. This is how the peripheral clinics developed. It is why we go to Waterford, Wexford and all over Ireland. We are running 17 different centres throughout the country. Today, with our technology, we could set up national protocols and standards but treat the patients locally. We have the computers to work this out and we could deliver the treatment in the regional centres and have the information moving backwards and forwards.

Professor Hollywood is correct that multi-disciplinary care cannot take place on the St. Luke's site because it is not adequate for modern cancer treatment. We cannot treat public and private patients separately. This is nonsense because there is not enough public work outside Dublin, and Cork perhaps, to treat private patients separately from public patients. They must be treated in exactly the same way according to the exact same protocols. There is no difference between a public and a private patient. They both want to be cured.

We need action on this matter. Why are we still talking? Progress needs to be made. We could set up the centres. There is no reason why, as Professor Hollywood suggests, we could not set up machines outside St. Luke's, take the weight off St. Luke's but run the machines there while building the new machines in the Dublin and university hospitals. It is not rocket science. There are only four or five potential sites in Dublin where we could do this, three on the south side - Tallaght, St. James's and St. Vincent's hospitals - and two on the north side - Beaumont and the Mater hospitals. Our decision must involve one out of three or one out of two.

However, the periphery should also be built up. The service outside Dublin should be built up to take the weight off St. Luke's, which could then deliver at least a proper service in Dublin. If given a field, the private sector will build a unit in 24 months. That will provide the key, following which machines can be switched on and progress can be made. This should be replicated in the public sector. There is no reason why the public sector could not have as efficient a service for the public patient as the private sector seems to be able to promise for the private patient.

Dr. Keane

On the isolation of machines and the transfer of information, to which Dr. Fraser has alluded, it is important to note the point made initially by Professor Hollywood on the best outcomes. They are best in comprehensive cancer centres, and this is definitively proven everywhere there are such centres. Patients' lives are longer, the cure rates are higher and outcomes are better.

The other worry I have about isolated individual sites, that is, linear accelerators in a multiplicity of different sites, is that the patients concerned do not just need radiation at those sites. If someone with a fracture is seeking radiation for a bone problem, and there is no orthopaedic surgeon on the site, the person will have to be shipped elsewhere.

Deputy McManus

That happens at St. Luke's.

Dr. Keane

That is exactly what happens at St. Luke's. It is why all of these centres should be at acute hospital sites. There is a gap outside of the radiation issue if a linear accelerator is installed in a hospital that does not carry out orthopaedic surgery.

Deputy McManus

I am not suggesting that.

Dr. Keane

The Deputy suggested that radiation machines could be placed at multiple sites.

Deputy McManus

A machine could be placed in an acute hospital like that in Waterford.

Dr. Keane

An acute hospital like that in Waterford, and many other sites where it is suggested that such centres should be located, will not have the comprehensive range of other services. Waterford is an exception in that it is a major hospital. There is a suggestion that these machines should be placed in other hospitals. For example, pathology services for cancer patients are more expensive than they used to be and it will not be possible to locate those at every site. There are a variety issues other than radiation about planning major cancer centres. Outcomes have been proven to be better delivered through such sites.

Mr. Watson

I would not suggest that radiation centres be set up in every small hospital; I said that it might be looked at for some of the major regional hospitals. I assure my colleague that Waterford has the biggest orthopaedic service in the country. We also have the largest grouping of medical oncologists in the country; as with St. James's hospital, we have three medical oncologists. The South Eastern Health Board is the third biggest health board area in terms of population and is bigger than the Western Health Board.

People are talking about big being beautiful. In Holland, for example, much good quality radiotherapy is delivered by middle sized or smaller groupings of linear accelerators. The structure there is a four linear unit and we would all accept that medical services in Holland are of the highest quality. Radiotherapy is provided in many small units in the United States.

This State has two facilities working on the basis of two units and Cork has done so for many years.

Deputy O. Mitchell

The patients will not go there.

Mr. Watson

They go to the Mater private and St. Vincent's and people from the area will go to Cork where they receive a good quality of service. If radiotherapists do not think they were giving a good service, they should close the centres straight away. We know that good quality radiotherapy can be given for average standard cancer care - and for difficult cancer care - in that type of centre.

Any good scientific journal or publication would have difficulty in accepting a publication that is biased. This focus group was a biased selection of patients. The number involved was small when it comes to looking at such a huge issue. Radiotherapy is not the only thing that is being discussed - we are discussing overall cancer care. It has been suggested that patients would prefer not to be treated locally if they could get good high quality care. Waterford hospital can give high quality care, particularly for the patient groups we deal with.

I now turn to fast tracking. We had to be in Dublin reasonably early this morning and I think everyone who had to travel from outside Dublin travelled the night before. As Dr. Fraser has emphasised, it takes a long time to come from Waterford to St. Luke's hospital, have the radiotherapy and return home. There is no direct rail link between Waterford and Dublin and people must travel via Kilkenny. There is no air corridor - not even Ryanair will provide this - as the Government does not support our airport in the same regional manner that it supports Knock Airport and others. Patients with health problems find it difficult to travel to Dublin. This is one of my worries about patient care.

We must also take cognisance of what the medical profession has termed "seagulls". Those are people from outside the jurisdiction that try to endorse or advise us on how to run our services. What happens here is very different to what goes on in Europe. One only has to go to Europe to see how different we are. We are somewhere between Britain and America and we are not true Europeans just yet. Because of this uniqueness we must find our own solution to this difficult problem. My premise is that we must have equality of access.

Deputy Cowley

I am glad that this meeting is taking place as I have sought to have this group examined. It is an extremely important issue and it would be a shame if we rushed this as many people's lives depends on what happens here today. A patient of mine waited for a long time on his appointment and it did not arrive until two weeks after he died.

Chairman

The Deputy must ask questions.

Deputy Cowley

Why did this happen? No matter how much capacity a unit has, what good is it if it cannot be accessed? What is this report going to do for north west Donegal where Mr. Moran has said that people are getting mastectomies because they cannot endure the long journey required to access palliative care. People suffering from prostrate cancer require 22 treatments. How can patients suffering from this be expected to travel 170 miles for 22 days? It is ridiculous. We are not seeking units everywhere. Letterkenny, Waterford and Limerick were designated as regional centres in the national cancer strategy. While they have two out of the three units, they lack radiotherapy.

We must do something to improve our treatment of cancer patients; Ireland is placed 13th of 15 in the EU in this area. Hospitals are crying out for capital investment. According to this report, a four machine unit will cost €34.77 million, yet treatment is being delivered in smaller units. I have seen a €6.733 million quote for a two machine unit for Limerick hospital. The costs are the same for running the unit and the savings on transport and accommodation would more than pay for the unit.

What is the problem with private units? One can be seen and have a plan done within hours. Dr. Fraser stated it took four to six weeks to have a public patient set up to undergo radiotherapy. Why is that the case when in a private unit one can be set up in hours? I would like to know the answer to that question.

Is it any wonder that this is happening when virtually all of the members are from Cork and Galway? In the 15 October edition of the Dungarvan Observer, Jimmy O’Gorman, Fianna Fáil Waterford town councillor, who was involved in a campaign with Deputy Ollie Wilkinson, in discussing the radiotherapy service issue stated the Minister for the Environment, Heritage and Local Government, Deputy Cullen, had said that the service would not be located in the south-east, that this was a Government decision which had been made before the general election. Fianna Fáil was canvassing on the issue before the election, yet the decision had been made even before the report came out.

It is obvious that one can have satellite units to do the bread and butter stuff. Certainly, there has to be a centre of excellence to do the rest. Do the representatives agree that this accounts very much for the minority and that such units could be provided for less than what it costs to take people to where they do not want to be? What is the point in having units with machines reserved in St. Luke's Hospital, in which Dr. O'Cathail stated he would not be found dead because he would not go to units which did not provide supports? It looks as if there is only one modality of treatment.

Chairman

I do not recall Dr. O'Cathail saying that but I am sure he will respond.

Deputy Devins

I also welcome members of the delegation. Everybody agrees that the facilities are grossly inadequate and that there is an urgent need to provide better ones. What is in dispute is the way forward. To drive the argument a little, I want to ask two or three specific questions.

Dr. Fraser stated in this submission that construction costs in supplying a four linear accelerator unit would amount to €34.77 million. He later said he had received a quote to build a two linear accelerator unit for €8 million. One does not have to be a rocket scientist to work out that there is a huge difference between the two figures. Is that a quote from a private contractor as opposed to a public contractor?

Dr. Fraser

It is a quote from the same server who Deputy Cowley saw quoting a figure of €6.7 million for a two linear accelerator unit. I am not sure if I can reveal the name of the company.

Deputy Devins

Is it a private contractor quotation?

Dr. Fraser

There are four major international producers of the machines in question. They say, "You give us a field and we will give you a fully working two linear accelerator unit within two years for €8 million."

Deputy Devins

What about the quote of €34 million for a four linear accelerator unit? Whose quote is it? Is it from another private contractor? The essence of the argument is cost. The Minister is obviously aware that the cost implications must be taken into account. If suddenly figures are put into the public domain that one can produce a two linear accelerator unit for €8 million and somebody else says it will cost €34 million to provide a four linear accelerator unit, we need to know if they are talking about buildings, ancillary staff, etc. We can all bandy figures around and they will get headlines in the newspapers but we need the facts if we are to provide a better service for patients.

Dr. Fraser

It is contained in the report which quotes a figure of €34.77 million.

Deputy Devins

We are all aware that there are private operators which are willing to supply a service in peripheral locations. Let me be parochial and say I agree entirely with Dr. Keane on the other modalities required - surgery, oncology, etc. - to provide a good service. Perhaps a unit in Sligo would meet all of those requirements.

Senator Henry

We all know the situation is dire for patients and would not be human if we did not have great sympathy for those who have to travel long distances. However, the Department of Finance must be delighted with this argument because patients have been denied services for much longer. Naturally, it would be fine if we could have an all-island spread in order that everyone would be within easy reach of a radiotherapy service. That would be desirable.

I will ask Professor Hollywood this question because I know what our friends on the periphery would say. To make progress, which one does he think we should press for first? The machines in Cork appear to be antique while there appears to be virtually no service on offer in Galway. Should we not try to give priority to what we should push for first?

Would it help the south-east if Tallaght Hospital was chosen and St. Luke's Hospital was sold for a vast sum? At least Tallaght Hospital would offer better access off the M50. Surely such geographic considerations should be taken into account.

Deputy Neville

I also welcome the members of the group and thank them for their presentation. I will also be parochial and direct my questions at Dr. Watson. As he is aware, there is deep concern in the mid-west about the exclusion of the regional hospital as a site for a service. Medical consultants in the region have convinced us of the need for a centre of excellence. Are they all wrong? Why was the mid-west excluded? Was the decision influenced by the fact that there was no member from the region on the committee?

Deputy Cooper-Flynn

I thank the members of the group for their presentation and apologise to Professor Hollywood for not being present to hear his presentation, although I have since read it. As I come from the Western Health Board region, I am extremely concerned about the issues of access and equality and quite relieved to hear Dr. Keane state that, if implemented, this report on four regional centres should meet the needs of the west provided they are resourced fully.

I wish to ask Mr. Watson a number of questions, particularly as he is making the case for Waterford. While access and equality are critical issues, medical outcomes must be the number one priority for patients. That is the reason we want to have this improved service in the first place. It is critical that we move ahead, at least with four regional centres. This should be the priority.

Let me play devil's advocate? Mr. Watson made reference to the two hour journey time to Dublin and the fact that there are no direct rail links or flights. Why are patients from his area not travelling the much shorter distance to Cork? Geography must be an important factor. There are parts of County Mayo which are over 100 miles from Galway, yet Dr. Keane states that if the report is fully implemented and the centres are properly resourced, he believes this will meet the needs of the Western Health Board region. Waterford is only 60 miles from Cork.

I take issue with others on how best we can get over the difficulties in Donegal where there genuinely does seem to be a huge problem but I have sat at committee meetings on orthodontic treatment and found that people from the county regularly travel to Northern Ireland to avail of such treatment.

Deputy Cowley

They are not sick. It takes four hours to get to Dublin.

Deputy Cooper-Flynn

That is not the issue. I am not comparing people who require orthodontic treatment with those suffering from cancer. If Deputy Cowley would listen for a few minutes, I am making a point about geography but, unfortunately, only his point of view counts as far as he is concerned. I am wondering if it would be possible to have people treated at the Belfast centre. This is something that must be considered.

I could have come to this meeting to state everybody wanted to be treated locally. I would like this service to be available in Mayo General Hospital but, realistically, I am looking at a report which states that if we develop four regional centres of excellence with proper outcomes, we might achieve full capacity in ten years. If we want to develop such a centre in every regional hospital, we could be talking about a period of 20 years. I would like to think that we could reach a position where we could treat everybody in need of radiation treatment within a reasonable length of time.

Deputy Gormley

I apologise for being late. I had to be present for the Order of Business in the Chamber.

I thank the delegation for coming. I will not be parochial——

Chairman

We have discovered the west and been to the south-east. Unfortunately, no one wants to go to Cork.

Deputy Gormley

I do not know if we have room in Ringsend for one of these units but we require the regionalisation of services. That is the reason I was supportive of Deputy Cowley's proposal.

Deputy Cowley

I wrote and take responsibility for it. Dr. Fraser gave me the information.

Chairman

The Deputy has had his opportunity. Will he, please, not interrupt?

Deputy Gormley

I welcome the fact that Dr. Fraser had an input. I want to return to the figures he gave. Like Deputy Devins, I believe there is a discrepancy and would like Professor Hollywood to comment. What accounts for the enormous discrepancy between the figures given by Dr. Fraser and those of Professor Hollywood? Is it the case that the private sector can do it cheaper? The bottom line is always what counts for the Department of Finance. The Minister for Health and Children, Deputy Martin, would like to have more money and believes in raising taxes. Eventually, it will all come down to money. I would like the members of the delegation to home in on this.

Chairman

Let me show bias. Dr. O'Cathail wants to answer about the antiques in Cork.

Dr. O’Cathail

I would like to answer a number of points. In case it is stated as a fact that people will not go to Cork, because of the structure of the system under which multidisciplinary clinics take place, patient referrals move in that direction. I get patients all the time from Limerick and Waterford, a surprising number of whom have come against the tide. They feel they were influenced unduly to go with the flow. However, if one is living in Tramore, it does not seem logical to go to Dublin for treatment when one could go to Cork. Not a lot of people know this. Not a lot of patients are assertive enough to say they do not want a particular service. All I would say to the committee is everybody should have an option. If they want to go to Timbuktu, that should be their choice and they should not be compelled by the structures to avail of services when it is not necessarily in their best interests to do so.

As regards the antiques, I would like to update the Chairman. We are fortunate in having two state-of-the-art linear accelerators. Ours is a three machine centre, having oscillated between none and one and then acquired two over the years. We will shortly have four which I hope we will reach beyond. The efficiencies of scale are enormous. I cannot highlight strongly enough the difference this makes in having adequately staffed units to cover sick leave, unexpected downtimes etc. The improvement in service experienced in Cork is incredible because of the extra capacity available.

Many patients are not unwell. They undergo treatment such as breast cancer surgery and are cured of the disease. They are as well as any of us. In this room there could be half a dozen people who have been cured.

Chairman

There is another vote. Unfortunately, the person with whom I was to pair has left the meeting.

Dr. O’Cathail

I appear to be unfortunate.

Chairman

How are we on a pairing arrangement?

Deputy Devins

I will just check.

Chairman

I would like the meeting to continue. We will accept the consequences later.

Mr. Moran

A mantra is being repeated time and again. It almost amounts to Texas philosophy: bigger is better; the bigger the better and the bigger it gets the better it gets. Everybody in Ireland should be going to the marathon in London or Sloan-Kettering: nobody should be treated for cancer here. There are international studies which prove that where there is a critical mass delivering cancer services in a multidisciplinary protocol-driven way, subject to progressive audit that can confirm the results are as good as those achieved anywhere else, the situation is satisfactory and state-of-the-art.

There is a concept as regards centres of excellence as if only two or three are to be found in Ireland. In fact, the results in some regional hospitals can be surprising when compared to those achieved in their larger counterparts. Nevertheless, I have not heard anyone say he or she wants to locate radiation oncology services at every crossroads. The only places suggested are regional hospitals which already provide cancer services, including surgical and medical oncology and the supporting infrastructure, that is, pathology, radiology, palliative care, specialised nursing, etc.

Deputy Devins has left but I am here as regional director for the north-west. As I am not competing with the Minister of State, Deputy McDaid, for votes in Letterkenny, I can support the provision of services in Sligo and Letterkenny hospitals, both of which could support a radiation oncology unit. To give an example, I have over 300 men on my computer register suffering from prostate cancer for which radiation treatment lasts approximately five minutes a day for a period of five or six weeks. A service such as this, what is called bread-and-butter radiation oncology, can be delivered in carefully controlled regional hospitals.

Chairman

The Whip has indicated that whoever is in the Chair may stay but the other Government Deputies will have to go and vote.

Mr. Moran

What I am saying in essence is that "big" does not necessarily mean better standards or higher quality as long as what is being done is carefully audited and compared with best practice elsewhere. My thesis, based on 13 years experience, is that either of the two hospitals in the north-west could support a complementary radiation oncology unit. Furthermore, with the best will in the world, the plan that Professor Hollywood and his group have come up with will not solve the problems in the region or provide much of an improvement in quality of access for patients.

Professor Hollywood

There are several issues involved. I will deal with the last of them first - scale and size and sustainability and the reason they are associated with improved outcomes. Evolution of care in radiation oncology is such that the term multidisciplinary teams has been used. What this means is that rather than doing what we do at present where clinicians treat all cancers, the modern standard is for them to treat a smaller subset and in so doing bring together a team of radiation oncologists. The minimum team - for example, in Holland - comprises four oncologists and is centred around a minimum structure of four linear accelerators. In Holland, which probably has the most advanced radiation oncology delivery system in Europe, centres with two linear accelerators are being closed down. They are closing down single-handed centres or institutions with two radiation oncologists because in such an environment, in two sequential studies undertaken in 1996 and 1999, the outcomes associated with smaller centres were worse. I will repeat a point I made. In 1995 a study of patterns of care in the United States identified the same trend. Last year the European School of Oncology did the same in an analysis across Europe. If one looks at small centres, outcomes are poor.

I would like to refer to the development of services in County Donegal. The expert group was particularly sensitive as regards the north-west. There was representation within the group from Northern Ireland. We had extensive dialogue with the North Western Health Board on three occasions. There is accurate documentation on page 147 of the report on the board's preference, to link in the first instance with services in Galway, and also Belfast. The dialogue to enable these links and the appropriate referral patterns of patients to be established has been initiated. The appointments that will be made this year in Galway at consultant level will facilitate the care requirements of patients from Sligo-Leitrim while discussions have been initiated with Professor Patrick Johnson and the group at Queen's University, Belfast on providing for a joint partnership service for the population within Donegal. In this way we can guarantee that patients within the north-west region will have access to the quality and excellence of care for which one is arguing in the remainder of the country on an identical scale. Excellence of care is associated with an improved cure rate.

Deputy McManus

There is a principle and while I fully understand that the professor is promoting that principle, he cannot say a person living in Galway and in Malin Head are being treated equally in the sense that the journey from Malin Head is horrendous.

Deputy Cowley

It is further than Dublin.

Professor Hollywood

I am not arguing that the journey is the same and that at this time there is the same opportunity for patients to access the existing service. The report categorically documents that there is under-provision. Equally, it documents, when one looks at the position at national level, that there is no clear relationship or linkage between distance from a centre and the opportunity for patients to avail of services at that treatment facility. There is a trend towards distance but it is not mirrored in individual health boards. For example, in the North Western Health Board there is a higher access rate than in other health boards closer to the eastern region. Therefore, the issue becomes what one should provide for such patients.

Deputy McManus

Medical care.

Professor Hollywood

How does one improve access for them? If people live a distance from a treatment centre, clearly one has to provide the highest quality care. Unequivocally, independent of whatever international evidence at which one looks, this is best delivered through large comprehensive cancer treatment centres - the European and North American norm. To enable patients to avail of such services, we must present them and their families with an equal opportunity. This means dedicated accommodation and transport mechanisms for those patients who want to present as day cases or for the period of time they will receive treatment. I have not come across a single patient who, when given the option to attend for five weeks with an improved chance of cure versus receiving treatment locally with a reduced chance of cure, will take the second option. Invariably, patients will take the option which offers the highest chance of success.

Deputy McManus

That choice is not available.

Professor Hollywood

It is not available at present but there will be the opportunity in the future for everyone to access the same level of care. The limiting step is access to treatment equipment and consultants in respect of which we are at one third of the European average with regard to capacity. In section 5 of the report we have recommended ways and means by which one can enable patients to access the service. If the number of consultants is expanded from ten at present to in the vicinity of 24 to 28, patients will be able to see a consultant within a week. They will also be able to avail of treatment within one or two weeks. We will match the guidelines in Canada, the Netherlands and Scandinavia.

I have heard people talk about satellite centres which are operational in jurisdictions with a vastly different geography, primarily Canada and Scandinavia. We have received responses from Professor Dag Olsen, head of the radiation oncology unit in Oslo. There are two centres in Norway which have been operational for less than 18 months, both of which have encountered significant difficulties in recruiting at medical and support staff level and both of which are open for review of service delivery. There is no certainty that they deliver the same quality of care. The distance from the hub is in the region of several hundred kilometres - in one case 1,000 kilometres.

In the Canadian model, it is equally the case that satellite centres are frequently a distance of thousands of kilometres from the hub. The best outcomes are achieved in British Columbia which has a population of 4.4 million and is the size of France. The service is delivered through four centres under a publicly funded system, each of which is of significant scale. They function as part of a clinical network.

Deputy Twomey

It is great to see members of the delegation because they are pointing out that the overall problem is the lack of radiation oncologists and the poor structure of the service. The argument is against the regionalising of services.

Professor Hollywood states that with small units with two linear accelerators there is a reduced chance of cure and that this is driving patients towards bigger units. How does this reconcile with the way the private service works because, to the best of my knowledge, all private units have one or two linear accelerator units? Is he stating they could be delivering poorer outcomes for patients? Are they in some respects distorting investment in the public service where the best outcomes are achieved? Does he have any views on the private radiation oncology services available?

Chairman

Will somebody answer Deputy Neville's question about the mid-west?

Mr. Watson

The question was put to me but perhaps I am not the right person to answer it because I supported the call that radiotherapy services be provided in the mid-west. I believe the consultants are right to argue cogently for such a service. Limerick or the Mid-Western Regional Hospital would have a slightly bigger number of consultants than we have in Waterford. I see the two hospitals, Waterford and Limerick, as similar and having a strong argument for a networked radiotherapy service delivered locally.

Deputy Neville

Why does the report not state that?

Mr. Watson

The Deputy probably should direct that question to Professor Hollywood. My strong feeling was that the Mid-Western Regional Hospital was a good one and had all the necessary facilities to support a radiotherapy service. I hold the same view as the Deputy.

Professor Hollywood

The group looked in detail at the position in the mid-west. When one applied international criteria - essentially the consensus view within Europe and North America - and looked at the population base, in particular, it struck us as highly unlikely that the catchment population would enable the development of the minimum centre specified, which, based on the evidence available on best practice, is framed on the provision of four linear accelerators and the appropriate development of multidisciplinary teams. The population caseload within the mid-west, projected to 2015, would not support this. It was our understanding and view that patients in the catchment area would be able to avail of services in a centre of sufficient scale that would become a centre of excellence, partly within the Western Health Board and partly within the Southern Health Board, with the capacity and ability to develop consultant numbers and a multidisciplinary team to enable patients access a modern standard of care. That is the fundamental principle. The evolving modern standard of care is moving towards site specialisation and multidisciplinary teams.

We have heard the comment that we are different and that perhaps we should not be inviting other Europeans to comment on our system but they have come here and done so. We are 13th of the 15 member states of the European Union and have the most mediocre radiation oncology service in Europe. However, we have an opportunity to get it right. When one asks the people in question, there is a clear sense in their minds on how it should be done. It is constructed around the large centre model articulated in the report. That is the reason the vast majority of members of the expert group, after two and a half years of meetings and analysis, formed this view. It is equally the view echoed by every expert we have asked in Canada, North America, Northern Ireland, the faculty of radiology - the consultant professional grouping within the country - and the medical board of St. Luke's Hospital.

Deputy Cowley

International evidence suggests that a unit should be located within a distance of two hours from the patient. The nearest unit to the north-west is four hours away. How will the position improve if the report is implemented? Galway is further away than Dublin to which it takes at least four hours to travel. People are voting with their feet. How will implementation of the report change matters when it will mean patients will be voting for a reduced chance of cure and nothing but pain in the weeks remaining to them. Patients are also opting for more radical operations.

Were investigations undertaken in the private sector and, if so, what is the position? Why does it take a public patients four to six weeks to access radiotherapy treatment when it takes only hours for a private patient to access such treatment? Mention was made of a HDR therapy unit in the Mater Private Hospital. Is there such a facility? Was an examination of the private system undertaken? Is the delegation suggesting the level of care provided for in the public system is lower than that provided in the private system? Were both systems studied?

Professor Hollywood

As part of our analysis of caseload and the extrapolation of their development plans, we asked private hospitals for details on the number of patients attending and their intentions in terms of service development. Our terms of reference - it is important to note this - did not provide for an analysis of the private sector which operates to some degree as a business model. Our ability to analyse outcomes was limited.

Deputy Twomey

Is Professor Hollywood saying the private sector is not delivering an optimum level of care?

Professor Hollywood

No, I am not saying that, neither does the report. The private centre model in Dublin operates in a different context to the satellite model proposed in other reports I have seen. The satellite model in Dublin has the advantage of having a significant consultant presence from St. Luke's. For example, in the Mater Hospital, four consultants attend a relatively small centre. On the southside five consultants attend the centre in St. Vincent's Hospital. This is quite different in terms of structural organisation and the provision of care than that being argued for for small centres in other regions. The small centre model articulated for the south-east or mid-west or any other location we examined was framed around one linear accelerator or two linear accelerator capacity with one to two consultants. This is unsustainable; it will not permit site specialisation and flies in the face of the European process in radiation oncology development.

Deputy Devins

Perhaps Professor Hollywood will deal with the matter of costs.

Professor Hollywood

Costing was undertaken as part of a detailed analysis by the respective division within the Department of Health and Children. We have outlined the scaling costs associated with moving from four to 12 linear accelerator treatment centres. We also undertook an analysis of smaller centres operating two linear accelerator models. It is clear that there is a cost penalty if the smaller centre closes. However, there is a cost saving associated with the larger centre because one does not have to build in the same degree of redundancy of staff or equipment. Equipment requires replacement. How does one replace equipment on a ten year cycle within a one or two linear accelator centre model? The process of replacing and recommissioning equipment can take up to a year or 18 months to complete. When one factors these figures into overall revenue and capital costs, it is clear that two linear accelerator centres are more expensive. Our estimates of capital costs are somewhat different from what has been highlighted in the private sector. I have not had an opportunity to examine the costings or derogations in detail. From the estimation of services which provide a public service facility within a two linear accelerator capacity they are considerably higher.

Chairman

When Professor Hollywood has undertaken an examination of the private sector, perhaps he will report back to the committee.

Deputy McManus

Perhaps we could hear from Mr. Moran before we conclude.

Chairman

Yes.

Mr. Moran

I would like, first, to correct a factual inaccuracy in Professor Hollywood's statement. I was closely involved in the North Western Health Board communications regarding radiation oncology services. The document refers to the preferred proposal of the North Western Health Board: "In the medium to long term the board has expressed a strategic aspiration to move towards the provision of radiation therapy services either within the board's area or possibly within a larger north western catchment area that would cater for the cancer workload and population of both the North Western Health Board and adjacent neighbouring areas."

Professor Hollywood

That is exactly what I said. That argument and discussion as presented by the North Western Health Board implicitly required dialogue and discussion with the equivalent authorities in Northern Ireland. It was developed to a significant degree during the expert group's thinking which continues in that the national radiation oncology co-ordinating group has a nominee from Northern Ireland. Discussions are taking place between the Northern Ireland authorities and the Department of Health and Children on the potential medium to long-term development of additional service capacity to address requirements in the north-west and Northern Ireland. The discussions will address the specific expectations of the North Western Health Board.

Senator Henry

Which option should we push for to ensure there will be a service in place in say, ten to 15 years?

Professor Hollywood

Without doubt, if one takes the majority view of the expert group and looks at the counsel and advice we have obtained from significant international experts in this area, we should be moving towards the four centre model. That is endorsed.

Senator Henry

Which one is most urgent?

Professor Hollywood

All four.

Chairman

I thank the delegation and members for attending. We are glad the delegation had an opportunity to elaborate on the significant differences in the development of services. There is agreement that funding for the development of services must be provided immediately and that everything else will follow.

As suggested by Deputy McManus, we will invite the Minister to discuss how this matter can be progressed.

The joint committee adjourned at 12.20 p.m. until 9.30 a.m. on Thursday, 19 February 2004.