Cancer Services: Discussion with HSE.

I extend a warm welcome to Professor Tom Keane, interim director, national cancer control programme, and Mr. Tony O'Brien, deputy director. Before we begin, I draw attention to the fact that while members of the joint committee have absolute privilege, the same privilege does not extend to witnesses appearing before the committee. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable. I call Professor Keane who is familiar with the system in place here to make a presentation which will be followed by a round of questions from members. We will return to Professor Keane to conclude. We congratulate the delegates on the superb work they are doing throughout the country.

Professor Tom Keane

I have provided the joint committee with a progress report which I do not intend to go through in detail. It is 23 months since I sat in this room. That was an intimidating experience, particularly in the context of that to which I had been previously used. It remains an intimidating experience but perhaps I have learned to live with the understanding that the cancer control programme must be publicly accountable for everything it does.

I wish to make a number of general remarks on where the cancer control programme currently stands compared to where it was 23 months ago. There is a major difference with regard to the public's understanding of the need for such a programme. Despite a great deal of the controversy that has surrounded the transfer of breast cancer, surgical and diagnostic services and the other controversies associated with the misdiagnoses of cancer, there is a realisation among members of the public that centralised cancer services make sense and that in the modern environment it is simply not possible to provide high quality, multidisciplinary cancer care in 33 or 34 hospitals across the State.

We took on breast cancer because it represented a huge challenge. We identified it as the first area in which we would attempt to centralise services. As the report outlines, we are close to completing the plan to bring breast cancer services into eight cancer centres, plus the satellite unit in Letterkenny. The amalgamation of the South Infirmary Hospital's symptomatic programme with the CUH programme will formally proceed when the brand new ambulatory care cancer centre at CUH opens in early December.

While we have been transferring the service, we have also been building the system. Significant challenges arose at some of the centres, particularly in the context of the recruitment of key personnel such as radiologists, pathologists and, in some cases, breast surgeons. Despite this, we are close to having in place the full complement of staffing that we need. There has been one extremely significant change which, perhaps, reflects public anxiety in respect of breast cancer. I refer to the fact that the number of women being referred to symptomatic breast services has increased by 50% during the past two years. This has placed a significant strain on the system.

We carried out some analysis of what has occurred — this is summarised in the report — and, in essence, what we have seen is a massive increase in the number of what one might term "worried women" or "worried GPs". The latter are referring to the symptomatic service women who do not have breast lumps but who have vague symptoms of breast pain or who are extremely anxious about the possibility of breast cancer. The symptomatic service was originally envisaged by Professor Niall O'Higgins as one which would deal with women who had a relatively high risk of breast cancer. At the time the best risk estimate available was that for every ten women referred to the symptomatic breast clinic, one would have breast cancer. The national average has increased to 15 women seen for every one case of breast cancer diagnosed and at some centres as many as 29 patients are being seen for every one diagnosis.

Two populations are now attending the clinic, the first of which comprises those who form part of the original high risk population of women with breast lumps. These women still have a one in ten chance of having breast cancer. The second population which constitutes 60% to 70% of the total number of women referred comprises women whose risk of breast cancer is ten times lower than their counterparts in the high risk group. Those in the low risk group who are referred to as routine referrals have the same risk of breast cancer as women who would be referred to a screening service. I highlight this because it is a massive change which we did not anticipate. It probably reflects the anxiety of women and GPs. Both are seeking reassurance with regard to breast cancer. However, this development is not something the service was originally designed to support. We are considering how we are going to address it.

Details on the performance of the breast cancer service are regularly provided in the monthly reports from the HSE. We have encountered the odd blip at centres where temporary staffing issues have arisen. As of September, however, 95% of urgent cases are being seen within the two-week standard. The figure in respect of lower risk women being seen is 82%. It has sometimes been difficult to meet the standard but we have reached a point at which matters are reasonably stable. There is a concern that the continued growth in the number of non-urgent patients would have the potential to put pressure on the clinic to manage its urgent patient population. This is another matter we are trying to address.

It is somewhat paradoxical that if a patient wishes to have a mammogram and approaches her GP in that regard, if she is in the age group to which BreastCheck relates, she can access a mammogram through the symptomatic service — essentially on demand — within 12 weeks, whereas under BreastCheck, she would be on a two-year cycle. An issue arises with regard to the target population and whether the symptomatic breast service is meeting its original mandate. That mandate has expanded.

While all the attention has been on breast cancer, there has been a great deal of progress elsewhere. We are halfway through establishing rapid access clinics for the diagnosis of lung and prostate cancer. Everyone present will understand that late diagnosis and late referral are major issues in the Irish system. We have had dialogue and tremendous interaction with general practitioners and are aware that their concern relates to access to diagnosis, particularly in respect of lung and prostate cancer. This is not universally the case and in some parts of the country access is very good. However, in other parts, particularly the west, access to diagnosis for prostate cancer is far below what it needs to be.

The rapid access clinics are intended to provide GPs with the opportunity to refer patients who present with certain high risk features directly to cancer centres for diagnosis and, ultimately, to be linked with a multidisciplinary team if a diagnosis is forthcoming. It is very similar to the breast cancer model. Four such centres will be open by the end of the year and the other four will, as originally planned, open in the first six months of next year. There has been an issue in respect of lead-in times in the context of the ability to recruit the necessary staff. However, matters are moving ahead reasonably well.

The area which receives little attention is that of progress relating to the national plan for radiation oncology. I am happy to report that the new centre which will be operated on the St. James's Hospital site by the cancer control programme will open in November of 2010 as planned. Construction will be completed in May and four radiotherapy machines will be commissioned on the site by November. We are running slightly behind in respect of the Beaumont Hospital site by approximately six to eight weeks. We may be able to catch up on the construction schedule. By either December 2010 or possibly January 2011, however, the second centre will be up and running. As members are aware, the latter is associated with the first phase of the transfer of the workload from St. Luke's Hospital.

The long-term plan was approved by the Government in 2005. Under this plan, the infrastructure for radiotherapy services nationally will be supported over a much longer timeframe.

That relates to a national network of radiotherapy facilities to be maintained, supported and renewed over a 25-year period through a public private partnership funded infrastructure proposal. We are very close to the point of procurement, which will be done through the National Development Finance Agency. The final benchmarking of the PPP project and final approval from the Government is expected in the next couple of months.

I referred to the centralisation of rectal cancer surgery and pancreatic surgery, which are the next two surgeries to be centralised. In this case, we have significant support from the surgical community which is focused on rectal cancer. Rectal cancer is a terrible disease and if the surgery is not done correctly, one's chances of cure are permanently compromised. To that end, we wanted to ascertain how we were faring with rectal cancer in Ireland and, with the help of the Royal College of Surgeons in Ireland and the National Cancer Registry, we performed an audit of all patients treated in Ireland in 2007. What this audit revealed was generally perceived by everyone to be unacceptable in that a huge number of surgeons were operating on very small numbers of cases. We found that 58 general surgeons, some of whom were rectal cancer trained, operated on five cases or less in the year and that 17 surgeons operated on one case each.

Consequently, I met the Irish Society of Coloproctology. While originally I had hoped to move rectal cancer surgery into just four hospitals, its representatives suggested it would be more reasonable to try to accommodate such surgery in eight hospitals and the plan is to proceed with that in two phases. All the smaller hospitals will cease performing rectal surgery as of 1 January and we will be left with 13 hospitals. We then will go from 13 hospitals to eight hospitals some time later in the year, when we are satisfied the capacity is present. As for pancreatic surgery, we plan to centralise all pancreatic cancer surgery, which arguably is the most challenging of all cancer surgeries, in a single hospital in Dublin, namely, St. Vincent's Hospital. This will mean that pancreatic surgery, which is performed in five hospitals at present, will be performed in four hospitals and there will be a resource reallocation to support this.

Those comments relate to what I call acute care surgical focus and radiotherapy. A huge thrust that does not get much public attention has pertained to the development of community oncology services. When I appeared before the joint committee previously, I identified the anomalous nature of the Irish cancer system, which is largely hospital based when compared to many other countries, where it is far more community based. We have made great progress working with the Irish College of General Practitioners, ICGP, and primary care teams across the country. Moreover, Dr. Marie Laffoy has built an excellent team of people who are engaged to develop the capacity within the community system to better manage cancer in the community. In particular, through surveys and dialogue, we have identified that general practitioners are anxious to be involved in cancer care. However, to a large extent they have been excluded over many years and therefore are anxious to have skill sets and understandings regarding what they should do. A huge amount of work is ongoing in respect of the development of referral pathways and the education and training of general practitioners and their staff on appropriate referral regarding the ongoing follow-up of cancer patients outside the hospital setting.

While this is low-level activity that is off the radar, it is perhaps the most significant change that the cancer programme will effect over the long term. It will be very good for patients and the evidence from other countries is that for many cancer patients, albeit not for all, once they have their interventions done they can be followed perfectly safely and happily in their own community by family doctors, nurses who have been trained to provide that care, or both. Patients seek reassurance that were anything to happen, they would be able to get back into the cancer programme in the hospital setting. We will give them that reassurance. One reason that people continue to return to a hospital for follow-ups for 15 or 20 years is that there is a great fear that were they to leave the hospital setting, they might not be able to get back in. We must provide that reassurance for people.

The report contains some notes on the integration of both the National Cancer Registry and the National Cancer Screening Service, neither of which is part of the HSE. Legislation has progressed to provide for the transfer of the National Cancer Screening Service and we simply await the passage of the health information Bill to facilitate the transfer of the National Cancer Registry into the cancer programme. These will be two highly important milestones. As for the functioning of the cancer programme within the HSE, at its last meeting the HSE's board confirmed that on foot of the organisation's restructuring, the cancer programme will remain as a separate business unit with the head of the cancer control programme reporting directly to the chief executive officer of the HSE. It is incredibly important that the profile of the cancer programme is maintained and that it is seen to be accountable and delivering on its mandate within the HSE and for the public at large. While a great number of issues pertaining to developing the business side of the cancer programme within the HSE remain outstanding, I am happy to state that with regard to the financial infrastructure and many other issues, there now is a clear commitment to create around the cancer programme the functionality to run cancer as a business within the HSE as a health care organisation.

I now will turn to my own position. Members will recall that I was seconded here for two years. Although it seems like two months, my time will be up at the end of November. To be fair, my employer, the British Columbia Cancer Agency, agreed to my secondment with a clear understanding that it was for two years, not for three or four years. Perhaps more important, I am a tenured professor at the University of British Columbia, from which I am on leave of absence for two years. Understandably, the university wishes to know whether I will return as planned. I am in discussion with my employers in British Columbia and with the university. I will return there in November to have some meetings with the expectation that, hopefully, they will agree to allow me to remain on for a period of months to facilitate the recruitment of a permanent director, for which I will provide support to the HSE. I am hopeful that I may be able to bridge that period when a new director is being recruited, and hopefully appointed, so that there will be continuity for the programme leadership. I will end at that and I thank members.

I thank Professor Keane. Does Mr. O'Brien wish to make a contribution at this stage?

Mr. Tony O’Brien

No.

I welcome Professor Keane and Mr. O'Brien. Notwithstanding Professor Keane's earlier comments about being intimidated, it was refreshing to see the two witnesses come before the committee without a flotilla of backers, which is a sight to which members normally are accustomed. No doubt it is to lull members into a false sense of security.

Joking aside, I thank Professor Keane for his presentation. While there has been much improvement, there still are some concerns. In particular and before "Councillor" O'Connor comes in, I will mention Tallaght hospital, whose services are being transferred to St. Vincent's hospital. However, many of the patients who should be going to St Vincent's hospital are heading off to the private sector, that is, to the Beacon Consultants Clinic, where one of the consultants is setting up a private service. The net effect is what members feared, that rather than centralising all our services in the four cancer centres, private centres are now emerging. There is no doubt but that the Beacon Consultants Clinic is performing such surgery and, furthermore, it is so doing on the basis of telelinks with Pittsburgh. This seems to be perfectly good for the people of Dublin South and the Beacon clinic but not for Sligo General Hospital. It was the model that was proposed for Letterkenny, I believe, to address the issue of there being no centre north of a line between Galway and Dublin.

The other issue that relates to Tallaght hospital, in particular, is pancreatic surgery. Professor Keane mentioned that it will be located in St. Vincent's hospital. There are approximately 600 cases per year, of which 200 are inoperable due to secondaries. Others might be inoperable because of other complications. The bottom line, however, is that most people with pancreatic cancer will want to go to St. Vincent's hospital to get the definitive opinion of the expert. I see Professor Keane shaking his head but even if people are told locally that they are not fit for surgery, they will seek a second opinion from the centre of excellence. That is just the reality; it is normal human behaviour. If it was me or my brother, we would do the same. The interesting aspect is that of all the surgeons we have in this country there is only one who is acknowledged by all the others to be far and away the best and of international repute. He is the only international expert we have. However, he is not moving, he is leaving the service. Will Professor Keane explain how or why a man of such international repute could become, according to what I have heard, so frustrated that he is giving up clinical practice and taking up an administrative job?

My other question is a general one but I will focus it on Tallaght hospital. What services have been transferred to Tallaght hospital to replace the services that have been removed? As Professor Keane acknowledged to the committee previously, this is what should happen. He will, for example, take cancer services from places such as Clonmel but will give the hospital something back. That is to happen with the various other hospitals. Some of these questions are relevant to Mr. O'Brien as well. I note that mammography is available in north Clare but the rest of the county does not have a service, as I was informed this morning. I have a query about cervical cancer screening and the letter that was sent out on 1 September. I am sure Professor Keane can tell the committee how many cervical smear tests were carried out in the first eight months of the year. What was the average number per month for that first eight months and what is the figure for September, since that letter was sent out? Many general practitioners are deeply concerned that they cannot now conduct the smear tests in the way they did previously, that the numbers are falling and that this red tape is controlling demand by limiting supply.

The other issue is the transfer of breast surgery from the South Infirmary Hospital to Cork University Hospital. Everybody knows the South Infirmary Hospital is dealing with over 300 cases and that its outcomes are excellent. At a time when we are strapped for cash and many places are finding it difficult to meet standards, how much is it costing to move the service from the South Infirmary Hospital to Cork University Hospital? Professor Keane mentioned radiology and radiotherapy. What are the plans for Donegal? What is the service there at present? There was talk of coming to an arrangement with Northern Ireland. Has that happened and have people got a service or must they still travel to Galway?

Professor Keane also mentioned the situation in Waterford, where the regional hospital is failing to see nearly 30% of its urgent cases within two weeks. He said he hopes that figure will reduce, but the Mater hospital is failing to see 20% of urgent cases and that situation appears to be getting worse rather than better.

I will continue my questions and Professor Keane can answer themen bloc later. That is how we agreed to conduct our business. He referred to the cancer control programme director and I thank him for that. Undoubtedly, the general practitioner’s role can be greatly enhanced in the delivery of chemotherapy. However, in light of the small number of general practitioners at present and the fact that we are only training 121 general practitioners, when the ESRI report shows we should train 350 annually just to stand still, not to mention what would be needed if their role were expanded, how will that be addressed? It cannot be dealt with in isolation.

I absolutely support Professor Keane's stand against the HSE hospitals division looking for money until it can prove conclusively that the additional services in cancer care are being delivered. The money cannot be hived off. This committee has had experience of money allocated for palliative care and mental health care being hived off by the HSE to meet budget demands in other areas. However, again this raises a concern. Professor Keane has been singularly successful in resisting that. My concern about Mr. O'Brien's service being amalgamated with Professor Keane's is that he will end up being under the HSE and, in light of its overall performance, that does not instil confidence. I would prefer it to remain a separate entity and be allowed to continue as an independent programme, not neutered by the HSE because it has other needs to meet.

I welcome Professor Keane and Mr. O'Brien. I congratulate Professor Keane on the work he has done in the past two years and I wish him well in the future. I welcome the fact that he is trying to arrange a smooth hand-over to his successor.

The one issue on which we differed from Professor Keane relates to the north west and the fact that there is no centre there. However, I am aware it was not his decision; it was a decision he implemented rather than made, but I will not revisit it now. I submitted the question about the necessary resources to establish the centres with the various areas of expertise that were required. On the last occasion Professor Keane appeared before the committee — I brought with me the recording of his meeting with us on 18 December 2007 — he indicated the need for additional consultants in radiology and pathology. In his reply to the question I submitted he has indicated there is a difficulty with the public service recruitment moratorium in respect of staff associated with the delivery of cancer services in the eight designated centres and that he has asked for an exemption from the moratorium. Has that request been complied with? It is vital that we have full teams in each of the centres to meet the targets.

Deputy Reilly referred to Waterford and the Mater hospitals and meeting the targets. I could also refer to Limerick with regard to meeting the waiting time targets for patients to be seen. Is Professor Keane satisfied that the targets will be reached by the time he hands over to his successor? In that context, Professor Keane referred to the 50% increase in referrals for symptomatic breast cancer. Does he think that is likely to settle down when screening is fully in place across the country? Is it a feature of the introduction of the screening programme? Deputy Reilly mentioned County Clare but many people in Limerick still have not been called even though the programme is in place there. Is the increase also related to the fact that in the past a general practitioner could order a mammogram without having to refer to the specialist centre? Professor Keane spoke about educating general practitioners but can anything further be done to ensure that people who are referred to the specialist centres are those who most need to be referred to them?

During his last meeting with the committee Professor Keane spoke about return patients and how many of the patients in the service are returning repeatedly after having been treated. He referred to this again this morning. Is he satisfied the balance is now right between new patients being seen and return patients or must work still be done in that area?

I am very concerned about the private provision of care and surgery. It seems wrong that on the one hand we say the eight designated public centres of excellence require a certain level of population, a certain number of specialties and so forth while there is no supervision of the service that is provided privately. Would Professor Keane care to comment on that issue? I do not think he has any control over what happens in the private sector. There has been a careful process of establishing designated centres but apparently anybody can set up a private service in Ireland.

The Irish Cancer Society has told us that it would like prosthesis provision to be included under the national cancer control programme.

Approximately 500 men and 400 women die each year from colorectal cancer, and a programme of screening for this cancer is urgently needed. I ask Mr. O'Brien to update the committee on the progress of the national colorectal screening programme, in respect of which the Irish Cancer Society has offered to provide funding.

Crumlin hospital is the centre for pediatric cancer services and I understand it already is a centre of excellence. Should it be linked into the national cancer control programme?

I welcome Professor Keane and Mr. O'Brien. I regret that I will have to leave shortly to attend a meeting of the Joint Committee on Social and Family Affairs. Like my colleagues, I applaud the efforts Professor Keane has made. He and his officials have always been helpful to me even though cancer policy has long been a serious political issue in the area in which I live. I acknowledge Deputy Reilly's new-found interest in Tallaght. I am glad my work appears to be impacting on the alternative Government.

Professor Keane will not have known that I tabled the question on Tallaght but I was interested in both questions. The issues raised by Deputy O'Sullivan have an impact on how we feel about Tallaght because there is a need for people to understand this is the right policy. I note that Professor Keane conceded that difficulties arise and I invite him to speak further in this regard.

May I be parochial? I will not compete with Deputy Reilly's interest in Tallaght but it is the third largest population centre in the country and the jury is still out on what Professor Keane is trying to achieve. Is he satisfied that he has taken the correct decisions and can he give absolute guarantees to people who live in the catchment area of Tallaght hospital? Do not forget that Tallaght hospital's catchment stretches beyond Tallaght to include parts of counties Kildare and Wicklow. I seek further assurance in that regard. We need guarantees that the people of Tallaght will be looked after in other hospitals in terms of appointments and a first-class service.

Many people in Tallaght, including those who work in Tallaght hospital, remain unconvinced about Professor Keane's approach but we have moved on and I appreciate the manner in which he has answered questions. I hope he will not be offended when I seek further guarantees. It is important that we continue to represent the interests of patients. If the shadow Minister believes Tallaght is important, it is fair enough for me to concur.

I do not wish to pick on Deputy Reilly but there are days, although not many, when I wish I was still a county councillor. I wish Professor Keane well. I am sorry that he is returning to Canada because it is accepted across the political divide, even in Tallaght, that he has done a reasonable job. People may not have agreed with everything he has done but he will be missed. I do not think the health service can afford to lose people of his stature. It was welcome to have somebody who was trying to do a job while also keeping public representatives fully informed. I am happy to say that he has kept me abreast of developments as a local public representative of Tallaght.

I am glad to hear that Deputy O'Connor values his colleague's interest in his geographic area. I suspect Deputy Kathleen Lynch may have something to say about Cork.

I am already half exhausted. I thank Professor Keane and Mr. O'Brien for attending. As usual, the information they have provided is almost too much but, unfortunately, it came last night, which was too late. It was difficult to absorb it even though not all of it related to our respective areas. Perhaps it would have been more helpful had it arrived somewhat earlier.

I have always maintained that centres of excellence are the way forward. We want those who are close to us to be treated where the best outcomes can be achieved and where specialists concentrate on particular areas. However, I have to speak about the South Infirmary Victoria University Hospital. I refer to No. 6 on the list supplied by the witnesses, which refers to changes to symptomatic breast services at that hospital. The new service at the hospital is due to open 1 December but worries have arisen that it will not be the same as heretofore. I do not think anything that moves can ever be the same and I am not referring to physical aspects. People are concerned about the splitting of services so that symptomatic treatment is in South Infirmary Victoria while remaining services are offered in Cork University Hospital. BreastCheck will be back-to-back with South Infirmary Victoria but the service will be moved to another hospital.

When I raised the issue with the Minister for Health and Children she argued that the services will only be separated by half a mile. It is not a question of distance, however. One can walk from South Infirmary Victoria to the regional hospital if one is in full health. The services provided by South Infirmary Victoria are extraordinarily well run. The hospital was developed into a centre of excellence over a 19 year period but now its services are being transferred. Many of the people who will deliver the new service, including radiologists and pathologists, will be split between the two hospitals. I remember reading that the purpose of centres of excellence is to provide all the relevant services on one site. How will one be able to deliver the level of service currently provided on one site by splitting the service between two sites? I also read that patient numbers in County Kerry have declined due to concerns arising from the decision to move services to Cork University Hospital commencing on 5 January 2010. As of that date, a person who has problems should attend Cork University Hospital because that is where the necessary treatment will be provided. Nevertheless, serious concerns remain about splitting the service.

Mr. O'Brien indicated that the BreastCheck service may move to another location. He did not use the word "shall". I understood the service would move. I presume financial reasons are behind this, which I understand. Approximately 2,000 women with symptomatic breast cancer are on a list in South Infirmary Victoria University Hospital. It is possible that these women are what are known as the "worried well", that is, people who have a lump or pain which is a cause of concern for their general practitioner. Staff who carry out mammograms in South Infirmary Victoria University Hospital have informed me that the machine they operate will move to Tralee General Hospital when the service transfers to Cork University Hospital. However, those involved in the unit in Cork University Hospital argue that 1,500 people on the list are not its responsibility. What will be the position of these women when the service moves?

On pathology, as our guests will be aware, the individual who did most of the breast pathology in the Mercy University Hospital until he left the hospital last June was, by all accounts, an incredible person. It appears he was doing the work of three people but negotiations on replacing him are ongoing.

Dr. Marie Laffoy is still in talks with general practitioners. I was staggered to learn at a meeting with representatives of the Health Service Executive that Dr. Laffoy's first formal meeting with general practitioners took place on 1 October. The breast pathology service will transfer in December. While Deputy Reilly has more experience of general practice than I have, in my experience general practitioners do not come to agreements quickly, although I may be wrong in that regard. The notion that one will have community provision agreed and up and running by the start of December appears improbable.

Serious concerns persist. If the transfer of services runs smoothly, these concerns will be addressed. I worry that this process is about cutting the ribbon rather than delivering the service. I know that is not what Professor Keane wants.

I propose to suspend proceedings to allow Deputies to attend a division in the Dáil. I apologise to our guests for the inconvenience.

Sitting suspended at 11.45 a.m. and resumed at noon.

I thank Professor Keane for bringing us up to date on the current situation regarding the provision of state-of-the-art cancer services. I compliment him on the work he has done over the past two years. The documents he prepared for us are very interesting, as are some of the statistics, particularly those referring to rectal surgery where 58 out of 86 surgeons operated on fewer than six patients a year. It is a telling statistic and the delivery of the service in a smaller number of units is very beneficial in ensuring everybody has access to state-of-the-art surgery. I have nothing to say against the surgeons who were doing the six operations; I am sure they were very competent.

Professor Keane named seven different areas regarding cancer services. What are his concerns about those areas, particularly getting them up to the level he would like them to be at? What needs to be done? Can this committee make recommendations to help him?

He referred to low risk and high risk spectrum for breast cancer. How should cases classified as low risk be dealt with, rather than sending patients to the units which have been established around the country? It is linked to the development of community oncology services. What does Professor Keane think can be done as a matter of priority in that area to speed up the development of these services?

There are many issues, such as GPs not having the right of referral to investigative technology. On the question of the recruitment embargo, what progress is being made to ensure the necessary staff are in place to implement Professor Keane's programme in full?

I raise the question of the type of debate we have in Ireland on health generally. I have made the point for a long time that the adversarial system of politics does not help the patient, as we often tend to miss the real issue and it is too easy to blame or defend the Minister. Perhaps there should be a different level of debate generally on the health service in Ireland, not just in the political arena. Professor Keane referred to being intimidated by appearing before the committee; but how can we become more objective and ensure patients, who are at the centre of our concern, are not intimidated by the level and type of debate? I would like to hear how we can ensure we do not cause unnecessary fear for patients, get a more constructive view of health services and how people could improve their own health.

I appreciate Professor Keane's employers for giving him the opportunity to come back to Ireland, and thank him. We appreciate the work he has done and he has made a major imprint for good on the Irish health service in the past two years, something which will be long remembered. He has only initiated the work, but I have no doubt this initiation and the plan he has put in place will be of tremendous benefit to the people for generations to come.

I too would like to associated with the warm welcome for Professor Keane and congratulate him on his achievements during his 23 months in the post. I hope his period of transition will be a smooth one. Many of my questions have been answered already, but I would like to raise a few more.

In regard to rectal cancer, what 13 hospitals will still carry out the services? I am aware that Mr. Murchan in South Tipperary General Hospital performs more surgery than is performed in Waterford Regional Hospital, and as the colonoscopy service is provided by Dr. Paud O'Regan in Tipperary, a very comprehensive service is available, which gives us a centre of excellence in its own right because of the throughput of the unit.

When will a neurosurgeon be recruited? Dermatology facilities are based in Waterford, where one consultant deals with 700 cancers annually which makes him quite an expert in his field. He deals with a population base of 461,000. When will the need for additional staff to deal with this be recognised? The consultant concerned is also involved with head and neck cancer reconstructive surgery.

I also wish to be associated with the words of welcome to Professor Keane and Mr. O'Brien and thank them for their presentation. Professor Keane has done an excellent job over the two year period. When he initiallly arrived, I did not think I would say that but the way he handled the entire debate, particularly how he dealt with the media, was excellent and helped bring about a greater understanding of the issues. I compliment him.

The first issue I wish to raise is the 50% increase in referrals for breast cancer. Professor Keane referred to this in his presentation and it is a cause of concern. How do we compare to other countries which have a breast screening service, in terms of the number of referrals? Are we out of synch with other countries in that regard? When there is an increase in the number of routine referrals, it causes women to be anxious, something to which Professor Keane referred, and many cases turn out not to be anything serious. However, a woman will probably go for an annual mammogram instead of the two-yearly check recommended under the screening programme because she feels she is in an at-risk group. If it is the case that the increase in referrals is out of kilter with other countries, it is something which will continue by virtue of the fact that there is an increase in referrals. What can be done to address that situation?

On the transfer from Mayo to UCHG of services for diagnostics and surgery, which has now been in operation for one year, how many surgeries took place in UCHG on patients from Mayo? What was the number of referrals for diagnosis to UCHG?

Professor Drumm from the HSE appeared before the committee last week on capital projects. I asked him about the new oncology unit for Mayo General Hospital. Professor Keane is probably aware the provision of the unit is in the capital programme. I am very interested in this issue because the current facility at Mayo General Hospital is completely unsuitable for the large number of people availing of chemotherapy locally. I know Professor Keane considers the provision of the unit is desirable, as do the people of Mayo. The oncology unit of Mayo General Hospital is completely overcrowded. Professor Drumm, when he recently attended the committee, stated that because it was such a modern facility at Mayo General Hospital, moneys would have to be found for the development of this unit either from the major or minor works capital budget. Will Professor Keane, as director of the cancer strategy, support this because it would heal any remaining divisions in Mayo?

During the summer, I wrote to Professor Keane, as well as to the general manager of University College Hospital Galway, on the lack of direct readmission of oncology patients at the hospital. It is unacceptable that a person whose medical history is already well known in a hospital would have to spend hours, often on a hospital trolley, in the accident and emergency department before being readmitted to the oncology unit. Last week at this committee Professor Drumm stated he was not prepared to defend this policy as there is a national readmission policy. I recently got a second reply from the general manager stating the hospital carried out a bed study and will be revisiting the issue. It must be addressed sooner as it has caused discomfort for oncology patients, many of whom have had to travel for up to two hours to Galway.

I also welcome Professor Keane and Mr. O'Brien to the committee. I concur with other members on the pressure absorbed by the programme and that the transformation of cancer services has been phenomenal. The effect of Professor Keane's work will be reverberating long after he leaves the position. Like others, I did not believe when he first began his work that it would have such an effect but he certainly has left his mark. I wish him well in his future endeavours.

Being parochial, I want to raise the matter of cancer services in Letterkenny General Hospital. Elements in Donegal believe cancer services in Letterkenny General Hospital are in jeopardy and will go the same way as services in Sligo General Hospital. Will Professor Keane give an update as to the hospital's position? Are there pressure areas and, if so, does he have plans to deal with them?

Mr. O'Brien absorbed much pressure during the roll-out of the BreastCheck programme. What is its position in County Donegal? Is the roll-out near completion? Is Mr. O'Brien satisfied colposcopy services in Letterkenny General Hospital are at the standards set by the national cancer programme?

I join members in expressing my appreciation for the work done by Professor Keane. As this may be the last time he appears before the committee, I hope he does not feel too intimidated.

Under his tenure, cancer services across the country have been revolutionised. One reason Professor Keane has been successful is that he is an effective communicator. Other service managers trying to manage change in the health services need to learn how to communicate as effectively as Professor Keane. He has done the State a considerable service.

Positive comments have been made about improvements in cervical, breast, colorectal and prostate cancer services. However, Professor Keane does not have a good story to tell about lung cancer, an area about which I have a particular concern. The note circulated to the committee states the incidence of the cancer is on the increase. There is a frightening statistic that survival rates at five years are at 9%, way below international standards. Up to 40% of patients do not receive specific treatment because of the advanced stage of the condition when they are diagnosed. Will a screening programme for lung cancer be devised? If so, what will be its position?

Professor Tom Keane

I am satisfied the right decision was made about Tallaght hospital. I would not have made it if I did not believe it was the right decision. I will not comment on the individual mentioned by Deputy Reilly other than to indicate I had several discussions with that individual. I agree he is a prominent and outstanding individual in the area of pancreatic surgery. His decision has nothing to do with the transfer of the service. We had entertained the likelihood — I saw no barrier to it — of him transferring with the service and potentially being its leader at the St. Vincent's site. I will say no more than that, other than that his will be a loss to pancreatic surgery if he will not continue the administrative role he has taken on at Tallaght hospital. We need people like him to take on this role of leadership in the field of leading a hospital as a physician.

There is no telelinkage around the management of breast cancer services. The telelinkage to Pittsburgh is around the treatment planning of radiotherapy for patients at the Beacon clinic, a separate issue.

There was always an expectation that Tallaght and St. James's hospitals, under the Trinity College Dublin banner of an academic medical centre, would be brought together. There have been some hiccups in the dialogue to achieve this but it is still ongoing. It was always anticipated that the migration of cancer services and the transfer of non-cancer services out of St. James's to accommodate cancer services would be part of a broad range of proposals which were discussed last year but have not yet been decided upon.

The service in Tallaght was an excellent service. It will be split, with approximately 60% going to the St. James's catchments based on GPs' preferences. We polled all GPs and will verify when the service is fully transferred as to whether the 60:40 split happened.

Several Deputies raised the issue of breast cancer services developing at the Beacon clinic and the lack of provision of services in the private health sector. I believe this issue will be addressed in forthcoming legislation which will allow HIQA to have responsibility for the licensing of private facilities. I am not sure of the timetable for the legislation but it should be introduced in the next year. While I cannot predict its provisions, I would advocate that the same standards for public hospitals would apply to private ones, a matter which many people support. While I am not saying the Beacon clinic does not provide a high quality service, there is a need for the same level of oversight for private facilities as there is for public ones.

Regarding Deputy Kathleen Lynch's concerns about the South Infirmary, we have been in dialogue with the hospital for over a year. There was an excellent service there. There were some issues around the South Infirmary which have now become manifest — it had no pathology within the hospital and relied on the service provided by the Mercy Hospital, which is now in serious difficulty with the resignation of an individual. As I understand it, significant advance notice was provided around that.

The amalgamated service on the CUH site will allow all the value that the South Infirmary brought to breast cancer treatment in Cork to be transferred to a single state-of-the-art breast cancer service on the CUH site, which will probably be one of the biggest services in the country. I am hopeful, in talking to the surgeons, that there is now an acceptance that this will happen and a positive view that it can provide a service. We are very sensitive to the concerns expressed and I have indicated that I would like to see co-leadership of the breast service in CUH, made up with somebody from the original South Infirmary service as well as CUH.

There are big changes occurring in Cork, as the Deputy probably knows, concerning the reconfiguration of hospital services. The personnel in Cork, both at the South Infirmary and CUH, are excellent. Despite some of the tensions, the relationships between the professionals are very good. We plan to move on schedule.

The concerns expressed about GPs in Cork are another issue. The engagement with GPs is not around the breast cancer service but rather the development of capacity and expertise. Breast cancer may be one of the issues but it is not a dependency we have seen as an issue. I have found GPs to be somewhat quicker than has been suggested on the take-up of new information and the issue in Cork primarily concerns bringing these two institutions together and having a world-class breast cancer service in Cork. The economies of scale being achieved in this issue are very significant.

Deputy Reilly wanted some information on cost. The costs are moving with the service and the money is following the patients. The major cost has been the development of an ambulatory care cancer centre at CUH which will house not only the breast cancer service but also the lung and prostate cancer services. There is also the possibility that other ambulatory services will be included. The cost is €5 million. Has Deputy Lynch had a tour?

Yes, it is an incredible unit.

Professor Tom Keane

As a representative of the South Infirmary, the CEO wrote to me and acknowledged that the facility being provided is better than anything that existed at either CUH or the South Infirmary before. I am very positive about what is happening in Cork not just with regard to breast cancer services but with the reconfiguration of pathology services. It is a significant change and I am glad to see that patients have not been drawn into this dialogue, which has stayed at a very professional level between specialists, etc. We are now at a point where most people are on board and we are very close to signing off on all the final issues.

I recognise the concerns. I have never transferred a service until I was happy it was going to work and the service will work at the South Infirmary.

I do not want to hog the meeting.

Professor Tom Keane

I need to come back to the issue of the 2,000 patients. The South Infirmary for many years has been running what I would call a mammography service for GPs. It was doing it before BreastCheck came about but the problem was when BreastCheck began operations, it continued to provide the service. Essentially, it was running a screening service; it is not a symptomatic breast unit and there are not 2,000 symptomatic breast patients. These are 2,000 women who are seeking mammograms and being referred. Some would have come to the South Infirmary before.

We need to find a method of accommodation and we are in discussion with the CEO of the South Infirmary to ensure that all those people eligible for BreastCheck have been shifted to that programme. There was a large number of such women. There are women who are not eligible for BreastCheck and who are slated to have mammograms, some on a repeat basis. We will have to find a way to deal with that. They will not be abandoned and we will work with the South Infirmary to ensure the service which was expected by those patients will be provided.

Deputy Jan O'Sullivan spoke about the moratorium. The cancer programme is exempt and it took a little while to get that exemption provided for all the posts listed as new posts. We still have a small problem as identified in one of the answers I gave around what happens when a whole-time equivalent post, and the money for that post, transfers but the person does not. We currently do not have an exemption to fill that post. It is essentially neutral but we are requesting the Department to allow an additional exemption where posts are vacated in association with transfers. The request ultimately goes to the Department of Finance through the HSE and I hope to hear about it in the coming weeks. The moratorium was explicitly lifted for all the posts we were funded to provide as part of the expansion of the cancer service.

Are issues such as maternity or sick leave covered?

Professor Tom Keane

They are not covered and we are still wrestling with the matter. There are big policy issues around maternity and sick leave with regard to exemptions in the system. I know there are significant stresses and strains, not just in cancer service coverage, when people go on maternity leave.

It must be addressed.

Professor Tom Keane

I agree. On the targets for access, Deputy Reilly mentioned that the Mater was only achieving a rate of approximately 80%. The Mater had difficulties during the summer because we were refurbishing the whole unit; we tried to off-load work primarily to Beaumont but also to other hospitals. There have been extra clinics and the service has been progressively getting back to what was historically a 95% to 100% service compliance.

The urgent cases are what we should be concerned about. We are achieving over 95% nationally for this group and the only centre not achieving the target as of September is the Mater Hospital. Waterford in September was at 98.6%. Significant efforts have been made to bring these services in line and a HIQA audit is currently under way. That is examining how well and to what extent we have satisfied the HIQA standards in the transfer of the service. I am optimistic about it and I believe that we now have a fine world-class symptomatic breast cancer service that is as good as anything I have seen anywhere in the world.

Not every centre is at the same level but, compared with where we were two years ago, there has been a massive improvement and I am satisfied and proud to have been associated with that.

The issues relating to the 50% increase in referrals is troubling. There is a large number of women, many of whom are between 20 and 35, seeking mammograms. In the most extreme cases, we have tried to feed directly back to GPs who are inappropriately referring young women with breast pain where there is no possibility of it being due to cancer. We recognise that some of it was, perhaps, a reflection of the huge publicity around breast cancer and the misdiagnosis and we have been waiting to see if that will settle but it does not appear to be settling. This trend is national, with the exception of Galway which still seems to be able to keep its numbers close to what they have been.

The solution we will discuss nationally with all the breast care providers — we may seek external advice from some independent experts — is whether these low risk women who, in truth, are being referred in with no breast lumps, have vague breast symptoms, or sometimes almost manufactured breast symptoms to justify getting them into the clinic. The GPs would put down "query breast pain" or something similar. We wonder whether these women could proceed directly to have a mammogram without having to go through the clinic and would only go into the clinic if the mammogram was positive. Given that we have detection rates of about ten per 1,000, only ten women out of every 1,000 in this category will end up going to the clinic and getting the full service, that would require us to have the standards revised. HIQA has signed off. We have made HIQA aware that this is an issue that needs to be addressed in terms of the standards. In other words; can we create a different pathway for these low-risk women who are no more at risk than women going into BreastCheck? There is a dialogue that has to happen and, obviously, we will have to get the standards agreed for a change to be made for the pathway for these women. That has to happen. This is not a blip. Every October and breast awareness month we are inundated with more patients who are anxious and concerned.

Breast awareness is good but it is simply not appropriate for 22 year old women to have annual mammograms, it is actually dangerous. We are working with——

This is something that has been bothering me since Professor Keane spoke earlier when he mentioned the GP mammography service. The service is for patients but GPs can access it for their patients. I am thinking of the very case Professor Keane is talking about because I had such a case. It involved a woman with no discernible lump who had retractable breast pain and I referred her in and it transpired that she did have breast cancer. That route needs to be open. What Professor Keane is suggesting is the way to deal with it in terms of a direct route to mammography for GPs who are concerned about patients — and not every patient who presents to her GP with breast pain for an hour the previous night but somebody who is suffering ongoing breast pain and is worried. I put it to Professor Keane that medically or legally I will not expose myself by not getting that patient a mammogram.

Professor Tom Keane

I understand what the Deputy is saying but I think GPs have a huge role to play. Clearly there are many examples of women who do not need to be referred because they have breast pain.

That is if one knows what the pain is.

Professor Tom Keane

They are 19 years of age and they are on the pill. Good GPs make that differentiation and only refer women about whom they are concerned. That does not apply across the board. There are some GPs who simply refer any woman with any breast symptom to the symptomatic breast service for a mammogram. When we look at the age profile and see 19 and 20 year old women starting to have mammograms — they may have benign breast disease — they almost certainly do not have breast cancer based on their age profile, we have got to find a way not to put those women on a track where they are getting annual mammograms because they get into the system and it is repeated. I agree with the Deputy that there is a need to find a balance in the system and it is a challenge we will have to address. It is certainly not something I would have anticipated.

On the issue of prostheses provision for the Irish Cancer Society, in my many discussions with the Irish Cancer Society I have never heard any such request but I am happy to engage with them. I note they have issued a press release today. It would have been much more helpful if they had chosen to engage with me rather than through the committee. I am happy to have that dialogue.

On the issues around the development of oncology services and the speeding up of same — Deputy O'Hanlon said that PC is important. We see it as hugely important. We are gratified at the response of GPs, primary care teams and the ICGP. We now have a contract through which we have a GP half-time in our team. We also have a contract with ICGP whereby we fund a GP on a half-time basis to lead the continuing medical education around cancer for GPs through the excellent education programme that exists within the ICGP. This is the future of the service but I do not agree that GPs should be the future vision for delivering chemotherapy.

The future vision for delivering chemotherapy is through nursing. I was in Letterkenny last Friday and I saw what would probably be described as the model advanced practice nurse in oncology. She is a superb individual who is the future shape of how we deliver chemotherapy. She is totally skilled in all of the skill sets that are required to administer chemotherapy. This is a model that exists in many other countries and is being done successfully. It would not be helpful to download the task of administering chemotherapy to general practitioners when we have very highly skilled oncology nurses in Ireland. We intend to develop within that group the capacity to take on many more in regard to chemotherapy services. Deputy Flynn will recognise that in the unit in Castlebar there is a group of nurses who are expert in chemotherapy administration and who need nothing more than a better facility which I am happy to support.

Senator Prendergast raised the issue of rectal cancer. The original recommendation that came from the Irish Society of Coloproctology was that hospitals that were doing less than 20 cases should stop. That recommendation was based on 2007 data. I am just updating the 2008 data. Outside the eight centres, the five hospitals that were doing a significant volume were Tallaght, Mercy Hospital, Blanchardstown, Wexford and Letterkenny. They will continue to do rectal cancer surgery until the capacity issues are dealt with and about 200 cases will have to be transferred from the smaller centres that are doing rectal cancer surgery. The plan is to have the HSE reallocate resources within the hospital system to accommodate the transfer of that service, hopefully by 1 January. When that settles down we will look at transferring rectal cancer surgery from the remaining five hospitals. There is strong support generally among the surgical community for what we are doing. That 86 surgeons are operating on 500 rectal cancers in a country the size of Ireland will not produce the outcomes we want. We have acceptance from the surgical community and the public that concentrating highly skilled technical rectal cancer surgery, which is associated with the best possible outcome, is something people will support.

On the issue of the neurosurgical appointment for a lead neurosurgeon, I formed a view that we needed leadership in brain tumour surgery. We have a single programme between Cork University Hospital and Beaumont and later this month we will interview the candidates to appoint a lead neurosurgeon to lead the brain tumour programme nationally. That appointment will be split between Cork University Hospital and Beaumont. There is strong support for such an appointment and we desperately need leadership in that area.

Unfortunately, I cannot comment on the dermatology services in Waterford. Our focus has not been on small skin cancers such as basal cell cancers. We are engaging with the dermatologists on the issue of melanoma. There are a huge number of issues around the management of melanoma. We are still not bringing it forward as a proposal but we are heavily engaged in the planning of how we will deal with its management which at present is not satisfactory.

The Chairman raised the question of lung cancer, but unfortunately all efforts to date to identify a way to screen patients for lung cancer have failed. No test has been developed and routine chest X-rays have shown that they do not improve outcome. There is ongoing research but at this time, there is no screening service. The rationale for setting up rapid access clinics is that people would be diagnosed earlier because we had clear evidence of people who were waiting four months to see a respirologist turned out to have lung cancer. Four months in the life of a lung cancer patient is a death sentence. Our goal is quite modest. We hope that if we can double the resection rate for lung cancer, we might get a 4% to 5% improvement in the cure rate. Given the incidence of lung cancer that is what other countries have done. Our resection is about half what it should be. In other words people are arriving too late or not getting access to the surgical opinion to take on a resection. In this regard I must compliment St. James's Hospital, which is currently doing more than 50% of all the curative lung cancer surgery in the country. They were doing that before the inception of the cancer programme. It was the initiative of two surgeons who took it upon themselves to focus on lung cancer rather than cardiovascular surgery, which is the area in which they specialise. We now hope lung cancer surgery will flourish and will probably occur in three or at most four hospitals in the country. I would like to see it happen only in one hospital in Dublin, St. James's and there are some negotiations around that. There is a centre in Galway that is doing a very low volume but we expect it to increase and there is a thoracic team in Cork, which has a capacity to increase the resection rate.

Questions on screening and colposcopy will be addressed by Mr. O'Brien.

In response to questions on the national centre for paediatric oncology, I met the team in Crumlin two weeks ago and I asked them to consider if they would prefer to be part of the national cancer control programme or to receive their funding through the national paediatric centre. It is important that they think this out as I do not have a view either way. In many countries, paediatric oncology is funded through the paediatric envelope and if Crumlin is going to the new paediatric hospital, that is an option. I am willing to hear their view and if they say they want their funding to flow through the cancer programme, I am happy to do that.

Before Mr. Tony O'Brien responds, will Professor Keane comment on the radiation service?

Professor Tom Keane

In Letterkenny? I am not sure if Deputy Reilly is aware that the Minister for Health and Children has the solution for the north west. Currently there is a funding stream going into Belfast City Hospital to allow for patients from Donegal to go to Belfast City Hospital for radiotherapy. There are some limitations around which patients can go. The solution envisaged for the north west is through the development of a radiotherapy centre at Altnagelvin Hospital in Derry. The Minister has been in touch with her counterpart and there is agreement in principle that the Government would support the development of such a centre which would provide cross-Border services for people in County Donegal. The Northern Ireland health authority is developing the business case. There is ongoing dialogue at Government level. That is the solution that is being proposed and I support it.

There will have to be equity of access——

Professor Tom Keane

Yes.

——as a key part because the current arrangement with Belfast City Hospital is on an "available" basis.

Professor Tom Keane

To be honest, I think there has been reluctance in County Donegal to refer patients to Belfast City Hospital. I sense the reason was the concern that if patients could go to Belfast, the case for Altnagelvin Hospital would be diminished. We have been saying that we will try to expand the indications. Fewer than those who could have gone were referred last year but the figure is improving this year.

On the point that Professor Keane made about Belfast City Hospital. There is reluctance among patients to go to Belfast because of the grey area of whether they are interested in patients from County Donegal. One of my earlier questions was on the provision of services and the waiting lists in Letterkenny General Hospital. Are there waiting lists and pressures on the hospital?

On the readmissions policy for cancer patients.

Professor Tom Keane

I will respond to the question on Letterkenny General Hospital. I was there last Friday and there is a wonderful team in Letterkenny General Hospital. They have a big problem around their benign to malignant ratio in breast cancers. It is 29:1. Mr. Sugrue and I had a long discussion about how to address that. They have two excellent surgeons who are skilled and they have agreed between themselves that one of the surgeons will do all the rectal cancer surgery. There is no threat to that service and I reassured them that we see that as a key component of the Galway satellite link and that has been working extremely well. There are issues around breast cancer and how they will cut down on the benign to malignant referral ratio. There are issues around BreastCheck opening in Donegal and the expectation that it will address many of the issues there.

With regard to the admissions policy, I agree with the Deputy that it is not ideal. I can encourage them to look, and if they are reviewing it, I am glad to hear that, but I have not received correspondence to say they are reviewing it. Obviously the ideal thing is for people to bypass the emergency department and not to have to spend long periods waiting if their arrival was anticipated. That is a systems issue not just in Galway but in many hospitals around the country. Unfortunately, cancer patients coming back after hours end up going through the emergency department. During the day they go to the oncology unit and are admitted directly.

There are a number of questions surrounding the screening service and Mr. O'Brien can take them.

Mr. Tony O’Brien

I will group the answers around the topics rather than the individuals who asked them, but it would be remiss of me not to start by acknowledging Deputy Reilly's expression of confidence in the National Cancer Screening Service, which is appreciated.

The cancer screening service is logically an integral part of any fully developed cancer control programme. The cancer screening service has been centrally involved in supporting the development of the cancer control programme in several practical and other ways. I am here today as deputy director of that programme. Within that programme, I have a degree of responsibility around financial resources and planning. A central feature of the control programme is to develop the mechanism that some members have mentioned already, around effectively ring fencing cancer control resources. That has already happened with the development moneys and is now being implemented with the core moneys that were in the system. The funds allocated specifically for cancer will not be available to be redirected for other purposes. That is a critical part of the functioning structure of the programme. When all of that is fully in place it will provide a measure of reassurance to the Deputy around the resource issues associated with the cancer screening service which were at the centre of the earlier expression of concern. Professor Keane for his part has made clear that while he sees the integration of the screening service as central to the successful completion of the cancer control programme, the timing of it is inherently linked to the creation of all the characteristics of the cancer control programme and will enable it to provide the environment in which the NCSS can thrive and be as effective there as it could be anywhere else.

BreastCheck does not screen the entirety of a county immediately but moves sequentially around it. There is now a BreastCheck mobile unit in St. Joseph's hospital in Limerick which is supporting screening in the county. We are screening County Clare from the static unit in Galway while our discussions with county council officials on the most appropriate location of a mobile unit are ongoing. We hope to deploy a mobile unit somewhere near Ennis in the not too distant future. Screening in Letterkenny and, more broadly, County Donegal commenced two and a half weeks ago from a mobile unit in Donegal town. This service has been successful and well attended thus far and we will be working hard to progress screening in the county until each of the 10,000 eligible women there have been screened. Screening is under way or has completed a first round in every county. The most recent counties are Clare, Donegal and Leitrim. Screening is at present being offered from two locations outside County Leitrim but we are committed to bringing mobile units to the county for the next round of screening. Leitrim's geography creates certain challenges in determining where to locate a unit.

Deputy Blaney asked whether I am satisfied with the colposcopy service in Letterkenny. The honest answer is that I am not completely satisfied with it. I personally visited the hospital on Monday. Two significant issues arose which affected our concerns about Letterkenny last year, namely, the level of staffing and the facilities from which the service operated. The staffing issue has been substantially addressed and the jigsaw will be complete when the final member of staff takes up duty at the end of next week. A dedicated space has been designated and decanting is under way. The space, which is on the gynaecology and maternity floor, will be given a lick of paint and made available by the turn of the year. I will be satisfied when all the elements are in place for an optimal colposcopy service. It has been a longer process than we anticipated but with the goodwill of everyone in Letterkenny, the issues have in effect been resolved.

The cancer screening service was tasked with producing a plan for a colorectal screening programme. This plan was submitted to the Minister last December and published separately to a health technology assessment which we asked HIQA to conduct last June. The Minister also announced an initiative on examining how to implement a colorectal screening programme which is cost effective and makes maximum use of existing resources. Professor Keane and I served on the expert advisory group established by HIQA as part of the overall health technology assessment process and I understand that a report is likely to be sent to the Minister presently. However, that is at present a matter for HIQA rather than the NCSS or the NCCP.

Does Mr. O'Brien think it will be delivered in time for inclusion in the budget?

Mr. Tony O’Brien

The basic mandate given to HIQA was to report back to the Minister in accordance with the Estimates schedule. Obviously a policy decision will be required on what can or cannot happen from that point. Even if a green light is given and all the resources are made available, we are looking at a two year preparation period before screening can be commenced in a programme of that type. A strong case can be made from the evidence of the health technology assessment that this should be the first screening programme to be funded if one was starting from a greenfield site and had a finite sum of money. However, we are not starting from a greenfield site and the general resource environment has changed considerably since the first reports were commissioned.

Deputy Reilly asked several questions about the cervical screening programme. The programme which was launched on 1 September 2008 clearly signalled its intention to progress toward a full population based call-recall process as a substitution for the previous process, which was active but opportunistic and failed to make a significant impact on the incidence of cervical cancer in Ireland. Having operated on what we call a general or open access basis for the first 12 months to ensure that people who had previously established an inappropriate pattern of annual screening would be recruited into the programme the next time they presented, we have moved from 1 September 2009 to a full call-recall programme. Approximately 1.1 million women are eligible for the screening programme by reason of age and a small number are eligible due to particular factors, such as post-transplantation. We have in place a population register which accounts for 98% of that population and, in common with BreastCheck, we have now implemented a process of systematically writing to a proportion of that population each month to encourage them to make appointments for screening. We have also implemented a fast-track opt-in facility so that any woman who wishes to take a cervical screening test can request an invitation letter by telephone, post or on-line. Thus far, more than 10,000 women have made that decision and all have received invitation letters. It is therefore untrue to suggest that the cervical screening programme has either ground to a halt or that women are being denied access.

The necessity for a systematic call-recall programme is influenced by a number of factors. We need to ensure that everybody who is eligible partakes in the programme rather than only those who come forward and bring evenness to the numbers called for screening and the resulting flow through to colposcopy services. As is common in all screening programmes, clear promises can be made and delivered in terms of the timeliness of access to assessment services and primary treatment. Open access was difficult to achieve in the early part of the year and this was exacerbated by incidents such as the unfortunate death of Jade Goody. The objective is to systematically and over time give the entire population reasonably even access to the programme and to ensure anyone who wants an invitation gets one. I recognise, however, this matter is not above controversy or criticism.

Can Mr. O'Brien give me the figures I requested?

Mr. Tony O’Brien

I cannot provide the statistics today. I am aware that the Deputy put down a parliamentary question and I will be preparing information on it for the Minister. In broad terms, the numbers being screened do not reflect anything like a collapse. There has been a sustained level of activity in the cervical screening programme since 1 September.

I have one question about brain tumours and access to investigation and treatment. Obviously, a neurological condition would not necessarily be diagnosed as a brain tumour without investigation but the waiting list for access is lengthy at present. What initiatives are being taken to improve waiting times?

Professor Tom Keane

I cannot make a specific comment on waiting lists, access to MRI or diagnosis of possible brain tumours. I cannot comment because I do not have any sense of where I would look for that data.

It is recognised that the majority of brain tumours are unfortunately very malignant, although there are many benign brain tumours and these are not a concern. Nearly all of those who present acutely are referred as emergencies and do not wait in the system. They present with serious neurological deterioration, including raised intracranial pressures and seizures. The major mode for what I call high end malignant brain tumours, which are a major cause for concern, is that they arrive through the emergency room, either in Cork University Hospital or Beaumont Hospital. The large number of benign brain tumours, which are not urgent, are often monitored with repeat MRI and CT scans and intervention is sometimes not required.

Once our new lead neurosurgeon is in place, I hope we will have a database and information systems. A key feature of managing the cancer programme is to have the information that allows us to manage it. The paucity of information and absence of a widespread electronic health record and computerised system are the largest, single difference I have experienced in Ireland compared to my work in Canada. Being able to look at information in the Canadian system meant we knew exactly what was happening with every brain tumour. In the Irish system, one is often alerted to a problem through letters from Deputies pointing out that a person cannot access the service. We do not have systematic information systems and must have investment in such systems to provide us with the intelligence we need and to be able to manage the system, particularly when resources are tight.

I am sorry I cannot answer Deputy O'Hanlon's question other than to say that people should not wait for diagnosis for brain tumours. However, the term "brain tumour" incorporates everything from tumours which can be in place for years without growing to tumours that could kill a person within a few months.

When does Professor Keane expect the lead neurological specialist to be appointed?

Professor Tom Keane

Interviews are being held this month. Usually it takes three or four months to get someone into post. The timeframe will depend on whether we employ an internal Irish graduate or attract interest from outside the country. There is a strong need for leadership in a national brain tumour programme. Leadership is the key in this respect and it is absolutely necessary to have this person in place.

I thank Professor Keane and Mr. O'Brien for their presentation and for addressing members' questions in such a comprehensive fashion. I wish both of them well in their future endeavours.

May I make a concluding contribution?

That is not the usual procedure.

In that case, the procedure must only apply when the Minister appears before us. I will make two concluding points. It is good to learn that a parallel system has been introduced to facilitate women who are anxious to have smear tests done. Its impact will be clear in a few months when the figures become available. We saw what happened in September as a consequence of the decision taken at that time.

I do not wish to detract from much of the positive work that has been done. However, while everyone present acknowledges that volume is important in securing good outcomes, I do not accept that everything must be done in one location. I also wonder about some of the decisions to move cancer treatment services, for example, in the case of South Infirmary Victoria University Hospital where services were transferred across the road to Cork University Hospital at a time when money is tight. Professor Keane referred to the new facility in Cork University Hospital, which everyone acknowledges is a significant improvement. I wonder how much it would have cost to have built the new facility at the centre in South Infirmary Hospital.

Breast surgery waiting times are still a problem. To give one example, a relative of a Member of this House was seen by her general practitioner and referred to one of the cancer centres. I will not name the centre as it would identify the Member in question and his relative. Fourteen weeks elapsed before the woman, in total frustration, decided to travel to Dublin to have surgery done. She has since had two episodes of surgery done in Dublin. Notwithstanding the improvements to which Professor Keane referred, the system is not working in certain places as well as it should.

Waiting times for neurosurgery, even for those who have been diagnosed, are substantial. A colleague of mine who was diagnosed with a brain tumour at the end of last year waited a month before being seen in Beaumont Hospital.

The Deputy is rehearsing our earlier discussion. The points he makes were raised by members. If he makes a long follow-up contribution, other members will also be entitled to contribute again.

I understood members would have a further opportunity to contribute. I ask the Chairman to indulge me for a moment. We shall see the impact of the national cancer control programme on five year survival rates. I hope it will be a positive one. However, some centres, including Sligo General Hospital, had excellent five year survival rates before the service they provided was transferred. I thank our guests for their time.

I thank Professor Keane and Mr. O'Brien for coming before the joint committee.

The joint committee went into private session at 1.05 p.m. and adjourned at 1.10 p.m. until 10.30 a.m. on Wednesday, 4 November 2009.