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JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Tuesday, 18 Dec 2007

Cancer Control Programme: Discussion with Professor Tom Keane.

I welcome Professor Tom Keane, who has accepted an invitation from the committee to discuss the national cancer strategy. Professor Keane was appointed interim director of the national cancer control programme at the beginning of December. He will be on secondment for a two-year period from his current post as provincial radiation programme leader for the British Columbia Cancer Agency in Canada.

His appointment follows the signing of a formal memorandum of understanding between the HSE and the BCCA in December last year. That understanding confirmed an agreement between the HSE and BCCA to work collaboratively in the establishment of a national cancer control programme within the HSE. A native of Dublin, Professor Keane attended UCD and subsequently completed three years postgraduate training in St. Vincent's Hospital and the Adelaide Hospital, Dublin, before taking up a post as consultant radiation oncologist at the Princess Margaret Hospital and the University of Toronto. He subsequently took up his current position with the British Columbia Cancer Agency. Professor Keane was directly involved in developing and implementing the system and process redesign of radiation services within a provincial programme at BCCA. He is accompanied by Mr. Tony O'Brien and Ms Anne McLoone, and by Ms Danielle Barron of the Irish Medical Union and Dr. Tony Holohan of the Department of Health and Children.

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

Professor Tom Keane

I thank the Chairman and members of the committee for the opportunity at least to begin to communicate my vision for a cancer control programme for Ireland.

I have provided a background document for members of the committee. I did not feel it would be useful for me to read its contents into the record. Essentially, it outlines the goals and objectives I have set for the two-year period in which I will be in situ. I have lived in British Columbia, Canada, for the duration of my career in oncology. I have maintained strong links with Ireland. My wife and I are the only members of our respective families who live outside Ireland and we have made more than 60 trips here in the past 35 years. I have a great deal of contact with the medical community here.

Many people have asked me why I took on this task, particularly as some of my colleagues view it as a poisoned chalice. The cancer strategy announced in 2006 was circulated to us in British Columbia and we were asked to provide an opinion as to whether it was sound and whether it contained any deficiencies. In the past, we were asked to examine similar strategy documents from other jurisdictions. We found the Irish strategy to be excellent. It clearly reflects the considerable work and consultation carried out, not just within the Irish community but internationally. It is a very good strategy surrounded by an excellent body of work based on international best practice.

Princess Margaret Hospital in Toronto is probably one of the five leading cancer institutes in the world. Its work is primarily focused on cancer treatment and research. I was involved in the major redesign of how care services in Toronto are delivered. Having completed that work, I shortly thereafter took up the chair of the university department in British Columbia and the leadership position, to which the Chairman referred, at the British Columbia Cancer Agency.

The BC Cancer Agency is different to Ontario's in that it was mandated by legislation in the 1930s. That far-seeing legislation gave the Cancer Control Agency of British Columbia, as it was called then, the mandate for cancer control for the population of British Columbia. It has an enviable record; it had the first organised cervical screening programme in the world some 50 years ago and it has had breast screening for more than 20 years. It has been a leader in cancer control on a population basis. As distinct from the way cancer services are organised in many jurisdictions, it is a cancer control organisation. Having not worked in such an organisation previously, I make the distinction. It is responsible for the entire population, namely, the people who do not have cancer, those who are at risk of getting cancer, those with cancer, those who have been treated and those who require ongoing care. It addresses a population's need and integrates all of the components of cancer care, including research, in a single agency.

The agreement of the Government and the HSE to form a separate business unit to execute the strategy was attractive. I was completing my tenure as a professor and leader in the BC Cancer Agency when I was approached and asked whether I would consider taking this position for a two-year period. I told the BC Cancer Agency that I really wanted to do it because there was significant potential for the strategy to be implemented in Ireland and I could bring something back to my home country as a result of the experience I had gleaned abroad. The agency seconded me generously for a two-year period and told me that I must return on 30 November 2009. The university has given me a leave of absence from my professorial position.

My vision for Ireland is reflective of my experience in British Columbia. The goals of the cancer strategy are threefold. The first is to reduce cancer incidence, which is high in respect of a number of cancers on an age-adjusted basis. Ireland has a relatively young population and the real incidence of cancer will grow as the population ages. By 2020, the incidence of cancer will reflect the fact that we have an older population. British Columbia has a similar population to Ireland, but it has approximately 6,000 more cancer cases because it has a relatively old population and cancer is a disease primarily of people beyond the age of 60 years. As people live longer, there will be a higher cancer incidence.

The first goal of any cancer control programme is to reduce cancer incidence. It is a broad strategy concerning cancer prevention and healthy lifestyles. I will not dwell at great length on this point, but it extends way beyond cancer. In the Canadian system, British Columbia has the lowest incidence of cancer in respect of many cancers and a considerably lower incidence than Ireland on an age-adjusted basis. Much of this reflects healthy lifestyles rather than any particular intervention at a population level.

The second obvious goal of a cancer control programme is to reduce cancer mortality and the morbidity inflicted on those unfortunate enough to suffer from cancer. While there has been significant improvement in the past decade as a result of the first cancer strategy, there is some considerable road to travel to be in the upper 25% of European nations in terms of cancer mortality.

The final goal is to improve the quality of life of people living with cancer, a significant issue in respect of many of the cancers that are similar to chronic diseases. It is not uncommon for people with breast or prostate cancer in particular to live with the disease for five years to ten years if they are not cured. Managing the quality of their lives and making decisions based on that is a very important objective. In terms of the vision for Ireland, they are the three big goals.

Obviously, we must look at where we are starting from. On the positive side, Ireland is lucky to have a huge cadre of very well-trained oncologists, clinicians, nurses, technicians and therapists skilled in oncology. Nearly all the oncologists I have met in Ireland have been trained in some of the best centres in the world and have come back here to practise. There is no deficiency of knowledge or skill in Ireland, which is a huge advantage. Many other countries would love to have access to the level of cancer expertise that exists in Ireland. That is the big plus.

The contrast with the experience in British Columbia in Canada is that cancer care is not an organised system in Ireland. Perhaps I should not use the word "disorganised" but it is certainly not organised. It is fragmented; there is significant duplication of services and essentially resources are stretched in many areas because of the failure to concentrate resources to provide the critical mass needed to provide effective cancer services. That is not unique to Ireland but the lesson from the Canadian experience is that concentrating resources and building critical mass of expertise are essential if we are to produce the sort of results in cancer control that are needed.

There are significant issues relating to the patient journey, all of which have been addressed in the cancer strategy. The patient journey from presentation to the family physician to diagnosis to treatment is very long. The longest interval is from presentation with symptoms to diagnoses. This is the same in nearly every country. This is vital time that is lost. Clearly, to address this, one needs a system that is accessible and where both patients and general practitioners are highly aware of the risk profiles for cancer so that patients with cancer can be diagnosed as early as possible. It is still a truth that despite all the improvements in technology, chemotherapy, surgery and radiotherapy, early diagnosis underpins all cancer strategy. One can address that through a cancer strategy but there are many facets that need to be addressed.

There are a number of issues that limit and cause hardship in the patient's journey and which relate to the lack of integration across the system. There is no single medical record in Ireland. Patients have medical records at the local hospital and records throughout the system but it is not possible for a patient to go into a cancer centre in Cork and have his or her cancer record from a hospital in Dublin available to them. This creates endless duplication and considerable delay and leads to tests being repeated because the previous results cannot be found, all things I am sure the committee is well aware of.

We have an excellent cancer registry in Cork led by Dr. Harry Comber which does a very good job. However, I was quite surprised to realise that the reporting of the diagnosis of cancer is not mandatory in Ireland. It is something that I wish to bring forward for the attention of the Minister. Nearly every major country has mandatory reporting of cancer diagnosis. It is currently voluntary and is fairly successful but is not 100%. More importantly, there is a paucity of information on cancer outcomes in Ireland. The clinical audit mechanisms, the identification of short-term surrogates for outcome and the feedback of that information so that people can learn from the results being achieved, is a fundamental part of any cancer control system. In many situations in Ireland the clinicians are flying blind, as is the system. There needs to be a significant investment in the turnaround of information so that one knows how one is doing.

The strategy is challenging and will challenge the Irish system to make major changes. Members are aware of this and I see managing change as a major part of my job. I will not minimise the amount of change required at all levels, how institutions manage cancer, how clinicians are integrated into the cancer process and to build a system that is connected, so that we address the current fragmentation.

My desk has a pile of requests from a variety of people across the country seeking to alert me to their need for greater resources. In every case, bar one or two, the request had no supporting information such as a business case or supporting data. It is clear that this information is not available to people. It is difficult to adjudicate on requests for resources unless benchmarks have been established on how resources should be distributed. There has been comment in the media about adding money and resources to the system. Some resources will be required but mobilising the existing resources is the most important part of the strategy. Resources are there but are widely distributed and there is widespread duplication, of which many committee members are aware.

There is an expectation that every initiative, such as a reorganisation of cancer surgery or a reorganisation at any level, requires an injection of new resources. My experience in British Columbia was that the history of the redesign of cancer services was precipitated by a major economic recession in 1997. It was a wealthy province but became a province requiring federal support in 1997. The Government challenged the health care system by saying there would be no additional funding for five years. The system was challenged to find a way to mobilise resources to provide a better service with the existing funding. This was thought to be impossible two or three years previously. As long as money was flowing, the reaction of throwing money at the problem has been shown not to solve the problem. I am a firm believer in that, having seen what happened in Princess Margaret Hospital, Toronto and in British Columbia. I will strive to identify where resources are and how they could be better spent. Practices that do not contribute to better cancer outcomes, but that are embedded in the system, will have to change.

Many of these are physician driven and I hope to engage the clinical and oncology community and leaders to examine how oncology is practised compared with other jurisdictions in terms of effective use of people's time and service to patients.

I will provide an example. There is a widespread belief - it is also a practice - that patients with cancer need to be followed by their oncologists. Patients, even though they have been cured, are sometimes followed for up to 20 years. Under the current system, patients return to see either their original consultant or a registrar and, even though the evidence indicates that they have been cured, they are given an appointment to come back again a year later. Under the system in British Columbia, patients are brought back for follow-up interventions at cancer centres only if there is demonstrable evidence that such interventions are likely to improve their chances of survival. There is significant literature to the effect that routine follow-ups in respect of cancer patients, which involve the deployment of a huge level of resources, represent money poorly spent and that they do not produce better cancer outcomes.

I use this example to highlight the fact that one could have a clinic where there might be four new patients and 40 follow-up patients. In such circumstances, one might not be able to provide new patients with appointments. A clinic of this sort could probably deal with eight new patients and 15 follow-up patients, who would really benefit from access to follow-up interventions.

There will be a need to change certain practices in Ireland. I will be obliged to convince the people who control those practices, which, as in Canada, are deeply embedded and traditional. In British Columbia 20 years ago, we followed everybody for ever until someone asked whether this was achieving anything. For many patients, this type of behaviour creates a dependency and a concern that if we are bringing them back to be seen, we must somehow believe they are at risk of getting cancer again. This is despite the fact that we know the disease will not return or the risk is small.

I see change on a very large scale being an integral part of what I will do. Two years is a very short period in which to take on a task of this magnitude. My goal is to get the fundamental elements of a cancer control programme in place and assist in the recruitment of a permanent director who can carry the job on after I leave.

Professor Keane referred to British Columbia and the size of its population. How many centres of excellence were established there?

Professor Tom Keane

We do not refer to them as "centres of excellence", that is not a term I use. We have five specialist cancer centres at present - the fifth is just opening - and there will be a sixth in 2013. These centres are located in Victoria, on Vancouver Island, Vancouver, the biggest centre, Colona, is located in the southern interior and Fraser Valley and Abbotsford, which are located in the large suburbs that lie between Vancouver and the American border, which is where all the growth in population is occurring. The population of British Columbia is approximately 4.3 million. British Columbia occupies a landmass that is approximately the size of France and Germany. However, most of the population lives in the lower mainland within approximately 100 miles of the US border.

The major issue for the committee today is that we are moving towards the selection of centres of excellence. How many such centres were closed down in British Columbia before the new policy was adopted?

Professor Tom Keane

There was no closure of centres. The system was built up from the ground. This cancer system has taken almost 50 years to evolve. There has been a steady evolution through Government policy and funding arrangements. We have had a turbulent time in British Columbia. When I first went to British Columbia, there were 54 hospital boards. The Government decided that there was too much fragmentation and duplication and, essentially, it disbanded these and replaced them with just five boards. British Columbia did not go as far as Ireland by creating a single board.

There was no dramatic reduction in services. Essentially, these services have been concentrated over a period of approximately 30 years. Requests to expand the system are driven by the growth in population. In the 15 years I have been in British Columbia, the population has grown by approximately 1 million people. They have driven the demand for planning cancer centres. It is not the same situation as Ireland's in that we did not need to take down and replace an existing system. The system grew from a slow devolution to specialist centres over several decades.

At this stage, we will turn to committee members. I invite Deputy Reilly on behalf of Fine Gael to make the opening statement.

I welcome Professor Keane and Mr. Tony O'Brien. I hope the former's enthusiasm for the job will carry us through.

I will ask questions instead of making statements. Professor Keane mentioned our cadre of oncologists and nurses, but there is a deficiency in numbers. We have few oncologists compared with the national specialty average. If Professor Keane does not mind banking my questions, what is the percentage of GNP spent on health in British Columbia?

Professor Tom Keane

I cannot answer that question. The HSE's budget is not comparable to British Columbia's because the former provides many social services. When I first saw the HSE's budget, I thought there must be an awful lot of money if it was all for health care. In British Columbia, health is health and social services is located in a separate Ministry.

We have OECD figures. Instead of answering individual questions, I ask that Professor Keane bank them to be fair to others. How much is clear about when the cancer centres of excellence will be implemented and fully operational?

Professor Tom Keane

Many of the cancer centres exist already. In terms of the vision, there is some misunderstanding among the media, which believe that we do not have centres of excellence. We have identified eight centres of excellence to be brought up to a single standard. Some of them are close to the optimal standard while some need considerable infusions of resources over time.

Does Professor Keane plan on moving all multidisciplinary diagnosis and curative surgery services to the eight centres of excellence, or however he refers to them? Will some diagnostic and treatment facilities such as chemotherapy and radiotherapy remain at other facilities? If some services remain, will they be located in regional hospitals and will Professor Keane provide the details of those hospitals? Is it fine to bank these questions?

Will Professor Keane take notes and bank the questions?

What hospitals north of the line--

It is nice to get immediate brief answers.

I have been keeping it brief. I have no problem with whatever suits the committee.

Professor Tom Keane

I would prefer to take the questions one at a time.

That would be fine. I asked about the centres and whether radiotherapy and chemotherapy will be carried out at other facilities.

Professor Tom Keane

The Deputy is aware of where the six designated facilities are for radiotherapy. According to the radiotherapy plan announced some years ago, the services at St. Luke's Hospital will relocate to the St. James's Hospital site, there will be a separate site at Beaumont Hospital, the existing sites in Galway and Cork will be expanded and there will be satellite centres in Limerick and Waterford. Part of my remit is to move this plan forward.

Chemotherapy services are widely distributed and there is no intention to remove access to them. Yesterday, I spoke to Dr. Maccon Keane from University College Hospital, Galway, who established a chemotherapy clinic in Castlebar. He does not continue to attend there and a new oncologist provides the service. Chemotherapy services will continue and there is no suggestion of a withdrawal of all cancer services to eight centres. A great deal of ongoing care of cancer patients will remain as close to home as possible. There will be no withdrawal of chemotherapy services or the ongoing symptomatic care of cancer patients in their local communities.

Something that is being changed, which may be reflective of some of the recent unfortunate and tragic events in Portlaoise, is the fact that the initial diagnosis and surgical management of cancer will take place in a designated cancer centre. This is because the decisions that must be made at that time require depth of expertise and increasing complexity. As Deputy Reilly is aware, it is no longer a situation where a cancer patient gets just one modality of care. Increasingly, they are treated with at least three modalities of care and the integration and sequencing of those modalities are critically important.

There is also the issue of expertise and the depth of expertise that we have. One of the areas that has come into focus is cancer pathology. Cancer pathology is a major area of difficulty, not just here but in many countries, and cannot be dealt with by a pathologist working in a small peripheral hospital. In British Columbia, all cancer pathology is reviewed centrally at a cancer centre.

I would imagine that after the initial diagnosis, a patient must go to a cancer centre for initial surgery. If they require chemotherapy, hopefully, if there is already an oncologist in their community, they will have it. We will identify if there are communities that are still not served. If patients are not in one of the six centres and they require radiotherapy, they must travel for it. Most people accept the view that this is the only way that radiotherapy can operate. One cannot fragment it beyond that.

That is fine. Will Professor Keane visit the centres that are currently providing care before they are closed? Is he in a position to influence the final outcome in respect of, not just the centres of excellence or centres of cancer care, but the fact that there ought to and could be satellites? Is it not the case that in British Columbia, there are satellites around some of the bigger centres?

Professor Tom Keane

We have community chemotherapy clinics which are very similar to those that exist for chemotherapy administration in Ireland. We do not have satellite centres. I should add that the first week after I came here, we assembled a group of breast cancer experts to essentially discuss the issue of the diagnosis and management of breast cancer and the organisation of breast cancer services into eight centres. They are the Irish experts in breast cancer in all modalities of care. I listened very carefully to that discussion, which was held at Farmleigh towards the end of November. The outcome of that discussion was a reaffirmation that there would be no satellite models and that the best way to approach this was through eight designated centres.

Will there be any hospitals north of the line between Galway and Dublin? Did anybody at that meeting at Farmleigh live north of the line between Galway and Dublin?

Professor Tom Keane

There were people at the meeting who live north of the line who were familiar with that issue. As Deputy Reilly is aware, a special arrangement has been made around Letterkenny in the strategy. It is basically an issue of how one can achieve quality and, at the same time, not force people to travel. That is an issue in British Columbia. I am somewhat surprised at the emphasis placed in Ireland on travel. Those members who saw the "Prime Time Investigates" programme which visited British Columbia probably heard the BC Cancer Agency being discussed. For several decades, patients in British Columbia have accepted that if they need the best possible care, they must travel to a cancer centre.

Hopefully, cancer is not something one gets more than once in a lifetime. There is a clear understanding that outcomes are better where care is concentrated. It is around the initial diagnosis and initial management decisions that outcomes are influenced. I recognise that it produces some hardship. We have identified that we will address travel in the budget for the coming year in respect of patients who must travel to cancer centres. If one wants quality outcomes, travel, unfortunately, will be necessary.

Is Professor Keane in a position to influence the final outcome in respect of the centres?

Professor Tom Keane

What does the Deputy mean by the final outcome? The decision has been made and I support it.

Notwithstanding any new information that comes to his attention or into his possession, has Professor Keane any notion of changing any of that?

Professor Tom Keane

No.

Is he in a position to do that if he so desired, even if it is not his intention?

Professor Tom Keane

I am in a position to do so but in reviewing the decisions I have no reason to question them.

Can I just ask--

In fairness to other members we must move on.

--some important questions? Did any of the services--

Deputy Reilly began at 11.35 a.m. and it is now 11.45 a.m. I must be fair to all members. This is the final question.

Did any of the services facilities in British Columbia close before the new services were up and running?

Professor Tom Keane

I think I have dealt with that already.

Professor Keane is saying "No".

Professor Tom Keane

I am not saying that but I dealt with that earlier. The evolution of cancer centres in British Columbia was entirely different and was not as the Deputy described, where closure was necessary. Over a long period there was concentration of cancer surgery and hospitals. There was no sudden decision to withdraw services, it became Government policy.

I also welcome Professor Keane and Mr. Tony O'Brien. Has Professor Keane identified what resources are in the Irish system?

Professor Tom Keane

I have not fully identified the resources. Before my arrival Mr. Tony O'Brien set up a group to extract the information from the HSE budgets. It is a complex process to identify all resources for cancer control. In some areas we know where the resources are but other resources are embedded in hospitals and it is a challenge to identify them. There is methodology in place. We know what we spend on diagnosis and screening, which are compartmentalised programmes. We also know what we spend on radiotherapy and chemotherapy. The major issue is getting into hospitals and identifying the money spent on cancer on a case mix basis, a function of how hospitals budget. There is no reason it is not achievable but it is complicated and must be validated. It will be the subject of intense discussions with hospitals, given that the cancer programme will assume responsibility for those resources.

The additional money is €35 million. Must that include the area within Mr. O'Brien's remit, cervical screening and breast screening? Must it include the development of pathology where there is inadequacy, and transport?

Professor Tom Keane

It is my intention to address all these issues with the sum of €35 million. Some €15 million has been identified for the roll-out of cervical screening but that does not refer to a full year. There will be additional pathology positions. Without wishing to pre-empt discussions with the pathology community, we may need to create a national reference centre for pathology, creating a virtual reference centre for Ireland so that pathologists who wish to have a second opinion can get one. This is a feature of many good cancer systems. Some €5 million is earmarked to hire consultants in radiation and oncology and the staff of the interim facilities at St. James's Hospital and Beaumont Hospital. That refers to the budget for the coming year.

As of Friday I have a good estimate of the needs of the breast cancer services in eight centres. Some two thirds of the cost will refer to additional consultant appointments, particularly in radiology and pathology. Surgical sessions will be managed through a process of relocation whereby surgeons will be in a position to relocate their surgical practices to a centre. That would be the option. The last thing I want to do is to waste existing cancer expertise within the system. We need to use it all. This will require flexibility and willingness on the part of people to make the changes I outlined earlier.

Breast and colon cancer services are widely distributed. However, 25 of the 37 hospitals on my list treat less than one colorectal cancer case per week. Clearly this is below any international norm in the context of achieving good results. Consolidation of colon cancer services will obviously involve a considerable degree of discussion and controversy. To that effect, I will attend a meeting of the Royal College of Surgeons, which represents all surgeons in Ireland, on 14 January. An entire day is being given over to a discussion on the implications of and the requirements for the change needed to implement the strategy.

With other cancers, it is not a major issue. For example, at present there are only two centres - a large one in Dublin and a smaller one in Cork - which deal with brain tumours. There are only five hospitals that offer services in respect of lung cancer. With one exception, these have all been identified as centres of excellence. For rarer cancers, consolidation will not involve major resource issues. Breast and colorectal cancer will be the two major areas because services are so widely distributed in the existing system.

I wish to tease out the transportation issue. I spent a year in Vancouver some time ago and I am aware that the geography of British Columbia is very different to that of Ireland. The majority of people in British Columbia - the population in parts of which is extremely sparse - would live relatively close to cancer centres. One of the major concerns people in Ireland have relates to access to transport, particularly in the context of accessing services at specialist centres. Will it be part of Professor Keane's remit to address that issue?

Professor Tom Keane

We have engaged with the Irish Cancer Society, which has been advocating strongly in respect of the transport issue. The society currently provides, from its own resources, some transportation support. Other transport supports are provided through the HSE budget. I understand the HSE is examining the possibility of bringing these together. We have chosen to discuss with the Irish Cancer Society whether we could facilitate its existing low-cost administration of a transport network and inject resources into providing transportation based on need.

Patients in British Columbia are obliged to travel much longer distances.

Yes, but there are fewer of them.

Professor Tom Keane

The distances are much longer. Anyone living in Vancouver or the lower mainland will be obliged to travel 60 or 70 miles. I accept that the roads may be better. Some patients who live on Vancouver Island, which is almost the same size as Ireland, are obliged to travel the entire length of the island to get to the cancer centre. With the exception of those with special needs or the First Nations People, who are covered under federal grants, transport for cancer patients in British Columbia is not supported by the Government. The majority of transport for cancer patients there is provided by the cancer society, which has transportation arrangements with all cancer centres and has access to fleets of cars and volunteer drivers.

There are opportunities to consider innovation in the context of how transportation might be provided in Ireland. Transportation is not an issue in British Columbia. The Government of British Columbia does not, by and large, pay for transportation.

Are supports provided in respect of accommodation for patients in British Columbia?

Professor Tom Keane

That is a significant issue. The Chairman is probably aware that inpatient bed use is the most expensive part of the Irish or any health care system. The remarkable contrast with British Columbia is that the total number of inpatient beds used for cancer care is dramatically lower. Its radiotherapy services alone use five times fewer beds than Ireland's. The reason is the shift in the past 30 years from inpatient care to outpatient care. We have superb links to community and superb ambulatory care programmes that do not necessitate patients being admitted to hospitals unless they require inpatient services.

There are issues concerning the scheduling of tests. When patients must come to Vancouver from Prince Rupert, which is up the coast, we schedule their tests so that their mammograms, consultations, blood work and CAT scans are done on one day and they do not need to spend one week in Vancouver awaiting tests. This is a system issue. It does not cost any more money to do the tests in one day than it does to take the tests over four days.

The Canadian Cancer Society has taken a significant leadership role in terms of accommodation. It has built in every cancer centre what would be equivalent to three and a half star or four star hotels. They have private rooms, private bathrooms and beautiful facilities. The patients are often from those communities, but they live in the hotels during the period in which they are having cancer treatment or tests done and then return home. The hotels are built adjacent to the cancer hospitals or centres. If any patients require care at night, they are transferred across the street to be seen by a physician.

This measure has a considerable impact on cost for the system, not only for the patient. There is no question that, were we to redirect the money being spent on inpatient care to a Cadillac outpatient ambulatory care oncology system, we would have happier patients, a more cost efficient system and something that could be displayed as a major change. The single greatest issue I see when I consider Ireland is the dependency on inpatient beds for cancer care. Obviously, I am not discussing major surgery, but day surgeries are done in respect of, for example, breast cancer in some hospitals. Some 80% of a particular hospital's breast cancer cases are done as day surgeries whereas the lengths of stay in some hospitals are up to eight days. Questions must be asked concerning these lengths of stay and what is occurring in terms of why patients are in inpatient beds. Lodge care as we call it - the lodge facilities run by the Canadian Cancer Society - removes a significant financial burden on inpatient chemotherapy, radiotherapy and, to a lesser extent, cervical cancer care.

I thank Professor Keane for his logical and rational account of where we are going. Putting many different hats on, I agree with everything Professor Keane stated and cannot be critical of anything. The travel issue was raised by Professor Keane and, subsequently, my colleagues. There is no doubt that travel is a considerable issue, but Professor Keane made a point I endorse, namely, that travel means a better quality outcome. This is the issue we must face.

Is the cross-Border delivery of services, such as the Derry-Donegal or the Dundalk-Newry axis, in Professor Keane's remit and how will it develop?

Professor Keane

I am aware of cross-Border discussions. Under an existing arrangement, patients from Donegal can go to Belfast for radiotherapy. I am unsure as to whether the service is being fully taken up, but it is in place. There are complexities associated with patients being seen by a doctor in a clinic in Letterkenny, a radiation oncologist in this case referring the patient to Belfast. Obviously, in Belfast, the patient must be seen by another radiation oncologist so one gets these "hand-offs" which are not ideal. Clearly, there is a geographic problem in respect of the north west in terms of access to radiotherapy and other services. I am not up to speed on where the discussions are because the matter extends beyond cancer and includes cross-Border issues so I am unable to give the committee a definitive answer. If there are opportunities for patients in the north west of the Republic of Ireland to access services in Northern Ireland, I would certainly choose to exploit them wherever possible.

The other question concerns research. Professor Keane said that research should be an integrated part of the overall programme. How does he see this developing?

Professor Tom Keane

The cancer agency in British Columbia is both a research and treatment centre. We do both fundamental research, as well as clinical research in terms of clinical trials of new drugs and treatment for cancer patients. Research is integral to recruiting and retaining the world's best people in Ireland. If one does not have research, one will not attract the people who need to be here and who need to train the people who need to be here for the next generation.

A committee chaired by Professor Muiris Fitzgerald has been looking at the integration of research and training in health care in Ireland. I intend to have representation within that group to fully understand how cancer research in Ireland can be embedded within the cancer control programme.

Again, there are many stakeholders in cancer research in Ireland. There are many entities that support research, such as the Irish Cancer Society, a number of voluntary organisations, the Health Research Board and a number of other institutions. Cancer research needs to be concentrated if it is to be successful in world terms. Cancer research is now a huge business. One will not succeed on the world stage in cancer research with what we in Canada call a "mom-and-pop operation". These are multi-million euro enterprises.

Certainly, a vision for cancer research is something I intend to develop. I have not given much attention to it up to now but it is an integral part if Ireland is to retain the people it needs. One of the great concerns is that Ireland has trained many people who have gone abroad and established themselves. In my area of expertise, two of the five professors in Toronto are Irish-trained. There are seven Irish-trained radiation oncologists, all of whom are at the top of their game in the Canadian system. Those people were lost to the Irish system at a time when there were no opportunities to return. Ireland has no shortage of talent but if it cannot provide this sort of research environment, we will not recruit people back to essentially fulfil their professional careers. I am not just referring to physicians but to scientists, nurses and people who work to create new knowledge in the system.

I thank Professor Keane.

That part of the meeting, which involved the contributions of the spokespersons, is now concluded. We now move into the next part, which involves contributions from members. I promise that every member will be accommodated inside the next hour. Deputy Connaughton will be the first to speak, followed by Deputy Neville and Senator Feeney. We will then move on to the next group of three.

I welcome Professor Keane to the meeting. For all our sakes, we sincerely wish him well. I have three questions for Professor Keane. I do not wish to go over the ground already travelled by Professor Keane and many of my colleagues.

An old Irish saying, which I am sure Professor Keane has often heard, states that there is many a slip between the cup and the lip. In two or three years' time the policy enunciated here might be far removed from what Professor Keane is now saying. I acknowledge that he will certainly do his best. The HSE had great ambitions a few years ago. Some of them have been realised, while others have not.

On transport, I would like to see action before I can believe this transport system will be as efficient as Professor Keane would like it to be. We do not have a good track record in that respect.

Professor Tom Keane

I do not fully understand why that is the case. I have outlined some of the opportunities. Some other suggestions, which I will not detail today, were also made. There is clearly an opportunity for innovation in this area. People need to examine how transport for cancer patients is organised in other jurisdictions. It is not unusual to have centralised cancer services. When I returned to Ireland, I did not expect that transportation would be the No. 1 issue with which I would be obliged to deal. However, I will get my head around it because I want to understand what is involved. There are certain parts of the country where it appears to be a much bigger issue.

I am cognisant of the importance of transportation to the success of the cancer programme. As long as this remains an issue and as long patients either cannot access or have difficulty accessing cancer care, the cancer programme will not succeed. Transportation is integral to the success of the programme.

Are the vested interests on Professor Keane's side?

Professor Tom Keane

The vested interests are multiple in nature. I like to see myself as being nobody's man. I have a vision.

Do they like to see Professor Keane coming?

Professor Tom Keane

I received a considerably warm welcome. I spent last Thursday night in Cork and I spoke to 70 specialists from there and the surrounding counties. They engaged me for slightly longer than the committee will today and I was hoarse by the end of the meeting. The questions posed were constructive and there was very little ranting or assertions to the effect that this cannot happen. The general attitude was very helpful. Members of the oncology community, surgeons and the Royal College of Surgeons in Ireland, on foot of its decision to give over an entire day to discussion, recognise that the time for change has come.

A number of people believe that if I am not successful - I feel I have a responsibility in this regard - the opportunity to build a world-class cancer control system in Ireland will probably never come again. It is quite possible that the latter could happen.

I wish to put to Professor Keane a technical question I posed on the previous occasion on which we were visited by representatives of the HSE. I imagine this question applies to many areas that are not directly linked to the centres of excellence. Last year, 1,000 mammograms were carried out at Portiuncula Hospital, Ballinasloe. Portiuncula is located 40 miles from the new centre of excellence at University College Hospital, Galway. Is it possible to convey, by electronic means, mammogram images taken at Portiuncula to University College Hospital, Galway to have them assessed?

Professor Tom Keane

In British Columbia, we are converting to digital and considering ways to convey information. We do not want patients to travel if they do not have to.

Particularly to hospitals where there is not much room.

Professor Tom Keane

Pathology cannot be done by means of transmitting information or samples by electronic means. For follow-up or ongoing care in respect of medical oncology patients, British Columbia has a system that utilises telemedicine to reach into small communities. In many instances, such communities do not have oncologists. However, we provide family doctors with special training to enable them to provide chemotherapy services and these individuals have 24-7 access to oncologists at Vancouver or one of the other cancer centres. If one of these specially trained doctors gets into difficulty, he or she can access an oncologist and obtain advice. Technology can bring many things to the table in terms of the ongoing management of cancer patients. However, there is no way to bridge the gap in respect of decisions around the initial management of cases and state that everything can be done through technology.

Professor Keane stated that he met several medical experts in Cork on Thursday evening last to discuss the need for change. Politicians will be accused of not defending their patch or not looking for centres in their area as the programme is rolled out. Some years ago a debate was held in the midlands and the National Cancer Forum decided on Tullamore as the location for a centre of excellence or the lead centre. I supported my own county and the town of Portlaoise and would not want to go through that process again. Unless all of Professor Keane's colleagues in the medical profession are on board with what he is discussing, there is no way that politicians can give a lead. Rather than the public, our constituents or whoever is placing the onus on us to deliver for their local area, I suggest it is more important for Professor Keane to ensure his medical colleagues give a lead in order that our thinking can be in parallel with theirs.

Professor Tom Keane

I agree completely. By 1 January I will have appointed part-time national leaders for surgery, medical oncology and radiation oncology to assist me. The executive of the cancer agency in British Columbia is led by four oncologists, two scientists and one administrator. It is a medically-led organisation, which gives it great credibility.

I have met members of the Royal College of Surgeons and told them that there is an opportunity for them to demonstrate leadership. Not everyone will take up the challenge, but I have been impressed. I have met the incoming president of the college who was supportive. I have met a number of people who are thoughtful and have considered this issue. They are aware of what has occurred elsewhere in the world.

I could not agree more with the Chairman. I am challenging the medical establishment, particularly members of the oncology establishment, to get behind this measure, as they are crucial to its success. If they undermine it, the process will be negated. I am satisfied that people are engaging and willing to discuss and make changes. I do not know how far I can move them down the road towards the ultimate objective, but they have demonstrated that they are willing to go down that road. A reason I took this job was I sensed a willingness to change and that people were finally saying something had to be done. I am challenging the doctors in the system to provide leadership. I can be out in front telling people where we must go, but it will not occur if I do not have them behind me.

I welcome Professor Keane's comments. If the policy is to succeed and we are to believe in it, it will be essential for his directors to be at public meetings with politicians to explain why a decision has been taken. We have moved a long way from needing to depend on the local politician to deal with issues such as cancer services. I hope Professor Keane will build into his principle the need for his directors to be active parts of the information process.

Professor Tom Keane

I hope so. I have not had an opportunity to visit all of the centres. Instead, I have been trying to target large groups to get my message out. I have spoken with individuals, including Mr. Tim O'Hanrahan in Sligo last week. He called and we had a private discussion on his concerns about what would be the situation for patients when the cancer services moved. He was constructive and helpful. It was a professional discussion with which I was pleased.

I can give direction and provide some leadership, but the people within the system must make the policy work. I refer to everyone in the system, not just doctors. Everyone must come on board because this situation has gone on for too long.

That is good to hear.

I welcome Professor Keane and Mr. Tony O'Brien and wish them well. Is Professor Keane happy with the system and procedures in place for the recruitment of specialists, or has he examined the matter? Some doubts have entered our minds regarding the recruitment of specialists by the HSE. Will Professor Keane have responsibility in that respect?

Professor Tom Keane

The issue has risen primarily in respect of locum appointments. Clearly, I do not have jurisdiction over the Medical Council which, ultimately, registers physicians. However, in respect of the hiring of physicians into the cancer programme, I want to ensure they are qualified, that their references are appropriately checked and that we have a good sense of their competencies. The fact that somebody is a pathologist does not necessarily mean that he or she is an expert in cancer pathology. There is no certification to say one is an expert. Sometimes, an individual can say he or she is an expert in breast cancer pathology but one must look at his or her curriculum vitae and check whether he or she has ever published or has a reputation in the field. I certainly believe there should be screening of oncologists and all specialists.

I do not know the details that gave rise to the concerns alluded to by the Deputy but in British Columbia all specialists are hired through a very stringent process of review. Referees are contacted in writing and usually by telephone. There is a systematic mechanism by which wherever a person practises in Canada, his or her track record goes with him or her. In other words, if there is anything on one's record, it will be known globally, even if one moves from one province to another. They are the standards. I do not believe they are bad here. I just think that in areas of sub-specialised expertise there is a need to address this issue because there is no formal certification process. Very few radiologists are certified just to carry out a mammography. Therefore, there is an issue around sub-specialisation and how we recognise competency in those fields. I certainly believe it will be an essential part of the people I will recruit into the cancer programme. I will certainly want to be sure they have the highest levels of competency and that they will maintain them on an ongoing basis.

Where the Canadian system differs from the one in place here is that doctors must reapply for their privilege to practise every year. It is a highly accountable system. I have 50 specialists working under me in Vancouver. Every year I must sign a form that goes to the board of the hospital or the cancer agency which says the individual in question is safe, that there have been no issues in terms of how they managed patients and that I believe they should continue to practise. That is a very accountable system, whereby physicians are held accountable, not only at the time of their initial appointment but also on a continuing basis in order that if there are any deficiencies, which sometimes arise, for example, we might find a specialist who has not kept up to date, they will be told they need to go off for three months and do some additional training if they are to continue to work in that area. We facilitate this. There is a higher level of oversight in the Canadian system around specialty qualifications, both initially and on an ongoing basis, which I hope, ultimately, will be the way it will be here. As the committee will understand, this is not part of my remit other than when I hire people, I will look very hard to make sure they meet the standards I expect.

I welcome Professor Keane to Ireland, and also Mr. Tony O'Brien. I agree with the three goals outlined by Professor Keane in respect of the strategy - reducing cancer incidence, reducing cancer mortality and improving quality of life. I put it to Professor Keane that what he is trying to do in reorganising services accounts for only a small percentage. In respect of the strategy for cancer control, all of the other matters referred to by him such as lifestyle and screening programmes, of which we have not had the benefit during the years, have contributed hugely to our poor statistics. Looking at the statistics, one can see that while we are performing less well than other countries, the position is not quite as bad as one would expect, given that we have not had any of these screening programmes. Is it the case that reorganising services can only contribute in a small way to the realisation of the three goals outlined?

Professor Tom Keane

The focus is on cancer treatment services. From a global perspective, prevention is clearly better than cure. The latter is certainly the case in respect of cancer and most diseases.

I was asked about a national strategy to examine cancer prevention and the need to invest money. We need to consider more than just cancer. Many of the strategies relating to cancer prevention are also strategies for cardiovascular risk reduction in respect of other diseases. Cancer prevention is not something that can be solely mandated through the cancer strategy. Reducing the incidence of cancer is obviously a goal. Early diagnosis is obviously the next step. As the Deputy stated, great strides have been made as a result of the adoption of screening programmes. I refer here to the roll-out of BreastCheck and the cervical screening programme. I hope there will also be a programme in respect of colorectal screening. We know that these will help reduce the incidence of cancer.

The truth is that even if there were a perfect system, cancer would still exist. Cancer is a disease of ageing. We know now that it is largely genetically based. The reason it peaks in the older age groups is that our defence mechanisms which detect cancerous cells as they develop or which detect mutations that lead to cancer become tired as we get older. As a result, there is a possibility that a mutation will occur, which can be lethal and which can produce a cancer, and will not be detected.

If autopsies were carried out on men who died at the age of 90, some 90% of them would have prostate cancer. The important point to recognise is that many men in older age groups may contract prostate cancer but may never die from it. There has been a realisation in Canada that we are grossly over-treating people in respect of prostate cancer. In that context, 80 year old men are being subjected to radiation treatment, chemotherapy and all sorts of other treatments when, in all probability, they will not die from prostate cancer. In many cases, this form of cancer is quite indolent.

The incidence of cancer has grown, a fact associated with improvements in longevity. As life expectancy in Ireland increases, we will see more cancer. Prevention is by far and away the most cost-effective strategy. It is, however, a long-term strategy. The problem we have in Canada - I will not comment on this matter in the context of Ireland - is that engaging the Government to commit to a 25-year objective is extremely problematic. It is difficult to encourage anyone to invest large amounts of money in respect of a gain that will not be seen for 20, 30 or even 40 years. Shifting money from treatment into prevention is politically explosive in any country because people with cancer want their treatment now. If one was very rational, one would say that the biggest bang for the cancer buck would be to invest significantly in prevention and one would only invest in treatment where it had been absolutely demonstrated to improve survival.

This matter is, in medical and political terms, a difficult one with which to deal. In British Columbia, 80% of the cost of treating patients with breast cancer who do not survive occurs in the last six months of their lives. I am not saying that this should not be the case. However, it is a remarkably skewed statistic. The huge amounts of money being spent on the care of people who are dying of cancer seem disproportionate because they will do nothing to improve cure rates. All this money does is improve the quality of life of people who are dying. I reiterate that 80% of the money for patients with breast cancer who are not cured is spent in the terminal phase of their illness.

Is there no way to avoid spending that money?

Professor Tom Keane

No, I do not believe there is a way to avoid it. However, questions are being asked, particularly in the United States, in respect of this matter. Patients obtain increasingly expensive care because of the failure to recognise that they will not be cured. We have patients who travel from British Columbia to the United States to try to access treatments they believe will cure them costing hundreds of thousands of dollars. I have seen patients mortgage their homes to pay for treatments that were clearly never going to be successful.

A discussion is required regarding how we should distribute resources in respect of the totality of cancer. At present, the vast majority of resources are allocated to cancer treatment in most countries.

I cannot help thinking that had Ireland, like British Columbia, been somewhat more proactive 20 years ago in respect of the 12 suggestions for dealing with cancer and had introduced screening programmes at that point, perhaps Professor Keane might not be present and we would not be reorganising our cancer centres.

Professor Tom Keane

Possibly. If the huge numbers of Irish people who emigrated in the three decades from 1950 onwards had remained at home, Ireland would have a significant cancer problem. We have a low incidence of cancer because the people in the relevant age group all left. However, the Deputy is probably correct.

To return to the Farmleigh meeting, Professor Keane stated that there was a fair amount of agreement, particularly on the point that, with one notable exception, namely, Letterkenny, there would be no satellite models. In light of what he stated earlier to the effect that he could not understand why travel is such a major factor, particularly in the context of his experience in Canada--

Professor Tom Keane

I understand that it is a major factor. However, its relevance here is greater than I am used to.

What will be on offer at the satellite centre in Letterkenny?

Professor Tom Keane

I have not yet visited Letterkenny so I cannot give the Deputy an accurate answer. I understand that the centre there is currently video-linked to Galway. The intention is that the decision-making will occur through that channel. Letterkenny was identified as the sole exception in the recommendations from the advisory group and was flagged as such. It was recognised that travel issues relating to Letterkenny are exceptional. One could clearly have a situation where every town could claim that the same exception should be made in respect of it. In such circumstances, matters would remain as they stand.

Does Professor Keane agree with the exception being made in the case of Letterkenny?

Professor Tom Keane

I recognise that the decision was made on the basis of the unique circumstances involved. The ideal solution would be if patients from Donegal could gain cross-Border access to a centre in Derry. The latter would make a great deal of sense. I do not know if this will happen but I hope a cross-Border arrangement might be reached in respect of patients from the north west in the future. As already stated, I was not party to the decision in question, which had been made when I arrived and which was the subject of considerable discussion.

It seems that Professor Keane does not agree with the decision. My question required a "Yes" or "No" answer. If he agrees with the decision, he would have answered "Yes". If he does not do so, he would have--

Professor Tom Keane

I support it.

I will accept that. Will diagnostics or primary surgery be carried out in Letterkenny?

Professor Tom Keane

No, I do not believe primary surgery can happen in Letterkenny. I cannot assess what is happening there and I cannot really provide details. In essence, the problem with Letterkenny is that the decision relating to it was made in isolation. That decision is a recognition that the position is not optimal and it represents a compromise based on the grounds of geography. In British Columbia there would be no special exception in respect of Letterkenny and patients would be obliged to travel.

If surgery will not be performed - I remain unsure as to whether diagnostics will be carried out there - what will be on offer at the centre?

Professor Tom Keane

My understanding is that diagnostics will be carried out. Consultations will also happen there but surgeries will be performed in Galway.

So in comparison with other hospitals where there will be chemotherapy and follow-up--

Professor Tom Keane

There will be chemotherapy in Letterkenny.

So diagnostics will be the only service on offer that will be additional to those offered at other facilities outside the cancer centres.

Professor Tom Keane

As I understand it, that will be the position.

Having read the various reports and taking on board Professor Keane's assertion that our personnel are well trained, the central message that seems to be coming across in respect of establishing cancer centres relates to money. I accept the points regarding duplication, etc. We are setting up cancer centres, appropriating resources from other hospitals and centralising services. Is it an economic model?

Professor Tom Keane

Not solely.

I will come back to that. What will be the main focus of the centres of excellence or cancer centres? Are we speaking in this regard about the provision of an excellent service?

Professor Tom Keane

Let us distinguish between providing a service for a select group of patients and what happens in a cancer centre. A cancer centre is an aggregation wherein essentially the vast majority of cancers are treated. I have looked at the data in this regard. For example, Sligo General Hospital provides treatment for several colon cancers and breast cancers but does not undertake any other work in respect of cancer. Essentially, Sligo General Hospital provides treatment for approximately 1.5% of the total cancer incidence in Ireland. I put it to the Deputy that one cannot build a centre of excellence with a concentration of expertise around that volume of cancer patients even though there exists in two areas a commitment to do so.

A cancer centre brings together pathologists and radiologists though not all are necessarily totally specialised in one area. This ensures a depth of approximately four, five or six pathologists and at least the same number of radiologists all doing cancer work with an ensuing ability for these people to essentially act as peer review for one another. This model creates a depth of expertise that cannot be provided by a centre with one surgeon doing cancer work or one pathologist who has an interest but who also has an enormous amount of non-cancer work to do. This also applies in respect of other disciplines.

We are speaking about a concentration of expertise. I believe this proposal is quality rather than economically driven. Quality is the issue here. The events of recent months have caused me to reflect on what would happen if there was a recurrence of this type in a future cancer system. Quality is the main priority. People get cancer once in their life and they are expected to have the best possible chance of surviving it.

It is interesting that patients do not fuss about having to travel to Dublin for a triple by-pass which is a life-threatening operation. However, there is enormous fuss about people having to leave their local communities to obtain cancer treatment. The concern appears to arise in respect of breast and colon cancers because these are the types of services provided by general surgeons. General surgeons are needed in the community and if they do not provide cancer care, concerns are raised about it.

In practice, the need for a quality service and the recent unfortunate episodes illustrate that concentration of expertise is the way forward. As was stated earlier Ireland is not fully endowed with cancer specialists as many of our talented people are training abroad. There are only 26 medical oncologists and 15 radiation oncologists in Ireland. Very few of our surgeons specialise in oncology only. This is the way of the future.

Deputy Flynn may ask a final question.

Will I have an opportunity later to ask further questions?

We must conclude by 1 p.m. A number of other members are anxious to contribute.

I understand that. Professor Keane referred to a triple by-pass operation. I respectfully suggest that if in local hospitals there was an expert surgeon specialising in cardiac activity people would not be happy to travel. That is an aside but Professor Keane referred--

Professor Tom Keane

The system for cardiovascular surgery has recognised that concentration of expertise is essential for quality care. It has been recognised in most jurisdictions that concentration of expertise for cancer treatment produces a great deal of push-back for people who have to travel. It is interesting that in Ireland the one area that is outstanding in terms of world class cancer results is paediatric oncology. This is the one area wherein patients have historically travelled for treatment to a single centre in Ireland. No parent in Ireland would be concerned about taking their child to Our Lady's Hospital for Sick Children in Crumlin for excellent cancer care. Again, it is a relatively rare cancer. Having achieved that concentration of expertise, it is the only possible way to go.

Nobody disagrees that rare cancers will be treated in fewer centres.

Will Deputy Flynn confine her remarks?

Professor Keane referred to three points, including the patient's journey. Will he bear with me while I illustrate my point by way of an example? If an individual is to have a needle biopsy in University College Hospital, Galway, today, it will take four days to receive a diagnosis.

Professor Tom Keane

Not in the way I expect it to run.

I am talking about the service as it is provided today.

Professor Tom Keane

I do not think that is acceptable. One could get a result within 24 to 48 hours.

One can get a result within 24 hours in Castlebar.

Professor Tom Keane

Yes, that is what I would expect.

However, if one has a full specimen sample, including lymph glands, it will take two weeks to get a result from UCHG, whereas in Castlebar, one will get a result in four days.

Professor Tom Keane

I hope that standard benchmark will be the standard across the country.

The patient journey in Castlebar is excellent. Does Professor Keane agree--

Please, Deputy Flynn, to be fair, I have to try--

In my defence, may I say that while the cancer strategy will apply to everybody, there are a few hospitals which offer an excellent service but will lose it. The service I have outlined is the level of service that has been endorsed by the HSE. Professor Keane is telling me it is hoped to get the service up to that level in University College Hospital, Galway, yet such a service is provided in a local hospital in Castlebar. My second point--

Professor Tom Keane

May I reply?

I want to be fair to all members. I have given a commitment that everybody will have five minutes. If I do not keep to that commitment, at least four or five members will lose out. I ask Professor Keane to respond to that question. I will then have to move on.

With respect, Professor Keane did not answer my question as to whether he would visit the centres in Castlebar, Sligo and so on.

As every member has an equal right to be here, why start going backwards? The priority must be to allow members to contribute. Will Professor Keane answer the question asked?

Professor Tom Keane

I am not sure what the question was.

I am asking members to allow us to deal with the issues involved.

Professor Tom Keane

The rationale for concentrating services in an area was based on a sound judgment. I recognise that some centres provided what I would call a threadbare service, but it was a good one. A threadbare service for a single disease is not a cancer centre. This addresses the concentration of expertise around cancer centres where we can put between 15 and 25 to 30 oncology specialised professionals in a single institution. Not everybody will necessarily agree with that strategy, but it is sound. That is the decision that has been made and I support it.

With respect, Professor Keane has misinterpreted the point. Rather than have the record--

I am sorry, Deputy, I will get to it later. I must be fair. I am ruling on the matter.

Chairman, it is too important an issue--

Every member will deem his or her question to be of equal importance. I must move on.

This question relates to every other hospital.

I have been on this stage for the past ten minutes. I have six members waiting since 11 a.m. I must give them a chance. I will come back to the Deputy, if I can.

We are more than happy to see Professor Tom Keane. Let me tell Mr. Tony O'Brien that we are absolutely thrilled with BreastCheck. It eventually opened in Cork yesterday and we are hoping for great things. I know the service is excellent. I read Professor Keane's paper in which he set out his intentions for the cancer strategy. What I felt then and feel today, having listened to his presentation, is that the mindset in Canada about cancer is entirely different from that in Ireland. I know several people who cannot say the word "cancer". I wonder from where that comes? Is it because we have had little success in treating it or that we see it as such a pervasive disease that we will never succeed in getting on top of it?

Professor Tom Keane

I have been in Canada for over 35 years. People in Ireland call cancer the "big C". One would never hear it referred to in that way in Canada, particularly because of the level of public dialogue and the openness surrounding the discussion in respect of it. When I went to Canada, I was astonished that physicians spoke to patients about their cancer in a totally open way. That was the position when I left Ireland; I am not saying it is the same now. Before I went to Canada, many patients were not told they had cancer. There was still a taboo attached to cancer and it was seen as a bad disease or as something which brought shame on one's family. As a result, it was pushed into a back closet. Matters have changed since, although perhaps not completely.

There are cultural differences between Canada and Ireland in how cancer is perceived. Ireland is probably approximately ten years behind Canada in the context of the public debate on cancer and also that relating to health care in general. There is continuous debate on health care in Canada, which has a public system. People in Canada are currently discussing whether there are alternatives. Canada is a multicultural society. There is a large Chinese community and its members remain reluctant to discuss cancer. We had to insist on having our own interpreters when we spoke with Chinese patients because family members who acted as interpreters would not transmit the information correctly and tended to skip the detail. I cannot explain it.

When reading the material, I found that a major concern.

On travel, I accept that the concept of centres of cancer control is a political minefield. The terms used in Professor Keane's background document are interesting. I refer to his use of the phrase "cancer control" when commenting on national cancer care services.

Professor Tom Keane

Yes, the term used should be "cancer control".

Use of that term sends a different message. I always judge how I react to various matters in the context of what I would do for myself or my child, mother, husband and so. I would want any of my relatives to be treated in a place where they might obtain the best possible outcome. It is in these terms that we should transmit a message to the people we represent. It may be political suicide to do so but that is how I see matters. If cancer control centres are where people will obtain the best possible outcomes, then we must focus our attention in that direction.

There is, however, a subtext to this debate which is also relevant to the issue of travel. As minimalist as are the services available, people do not want to lose them before the centres of excellence are up and running. The research relating to cervical cancer in Ireland is frightening. Women who die from cervical cancer are usually under the age of 56 years and they would have been diagnosed with the disease in their 30s. Those are their childbearing years, when women have children at home for whom they are responsible. I was interested in Professor Keane's comments on the community resources and home care packages available in British Columbia and how he intends to apply them here. Many people's desire not to travel far from home to receive treatment relates to their responsibilities at home. How can we give them cause for comfort in this regard?

Professor Tom Keane

The Deputy should not get me wrong; those issues are real in Canada. It is equally traumatic for a mother there who has four children at home to travel in order to undergo radiotherapy. However, patients have generally accepted that if that is what they have to do, then so be it. There are more interventions at community level in terms of supports. In such cases efforts are made to mitigate travel and patients who must travel long distances are fast-tracked into the system so that they do not have to wait for tests. A patient coming from the north will come down to get his or her test and - to address Deputy Flynn's point - everything will be done in 48 or 72 hours. They will be prebooked on the machines and they gain faster access to the system than patients who live in Vancouver. That recognises that we want them to stay for the shortest possible time. Community resources often provide for those patients to travel back to their homes or provide home care support for the family to look after the children or if there are special needs. The Canadian Cancer Society does an amazing job to mitigate patients' difficulties in such cases. It mitigates those difficulties rather than avoids them because it recognises, as members of this committee do, that this is the best way to get the best possible outcome.

When I ask doctors in Ireland where they send their family members, their mothers and sisters, for cancer care it is very interesting to hear that they send them to centres of excellence, sometimes not even in Ireland. When doctors, who should be in the know, send family members to a centre of excellence in Dublin or out of the country, while adopting a different standard for patients in their own community, it says something. It says there is a double standard in what people really believe and what they say. I have had many requests and telephone calls from colleagues, family members and friends of friends asking if they could send family members to Canada for an opinion. I have told them there is no need to do that as there are excellent people in Dublin, Galway and Cork who can give them an opinion. I have a sense that patients travel all the time from many parts of the country, such as some represented at the meeting today like Cavan and Monaghan. Two friends of my wife from Cavan, who had breast cancer, received treatment in the Mater Hospital and chemotherapy in Cavan and they have no complaint about the care they received. They have done very well. There is an acceptance in those communities of the need to travel but that acceptance is obviously not widespread.

With regard to a stand alone or specialised unit for adolescent cancer, clearly, the results are much better from a specialised adolescent cancer unit. Does Professor Keane have a budget?

Professor Tom Keane

For such a unit?

For the entire strategy.

Professor Tom Keane

I have a budget for the entire strategy, at least for the first year of that strategy. The things I will spend money on have been identified but a significant amount of the resources I described earlier will have to be mobilised to fully establish the cancer centres of excellence. We said we would try to get 90% of initial diagnosis and treatment into a cancer centre in two years. Some 60% to 70% of lung cancer surgery is already happening in big centres. The really different cases are breast and colon cancer. They are widely dispersed but are the two commonest cancers for which results, currently, are not as good as they should be in Ireland.

What about adolescent units?

Professor Tom Keane

I have become aware of a proposal in Our Lady's children's hospital, Crumlin, for the creation of an adolescent centre, on which there has been much dialogue and lobbying. I support the concept but have not yet met the people and only recently came across the correspondence from the protagonists. Such a centre has been established in many other jurisdictions and it is clearly helpful to provide a special environment for people aged 16 years, who are no longer children but are not yet adults. I do not know whether that environment needs to be uniquely for cancer or whether all 16 year old patients should have a teenage environment in which to be managed.

Has a benchmark been set for the time between diagnosis and the beginning of treatment? There was a highly publicised case recently.

Professor Tom Keane

This concerns colonoscopy. The Susie Long case to which the Deputy refers was totally unacceptable. At a meeting with some of the experts in this field I asked them to give me an understanding of what needed to be done to ensure there was no recurrence. As in many countries, including British Columbia, there are what one individual described as the "worried well", namely, people with mild symptoms who queue up for a colonoscopy, despite there being others with more worrisome symptoms of colon cancer.

There is a mechanism in place for an urgent referral through general practitioners but it depends on the GP identifying the patient, as is the case in respect of symptomatic breast cancer, as someone who is at a higher risk than someone with minor symptoms who is looking for a colonoscopy to be reassured. It is an issue of streamlining the triage process in order that the people put at the head of the queue are those with significant worrisome symptoms rather than those with less serious symptoms. Recommendations have been made, but referrals are small, in many cases scribbled notes from family doctors.

They are not followed up.

Professor Tom Keane

They do not give staff in the triage unit any indication of whether the case is urgent. I have stated we will try to move on this issue during the next year to ensure the quality of information received by the referral unit will allow it to match the patient with an urgent appointment, if necessary. It works well in respect of breast cancer checks, but I do not know why it has not worked as well in respect of colon checks.

It is time to move on. To let members know where they stand, as they may be worried about having a chance to get back into the discussion, Professor Keane has kindly agreed to stay for another 15 or 20 minutes. The next members to be called upon to speak are Deputy Conlon, Senators Prendergast and Mary White, Deputy Blaney and Senator Fitzgerald. Senator Feeney will speak after Senator Prendergast. The non-members who will be called upon to speak are Deputies Ring, Ó Caoláin, Calleary and Chris Andrews. Deputies Reilly and Flynn have two questions outstanding. I will move as quickly as I can and ask members to try to get as much in as possible.

I welcome Professor Keane and Mr. O'Brien. From personal family experience, the service is good, once one enters the system. However, I am concerned by the length of time between one's GP visit, being diagnosed in hospital and having surgery. I welcome Professor Keane's opinion in this regard.

The travel issue cannot be trivialised. Those of us living in Monaghan must travel, as was rightly stated. If a family member was diagnosed with cancer, one would go to the moon if one thought it offered the best available treatment. There is no dispute about this. For those of us living in remote and isolated rural areas in the north west where the scenario is changing, the travel issue is significant. The resources of the North West Hospice, Cavan-Monaghan Hospice and so on are stretched to the limit. Extra resources and transport services must be considered. When someone is diagnosed with cancer, the location of and how treatment will be accessed should not be at issue or affect the outcome.

Professor Tom Keane

I agree, as travel should not be a barrier to accessing care. We will do whatever must be done to mitigate the effect of travel as a barrier. There is an issue between travel and convenience, in terms of, for example, the hardship experienced by someone who is unwell. In respect of cancer surgery, many patients are reasonably well. They are not terminally ill patients being referred to centres of excellence. Rather, they are patients who have walked in off the street and had breast lumps or colon cancer diagnosed. The Deputy mentioned hospice care. I did not quite understand--

What I am talking about is fund-raising--

Professor Tom Keane

For the hospice.

Yes, to help people access treatment.

Professor Tom Keane

Palliative and hospice care is a feature of the Canadian system. Obviously, hospice care should be provided as close to home as possible. There is a significant number of requests in the pipeline for the expansion of palliative care facilities. Palliative care is not currently identified within the cancer portfolio. I am not saying it will not be included but I have not had dialogue within the HSE as to whether it will come under the cancer programme. About 90% of palliative care patients are cancer patients; a small number of them are not. I cannot comment on what palliative services are like but clearly they are very important in providing ongoing care.

In respect of early diagnosis, the time between when a patient visits his or her GP and when he or she receives his or her diagnosis of cancer is problematic everywhere in the world. Clearly, public education is one piece. Education for family doctors to enable them to recognise symptoms of cancer is another. In British Columbia we have had a superb programme of educating dentists to recognise oral cancer because who looks in people's mouths more than dentists? Unfortunately, as the people who develop oral cancer tend not to go to dentists, it has not necessarily produced the results we expected. Early diagnosis is an educational issue.

In my area where I treated cases of head and neck cancer I saw patients with cancer of the throat who had been on five different courses of antibiotics for three or four months before they finally took themselves off to see a specialist. There is an issue around how we educate family doctors about the signs and symptoms of cancer and create a resource within the community which can be the first port of call, which need not necessarily be physicians; it could be nurse practitioners or nurses.

I had a meeting earlier this week with two individuals representing the All Ireland Cancer Foundation who were interested in funding a men's clinic for the early diagnosis of prostate cancer. This proposal has considerable merit in trying to move the sides of the gap described by the Deputy closer together. The issue of early diagnosis is not easily addressed. It is an enormous issue that needs to move beyond the hospital because it must be dealt with in the community.

Professor Keane is obviously aware of the difficulties we had in recent times in respect of breast cancer. Many women recognise that BreastCheck is a centre of excellence and would have faith and confidence in it. Is it part of Professor Keane's remit to see that the BreastCheck programme is rolled out to all parts of the country as soon as possible? In respect of preventive measures to reduce cancer, is it also part of Professor Keane's remit to look at the delivery of a vaccine for cervical cancer, which would go some way towards preventing this cancer?

Professor Tom Keane

My colleague, Mr. Tony O'Brien, has responsibility for both BreastCheck and the cervical cancer screening programme. It is envisaged that both programmes will come within the national cancer programme next year. They are being very ably led and have been very successful.

The BreastCheck programme is better than the breast programme in British Columbia, as we recognised when several people from the cancer agency visited Ireland last year. Although it was late starting, it is truly excellent. The roll-out to the remaining areas--

Mr. Tony O’Brien

The west and south.

Professor Tom Keane

I believe the roll-out has started in the south and west. I am not sure what the final completion date will be.

We should look at extending the programme because, as Professor Keane rightly says, we are talking about older people being diagnosed. As somebody with a family member in receipt of follow-up treatment, I was alarmed to hear this may no longer--

Professor Tom Keane

Follow-up treatment or just follow-up?

How long in British Columbia would Professor Keane chart a patient's progress following surgery, radiation or chemotherapy?

Professor Tom Keane

I will take breast cancer as an example. Many studies show that routine follow-up of patients who complete their recommended protocol of treatment does not improve survival. Patients are discharged to their family doctors and can re-enter the system at any time without delay if they have a problem and they do so. Only a small fraction of people re-enter the system as the majority of them are cured.

To have patients travel hundreds of miles for a follow-up visit that takes ten minutes, especially when we know this does not produce any survival benefit, creates an unfair dependency on the system and unfair cost and travel on the patient. It also dislocates the family doctor from participating in the ongoing care of the patient. We have a very strong programme in British Columbia which ensures patients only return to the cancer centres if it can be clearly demonstrated that we have services which they need to access on a continuing basis. Clearly, people who have recurring cancers or ongoing problems require continued care. I am speaking about people who have completed treatment. These people are referred back to their local doctors and do not continue to attend the cancer centre unless in respect of testicular cancer, head and neck cancer or cervical cancer for which careful examination might detect an early recurrence.

I extend a warm welcome to both gentlemen. I support Deputy Conlon's comments in respect of cervical vaccines which would be a welcome development.

Currently, BreastCheck is available to people aged between 50 and 64 years. I would welcome an extension of the service to people beyond 64 years of age. I do not believe cancer knows age. It was stated in respect of the plan that, based on work to date, it is envisaged that three services and two functions should be transferred during the transition phase. Perhaps Professor Keane would elaborate on this.

Professor Tom Keane

The three services are a cancer registry, with its own board, to be located in Cork. This is currently a function of the Department of the Health and Children. It would be very unusual to have a national cancer programme which did not have the registry located at the centre of the programme. This is not particularly controversial. As is the case in every country that has a cancer control programme, cancer screening will be part of Ireland's cancer control programme. This is why that recommendation is included.

In terms of radiation therapy services, about which I know a great deal, the plan is to establish a national programme which will integrate the radiation therapy services currently administered across six sites.

On financial control and workforce issues, obviously we will have to extract from the HSE envelope the workforce for cancer to come under the issue pre-cancer. I spent some time earlier identifying the financial resources associated with the cancer programme currently embedded within the HSE. I will ask my colleague, Mr. Tony O'Brien, to respond on the question relating to cervical vaccines as I have not been part of the discussion here.

Mr. Tony O’Brien

On cervical screening and cervical vaccines, a national cervical screening programme will be launched next year for all women aged 25 to 60. As part of the preparation in this regard, the national cancer screening service and the national immunisation advisory committee have commissioned a health technology assessment of the HPV vaccine from the Health Information and Quality Authority. This assessment, which is expected next February, will provide the basis for advice to the Minister. It will then be a matter for policy decision at ministerial level as to whether there will be a HPV vaccination programme and the extent of such a programme.

In regard to BreastCheck, screening commenced in the west from a static unit last week and prior to that in County Roscommon from a mobile unit, and in the south last week. It will take approximately 25 to 27 months for the first round of screening for women aged 50 to 64 years to be completed. It has been generally indicated that once it has been completed, screening will be open to an increase in age range up to the age of 70 years. Some preparatory work has already begun in that regard. There is significant medical evidence to show that the first priority should be to complete one full round of screening for women aged 50 to 64 years before increasing the age range.

When will it be available to those living in the south Tipperary and Waterford areas? Will it be in mobile units from Cork?

Mr. Tony O’Brien

All areas distant from the static units in Galway and Cork will be served by mobile units on a cyclical basis. We are not in a position at this stage to indicate the sequence by which persons in each county will be screened. However, we intend to cover the full screening area within 27 months. That will provide the basis for a repeat cycle of screening at two-yearly intervals.

I welcome Professor Tom Keane and Mr. Tony O'Brien. I congratulate Professor Keane who is a brave man. I read a profile a couple of weeks ago in one of the Sunday newspapers and somebody who had been asked whether Professor Keane was the Messiah, the magician who could put matters right, responded that it had to be borne in mind that this was a process, not an event. The presentation of the strategy this morning leaves us in no doubt that this is a process which will take time to complete.

As with everything else, politics is involved and, sadly, I intend to be parochial. Like other members, I come from the north west. I was interested to hear that Professor Keane, although he did not use the word "vacuum", was of the view that there was a vacuum in regard to radiotherapy and other services in the north west.

Professor Tom Keane

Particularly radiotherapy.

Professor Keane supports the establishment of eight specialist centres. There is no one here who does not support such a move. However, there is a case to be made for the establishment of networks. Again, I come back to County Donegal. Why County Donegal when it is a two and a half hour journey from Sligo to Galway or from Sligo to Dublin? There is probably much better road infrastructure in British Columbia. Some critics also say that in British Columbia there are five, nearly six, specialist cancer centres not attached to a general hospital.

Professor Tom Keane

They are all attached to general hospitals.

I am sorry, a doctor friend of mine put it to me that they were not.

Professor Tom Keane

They are all attached. That is part of the focus. The general hospital in Vancouver is co-located, to use the Irish term, with a large tertiary general hospital.

Professor Tom Keane

The other centres are all located on a site similar to a large regional hospital where the cancer surgery takes place.

We in Sligo have been told Professor Keane will come and visit Sligo General Hospital. Does he intend to do so?

Professor Tom Keane

I have had a meeting with the Minister of State, Deputy Devins, in that regard. I told him I would be happy to do so. It was suggested in the media that if I went to Sligo, I would have a conversion and change my mind. It is not the case that I believe there is not a good surgeon there. This is a systems issue.

Has Professor Keane spoken to him?

Professor Tom Keane

I have. The focus of our discussion was that he wanted to be sure that in the transition there would be no gaps for patients in County Sligo. He wanted an assurance that we would be able to provide access to services in Galway. I offered him that assurance. My discussion with him was not in the context of trying to change the decision that was made. I want to understand the services that will remain in place and issues that arise in this regard. However, I have made clear that my attending Sligo or Castlebar hospitals or, any centre in the country, will not be in the context of continuous negotiation or discussion on altering the strategy or decisions made. I hope, in the fullness of time, to visit Tralee hospital and I have been invited to visit a number of other hospitals. I have done nothing but meet people for the past three weeks. I want to understand on a broader scale what is happening in the communities in respect of patient journeys and not this one controversial issue. There are many other aspects of the cancer strategy.

I recognise and understand that.

Professor Tom Keane

I do not want to create the impression that if I visit Galway hospital, Sligo General Hospital or Castlebar hospital that it is a prelude to or signal that I am considering a change in policy as has already been stated. I want to put on the record today that I am happy to make these visits but not in the context of a discussion in respect of policy change.

I am sorry to hear that. Rightly or wrongly, the impression has been created that Professor Keane will visit Sligo General Hospital and that an independent clinical audit would be carried out. The numbers for Sligo in terms of breast cancer in particular are quite high. During discussions on numbers in respect of qualification for a specialist centre, I noted that numbers had to be between 100 and 150. However, I do not wish to get into the numbers game at this point.

Professor Keane stated that the north west is an area out on its own. This area, which is between Dublin and Galway is bereft of services. BreastCheck has not yet been rolled out in this area. Is there any way a radiotherapy unit, be it satellite or otherwise, could be located in this region?

Professor Tom Keane

I have great respect for Mr. Donal Hollywood who for several years authored the radiotherapy report published in 2004. That proposal limited the development of radiotherapy to four major centres and two satellites located in Waterford and Limerick. I am happy to be educated about trying to access a radiotherapy unit were one to be constructed in Derry. Single machine satellites are not an option. This issue has been debated in Canada for many years. The minimum size for a centre is two linear accelerators which is enough to treat approximately 1,000 patients per annum, way in excess of the workload for the north west. I do not wish to get into numbers either, but there are strong reasons for the recommendations in respect of radiotherapy.

I have agreed to meet early in the new year with an action group from Donegal to hear its views.

Professor Keane mentioned he met with the RCSI and that it is fully on board with him. What about the Royal College of Physicians of Ireland, RCPI?

Professor Tom Keane

I will meet with a delegation from the Royal College of Physicians of Ireland and the Irish College of General Practitioners.

Is Professor Keane aware of the RCPI's position in regard to the centres?

Professor Tom Keane

I have not received any correspondence from it.

I am open to correction if I am wrong but two or three weeks ago the Royal College of Physicians--

Professor Tom Keane

I believe a long statement was issued and that within that statement reservations were expressed.

It dealt with the whole northern part of the country be it west or east of the centres.

Professor Tom Keane

I recognise the concern that exists will not go away. As Senator Feeney stated it is an issue for the community there. However, the issue does not relate to cancer services only but to all health care services.

I ask that Professor Keane gives serious consideration to the issue of transport. Half the country must travel, whether for surgery or radiotherapy, and it is not acceptable. We are the poor relation.

Professor Tom Keane

I heard the message today very clearly that transport is an issue. I take it to heart.

I thank Professor Keane and Mr. O'Brien for coming to this meeting. It is a pity the rest of the country has not had the opportunity to hear Professor Keane today. I have been educated on the subject of centres of excellence. Everyone, including myself, suffers from fear and ignorance with regard to cancer. Anyone who heard Professor Keane speak this morning can have confidence in the future of the system.

I produced a document on a new approach to ageing and ageism. Professor Des O'Neill, who is consultant geriatrician in Tallaght Hospital, told me that women between 55 and 75 are more prone to breast cancer than other age groups. Did I understand Professor Keane to say that the system in Canada is public?

Professor Tom Keane

It is an entirely public system. We have no private medicine.

I believe it is because of ageism that BreastCheck is not made available to women over 65. This is wrong. I would like to hear Professor Keane's view on this.

The Government walked a very tricky political tightrope in abolishing smoking in public places. However, the measure has been very successful and is a proud achievement by the Government. Professor Keane referred to prevention. Are measures such as the abolition of smoking part of his remit? Are there other areas where politicians could promote measures to help prevent cancer? The promotion of exercise and good diet has reduced the incidence of heart disease in the United States. What can we do in Ireland to prevent cancer?

Professor Tom Keane

As Mr. Tony O'Brien said, the intention is to extend the BreastCheck programme.

That is merely an aspiration.

Professor Tom Keane

No, I believe there is a plan to extend the programme. Mr. O'Brien can speak about that issue.

Whenever I telephone to inquire about the extension of BreastCheck, I am told no timetable has been drawn up and the extension is a mere aspiration.

Professor Tom Keane

It is my understanding that the programme will be extended and I support that extension.

Can Professor Keane say that loud and clear? Can he please say it again?

Professor Tom Keane

I will say it again for Senator White. The programme should be extended and I believe it will be extended.

Go raibh míle maith agat. I thank Professor Keane.

Professor Tom Keane

Prevention is a public health issue. Cancer is genetically driven. That is not to say it is inherited but one is more likely to get cancer as one ages. The mutagents that cause cancer are well understood. Interventions such as reducing fat in the diet are common to many diseases. Therefore, in Canada the strategy is not uniquely under the cancer agency. We have had a coalition of interest groups including the heart and stroke society and the cancer agency which work towards a single public health strategy for healthy lifestyle. Rather than say it is an anti-cancer strategy we promote a healthy lifestyle. That is already happening in Ireland and it is the solution. I do not believe there should be a separate strategy for cancer. There should be a public health strategy for healthy living which will affect cancer, cardiovascular disease, diabetes, obesity and other diseases. Such a strategy will bring several health benefits. It should not come under the umbrella of the cancer programme.

We are aware that exercise and diet reduce the possibility of stroke or heart attack. Is the position the same in respect of cancer?

Professor Tom Keane

It is well recognised that people who are overweight have a higher risk of contracting cancer. If one's diet is high in fat, one is much more likely to contract colon or breast cancer. One of the reasons the incidence of these cancers in Ireland is high concerns the high animal fat content in people's diets. Women in Japan have a low fat diet and the incidence of breast cancer among them is very low. There are facts relating to diet that are well known and understood.

I intend to bring these proceedings to a rapid conclusion. I ask Deputy Blaney to limit himself to two questions.

I welcome our guests. There is no doubt that Professor Keane has a tough job ahead of him. We created the difficulties relating to travel when we announced the establishment of centres of excellence. Before the strategy was announced, people accepted that services could not be provided on their doorstep. The travel issue arose because, under the strategy, people in the south are well catered for and most will only be obliged to make 90 minute or two-hour journeys in order to reach one of the centres. Everything north of the Galway-Dublin line has been ignored. That is why travel has become a matter of such debate.

Patients from Inishowen in County Donegal are obliged to leave their homes at 4 a.m. or 5 a.m. in order to catch a bus in Letterkenny and travel to Dublin for treatment. That is crazy. I will not detract from the arguments in respect of Sligo and Monaghan because they represent the halfway points on people's journey south. We have a serious problem and I accept what Professor Keane is trying to do regarding the establishment of a cross-Border arrangement in respect of Derry. However, he is going to encounter major problems, particularly in encouraging consultants to agree a framework to allow them to work on a cross-Border basis. Difficulties will also arise regarding different procedures, the prescription of drugs, etc., and I do not want County Donegal to lose out as a result.

Does Professor Keane agree Dublin does not need three or four centres and that it would be much better to provide one proper centre?

Professor Tom Keane

Consolidation is occurring in Dublin. St. Vincent's Hospital and the Mater Hospital have come together under a single programme - the Dublin medical centre. In addition, St. James's Hospital and Tallaght Hospital - although the latter is not a designated centre - are also coming together. In the long term there will be a consolidation of hospital care in Dublin. This consolidation is long overdue and I expect that it will happen.

It is a matter of where the expertise is to be found. If I were asked should there be four cancer centres in Dublin, I would say no. However, the fragmented nature of hospital development has led to the current position. There is, in the light of the population to be served, a large number of teaching hospitals in Dublin. There are more teaching hospitals in this city than there are in Toronto which has a far larger population. People are obliged to work against a backdrop of history and must take account of where resources are located. Ideally - if we could wave a magic wand to make it happen - I would like there to be one or two cancer centres in Dublin. In practice, this is not an immediate option. However, I expect significant change to occur. Ten or 15 years from now, I do not believe there will be the same number of hospitals in operation in Dublin.

My final question relates to BreastCheck which initially was supposed to be introduced in County Donegal during the summer. The date was then moved to the end of the year. The Minister has indicated that the budget has been allocated. When will the BreastCheck programme be rolled out in County Donegal?

Mr. Tony O’Brien

BreastCheck's western region which is now operational covers the area from Tipperary North Riding to County Donegal. The process of screening involves a two-year cycle. This means that within the first two years screening will be offered to every woman in the eligible age range. I cannot give the committee full details of the sequence for each of those counties, but the first round of screening in the west is under way, during which every woman aged between 50 and 64 years in County Donegal will be offered screening by BreastCheck.

Will Mr. O'Brien give the committee an update as soon as he can?

Mr. Tony O’Brien

Yes.

I will take the next group which comprises Deputies Ring, Ó Caoláin, Calleary and Scanlon. Two questions from Deputy Reilly will then be finalised.

I will be very brief because I have been waiting since 11 a.m. I welcome Professor Keane. However, I am not delighted to see him because I do not believe the Government policy he is to implement in the west is the right one. I will say why and then ask a question in the hope he will reassure me. Governments have made major commitments on BreastCheck for many years but nothing has not happened. We are told it will happen in the next 18 months but we have been told this for a number of years with the result that people in the west do not believe the Government or the Health Service Executive. The Government has already made a mess of the changeover from health boards to the HSE and it worries me that Professor Keane has been appointed for two years, after which there will be a successor in the post. He will remove an excellent service from Mayo General Hospital and transfer it to Galway, where one cannot park, the facility is already overcrowded and cannot cope as it is. Professor Keane's successor will then say it was Professor Keane who did this. How can he reassure me and the people I represent such as the women who are fighting to hold onto the service which he is to dismantle? The HSE has already made a disaster of health services. Now Professor Keane is to implement a Government policy with which I disagree on account of the fact that we cannot trust the HSE. The Government has made a mess of everything in the past ten years.

I do not want to get angry because this is not Professor Keane's fault but that of the HSE. We were given commitments by it on bringing patients to hospital for appointments but it has broken its word. It has told lies to cancer patients who cannot get to existing hospitals because they cannot afford it. That is not Professor Keane's problem but mine and that of the HSE. Nobody has taken responsibility. How can Professor Keane make somebody responsible for dealing with transport problems? The HSE and the Department of Transport will not take responsibility. I am trying to get the Department of Community, Rural and Gaeltacht Affairs to be part of a group which will do something about the problem. Will Professor Keane tell me how he will work on it?

I will ask the professor to bank that question for the moment.

I join colleagues in welcoming Professor Keane and Mr. Tony O'Brien and wish them both well in their respective responsibilities. I also welcome back the Chairman who was absent for some time.

I do not want to repeat the questions asked but will pick up on some of the remarks made. I appreciate Professor Keane has a contract to implement the programme as adopted by the Government. I mean no disrespect but his responses confirm his intent in that regard and his adherence to that contract. His single word answer of no to one question demonstrated clearly that he would be an adherent to Government policy as it is rolled out. As somebody who comes from a Border county and as a representative of Cavan-Monaghan which he mentioned, I do not want him to form the view from any of his experiences that we are always happy to travel. The north west has rightly been argued for but the north east has not been mentioned and the gravitation towards this city continues. That is what this programme spells for the future for the north east.

Having listened to what he said, I will refer to Professor Keane's briefing note and, in particular, the preamble. Point 4 deals with progress on the national plan for radiation oncology, NPRO. It indicates that the national cancer control programme will work with the HSE to mitigate any perceived risks in the public private partnership to deliver the final phase of permanent radiotherapy infrastructure within the agreed timeline. Professor Keane has a limited contract period, unless he is already considering staying for longer than two years. Perhaps he is eager to get back to British Columbia, about which I would not be surprised after today and other experiences. What timeline are we referring to and does he agree with the question of the PPP? May I bundle the questions, as time is short? The PPP presents a serious problem in respect of timeframe delivery, as signalled in Professor Keane's briefing document. What are the problems from his perspective and how does he propose to address them?

In the course of Professor Keane's preamble, he made an important point about how we do not have mandatory reporting, which is the practice in other jurisdictions. I agree that mandatory reporting is essential and will be an important development for a whole raft of reasons, not just in terms of our knowledge of the incidence or clustering of cancers. What other information could it offer? Are we discussing the incidence of all cancers as people present?

Professor Keane has come from a British Columbian experience in Canada, which has been alluded to as having a single tier health care delivery system. He must now function within a seriously divided two-tier system. He referred to co-location, but the instance in Canada to which he referred is very different from the co-location that is envisaged here and that is the Minister's clear intent. There are no prizes for guessing on what side of the battle line I stand. Within the complexities of a two-tier health system that mirrors apartheid in many ways, there are difficulties in terms of ability to pay and geographic location. The latter and how it can mitigate against the interest of patients presenting is already indicating. While it may be a step too far for Professor Keane at this early stage of his contract, would it not be much easier to get on with the work were we to have a single-tier system like that in Canada? He might commend it to the system here before he departs.

I reiterate the welcomes. The current arrangement between Castlebar and Galway is for a weekly meeting between the team in Castlebar and all of the various specialists and surgeons from University College Hospital, Galway, who travel to Castlebar. Every case referred to Castlebar in a given week is discussed at the meeting and its recommendations dictate the manner in which the cases will be treated. What are the weaknesses of that system in Professor Keane's estimation?

I want to give Professor Keane an idea of how difficult it is for people to get their heads around the notion of centres of excellence or of how they blame whoever wrote the document which came up with the term "centres of excellence". In recent months, I have had four cases of oncology patients who could not get beds at UCHG because there were none available for them. Deputy Flynn has discussed the variance between tests in Castlebar and Galway and Professor Keane aspires to the latter reaching the standard of the former. Regarding the physical facilities on the hospital campus, there are not enough car parking spaces, which is just the start of the patient's journey of which Professor Keane spoke at the beginning of this meeting. Will Professor Keane guarantee that beds will be ring-fenced?

The Royal College of Surgeons referred to by Professor Keane has considerable problems with the strategy. While I welcome that he has met the college, objections were recently published in its in-house journal and there is a feeling in the surgical community that the cancer strategy was drawn up without surgical input.

Professor Keane stated that he met Mr. O'Hanrahan in Sligo, but has he met or does he intend to meet Dr. Kevin Barry in Castlebar? I am rushing my questions. Given that Professor Keane is meeting the Donegal councillors' action group, will he be available to meet other groups?

I welcome Mr. O'Brien and Professor Keane to the meeting. I fully understand that Professor Keane has a job to do and I wish him well. However, as a public representative, I also have a job to do. I respect Professor Keane's job and I hope he respects my position. I represent the constituency of Sligo-North Leitrim in the north west. I do not agree with what is being proposed for the people of that area. It is very wrong that there will not be a centre of excellence in the north west.

Professor Keane stated that there will be four centres in Dublin, but he believes two would be sufficient. We are told there could be another three privately provided cancer centres in the Dublin area. There would be seven centres in Dublin while half of the north west of Ireland would not have any centre. The people in Sligo feel a good service is provided there by Mr. Tim O'Hanrahan. The people in that area are the judges. There should be an audit of the services provided in Sligo General Hospital. It is the least the people of the northwest deserve and I ask Professor Keane to consider that.

Those are all of the questions. I will ask Professor Keane to take into consideration the question asked by Deputy Reilly and where we left off with Deputy Flynn.

Professor Tom Keane

Does the Chairman want me to take all those questions now?

Yes, if you could. I know I really stretched this for you.

Professor Keane

I could spend a large amount of time speaking on public private partnerships but I will not. Clearly, there are complex issues around PPPs which relate to Government policy on which I will not comment.

Mandatory reporting should be required in Ireland. I do not see that this should be a significant issue and I will bring it forward as a recommendation.

In respect of the two-tier health care system, I agree that I have come from a system that is publicly funded. It is under tremendous pressure but I am still a believer in public health care. I also recognise that many countries other than Ireland have excellent cancer systems that are two tiers. I do not believe that a two tier health care system is, essentially, a barrier to having good cancer care in a dual system. I am playing the cards as I find them and will do the best I can. Clearly, it would be simpler if one had just a single tier. However, that will not happen so I must work with what I have.

Did Deputy Ó Caoláin ask me something about the timeframe for the delivery of the PPP?

Professor Keane alluded to the difficulties in the PPP process.

Professor Tom Keane

PPPs are complex. I have done a PPP for a cancer centre in British Columbia. It was a learning experience. Economically, it turned out to be better. There was considerable controversy in British Columbia around the use of PPPs but in that case, this cancer centre was built six months ahead of schedule and, basically, was under budget. From my limited experience of the PPP arrangement, I cannot say that it did not work. It is a more complex process.

I will take the questions about Castlebar and Sligo together. I received mail about Sligo becoming a ninth centre of excellence. What must be understood is that a cancer centre is more than a centre that just treats two diseases. Essentially, the only cancers that are primarily managed surgically in Sligo and Castlebar are colon and breast cancer. There is no expertise in a whole range of other cancers nor is there likely to be. We are talking about services for particular subsets of patients rather than the integrated service of a whole cancer centre. Both Castlebar and Sligo have something between 1% and 2% of the cancer incidence in Ireland. One cannot build a cancer centre around that small percentage. The model does not fit that. I accept people will say that does not make sense to them. However, I and others have concerns about this matter. As I understand it, Mr. Tim O'Hanrahan is the only surgeon in Sligo General Hospital doing breast cancer surgery and Mr. Kevin Barry performs all the breast cancer surgery in Castlebar. The availability of only a single resource is not what I would call a robust system. I am not criticising Mr. Kevin Barry or the surgery performed or care provided at Castlebar hospital, I am simply saying the system does not have the critical mass necessary to provide all the benefits of a full cancer centre. In repeatedly saying this, I am recognising that the system rather than individuals is at issue. I make no criticism of these individuals who provide excellent care.

What about the--

On a point of information, this is not about a cancer centre. We never wanted--

Professor Tom Keane

The strategy is about a cancer centre.

Yes, but we never asked for a cancer centre in Castlebar. That was never on the agenda. We want to be part of--

Professor Tom Keane

I was quoting Sligo.

Yes, but Professor Keane also mentioned Castlebar. We want to be part of the Galway centre of excellence as part of a managed cancer network. That is a critical point. Professor Keane is correct that Mr. Kevin Barry performs all the breast surgery in Castlebar. However, he also carries out surgery in Galway. Mr. Ray McLaughlin, the consultant from Galway has a sessional commitment to Mayo General Hospital. Currently, we are sharing pathologists and medical oncologists. I ask that Professor Keane consider the following. If our consultant attends the multidisciplinary team meeting in Galway and discusses his case with the full team and does everything within the guidelines set out for the Galway centre of excellence, why can he not operate in Castlebar?

Professor Tom Keane

We have covered this ground many times today. The decision has been made. I am not saying it was the only option but a decision was made following consideration. I am not going to change that decision.

Can Professor Keane explain it to me?

Professor Tom Keane

No. A decision has been made. I am not saying alternative models do not exist but a decision was made to opt for a cancer centre model. I never said that alternative models could not exist but they have risk associated with them in terms of critical mass. Deputy Flynn is speaking about the provision of breast services in Castlebar.

Absolutely. It is part of an overall service.

Professor Tom Keane

I am speaking about a cancer centre model and that is where we differ.

I am saying we want to be part of the full cancer centre. We never asked that everything be done in Castlebar. We never expected that, we are realistic.

Professor Tom Keane

I have stated my position. I am quite happy to listen but I will not change the decision.

Professor Keane has accepted the Government's position on this.

I asked earlier if Professor Keane will visit all the centres that currently carry out cancer care before they are closed?

Professor Tom Keane

I already stated that they are not being closed and will not be closed until such time as the service is available. Deputy Reilly may not have been in the room at the time, but I stated earlier that, as discussed with the Minister of State, Deputy Devins, I will not visit those centres in the context of it being a prelude to the decision being changed. I am happy to go down so that I would understand the many aspects of care that will continue in that community, but the premise that was put out, that if I visited these centres the decision would be changed, will not happen.

May I say for clarity - I hope this is what Professor Keane is saying - that there will be no further loss of service in any community until the new services are up and running?

Professor Tom Keane

I want to ensure there is no deterioration in service over what currently exists.

May I ask a supplementary question?

The Deputy must be brief as Professor Keane should have left 45 minutes ago.

The cancer control strategy states that the director of cancer control will provide incentives for care to be provided through the cancer centres while applying financial disincentives to smaller facilities which are not designed as cancer centres to ensure that care does transfer to the dedicated centres. What financial incentives and disincentives will be applied?

Professor Tom Keane

I cannot answer that question right now as I have not yet considered what they should or should not be. The incentives for staffing will be related to trying to encourage people to meet a standard. Disincentives are designed to discourage continuation of a standard of care that does not meet a national standard. There are many ways in which that can happen.

I thank Professor Tom Keane and Mr. Tony O'Brien for the three hours they have spent here today. We look forward to meeting them again in the next quarter and thank them for their clear presentation and answering all of the questions asked.

The joint committee adjourned at 1.45 p.m. until 3 p.m. on Tuesday, 15 January 2008.
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