Discussion with NTPF and NCSS

We are about to hear an update from the National Treatment Purchase Fund and a presentation from the HSE on the national cancer screening programmes.

Before we begin I wish to advise that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. If witnesses are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him or her identifiable.

You are all welcome. I invite Mr. Pat O'Byrne from the National Treatment Purchase Fund to commence his presentation. His paper has been circulated to all members of the committee. I will take a brief synopsis from Mr. O'Byrne and Mr. Tony O'Brien, HSE, following which I will invite questions from members.

Mr. Pat O’Byrne

The National Treatment Purchase Fund was established in 2002 to treat public patients on hospital waiting lists by acting as a resource to patients of the public hospital system. It must be remembered that in 2002 the position was much different from that of today. A report by the Comptroller and Auditor General around that time concluded that previous waiting list initiatives with the health boards had not achieved appreciable reductions in waiting times for procedures. At that time there were approximately 10,000 patients waiting more than 12 months for surgery. Today, the comparable figure is 900. We have always maintained that it is not the number of patients waiting for operations that is the critical factor, but the length of time they have to wait is more important when measuring progress in hospital care provision. In 2002 patients typically waited two to five years for their operations, today the median wait time is 2.6 months.

The fund does not seek to promote or underwrite private medicine. It is a resource for public patients which helps shorten the length of time spent waiting for their treatment. In its first year of existence fewer than 2,000 patients were treated. In 2009 almost 29,000 patients benefited and in all, 200,000 patients have been facilitated to date.

I have tried to set out briefly a number of the services provided by the National Treatment Purchase Fund. As most people are aware, our job is to get public patients treated faster. Our main focus to date has been on inpatient lists. They are patients who have been assessed by a hospital consultant and placed on a waiting list for treatment. Treatments are purchased primarily from private hospitals with a small amount allowed from public hospitals. The service is consultant provided and only provided with the prior approval of the NTPF. We hope to treat 20,000 public patients in this way, this year, with the concentration being focused on those who have waited longest for surgery.

Since 2004, the NTPF operates the national patient treatment register. The NTPF is responsible for the publication of national waiting list data and patients are placed on the national list only after they have been waiting three months. This is because the majority of patients receive their treatment within three months and, in many instances, with little or no waiting. The patient treatment register, PTR, was established in line with international norms and is a register of patients waiting for specific procedures and is updated on a monthly basis.

There are currently 15,500 patients on the patient treatment register awaiting surgical treatment for longer than three months. Recent reports that there are more than 40,000 patients waiting a long time are incorrect and confusing. The HSE tracks all patients from day 1 of referral but tracks those newly referred, and under three months, separately. As I have said, the average waiting time for all procedures is 2.6 months. It is then the NTPF's responsibility to arrange treatment for the patients waiting for the longest period who the system did not treat within three months. The NTPF is not responsible for collecting outpatient waiting list data.

In 2005 the National Treatment Purchase Fund commenced its first outpatient consultations on a pilot basis. This involves offering first-time appointments to public patients who have been referred by a general practitioner to an outpatient clinic with the intent of getting them treated faster. Our focus is on those waiting the longest time. In 2010 we hope to facilitate approximately 8,000 patients in this way. I have set out the results of the pilot we have operated in the outpatient consultations for the past five years. It shows that of the 82,000 patients asked to come for an outpatient appointment under the NTPF initiative, about half accepted the offer. That means that just over a quarter of patients were immediately removed from the list. Some 11% of patients declined the offer and 13% of patients did not respond to the offer. In examining those results, it is clear that a large proportion of patients currently recorded on outpatient lists do not belong on them. I have set out the reasons.

We also provide MRI scans. In the past five years we have provided approximately 13,000 such scans. Our involvement in MRI scanning has been small to date and has concentrated on those waiting the longest time.

The fund, working together with public hospitals, the HSE and the Irish Cancer Society, places a particular focus on arranging colonoscopies for patients who have been on hospital waiting lists longer than three months. There are currently 705 patients waiting longer than three months for this procedure on public hospital waiting lists. The NTPF has stated publicly on a number of occasions that there is absolutely no need for any public patient in Ireland to be waiting a long time for a colonoscopy as we have the budget and resources to arrange the treatment. In 2009, the fund arranged colonoscopies for 2,300 public patients and has arranged 2,800 so far this year. We can easily arrange for another 705 colonoscopies. We have written to all patients waiting over three months for a colonoscopy offering the service.

In 2009 the NTPF assumed new duties under the Nursing Homes Support Scheme Act, otherwise known as "fair deal". The NTPF negotiates maximum prices which the State will pay to private and voluntary nursing homes in respect of long-term elderly care. The fund is mandated to negotiate prices on bed and board, nursing and personal care appropriate to the level of care needs of the person, bedding, laundry service, and basic aids and appliances. Competition law dictates that agreeing a single national price is not permitted. Price negotiations were conducted separately with 450 private and voluntary nursing homes setting prices for a market which will cost approximately €850 million in 2010. Therefore, the importance of protecting the taxpayer and achieving value for money cannot be underestimated. What the fund endeavours to do is to strike a balance between a fair price while at the same time keeping the interests of the public purse in mind.

Obtaining value for money is a key priority for the NTPF. We work to maximise the number of patients that can be treated from its budget. If particular treatment prices offered to the NTPF by a private hospital are higher than the market rate, the fund will source an alternative supplier. We do not have to accept the prices offered by private hospitals. This ensures that when and where it makes sense to do so, NTPF patients are steered to quality providers that represent value for money.

The NTPF has negotiated discounted volume arrangements and has leveraged the increased supply of private hospital facilities in the past few years to lower the prices it pays. This approach has resulted in a 15% reduction in the average inpatient and day case costs paid by the fund since 2006. Our experience has been that as the budget for the NTPF has grown, so has our ability to leverage better value for money.

The fund negotiates prices with each treating hospital in advance for the full episode of care. Prices are fully inclusive per procedure of all hospital and consultant costs incorporating pre-admission, admission and post-discharge care. We do not enter into discussions with consultants or any other staff on fees. No payment is made to the hospital until the full episode of care is complete.

The NTPF has been independently assessed by the Comptroller and Auditor General to ensure value for money and competitive pricing. In his 2008 report, the Comptroller and Auditor General concluded that prices negotiated by the fund from private hospitals generally cost less that those carried out in the public hospital system and that most treatments purchased cost less than the case mix adjusted benchmark cost, which is used by the public system and internationally recognised.

The NTPF has facilitated 200,000 patients to date. It provides faster surgery for public patients and will continue to do so. The experience for patients continues to be positive with patient satisfaction levels at upwards of 98%. The fund pays hospitals per episode of care when treatment is completed. In that way payment is made on an output basis and with this model, money follows the patient. The NTPF acts as a safety valve for public patients in the public hospital system.

In many ways the model operated by the NTPF is akin to an insurance type system for public patients. This model was also acknowledged by the recently published report of the expert group on resource allocation and financing of the health sector which recommended that the prospective payment system should be adopted across the wider health system. The job of the National Treatment Purchase Fund is to treat public patients. Its target is to facilitate 30,000 patients in the current year and it is on course to achieve that.

Thank you, Mr. O'Byrne. To avoid confusion, I will invite members to put a number of quick questions and we can then take supplementary questions after we have heard Mr. O'Brien.

I welcome the delegation from the NTPF. Mr. O'Byrne states the NTPF "provides MRI scans for long waiters." Will he define what this means and how long must a patient wait before he or she comes to the notice of the NTPF? What budget does the NTPF have for colonoscopies for this year? What length of time must a patient wait before the NTPF provide the colonoscopy? A friend of mine told me that his mother had been in a nursing home for five years, and when the new fair deal scheme was introduced, she had paid her dues so there was a renegotiation through the NTPF and he was astonished to find that the nursing home was getting an extra €110 per week. It was not costing him anything but it was costing the State. If it is not appropriate to comment on this here, will Mr. O'Byrne do so elsewhere?

I believe that treatment was provided by the NTPF for 28,000 patients, 20,000 inpatients and 8,000 outpatients. What is the anticipated budget for next year — last year it was €90 million, €110 million in 2008 and €100 million the year before that? Why is more use not made of the smaller hospitals that might have capacity? In Monaghan, two quite modern theatres lie idle.

Will the person with the mobile phone please switch it off?

May I confirm that a patient must wait a further 2.6 months after being referred to the NTPF? I am aware of orthopaedic cases in Dublin that are not getting to the NTPF and they have been waiting at least six months.

It was stated that the fair deal scheme will cost approximately €850 million in 2010. What was the spend in 2009 and 2008 on nursing home care? I thought it exceeded €850 million and that there was an additional allocation for nursing home care as a result of the fair deal. Patients who are currently in public nursing home facilities are being moved into private nursing homes, and Loughloe House is an example. There are several others around the country.

While the NTPF is a safety valve, it is paying on the double because we have paid for consultants and hospital budgets and now we must pay a second time for other consultants or sometimes the same consultant to do the job while they sit in their original hospital frustrated because the theatre or ward has been closed.

Thank you, Deputy Reilly. I am not referring to Deputy Lynch but may I ask members to be as quick as possible as we are under time constraints.

The Chairman knows he has no reason to ask me to be brief.

That is true.

I welcome the delegation from the NTPF. I have always found the NTPF to be exceptionally efficient and very forthcoming with information, even in the event that it cannot help the particular person involved.

I am not certain I understand the system entirely but will Mr. O'Byrne explain the following. A friend of mine tells me — and this works when a public and private hospital are located cheek by jowl — that a person is seen by the consultant in the public hospital and is then referred under the National Treatment Purchase Fund to have the procedure carried out and the same consultant in the private hospital next door does the work. They are paid to make the initial diagnosis and work in the public hospital, and then they are paid an additional fee to carry out the procedure in the private hospital. I see from the presentation that the price is all inclusive, but the private hospital is paid to carry out surgery. In the event that the consultant does not do the work in the private hospital, it will probably be his or her pal who is doing it in the private hospital.

The NTPF is a very good idea and it really works in term of providing services when they are not available in certain public hospitals. Has any study been carried out on that? Clearly, significant research has been carried out in terms of value for money and so on, but has any research been done on that issue? It would be enlightening to see the result of such a study. I was staggered when I heard about it, but it seems to be quite common.

I thank Mr. O'Byrne for his presentation. I was very impressed with the figures he presented and by the work that is being done. I also acknowledge the favourable comments of the Comptroller and Auditor General on that work. Having regard to the time pressure, I will put a couple of questions. Why are public patients still waiting more than 12 months for surgery and why are so many patients waiting more than three months for colonoscopies? What can the National Treatment Purchase Fund do to expedite access for patients to consultants?

I note that last year there were some eight public hospitals to which no patients were referred through the NTPF, including the two smaller hospitals, Roscommon Hospital and Portiuncula Hospital. Can Mr. O'Byrne explain why these smaller hospitals are not used when they have the capacity to treat patients? Why are patients always referred away from their local area to some of the major private hospitals?

Earlier, I asked the Irish Cancer Society delegates about colonoscopies. If the capacity lies within the system to deal with the backlog of colonoscopies, why is there such a long waiting list for them? Has that issue been looked into? It is fundamental to the screening programme that we know why people are not availing of colonoscopies if the capacity is there to provide them. Is it the case that under the NTPF, patients are provided with transport to appointments or with overnight stays prior to the procedure taking place? Do we need to address such issues, perhaps not just in the case of colonoscopies, but for other treatments also? Based on the figures presented here today, it is projected that by the end of this year there will be a 50% increase in the number of people provided with colonoscopies through the NTPF. There is something seriously wrong with the system if we have a 52% increase this year in the number of people who will avail of colonoscopies through the NTPF when the capacity already exists within the system to treat them. How can this be explained or justified?

Are there any plans to expand the available treatments provided under the NTPF? Have there been any indications as to the funding that will be available in 2011? It is clear that capacity will not be provided in the public hospitals, although, as Deputy Reilly said, there is plenty of spare capacity. We are paying consultants on the double to twiddle their thumbs in the public sector while being paid private fees for carrying out procedures under the NTPF. There seems to be no justification for this, yet this seems to be the way the system is developing.

I welcome the presentation from the National Treatment Purchase Fund delegation. From my experience as a Deputy trying to get treatment for patients, I have nothing but praise for the NTPF. While I could get nowhere with trying to get treatment for patients on the public waiting lists, I got satisfaction from and succeeded in getting patients looked after by the NTPF. The report of the Comptroller and Auditor General proves that the NTPF provides value for money. I note that the administration costs of the NTPF are only 4.5% of its budget. This is something we should be conscious of at this difficult time. I need not go through the results — 140,000 operations provided from 2002 to 2010, 14,000 MRI scans and 50,000 outpatient consultancies arranged. These are good news stories and must be commended.

I have just a few questions, one of which was put already by Deputy O'Hanlon. Why are public patients still waiting more than 12 months for surgery? What can the NTPF do to expedite access for patients to consultants? Can the delegation provide an example of the value for money achieved? Can it explain why patients must wait more than three months for colonoscopies? Will the NTPF delegates explain its role under the fair deal scheme?

Another issue relates to private hospitals competing with public hospitals. I am from the south east, but do not want to mention any names. I have been told by people working in a public hospital that their hospital can provide better value for money for hip and knee replacements. Why does the NTPF not give more of that work to such hospitals, particularly when they can carry out the operation for €4,000 or €5,000 less than private hospitals? This is important when we are concerned about getting value for money. If a public hospital wants to keep wards open and can provide orthopaedic services for less, we should consider that. I have been told that is the current situation in my area where two private hospitals are competing against the public hospital. Most of the patients are attending the private hospitals.

I thank Mr. O'Byrne for his first class presentation. The NTPF is a first class organisation and I congratulate everybody involved. We never hear anything negative about the organisation.

Mr. Pat O’Byrne

I thank the Senator.

We regularly hear about waiting lists and about children on waiting lists for psychiatric treatment. Could the NTPF help out in that area? Currently, some 500 children are waiting for psychiatric appointments as public patients. This is a crisis situation. Is there anything the NTPF can do in that regard?

I welcome the NTPF delegation and thank it for its presentation. I am concerned about the accuracy of the patient treatment register, given that the organisation has to write to so many people, half of whom do not take the fund up on its offer. The point was made that some people do not belong on the list in the first place. What are the reasons for that? It was mentioned that the register is updated monthly, but it is obviously only as good as the information provided. Is there a problem in that regard? I am aware that in one hospital where there is a waiting list of 12 months for non-urgent MRI scans. Why is it that these scans do not seem to filter into the NTPF system?

I welcome the delegation. Once people who have been waiting over three months have been referred to the NTPF, they are then on the NTPF list. However, the problem is getting the initial appointment so that they can get a referral. People must wait significant lengths of time before they can get an appointment that will help them get on the NTPF list. We have all met these people who are waiting a long time, whether for tonsillectomies or something else. Many of them cannot afford to pay for a private appointment and, if they are public patients, they must just shut up and wait until the appointment comes. This is a serious concern.

It was mentioned that 25% of patients on the list for outpatient consultant appointments were immediately removed from the list. I presume that was because those people had already been attended to and no longer needed an appointment. Some 11% of patients declined an offer, but chose to remain on the list. I find it startling that people who have been waiting for an appointment and who are then offered one decide not to take it. Why would they refuse or what is the reason for this statistic? Some 13% of people did not respond to an offer of an appointment. What is the reason for that?

The National Treatment Purchase Fund is regarded as one of the success stories of the health service on which I congratulate Mr. O'Byrne. Would it be possible to give direct referrals to general practitioners for MRI scans and, if so, would that help to reduce waiting lists? Is the technology available in the public or the private sector for non-invasive virtual colonoscopies as a means of speeding up waiting times? It strikes me there is a significant problem in Tallaght Hospital because people from my constituency are being referred for orthopaedic procedures to Tallaght. They are being told they must wait at least a year and at least a year to be taken on the NTPF waiting lists. Surely we have an obligation to have a level playing pitch across the country rather than black spot areas where people, by virtue of the location in which they live, must suffer agony and misery while awaiting serious orthopaedic surgery. I will come back to Mr. O'Byrne for the responses to those questions because I want to move to Mr. Tony O'Brien from the National Cancer Screening Service.

Sorry to interrupt, I have an urgent appointment at 6 p.m. in Trim. Would it be possible to respond to my question about the 500 children who are waiting for psychiatric appointments as public patients?

Perhaps Mr. O'Byrne will forward his response directly to the Senator.

Every time Mr. Tony O'Brien appears before the committee there is a delay in getting to him. I am very conscious of that.

It is not acceptable because he got this treatment the last time he appeared before the committee. It is totally inadequate for Mr. O'Brien and for members.

Our apologies. We will have to do something about scheduling and will have to put him as the number 1 speaker in future. Members are very conscious of the superb work his organisation is doing. I invite Mr. O'Brien to proceed with his presentation after which I shall take questions from members.

Mr. Tony O’Brien

I thank the Chairman. Members of the committee have received a detailed presentation and in the interests of expediency I shall abridge it and skip over some of the points.

The National Cancer Screening Service encompasses BreastCheck, CervicalCheck and the planned national colorectal cancer screening programme. The aim of BreastCheck, the national breast screening programme, is to detect breast cancer at the earliest possible stage. It does that by providing free mammograms to women aged 50 to 64 years, sequentially, on an area-by-area basis, approximately every two years. It is the world's first fully digital programme. It is well supported by the population and the OECD ranked it third in the world for percentage of women who had taken part in the programme.

Some of the key statistics in terms of the programme since its inception to date are that it has provided almost 680,000 mammograms to more than 321,000 women and 4,259 women have had their breast cancer diagnosed through BreastCheck and, therefore, proceeded to earlier treatment than would otherwise have been the case. That is based on an overall acceptance to invitation of 78% — the minimum target being 70%. Obviously we would like a greater acceptance level to invitations.

I have provided some detailed briefing in respect of our plans in County Donegal. There are some issues with regard to surgical admission. The age range for BreastCheck is 50 to 64 years. In Ireland, more than 70% of breast cancers occur in women aged over 50 years. While the incidence of breast cancer in women aged 40 to 49 is increasing, the incidence is still approximately 50% lower than that for the 50 to 59 age group. On completion of the first full round of screening to all women aged 50 to 64 years and subject to overall resources and the reallocation of resources, the former board of the National Cancer Screening Service, which no longer exists, approved extending the upper screening limit to women aged 69 years. This is in accord with the European Council's recommendations and with the cancer control strategy. At present, there is no timetable in place but it is a key priority for the screening programme.

The eligible population for CervicalCheck is approximately 1.1 million women aged 25 to 60 years living in Ireland. The aim of CervicalCheck is to reduce the incidence and mortality from cervical cancer by detecting changes in the cells of the cervix before they become cancerous. According to the recently published detailed statistics, in the first year of operation which ended on 31 August 2009, 284,833 women availed of the programme. Some 85% of those women received a negative or normal result. Of the remainder, 13.9% showed low grade abnormalities, 1.4% showed high grade abnormalities, resulting in 11,112 women being referred to colposcopy for further investigation and 4,714 women received treatment. In that first year, 100 women were diagnosed with cervical cancer. The overall aim of the programme is not to detect cervical cancer but it is natural, at this early stage, that we would do that.

During the reporting period, CervicalCheck's laboratories recorded in excess of 86% positive predictive value for high grade abnormalities and in excess of 95% for low grade abnormalities. That is considered a very good result by international standards. While a detailed report for the second year of operation is not yet available, I can share that during its second year of operation CervicalCheck provided 304,000 smear tests to 278,000 women aged 25 to 60. This shows that overall participation in the programme held up well between the first and the second year of services.

I have detailed the significant investment that has been made in colposcopy services but I will not absorb time by going through it in detail.

We have specific initiatives in place to target "harder to reach" populations. The programme has gone through different phases. In the first year of operation where the aim was to recruit people who had been having annual smear tests, we had what was known as open access. In the second year, we successfully established the call recall system which was met with some concern at the time but the data show it has been successful. Now in the third year we have a combination of call recall and direct recruitment by smeartakers in general practice or women's health clinics. This is part of the strategy of getting to 80% participation over the first two screening rounds, in other words the first six years. Evidence internationally has shown that if we can successfully do that, we can potentially reduce mortality from cervical cancer by up to 80%. That is our major target.

In regard to the planned national colorectal cancer screening programme which has an overall eligibility target of women and men aged 50 to 74 years we have been preparing for this for some time. In January 2010 the Minister for Health and Children, Deputy Mary Harney, asked us to proceed with the introduction of a national population-based colorectal cancer screening programme. We will be implementing it on the basis of recommendations from a number of expert groups which recommended the introduction of screening for this age group on a two-yearly cycle, using the faecal immunochemical test, FIT, which operates on an automated testing platform, as the primary screening tool. We have a few samples — members may be interested to see them because they are new in terms of the way we run population cancer screening programmes. FIT is a screening test that is carried out in the home. Eligible men and women who wish to participate in the screening programme will be posted a test kit and instructions for use. A stool sample is taken and returned to a screening laboratory by Freepost. This will be one of the first international population-based screening programmes that utilises this technology as the primary screening tool.

The vast majority of people who carry out the FIT screening test at home will receive a normal result. It is expected that approximately 6% of all people screened will require further investigation, primarily by colonoscopy. In order to develop capacity to implement a screening programme for the 55 to 74 age group, the programme will be implemented on a phased basis starting with men and women aged 60 to 69. Phase 1 of the programme, for that age group, is to be introduced in 2012. The target date for the first of these kits to be posted out is the first working day of January 2012. There are approximately 400,000 men and women, aged 60 to 69 years. The programme will be extended to include the full age group on a phased basis as soon as possible thereafter. We expect that over time the programme will be expanded to include younger and older individuals until the full 55 - 74 age group is reached. This phased approach is based on a clear commitment to reaching the full target population as soon as possible.

In the preparatory phase, leading up to 2012, there are a number of work streams under way. The most important of these in some respects is the process of developing colonoscopy capacity, accreditation and training. The vast majority of the population screened will receive a normal result from their screening but approximately 6% will require further investigation by colonoscopy. The NCSS is focused on immediately identifying and building sufficient capacity in colonoscopy services nationwide to sustain the implementation of the programme, while maintaining and enhancing the symptomatic service capability. Some 30 public hospitals nationwide expressed an interest in providing colonoscopy services. Baseline assessment visits have been conducted by the NCSS in partnership with the representative professional bodies, namely the royal colleges and the national endoscopy team who have acted as advisers to the Joint Advisory Group on Gastroenterology in the National Health Service in the UK. All 30 of those who expressed an interest in providing the services will attend facilitated workshops next month with the aim of reviewing and building upon individual unit baseline assessment reports and developing a standardised approach to common problems encountered in endoscopy service provision. All units will receive a follow-up visit from the assessment team that carried out the first visit by the end of this year. In January of next year we expect to make an initial selection of eight to 12 candidate screening colonoscopy units that are best placed to provide screening colonoscopies in addition to their symptomatic workload. All endoscopy units will operate to a common, quality assured standard. During 2011, selected units will be required to demonstrate their capability of managing this workload while adhering to the quality assurance standards for the screening programme. Each will be required to achieve international accreditation by the end of 2011. For those centres not initially selected, there is a process to enable them to become screening colonoscopy services later. The quality and clinical directorate of the HSE will support these units in achieving international accreditation. Each of those units must be up to date in terms of its symptomatic workload to be a screening centre.

We are developing also an overarching quality assurance process. We have established a number of multi-disciplinary committees to do that. As with CervicalCheck, the guidelines will be internationally validated and will be completed by mid-2011. The faecal immunochemical test, FIT procurement will be under way. I emphasis that based on the age range, there is a 6% positivity range. If 50% of the target population take part — which by international standards would be considered a good uptake, although we would aim for a higher level — and we select ten locations, that would result in a referral panel of about ten to 12 additional colonoscopies per centre per week.

I also make the point that whereas colonoscopy is often and widely referred to as a cancer test, it is a test with much wider application in terms of its general population usage. Approximately 97% of those who have a colonoscopy receive a result other than cancer and a wide range of other symptoms and causes will be investigated. It would be unfortunate if in the general discourse around colonoscopy as a cancer screening test, we would produce the result where persons referred for colonoscopies by their GPs automatically assume there is a suspicion of cancer. I have had contact from individuals in that situation, needing to be passed on to those who can reassure them in that regard. It is important that we ensure there is a proper understanding of the full nature and usage to which colonoscopy is put.

I welcome the delegation from the National Cancer Screening Service. I will ask Mr. O'Brien some questions. What is the current status of BreastCheck delivery across the nation? Is BreastCheck currently available in every county or do people have to travel out of the county? When will BreastCheck screening be provided countrywide? What is the BreastCheck timeline for the extension of the age range to the 65 - 69 age cohort? What is the NCSS's position on breast screening for women under the age of 50 years? What are the current uptake levels and measures in place to maintain the take-up rate in hard to reach communities to which Mr. O'Brien alluded but in which he did not tell us what he is trying to do? If I have asked too many questions and time does not allow, I would be happy to get written answers to these questions.

What is the NCSS doing about providing cervical screening to women under 25 years? When one looks at the figures provided by NCSS, we advised there would be a dip as a consequence of reverting to a letter by invitation and there was a dip and it has not recovered. I suppose, I anticipate Mr. O'Brien's answer, by saying if on 1 September 2009 in line with best international practice, CervicalCheck moved to an organised call and recall system of invitation to screening, why has it now reverted? There is a considerable difference in the figures. In January 2010, the figure is 21,000, that figure is much the same as in 2009, but in February 2010 it was 28,000, but 32,000 last year, in March 2010 it was 38,000 but was 48,000 the previous year.

In regard to bowel cancer screening, how is the provision of advanced nurse practitioners proceeding? What is the timeline for the extension of the age cohort from 60 - 69 to 50 - 74 years, which was alluded to but there is no timeline? What is the NCSS's position on screening for prostate cancer and suspected hereditary breast cancer gene in men and women? What is the position on lung cancer screeningvis-à-vis smokers with a long history of a high level of smoking and those with chronic respiratory problems?

What is the likely effect of the proposed €1 billion cuts on screening? Is the NCSS concerned that people are waiting for a colonoscopy longer than the promised time of four weeks? The proposed additional ten colonoscopies per centre per week is quite a high number of colonoscopies and how will that be catered for? As outlined by previous speakers to the NTPF, has the NCSS considered the availability of existing capacity in some of the smaller hospitals to meet the demand? Is there a likelihood of colonoscopies being carried out in community primary care centres that are suitably equipped and staffed?

Mr. O'Brien may know that I am a big fan of the National Cancer Screening Service. The experience of Cork people with the NCSS is very positive. I am a little disturbed by what I heard in Mr. O'Brien's presentation on the figures for BreastCheck South in respect of delay in surgical admissions. We had an ongoing campaign against the move of the centre of excellence from the South Infirmary Victoria to CUH and this was exactly one of the issues we had. I know that BreastCheck goes into the system through a different route. I am very worried about the delay in what is supposed to be the centre of excellence, which we never had when the service was provided in the South Infirmary Victoria. Can Mr. O'Brien provide an explanation as to exactly what is happening there? I asked the Irish Cancer Society, which was unfair. However, in the breast clinic in CUH, I hear there are difficulties around beds and they confirm that. Perhaps I am misreading that, but I hear that some of the patients being dealt with in the breast clinic are being referred back to South Infirmary Victoria. Will Mr. O'Brien confirm that?

In terms of the target of 1.1 million eligible women for cervical cancer screening, am I right that almost 285,000 were reached, which is less than one quarter?

Mr. Tony O’Brien

That is the figure for year 1. We doubled it in the first two years.

How many women have not received a letter on the second round and have slipped through the net? Have the letters already gone out to the women who should be called for appointment?

I welcome Mr. O'Brien and his colleagues in the delegation. I thank him for his presentation and the supplementary material provided to members. My first point deals with the need to extend the age range of those eligible for BreastCheck because the statistics show that as people get older they are at greater risk. Mr. O'Brien refers also to the call and recall system. Once one reaches 65 years of age, one does not get recalled for BreastCheck. There is a danger that people will not make an appointment to have the necessary test if they are not reminded about it and sometimes people think that because they have had the test on a number of occasions, they are obviously all right. There is a need for work to be done on BreastCheck for those over 65 years.

One very impressive statistic on CervicalCheck is that 85% of the smear test results were negative or normal. That is a wonderful statistic that needs to be highlighted. Women, no more than men, are terrified about having a smear test. When one sees such a statistic, it allays the fears of many people.

Mr. O'Brien did not refer to the roll out of the vaccination for school girls. Has he information on the take up of the vaccine or the roll out of the programme and if there are problems with it?

Mr. O'Brien referred to the faecal immunochemical test, FIT, which he hopes will be rolled out in early 2011. How do people avail of it? Is it self-referral or a referral from a GP? If people have issues or are worried who do they need to contact to avail of FIT?

I welcome Mr. Tony O'Brien, the director of the National Cancer Screening Service. I am a big fan, because when Mr O'Brien first came before the joint committee, he had a rough encounter. There was a great deal of doubt about the service, but he has stuck by the programmes and has delivered quite well.

I am quite pleased that the second mobile unit has been delivered in County Donegal. I know we are at the bottom of the pile, but we were very pleased with the lengthy deliberations in Letterkenny General Hospital on the colposcopy services and sorting out the issues with the services. There were threats that the service would be shut down, but Mr. O'Brien stuck with the task and the service now is as good as anywhere else in the country.

In an earlier presentation, the issue of screening for prostate cancer was raised. Other issues around prostate cancer were raised also. I have concerns about the provision of resources for research on possible tests to detect prostate cancers earlier. I would be interested in hearing Mr. O'Brien's views on that topic. I certainly believe, as one of the male population, that the level of emphasis on prostate cancer is less than that given to BreastCheck and breast screening.

Go raibh maith agat. I apologise to Mr. O'Byrne for missing his presentation, but as a member of a small party, I am running around and covering all fields. In any event, I had the opportunity to read the written presentation that was circulated in advance of the meeting. I wish to focus on the two references to the Comptroller and Auditor General in his presentation, the first relates to 2002 and the other to the 2008 report of the Comptroller and Auditor General. With no disrespect, this is selective regarding the Comptroller and Auditor General's commentary on value for money. There was no reference to the fact that in his report he highlights that the NTPF has been purchasing consultant time in private practice in public hospital sites and in 8.5% of treatments arranged by the NTPF, the consultant referring and the consultant treating were one and the same person. I find that difficult to accept. We are already paying these consultants in terms of time in our public hospital network. Now the NTPF is paying them further to carry out procedures that they did not find or make the time, whatever is the case, to address in their capacity as public hospital consultants. Would Mr. O'Byrne agree with me that this suggests a conflict of interest?

To my mind, a referring consultant who is then the beneficiary in terms of being the treating consultant raises serious questions as to the appropriateness of such a situation. One might dismiss the incidence of 8.5% as identified by the Comptroller and Auditor General, but that is a considerable and unacceptable percentage. The practice is unacceptable, full stop and end of story. I am anxious to know what the NTPF has been doing about this. Does it accept it as the norm and that it will continue? Is it concerned about it in the way I have reflected my concern? Is it proposing to do anything to eliminate the practice, which I think must be a goal to be shared? I will leave it at that because this is an issue of major importance and I would like to have it addressed substantively.

I have a further question for Mr. Tony O'Brien, and again I apologise for missing his presentation. I had addressed a couple of questions earlier to the Irish Cancer Society, but I thought it more appropriate that I put them to Mr. O'Brien because they were never answered. I know they are in the domain of the national cancer control programme but I thought the ICS might have given me an opinion, which is all I sought.

My question relates to the significant number of women to whom invitations were issued to present for cervical cancer screening and because of inaccurate addresses, these were returned. May I have an update on that? Is there any way we could be assured that women are not falling through any safety nets as a result and are missing out on an important opportunity to have their test carried out? I had made the point to the Irish Cancer Society that it had been mentioned to me recently in these hallowed halls and others that women have been called by their GP to discuss their test results subsequently, having presented for cervical cancer screening. Their understanding was that there would have been a simultaneous issuance of the report to the women themselves, which has not happened in a number of cases that have been reported to me. I seek clarification. Is it not the case that these reports are to be sent out simultaneously to the woman and to the GP referring? If there an explanation as to why the woman would not have received the report? What steps can be taken to ensure that if it is the intention to issue simultaneous reports that is happening in 100% of cases?

Perhaps Mr. O'Byrne could deal with some of the questions.

Mr. Pat O’Byrne

I will try to do justice to all the questions that have been asked. I will take, first, the question on double payment. I will also include Deputy Ó Caoláin's point on the same issue. Quite bluntly, the NTPF does not engage in double paying of consultants. In the current year we have facilitated approximately 14,000 in-patients, that is patients who have received operations, and in the private hospital system, 111 of those were done by the same consultant. There are reasons for that which I will ask Professor Tanner to expand on. The second point is that we are allowed to purchase 10% of activity in the public hospital system — that is by direction; therefore, 90% of activity is directed towards private hospitals, 10% towards public hospitals. Within that 10% there will be cases where the same consultant does the work because there is no other expertise available. A good example of that is paediatric cases. As well as that, the Deputy referred to the Comptroller and Auditor General reports of 2002 and 2008. I will let the records speak for themselves. I do not think I am selective because the 2002 report states that about €500 million was spent on previous waiting list initiatives over the preceding ten years — the words used were — to little or no avail. That is the main reason the NTPF was established in the first place. In 2008 the record is clear in regard to NTPF prices as compared to case mix. The other point raised was in regard to the 8.5% of cases. I do not accept that figure. Last year 1.7% of the total cases purchased were purchased in the private system. About 5% were purchased in the public hospital system. That 8% includes outpatient cases that, admittedly, were conducted in the same hospital.

Deputy Naughten asked why I am not using Roscommon Hospital, Portiuncula Hospital and other hospitals. I am mandated to purchase no more than 10% in the public hospitals system. As I understand it, Roscommon Hospital, Portiuncula Hospital, University College Hospital, Galway and Merlin Park Hospital, are all part of the same hospital group. I have no problem if some of the NTPF quota for those four hospitals is conducted in Portiuncula Hospital or Roscommon Hospital. I do not dictate where the work is done. I do not accept the 8.5% because much of it is a mishmash of cases that if they were classified correctly they are not by the same consultant. For example, if a person was on an outpatient list in a public hospital setting and had never been seen by a consultant, how could he or she be referred by the same treating and referring consultant? To me, that does not make sense.

I do not understand what Mr. O'Byrne has said.

I think there is a misunderstanding.

Mr. Pat O’Byrne

I think so.

The misunderstanding is that they have already been seen by a consultant and referred.

Mr. Pat O’Byrne

They have not been seen by a consultant. They are GP referrals into a hospital. They are put on the orthopaedic list or whatever. The only outpatients we are involved with are those who have not been seen by a consultant. The reason we got involved in that in the first place was to try to speed up the process. The biggest bottleneck in the public hospital system at present is out-patients. I am on record as saying this. The problem is trying to get access for public patients to be seen by consultants. We got involved in out-patients in 2005 in a small way. The number of outpatients we provide each year is fairly small. We concentrate on those waiting longest. I mentioned in my opening statement that it is necessary to call twice as many outpatients as will be seen. Are these people being referred by the same treating and referring consultant? I do not think so. The other thing I would say about outpatients is that if we, as hospital managers, do not try initiatives and get involved in, say, retina screening in Tallaght Hospital, as we did last year, where I can get 1,000 patients treated for €70,000 or €80,000, those 1,000 patients would not be treated. Why should I not try that? In fact, it is incumbent on me to do that. Some 1,000 patients would not be treated if I did not try such an initiative. If I am being criticised for doing that, that is another issue, but I do not accept that 8.5% of those patients were referred by the same treating and referring consultant.

With your indulgence, before we go off that point, the 8.5% is not our view but the view of the Comptroller and Auditor General.

Mr. Pat O’Byrne

Yes.

It is his report that Mr. O'Byrne is rejecting.

Mr. Pat O’Byrne

I said I do not accept the 8.5%. I am not rejecting the report. Let us be clear on that. I do not accept the figure.

Mr. O'Byrne does not accept it. Before this, has Mr. O'Byrne in any way challenged that statement by the Comptroller and Auditor General in his 2008 report? When I made the point about being selective earlier, Mr. O'Byrne had no problem in referring to the same report as stating that it was an independent assessment of the NTPF as ensuring value for money and competitive pricing. I was making the point that was a selective piece from the Comptroller and Auditor General's report——

Mr. Pat O’Byrne

The Deputy was correct when he said that.

——but he did not refer to the 8.5%. Here is the kernel of it. Mr. O'Byrne has made an argument about 8.5%——

Can we proceed?

He accepts, nevertheless, that there is some level of this taking place. Whatever the argument about the percentage — we will let the Comptroller and Auditor General come back — my question was, what steps is Mr. O'Byrne taking? Does he accept it is an unacceptable period and what steps is he taking to eliminate it altogether?

Mr. Pat O’Byrne

I said in the current year that there were 111 cases out of 14,000. I do not accept that it should be eliminated altogether because there are mitigating circumstances and patient-benefit reasons it should happen.

Does Mr. O'Byrne want Professor Tanner to address that issue?

Professor Arthur Tanner

It is fair to say that if one looks at the issue from the point of view of the consultant in the public hospital, he or she does not wish any patient of his or hers to be taken off his or her waiting list. They would like to be able to carry out the work within the public sector. I come under quite a bit of pressure from my colleagues in the public sector from the point of view of why the money from the NTPF is not put into dealing with more patients in the public sector. The unfortunate point, however, is that it is not the consultants' fault that they are not able to operate within the public sector. It is a capacity problem. The only way one can deal with that problem is by creating more beds in the public sector or by purchasing spare beds from the private sector.

Some patients need the care that can be provided for them by their original consultant, who cannot, despite his best efforts, do the necessary work within the public sector. Therefore, it is in the patients' best interest — I refer to the 111 patients — that they be referred to the same treating consultant. Certain procedures can only be carried out by one or two consultants in the country. These include oblation and heart valve surgery, for example.

Every one of the 111 cases comes on to my desk. I must make a decision on whether it is in the patient's best interest that he be treated by the same consultant as he had in the private sector, which has the capacity, beds, theatre space and anaesthetists to do the work. The decision is always taken in the patient's best interest on medical grounds only.

That is very clear.

I apologise because I must leave. A group has been waiting for me since 5.30 p.m. I would appreciate it if I could receive written answers to the questions I asked.

Any matters not addressed during the meeting will be dealt with in writing.

Professor Tanner, with whom I am very reluctant to disagree, should note there is a third way, namely, to get better use out of existing capacity. Why is it that a consultant ophthalmologist performs nine cataract operations per week in a public hospital when he can carry out ten on a Saturday in a private hospital? That is a big question.

Professor Arthur Tanner

Yes.

I ask Mr. Pat O'Byrne to conclude as briefly as he can. I regret there are time constraints.

Mr. Pat O’Byrne

With regard to OPD, questions were raised about access for public patients. We agree there is a big problem in that regard. It was mentioned in the context of the accuracy of the PTR that we do not collect outpatient waiting lists; rather, we only collect inpatient waiting lists. I do not know about accuracy or otherwise but am saying our experience is that there are problems with outpatient lists.

Questions were asked about the budget. I do not know the budget for next year and do not believe anybody knows it at this stage.

I do not determine what a long time is in regard to colonoscopies; all I am saying is that I deal with colonoscopies that are deemed non-urgent and that are listed on inpatient waiting lists for more than three months. There is an offer to deal with all patients who have been waiting for more than three months. With regard to MRIs, the Chairman asked whether referrals from GPs could be dealt with. The answer is "Yes". We are prepared to sit down and talk about this. There is no doubt but that more MRIs could be dealt with.

Questions were asked about nursing homes. I tried to explain that our remit under the nursing home legislation is fairly specific in terms of costs. We do not have the budget. We price private and voluntary nursing homes and do not price homes in the public system.

Deputy Aylward asked why so many patients are on waiting lists for more than 12 months. At present, approximately 900 patients around the country are on surgical waiting lists for more than 12 months. Half are deemed suitable for in-house treatment only in the public hospital system. This means they should not be referred out under the NTPF.

Why? That is not satisfactory because patients are waiting.

Mr. Pat O’Byrne

I am not saying it is. I am saying that the patients are deemed suitable to be treated only in-house in the public hospital system. I must accept that. There is no compulsion or compellability in the system at present such that patients who are waiting longest can be treated by means other than through referral to the NTPF. Approximately 1.2 million overnight and day-case patients go through the public hospital system every year. If 1.2 million cases can be dealt with, why can a small number of cases, amounting to between 400 and 500, not be dealt with over 12 months?

Problems arise in regard to the management of waiting lists in a small number of hospitals. That is another reason some patients who could be referred to the NTPF are not being referred to it.

What about those who are referred to the NTPF but are told by it that it cannot take them and that they must wait a year? I return to the issue of orthopaedic services in Tallaght. Why do we not have uniformity in our approach? Why should somebody who is referred to Tallaght suffer for a year before he can be taken on board if some other part of the country can provide the service much more readily?

Mr. Pat O’Byrne

There are particular problems in Tallaght with orthopaedics. We increased the number of hip and knee procedures we agreed to carry out in Tallaght this year by 100% but I cannot deal with all of Tallaght's orthopaedic problems. My budget does not allow it. However, I have increased our input in orthopaedics this year by approximately 100%. The waiting time for hip and knee procedures in Tallaght has reduced to seven or eight months.

An orthopaedic ward is being closed down in Kilcreene in Kilkenny. I did not want to mention names but now names are being mentioned. An effort is being made to keep the second ward but it is being closed down although it has perfect services. Seemingly, the patients are going to nearby private concerns in the south-east. I am told the public system can carry out the same operation for €4,000 less than the private system. Perhaps my information is wrong but, if not, money is being saved all around by the NTPF and the insurance company providing the cover.

I ask Mr. O'Byrne to deal with that, after which we will proceed to Mr. O'Brien.

Mr. Pat O’Byrne

In the first instance, nobody in the south east tells me he can carry out hip procedures for €4,000 less than in the private sector. The NTPF is restricted in terms of the number of referrals it can make to the public hospital system. We can only refer 10% of the total number of cases to the public hospital system. The remaining 90% of cases are referred to the private hospitals. That is a restriction.

Who can change that?

Mr. Pat O’Byrne

It is a policy matter.

If there are other issues that Mr. O'Byrne has not dealt with, perhaps he can correspond with us in regard thereto.

I do not wish to be contentious but I have a straightforward question for Mr. O'Byrne. Has he indicated to the Comptroller and Auditor General that he does not accept the claim in his report that, in 8.5% of cases, the referring and treating consultants are the same?

The Deputy made that point clearly. Is the answer "Yes" or "No"?

Mr. Pat O’Byrne

No.

Mr. Tony O’Brien

I will group the subjects and address them as quickly as possible. With regard to CervicalCheck and the overall level of participation, the target population, as best we know from census data, was 1.1 million women. The aim is to screen at least 80% of the population by the sixth year. At the end of the second year, we had screened 565,602 women, which is almost exactly 50% of the population. This would objectively be regarded as a good level of activity.

With regard to the recall process, the recall per screening interval is three years. We have not reached the third year yet so we have not triggered the routine recall system. When we trigger it, everyone will be recalled who has not had intervening treatment on the third anniversary of her first test. The screening will roll on sequentially.

Deputy Reilly referred to the fact that, in March 2009, 48,363 women received screening whereas, in March 2010, 38,383 received it, the inference being that the introduction of the call-recall system led to depression in uptake. He did not mention March 2009 was the month in which the reality television star Jade Goody died of cervical cancer. This led to a very significant surge in screening throughout Europe. I would not expect that to be replicated in any subsequent year. Deputy Ó Caoláin asked about letters. This country does not have a population register, so in common with our other screening programmes, we are developing a register using a number of data sources which we will then duplicate. The simplest way of verifying whether the contact details we have are correct is by sending a letter to the address we have. Our return rate is approximately 5%, which is considered to be within the bounds of expectation. This is the cheapest way we can verify whether an address is correct. We supplement our register with self-registration and with the right of general practitioners and others to directly recruit into the programme. Sending letters is what I would call our safety net. That a number of letters rebounded was neither unexpected nor exceptional, although it was greeted with some surprise at the time. I understand a similar system is used by the Department of Social Protection as a mechanism for checking the validity of addresses used by claimants and it is considered an appropriate way to go.

On the question of sending the reports to women, we do not send them the report, but send them a letter confirming that their GP has the result. In the early stages of the programme, due to the speed with which our outsource laboratory service provider returned data to us, we discovered that we were causing a problem by getting our letters out to women telling them to contact their GP for their result before their GP was in a position to give them that result. That caused unnecessary concern, so we deliberately slowed down to give GPs the opportunity to make contact. Our letter therefore is in the nature of a fail-safe letter, to ensure that the woman is aware her GP has her result. Ultimately, every woman receives a letter from Cervical Check regarding her result. However, we have ensured we are not too speedy in sending the letters out because they were causing an unintended, unexpected problem.

Deputy Lynch asked certain questions which I will answer here but I will also make contact with her on the issues. The issue in Cork University Hospital, CUH, is not a negative reflection on the excellent cancer centre which has developed there and which in terms of its symptomatic services performs extremely well. In all our centres, from time to time we experience difficulties with adhering to our surgery admission charter, which is 90% within 21 days where we have uneven patterns of cancer detection which present challenges for hospitals. Therefore, I would judge CUH not on whether the problem occurred, but on how it responded. It has responded very well, with significant additional theatre lists and so on, to ensure that the problem can be brought into line. Deputy Lynch asked whether any breast cancer patients were being referred back to the South Infirmary. They are not. All of the breast cancer surgical treatment, for symptomatic women and BreastCheck patients takes place in CUH. However, in common with every other place from which breast surgical services have been withdrawn, the administration of medical oncology remains in the South Infirmary, as it does in places like Sligo and Drogheda. Therefore, there would be a referral back to the South Infirmary for women for whom that is a more convenient location to receive medical oncology. It is in that context women return to that hospital and that is appropriate.

Several questions were asked about human papilloma virus, HPV, immunisation. We are not responsible for the administration of the HPV immunisation programme and I have no information on it. The HSE's national immunisation office is responsible for it. Deputy Reilly asked whether there was a timetable for the extension of the age range for BreastCheck, but as I indicated earlier there is no timetable in place currently. While there is clear evidence that the next move should be an upward move, this is dependent on resources. By this I do not mean financial resourcesper se, but the availability of the skilled personnel necessary to deliver the programme, specially trained mammographers and radiologists, both of which are in short supply. We do not currently have the capacity to deliver the programme to a greater population. This is not affected directly by the moratorium, but is a particular problem. With the significant increase in our capacity in symptomatic breast services and the number of additional radiologists that have been recruited, we have, effectively, absorbed the current supply. I suppose that is a good problem in that we have managed to appoint so many to deal with symptomatic issues.

With regard to the bowel cancer screening programme, the advanced nurse practitioners are not intended to be productive for three to five years. We are working in partnership with the HSE's national nursing directorate and An Bord Altranais in drafting and agreeing the scope of practice for advanced nurse practitioners. We are also working with the assistance of key contacts in the English and Scottish bowel cancer screening programmes, who are advising us on the development of the programme. We anticipate that early in 2011, subject to the regulatory approval I have already mentioned, between 15 and 20 advanced nurse practitioner candidates will be appointed. They will become the key link persons between the National Cancer Screening Service, NCSS, and the individual screening colonoscopy units. It is only once they have fully qualified that they will be in a position to become productive in terms of delivering colonoscopy services. Currently, there is no hard and fast time line with regard to the outward age range extensions and given that we have not yet started the programme, it is reasonable not to include a time line.

In the context of the screening programme and colonoscopy services more generally, the work we are undertaking with the joint accreditation group is being undertaken to level up quality and improve efficiency within our endoscopy services. The work my colleagues are doing is very important. The more fundamental requirement is to fix any deficiencies within the services and that is the purpose of the work being undertaken currently for the screening programme and with the quality and clinical directorate for other services.

A number of questions were asked about programmes in which we are not involved, such as prostate and lung cancer programmes. I will ask my colleague, Dr. Alan Smith, to speak about those.

Dr. Alan Smith

There are well established international criteria to evaluate the case for any new screening programme, be it for prostate, lung or any other cancer. The criteria number more than a dozen, but can be distilled into three key ones: whether there is an accurate screening test; whether the condition being screened for can be treated; and whether we can make a difference in terms of mortality and whether we can save lives. There is no point in just detecting these diseases and putting a label on a person to say he or she has cancer, if one cannot, ultimately, make a difference at a population level.

With regard to where we would seek this evidence in the case of prostate cancer, we seek it through randomised control trials. We are in an evidence based era and must look to evidence to support our policy decisions. Two randomised control trials are under way to examine screening for prostate cancer and these reported for the first time last year. One of the trials is US based and the other Europe based. Both trials had conflicting results so we are still in the same position where there is insufficient evidence to support a case for a population screening programme for prostate cancer.

The problem currently is that the PSA screening test, the one most often referred to, does not seem to be sufficiently accurate. There are also problems with regard to treatment. There is a division of opinion in terms of the best treatment for particular individuals, whether it should be radiotherapy, surgery, a combination or a watch and wait approach. On whether we can make a difference in terms of mortality, the results from the randomised control trials are mixed. One says it makes no difference. Screening will detect more cases, but what it seems to detect are those milder localised cancers that stay localised in the prostate gland and which are ultimately destined not to cause any harm. It is a cancer one dies with, not necessarily from. The jury remains out, therefore, on whether we should implement a population screening programme for prostate cancer. We need to await results from the randomised control trials.

The same can be said for lung cancer. There is no accepted screening test for lung cancer. Surgery is the standard form of treatment, but from the population perspective it does not appear to make a mortality difference. This is not anybody's fault, just the limitation of science and medicine at the present time.

Mr. Tony O’Brien

To add to that, the HSE, through the National Cancer Control Programme, has focused on putting in place rapid access lung cancer assessment units to provide more speedy access to treatment when lung cancer occurs. It recognises that in Ireland, the level of surgical intervention for those with lung cancer is relatively low and survival prospects are poor historically. The rapid access service is designed to deal with that.

I failed to answer two questions. Deputy Conlon asked about access to the colorectal screening programme. We will compile a national register of eligible persons and will contact them directly. That will be supplemented by public information encouraging registration so it will be a proactive communication. In regard to cervical screening for those under 25 years of age, all the evidence is going in the opposite direction. Our colleagues in the Northern Ireland screening programme recently received a policy decision from the Northern Ireland Executive to increase the entry age from 20 to 25 in line with that evidence. We anticipate no downward move in the entry age for CervicalCheck.

I thank Mr. Tony O'Brien, Dr. Alan Smith and all those representatives with Mr. Pat O'Byrne from the National Treatment Purchase Fund. We salute them for the excellence of the service that both organisations are delivering and we look forward to engaging with them in the future. I apologise for the delay in getting to them, our earlier session ran over time.

The joint committee adjourned at 5.30 p.m. until 3 p.m. on Tuesday, 2 November 2010.