Léim ar aghaidh chuig an bpríomhábhar

Special Committee on Covid-19 Response díospóireacht -
Friday, 17 Jul 2020

Non-Covid Healthcare Disruption: Waiting Lists and Screening

I welcome our witnesses, who are in committee room 2. From the Irish Cancer Society, ICS, I welcome Ms Rachel Morrogh, director of advocacy and external affairs, and Mr. Donal Buggy, director of services. From the Irish Medical Organisation, IMO, I welcome back to the committee Ms Susan Clyne, chief executive officer, and welcome Dr. Peadar Gilligan from the IMO's consultant committee and Dr. Denis McCauley, chair of the IMO's GP committee.

I wish to advise the witnesses 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 this committee. If you are directed by the committee to cease giving evidence in relation to a particular matter and you continue to so do, you are entitled thereafter only to a qualified privilege in respect of your evidence. You are directed that only evidence connected with the subject matter of these proceedings is to be given and you are asked to respect the parliamentary practice to the effect that, where possible, you should not criticise nor make charges against any person or persons or entity, by name or in such a way as to make him, her or it identifiable.

I invite Ms Morrogh to make the opening remarks for the Irish Cancer Society. I ask that she confine them to five minutes to allow time for questions and answers.

Ms Rachel Morrogh

I thank the Chair and members of the Special Committee on Covid-19 Response for inviting the Irish Cancer Society here today. We wish to start by formally recording our appreciation for healthcare workers, support staff and anyone involved in the delivery of healthcare during the pandemic which includes our own staff at the Irish Cancer Society. Their selflessness allowed for the ongoing provision of urgent cancer services in even the exponential phase of the Covid-19 pandemic. This included the Irish Cancer Society's night nursing team who provided nursing care in the home of patients who were at the end of their lives.

Our national support line was extended to seven days a week to assist with increased queries from anxious patients and family members. Our volunteer drivers continue to provide transport to people right across the country enabling patients to get to life-saving chemotherapy treatment.

Regarding the impact of Covid on cancer services, a few key points need to be addressed. On 27 March all non-essential surgery, screening and diagnostic procedures were postponed causing huge additional anxiety for patients. The impact of these postponements on cancer outcomes will take years to be fully uncovered. The immediate impact is that it has led to thousands of people not being screened, as well as growing waiting lists for cancer tests and treatment. There is little clarity in sight as to how these will be addressed. It is evident that without immediate action there will be excess and avoidable cancer deaths in the years to come as a result of people getting the care they need later than they should. An illustration of this is that we would expect approximately 450 cancers and 1,600 pre-cancers to have been detected in a typical four-month period if the screening services had been operating as normal. As such, we are very pleased that CervicalCheck has now resumed but disappointed that BowelScreen and BreastCheck may not return until autumn. In addition to screening we are concerned that there are still symptomatic patients who have not sought medical advice and as a result may experience a delayed diagnosis and access to treatment. If action is taken immediately then we might avoid the most dire predictions becoming a reality. Some of these are included in the submission we made to the committee.

As a first step the HSE must publish a recovery roadmap without delay and the Government needs to fully fund this before budget 2021. The crisis in cancer care pre-existed Covid-19 and the pandemic has just made things worse. Before Covid, targets in the national cancer strategy relating to timely access to diagnostics, surgery, radiotherapy, and the uptake of screening were all being missed. This is a direct consequence of consistent underfunding of a system that has been running to stand still in recent years and which has frequently budgeted in the knowledge that it will not meet demand. As such a return to normal is in fact undesirable for us. We want and need to do so much better. All of us - Government, Oireachtas Members, advocacy organisations and healthcare workers - need to ensure that cancer services are fully restored in the short term. We need to take the opportunity to build back a better cancer system focused on the full delivery of the national cancer strategy. Rather than using a challenging environment as a reason not to improve services, we need to use it as the precise reason for building better, more equitable, high-quality care that addresses the many needs of cancer patients in Ireland.

I thank Ms Morrogh.

I invite Ms Clyne to make her opening remarks and ask that she also confine them to five minutes to allow for questions and answers.

Ms Susan Clyne

Good afternoon. I thank the committee for the opportunity to address it.

The IMO is the trade union and representative body for all doctors in Ireland who are delivering care to patients across the health services. This includes consultants, public health doctors, community health doctors, GPs and non-consultant hospital doctors, NCHDs. The fundamental problem within our health services is one of capacity and this predates Covid. As a country, we have restricted patient care to match the deficits of our services rather than investing in those services to meet patient need. The Health Service Capacity Review was published in 2018 but little or no progress has been made since. Covid has resulted in extreme pressures on our health services. Our response should not be to limit all other care, but to proactively increase capacity to allow for non-Covid care pathways and create capacity for any Covid surge. To do otherwise will only compound the problem. It is inevitable that patients whose care has been delayed will present with more complex needs as they deteriorate and they will suffer negative health outcomes. Mortality rates will increase. We now have a situation where capacity will be reduced by up to 50% while at the same time there are more than 800,000 people waiting for an outpatient appointment or inpatient care.

We have mounting pressures on our emergency departments throughout the country. Extremely limited referral pathways are available to GPs and there are increased pressures on GP services in situations when patients cannot access secondary care, diagnostics, mental health services and other community supports.

There is severe overcrowding in our emergency departments with patients languishing on trolleys, elective procedures are routinely cancelled, there are lengthening waiting lists and hospitals are operating at dangerous levels of occupancy. Unfortunately, this year will be worse with the additional impact of Covid-19.

In summary, we have too few beds and we need to plan for an additional 5,000 public acute beds and 300 additional ICU beds. In this context, we must immediately embark on a temporary build programme in tandem with longer-term builds. We have more than 500 vacant consultant posts, and for many years the system has not been capable of attracting sufficient numbers of consultants due to inequitable pay policies. General practice and the much needed shift of care to the community must be planned and resourced. There is little additional capacity in general practice at the moment. We must strengthen our public health capacity. We have relied on public health throughout this crisis, but public health is understaffed and undervalued within our system. Care of the vulnerable and elderly in our society requires urgent attention with significantly more resources deployed to allow people to remain at home. We need to continue to invest in prevention with appropriate resourcing of our vaccination programmes and significant investment in diagnostics and treatment pathways to support our screening programmes, and those screening programmes should open as soon as practicably possible. We also need to invest in e-health across all hospitals and community healthcare settings.

Since the commencement of the pandemic, doctors and all other healthcare workers have shown dedication to patients, professionalism and agility in adopting new ways of working. We now appeal to the members of the committee and the new Government to respond in kind to support us and our patients by investing immediately. This is a health crisis and we must respond accordingly and prioritise investment in our health services.

I welcome Ms Morrogh and Ms Clyne. I thank them for the kind words expressed about our front-line staff across all our healthcare settings.

As a committee and as Oireachtas Members we have to look at a health catch-up programme that includes acute care across a range of specialties and we are looking at mental health services and older people. Obviously there are challenges for the healthcare system to catch up on delayed care. I will start with cancer screening. Ms Morrogh referred to this in her opening statement when she said that thousands of people had not been screened, that it may take years before we know the full extent of what this will mean for patients, and that some patients may die prematurely if we do not put in place the catch-up and if people do not get a diagnosis as quickly as they should. How serious is this matter? Is Ms Morrogh satisfied that enough is being done by the Department of Health and the HSE at this point in time to get the screening services back up and running? That is a starting question.

Ms Rachel Morrogh

The Irish Cancer Society believes it is imperative to get screening services restored, and restored to the way they were before Covid-19. We know the environment is extremely challenging but consider the figures calculated by the Irish Cancer Society. Some 450 cancers have possibly been undetected to date and additional pre-cancers have been undetected. One can start to understand that without our screening programmes Ireland is missing a central plank in its cancer prevention and early detection strategies. If we do not restore the screening programmes to the high-quality screening systems that were in place before Covid-19 then we risk the general public's health and the chances they have of being diagnosed with cancer early. We know the importance of an early cancer diagnosis. If a person is diagnosed at an early stage then his or her chances of survival are so much better. Ireland is not doing well in cancer survival. Ireland is lower than the OECD average and we need to do much better. This is why the national cancer strategy sets out that blueprint for excellent cancer care, and why we as an organisation, and many other organisations, are extremely disappointed at the lack of momentum and funding behind that strategy.

We want the screening programmes to be restored as soon as possible. We are pleased that CervicalCheck is getting under way. For breast and bowel screening, there are people who, unfortunately, have cancer and do not know it. Until those screening programmes are restored, we are not giving them the best chance of detecting that cancer as early as it could be.

I thank Ms Morrogh. She said earlier that before Covid, we already had untimely access to diagnostics and we now have a backlog, which creates more problems and challenges. The HSE will tell us today that it accepts that there is a developing backlog of cases, including in the four main screening programmes, including cancer. It says that this backlog will now have to be cleared in a Covid environment. If Ms Morrogh was talking to the HSE, what is the timeframe? One can say that we will clear the backlog but in reality, how quickly do we need to clear that backlog? From Ms Morrogh's perspective, what timeframe are we looking at?

Ms Rachel Morrogh

We need to clear it quicker than we are. We need to do a capacity review and we have made that recommendation in the submission to the committee. It is important to know what capacity is there. In the case of endoscopy services, capacity has been reduced to between 30% and 50% of pre-Covid levels. Before Covid, there were extremely long waiting times for non-urgent colonoscopies. There is a cancer detection rate within that group. There are currently 19,000 people waiting for a colonoscopy. How are the endoscopy services able to do more, since there is a backlog, with less, due to the capacity issue? We need to consider, while I do not know the answer to this, whether the workforce has been fully restored or if people are still in roles to provide Covid services. We have many different things to consider but we need people to take action today. We are at a crossroads. If we do nothing, we face a dire situation.

If we do not take urgent action, the dire situation is that, unfortunately, people will die of cancer prematurely because of a lack of a diagnosis. Is that the case?

Ms Rachel Morrogh

Unfortunately, that is the case. We need people to be diagnosed early. That gives them the best chance of survival. We are worried that some people have not accessed medical services yet. Perhaps they are worried about seeking help in a healthcare environment. We strongly encourage them to phone their general practitioner if they are worried about going in themselves to seek the help that they need. If a person is diagnosed with cancer early, he or she is much more likely to survive it. The likelihood is that if anyone has a sign or symptom of cancer, it is, one hopes, not that disease, but it needs to be checked out.

I see that in Ms Morrogh's submission and opening statement she refers to public awareness campaigns to encourage people to get screened and checked, and to have a diagnosis. If the capacity is not there, the screening services are not up and running, and people are contacting the programmes but not hearing back, that will add to their stress. Ms Morrogh is right in saying that we need to have advertising programmes and that people need to be informed and encouraged. If we do that, would Ms Morrogh agree that it is important that the programmes are up and running? Otherwise, it gives people false hope and adds to the stress that they will be under.

The submissions that we have got from both organisations are really high quality, with many good recommendations that this committee should forward to the HSE. The IMO talks about investment in diagnostic and treatment pathways being needed to support the full re-establishment of these life-saving programmes. It is talking about the screening services. Would Ms Clyne from the IMO speak generally about the need to accelerate the reopening of screening services and the importance of it from her perspective?

Ms Susan Clyne

The screening services are important and have been a major health initiative over recent years. The IMO would fully support that. There is a slight difference in the screening services between the women and patients who are called for screening and the encouragement of patients who are developing symptoms outside of screening. Screening is not a diagnostic tool in and of itself.

The message we give to the public should be that anyone who discovers any lumps or bumps about which they are concerned should contact their GP. We need very quick referral pathways from general practice into cancer services in hospitals. The screening programmes are one element of the issue and they are valuable. There is also the issue about the public being almost afraid to attend or concerned that the service they need will be unavailable. It is important that members of the public attend or call their GP when they notice a change in their health. We cannot make everything about Covid-19.

That is an important point and I accept it. I just want to put a further two questions to Ms Clyne because we are tight on time. There is an awful lot I would like to ask about, but we are confined by the time limits. Ms Clyne mentioned preparation for the winter flu season and what will happen with the added concern of Covid-19. Those concerns relate to vaccinations and how they are rolled out, as Ms Clyne referred to. I ask her to expand on that.

Ms Clyne has also talked about the need to increase physical capacity in the system. We have also heard from the HSE that the two-metre social distancing rule has meant that capacity is down approximately 25% in acute settings. Is there a need to get additional physical space? Is that what Ms Clyne is calling for and has she made submissions to the Department and HSE in that regard? What type of physical accommodation is Ms Clyne talking about? What would that additional capacity be needed for?

Ms Susan Clyne

There is absolutely a need for additional capacity and there has been for more than ten years. We cannot possibly accept that we are delivering a health service with this reduced capacity. All it will mean is that things get worse, problems will be worse, and people will get sicker. Temporary builds must be the first option. Purchasing or renting space will have to be the second option, while we develop longer term deals or acquisitions. Other than the provision of funding, there is no reason temporary builds cannot proceed. I will ask my colleague, Dr. Gilligan, to speak to the question about the bed situation.

Dr. Peadar Gilligan

As committee members are aware, we have had significant issues with capacity and occupancy in the acute hospital system for many years in Ireland. There are currently 580,000 people on outpatient waiting lists and nearly 250,000 people awaiting various procedures or day case admissions. There was already huge pressure and massive unmet need within the system at a time, before Covid-19, when we were running our acute hospitals at between 97% and 104% occupancy. The public is aware of this because members of the public are waiting for procedures. They are also aware of the fact because of the level of crowding in emergency departments. We can never return to a situation where, when a patient arrives to an emergency department with an emergency condition, he or she is faced with a crowded waiting room, treatment area or resuscitation room. The only way to move away from that situation is by having the required capacity. We were advised in 2018 that a minimum requirement of 2,690 beds needed to be addressed. In the context of the Covid-19 crisis, that minimum requirement has, conservatively, increased to 5,000 beds.

Dr. Gilligan can reply further in writing. I thank him very much. Somebody else may wish to ask him about the same point, but I must give way to the next speaker, Deputy Colm Burke of Fine Gael. Is the Deputy taking ten minutes?

I am taking ten minutes. I thank our guests for their presentations this morning and the work they have done over the difficult past four months. I especially thank the front-line staff in all our hospitals and community settings.

We are facing new challenges. The hospitals do not have the same capacity because of issues around social distancing and the new processes and procedures that must be followed. I am regularly hearing GPs complain about a lack of access to diagnostic services. Is there any way that we can fast-track and improve that service immediately? People are being referred to outpatient clinics that duplicate a lot of the work that GPs are already doing, but GPs have to refer patients because they cannot get access to diagnostic systems. How can an improvement in that regard be fast-tracked?

Since December 2014, the number of people working in the HSE has increased by 20,000. The figure has increased from 103,000 to 123,000 whole-time equivalent staff. If we were to prioritise recruitment in the morning, which areas should be prioritised? When consultants are recruited they also need to have access to beds, operating time and support staff. Where should the priorities be for staff recruitment?

Ms Susan Clyne

I will answer some of the Deputy’s questions and pass others on to my colleagues.

The idea of prioritising has been the fundamental problem. We have to accept that our health services do not have enough doctors, nurses and other health professionals working in them. We have to accept that we do not have enough beds. This idea of robbing Peter to pay Paul and making a choice between a consultant and a nurse will not improve the lot of patients. We need significant financing of our health services and we must take this opportunity, as our colleagues in the Irish Cancer Society said. We do not want to go back to the way it was before Covid-19 when it was not good. We want to move on and go back to a system that meets patients' needs and allows people to work in a system and deliver the care they are trained to deliver, rather than running around everywhere trying to source a diagnostic for patients.

On the issue of diagnostics in general practice, I have been looking at budgets from various Governments for many years that show an allocation for diagnostics for general practice, but this budget has yet to materialise. I understand representatives of the HSE who appear before the committee this afternoon will say the HSE is bringing diagnostics to general practice. We would very much welcome that. We would also welcome sitting down with the HSE to see how that will be run. If GPs had quicker access, we would prevent some people from being referred to hospital. People will still need to use hospital services so these services cannot be limited by virtue of capacity. We have to think outside the box and ask how, if this is the limit, we will improve capacity, not just operate within capacity.

I will ask my colleague, Dr. McCauley, who is the chair of the general practice committee and a GP in County Donegal, to talk about the diagnostic flow through from the GP to secondary care.

Dr. Denis McCauley

I thank Deputy Burke for his question. On the principle of care within the community without referral to the hospital, the clinical evidence is that this approach is effective and also cost-effective. When that care is properly resourced and planned it works.

Last year, the Irish Medical Organisation introduced a deal under which chronic disease will be managed more in the community. We will be able to manage some 80% of the chronic diseases in general practice to a very good standard. The resources, evidence and planning for this are available. This is a template we can use in other areas. As Ms Clyne has said, 20% of those people will need to be referred on. The concept of care within the community is good for a certain cohort.

There is no doubt that if diagnostics were more freely available to us, we would be able to attend to a certain number of people and reassure them that everything is fine. We could also be able to identify people who need to go to hospital. There are ad hoc systems in place throughout the country where scanning has been made available to GPs. The feedback is that these are responsive, very effective and give reassurance to patients early on that everything is fine. It also gives reassurance to the doctor that the person does not need to be referred. If 100 people with abdominal pain come in, it will be possible to identify and screen out those who need to go to hospital.

Does there need to be a more structured approach to GPs accessing diagnostics? The big complaint I have is that-----

Dr. Denis McCauley

Yes. Following on from that point, when GPs have access to the ad hoc system, where that is available, it is very useful. To make the system effective diagnostics need to be available to all GPs nationally. The word we are hearing is that there will be a system whereby GPs will have more access to diagnostics. If such a system is announced by the HSE, implemented and made available to all GPs, it will be supported by the IMO.

Is the IMO satisfied that this can be fast-tracked in order to help?

Dr. Denis McCauley

That is beyond my pay grade. If it is fast-tracked, that would be a positive development but I would have no influence in that. I would only encourage that it is fast-tracked. It is like all systems in that it is in the community and it would be cost-effective management. Therefore, it would ultimately save money and lives, which is what we all want. We primarily want to save lives but if it saves money as a secondary feature, that is excellent.

I want go back to the cancer services and how they are coping with the new challenges. What kind of numbers do we need to be able to deal with these new challenges in staffing numbers? Have we looked at what we need in that area and where we can recruit staff from? One of the other issues we have with healthcare is that while everyone is talking about the numbers of people we have in the system, no one is looking at the numbers of people who will be retiring out of the system over the next three to four years, which is also something that needs to be looked at. I am not sure if we have any figures from the HSE on the numbers of people who are retiring out, including nurses, care assistants and consultants.

Ms Susan Clyne

I can quickly respond on the manpower issue and Ms Morrogh will talk specifically about the oncology and cancer manpower services. We know that over 600 GPs are due to retire out of the system in the coming years and there are no supports to help younger GPs to establish themselves. We also know there is a large percentage of consultants who are due to retire. This information is easy to get. The HSE has the data of everybody in the system.

We have failed miserably to attract people to work in the system. That is down to the undervaluing of doctors and other healthcare professional staff within the system and this is known. The healthcare capacity report from 2018 clearly indicates what levels of manpower we need. That is starting from a base of where we have manpower but we are 500 consultants short in the system. That is 20% to 25% of the workforce on any given day that we are short of in the system.

The IMO made a request to the HSE and the Government that specialist registrars, SpRs, who had qualified and finished their training in July of this year would be given a locum post for six months because they cannot travel on to do fellowships. They have not been given those posts. Some are now operating in jobs way below their skill levels and they are not there to deliver much-needed services to patients.

How many SpRs is Ms Clyne talking about?

Ms Susan Clyne

There were 160 SpRs who finished their training two weeks ago.

Of that number-----

Ms Susan Clyne

Not one was given a locum consultant post.

Ms Susan Clyne


Has there been any response from the Department on that matter?

Ms Susan Clyne

We put in a submission and there was no response. Anyone can see on social media that NCHDs, the hospital doctors I am talking about, are working over 24 hours on a shift, which is illegal and in complete breach of their contracts. They are burned out. They have been scrabbling around for jobs at the changeover, moving locations and going to different parts of the country to try to source jobs. Many are working below their training grades.

On the SpRs, is it in all categories?

The time Deputy Colm Burke takes will be taken from another Fine Gael speaker subsequently.

In what areas are the SpRs qualified?

Ms Susan Clyne

All of the specialties and all of the training programmes. I can send the Deputy a listing of the number of SpRs who have qualified in each of the specialties later.

I am sorry I had to cut across Deputy Burke but it is difficult to get everybody in.

I thank both organisations for attending today. I hope to use some of the responses the witnesses will give in the sessions with the HSE later on. What level of engagement have the Irish Cancer Society and the IMO had with either the HSE or the Department since the pandemic in terms of the restoration, or as has been said, the improvement of services?

Ms Rachel Morrogh

We have been in touch with the Department, the HSE and the National Cancer Control Programme, NCCP, about preparing cancer services for the pandemic since before the first coronavirus case in Ireland. We wanted to ensure that urgent tests and treatment continued throughout the pandemic and that Covid-19 would not be prioritised for all resources at the expense of non-Covid-19 diseases. We were pleased that the urgent tests and treatment continued. We continue to have good engagement with the HSE, the Department and the NCCP. To make any progress, we need to see the HSE continuity plan and we need it to be funded. That is where we will see what is next for cancer services and for the health service generally.

Ms Susan Clyne

In fairness to the HSE and the Department, we engaged with them very quickly at the outset of the pandemic. However, that was more in regard to GP issues. We have had little or no engagement about the building up of capacity. We are disappointed that some of our manpower requests have not been addressed. In fairness to both the HSE and the Department, the core issue behind most requests from organisations like our own or the Irish Cancer Society is funding.

I was going to say "Ms Morrogh", but I am very familiar with her from my days on the rare disease task force so it seems quite strange to address her so formally. Perhaps Rachel would outline the feedback from the cancer support line on the impact on the mental health of patients who have already been diagnosed with cancer. Could she outline some of the experiences she has heard about, albeit anecdotally?

Ms Rachel Morrogh

I thank the Deputy. I will pass that question to my colleague, Mr. Donal Buggy, who is the head of services and has real insight into that.

Mr. Donal Buggy

Upon the shutdown of the country in mid-March, the Irish Cancer Society immediately extended its nurse helpline services to seven days a week with longer hours in the evening. That was intended to address the distress we were hearing on our phone lines on a daily basis. We were also in a position to very quickly start a new remote counselling service to step into the breach where the usual psychology services were not available. That has been a very successful programme. We have linked up with Cancer Care West and the National Cancer Control Programme to provide psychological and psychiatric assistance to those services. That has been really valuable. More than 150,000 patients have used that service to date. As lockdown eases, we are finding that distress is increasing among cancer patients, many of whom continue to cocoon or remain very concerned about the impact of infection on them. We have also had lots of conversations with parents of children with cancer who are extremely concerned about their children contracting Covid-19. They are also very concerned about their children's development, their treatment, and how their families will cope with the challenges of continued isolation. This issue is growing. Rather than a decreasing psychological impact as we move through the phases of reopening, we are seeing increased distress and an increased number of people calling our services to seek psychological help and support. That will continue in the future.

To expand on that point, I have been contacted by several people who have rare forms of cancer. They have found the lockdown period very difficult. However, as we emerge from lockdown there is so much uncertainty about how they can safely operate in society and the period for which this will continue is indeterminate. In many ways this is having a more severe impact on their mental health. Does Mr. Buggy believe the Irish Cancer Society is currently able to meet that demand, or are additional programmes or funding needed to cater to mental health needs?

Mr. Donal Buggy

We are able to meet some of the demand, but that does not take the place of a properly funded psycho-oncology service, as envisaged in our national cancer strategy. It sets out what I think is a very comprehensive plan for psycho-oncology services, but again the funding is not in place for that. There are also issues for patients' employment. If they are cocooning because they are at significant risk of infection, how can they engage with their employers in such a way that they can work from home? For many people it is impossible to work from home. We need to do many things to support people who remain in that extremely vulnerable position and who cannot enjoy the freedoms many of the rest of us have enjoyed as we have moved out of lockdown. Mental health and joining that up with the services required for these people needs to be given significant consideration.

The submission outlines the need for a clear communications campaign on the signs and symptoms of cancer and to encourage people to attend their healthcare professionals on that. Has there been any positive feedback from the HSE on that? Radio and television are full of advertisements on Covid-19. Has any of that pre-booked advertising been considered to target those who may be developing symptoms of cancer?

Ms Rachel Morrogh

We have run a communications campaign, as has the National Cancer Control Programme, to encourage people. The chief medical officer, CMO, and Paul Reid, the chief executive of the HSE, have talked about the importance of getting people into the diagnostics. It is important that we expand those services, as the IMO has illustrated. Part of that will be physical capacity. We need to reassure people that cancers are still being diagnosed during the Covid pandemic. Anyone with a sign or symptom of cancer really needs to seek medical help.

Based on what the Irish Cancer Society has been hearing on the cancer support line, what has been the experience for those patients undergoing radiotherapy or chemotherapy treatment who may have suppressed immune response?

Mr. Donal Buggy

We are getting feedback from our daffodil centre nurses, many of whom have worked directly in the acute cancer services in recent months, that there are challenges with communications and logistics, and ensuring patients can continue to get access to the treatments they need to get better. There has been considerable upheaval with the transfer of services from public hospitals into private hospitals. We have patients whom we bring to chemotherapy treatment through our volunteer driving programme who were getting treated in Tullamore. Very quickly that treatment was delivered in the Hermitage hospital just outside Dublin. There are many challenges for patients even understanding the new logistics of their treatment without even getting into the detail of the challenges associated with how they will navigate the health system.

The backlog was discussed earlier. Has the HSE discussed how that backlog may be addressed with either of the organisations? Will it address it purely through the public system, or will it seek short-term capacity from the private system?

Ms Susan Clyne

The CervicalCheck programme, which is back up and running, has always been outsourced mainly to the private system anyway. The HSE has prioritised women for callback based on clinical need. With the new human papillomavirus, HPV, element to that test, the length of time to someone's next callback will be extended, but that is based on clinical evidence and we are quite happy with that.

On the other screening programmes, I do not know how they will address the backlog because we have not engaged on those particular programmes.

I thank Ms Clyne and Deputy McAuliffe. The next speaker is Deputy Duncan Smith.

I thank both sets of witnesses for attending. I will address my first question to Ms Clyne. She mentioned preparations for future surges in her submission. All of us are more nervous about future surges now than we were two weeks ago but I have two questions on the expansion of acute bed capacity. First, on the immediate expansion of physical capacity through investment in temporary builds, would that mean new hospitals built in a temporary fashion or the extension of existing hospitals? What does she envisage in that regard? People generally get a little queasy when they hear that something is temporary. I am thinking of our school system and so on.

Second, is there any role for the use of private hospitals in providing that bed capacity? I note in the ICS submission that one of the aspects of the health response that supported cancer care was the use of private hospitals for cancer care, which the society said worked well and offered continuity of care for some existing public patients, although it may have proved somewhat disruptive to normal schedules. Is there any role for the use of private hospitals in the IMO's suite of recommendations?

Ms Susan Clyne

I will ask my colleague, Dr. Gilligan, to answer the first question about the temporary builds.

On the second question about the use of the private hospitals, we cannot get into this position where we think the private hospitals will save us. If the number of beds available in the private and public hospitals are added, we are still below capacity. The previous Government decided not to renew the contract with the private hospitals. I understand the private hospitals and the Department of Health are in discussions as to how capacity may be used in the event of a Covid-19 surge but we are still getting away from the fundamental problem of capacity. There is a way to move towards that. People may be a little queasy about the idea of temporary builds but temporary is better than no builds. I will ask my colleague, Dr. Gilligan, to elaborate on that.

Dr. Peadar Gilligan

It is fair to say that the acquisition of the private hospitals for a period by the State was absolute recognition of the challenges we have had in capacity. What we in the IMO would like to see, and what every doctor in the country would like to see, is an actual plan to invest in the capacity requirements of the system. Essentially, 5,000 beds would look like a 500-bed hospital. My concern is that, to my knowledge, no plan as yet has been put in place with regard to capital expenditure, despite a 2018 document advising us that significant investment needed to take place. We need the planners, the engineers and the architects of the country to address the requirements to provide that capacity, but we need 5,000 beds. With those beds we also need specialists in the acute hospital system. We need approximately 1,600 more specialists in the system just to bring us close to the OECD specialist per capita average. Without those, we cannot provide the timely care that our patients need in a safe way.

Modular builds now are significantly better than they were when I was in school where one could put one's pencil through the walls of the prefabs. They are significantly better now and many countries have invested in those as a temporising measure while putting more significant structures in place. There are tents on nearly every hospital campus in the country. Available capacity within acute hospitals has been looked at whereby areas that historically were not clinical areas have become clinical areas in those hospitals but we need to see that commitment.

Part of the challenge we face is that we want to attract specialists back to Ireland but since October 2012, we have treated them poorly. We have paid them 30% less than existing colleagues. A colleague who took up his appointment after 2012 told me recently that the applause and the thanks were very nice but the reality is that he goes to work and he gets paid 30% less for doing the same job as me. He asked if that was acceptable. I know it is not acceptable. I know that this committee knows it is not acceptable but we need to address that to allow us recruit the specialists we need in our acute hospital system.

I thank Ms Clyne and Dr. Gilligan. I am sure they will accept that, if I ask a question on only one point in their submission, it is because I only have five minutes. I like to hear full answers and I got a full answer there. It is not to say that I do not agree with or understand the other points raised in the submission. I am out of time. I thank the witnesses for their answers.

I thank the Deputy. I again apologise that we must constrain everybody's time. Deputy Shortall will be similarly constrained to five minutes; I apologise.

It is very difficult to do anything within five minutes.

What we have heard this morning from the IMO is by no means new. Its representatives were before the committee some weeks ago and told us the same story. There is a lack of bed capacity and a lack of staff. Since then, many of us have raised these issues with the Minister for Health. To be frank, there has been little indication that the scale of the problem has been recognised. These issues have not arisen only in the past few weeks; the IMO has been raising the issue of the lack of capacity in the public health service for years, as have many of us. Covid has exposed the significant weaknesses and inadequacies in our public health service. One has to ask when Government is going to get serious about implementing a public health service that meets the needs of the population.

On an issue members have raised with the Minister, since the witnesses were last before the committee, has the IMO had any further contact from the Department, the Minister or the HSE with regard to the pressing issues of the 500 consultant vacancies and the need for additional rapid-build temporary capacity until such time as we have the capacity that was promised? Has there been any contact at any level or any indication that the IMO and the rest of us are being heard? Are there any grounds for hope that these issues will be addressed soon?

Ms Susan Clyne

There has been a change of government so the officials of the Department and of the HSE have to wait to see what the new Government will decide to do. The short answer is "No", there does not seem to be any plan for significant increases in capacity. We might get 100 or 200 beds but that just will not cut it. It certainly will not cut it this winter.

With regard to consultant vacancies, when we started this campaign we were talking about 100 vacancies. That then increased to 200, then 300. We have yet to be invited to any talks to deal with this crisis in manpower.

Has there been any discussion with the IMO on the 1,000 Sláintecare consultant contracts promised a number of months ago?

Ms Susan Clyne

There was discussion with us approximately six months ago. As the Deputy will be aware, we have issues in that regard and in respect of the 30% pay cut. We maintain the view that we are more than happy to go into talks with the Government on a new public-only contract but we are not at all satisfied that this will address the recruitment problem. A public-only contract is currently on offer, the type A contract, and we cannot recruit anybody on it. The fundamental problem is the 30% unilateral cut applied in 2012, which bore no reference to a person's qualifications or skills. It was simply a matter of political expediency for the Minister. This has had a devastating effect on the recruitment of consultants in our health service. People feel that it is not about the money but rather about the psychological impact of feeling one is less valued than a person with whom one is working and who is doing exactly the same job.

That is a well-made point. I have a question for the ICS delegation. What is the position with regard to people who have undergone cancer treatment and who need screening as part of the follow-up? Are such people being seen for screening? My second question relates to the BreastCheck and bowel screening programmes. What is the reason for the delay?

It is very hard to understand it because both services are operated separate to the acute hospitals. Do the witnesses know why those services have not resumed?

Ms Rachel Morrogh

I am afraid I do not know the answer to the Deputy's first question. Now that CervicalCheck has resumed people who need three-month and 12-month screens are being included as a priority group and people entering the service for the first time are being included.

BreastCheck and BowelScreen representatives will come before the committee later and may provide more clarity. Certainly one of the issues is capacity in the hospital system and diagnostics. These are the assessments that people need after they get screened because, as Ms Clyne said, screening is not a diagnostic in itself. If people's access to screening and health care is limited because of capacity issues, this is something the ICS would be very concerned about. We need to address capacity in hospitals to ensure people's diagnoses of cancer are not delayed because of capacity issues. We need to get those screening services resumed as soon as possible.

Is it the case that screening services are done outside of the mainstream acute hospital services? I am curious to know where is the logjam. Where are the obstacles to resuming these programmes?

Ms Rachel Morrogh

For BowelScreen people must do a faecal immunochemical test, which they do at home, but if this is positive, they need an urgent colonoscopy and this is part of the endoscopy system.

Does Ms Morrogh accept we should at least restart screening so that people at least know and can-----

Ms Rachel Morrogh

Our position is that if people's access to healthcare is limited, and the demand side is limited because of problems on the supply side, it is not acceptable. We need to look at the capacity issues, address them, get them resolved and ensure people are diagnosed with cancer as early as possible.

I thank our contributors. I reiterate the sentiments of a previous speaker that the submissions are comprehensive. One thing that comes out in almost all of them is frustration, and severe frustration at that. We are all frustrated by what we have heard over recent weeks. We also have significant worries about what September, October and November may bring into the health service.

Mention was made of specialist registrars who were not given temporary fellowships or asked to remain in the service. We could impact on many of the waiting lists if we were to group them under radiology and scopes and increase activity in this area. A significant number of retired surgeons put themselves forward to be available through Be On Call for Ireland. I understand that technically specialist registrars could do some of this radiology and scope work if they were supervised by people with greater experience who have kept up their competencies. Are the witnesses aware of any plans, or have they spoken to the HSE about implementing something like this after hours using operating theatre space, these specialist registrars and some of the people available through Be On Call for Ireland to increase activity, thereby increasing capacity and impacting on the waiting lists?

Dr. Peadar Gilligan

It is important that we use the resources available to us. People who have completed their specialist registrar training are ready to take up consultant positions. The IMO asked that they be offered temporary consultant positions, pending removal of the international lockdown such that they could travel to undertake further fellowships if they so wished. Essentially, they have completed their training.

Many retired colleagues offered their services to the health service again and it was terrifically courageous of them to do so, particularly given the risk of Covid to older patients. Their help was certainly very gratefully received. However, we need a more permanent solution to this, which is about getting the recruitment very definitely right. The challenge is that if we want to bring in a patient for a procedure, that patient must undergo Covid testing three days before the procedure, such that we have the result back and know the procedure can be safely undertaken and experienced by the individual.

We know that patients with Covid who have surgical procedures do less well from those procedures than they would have done if they had not had Covid, for obvious reasons. There are delays in the system as well in respect of the space that patients need, and the processing needs are impacted by that. It is a question of manpower and capacity and, I agree with the Deputy, definitely using the resources that are available to us.

I have a question about the National Treatment Purchase Fund, NTPF. I understand that a large amount of the procurement of the NTPF is based on large groups of procedures probably directed at one or two hospitals. Is there an opportunity in the NTPF to consider smaller bundles directed at more institutions and to use increased service level agreements to ensure we get capacity and continuity into 2021?

Ms Susan Clyne

First, we should be honest and say that we do not believe the NTPF is a long-term solution to the capacity issues in the health service. In fact, it could deprive public health services of much-needed funding. If there is to be an NTPF, and we understand it is to be supercharged with more money, we would prefer to see that spending in the public system, or the public system to be supported to deliver more care. Currently, it is quite complex to do business plans and get funding through. All of that has to be speeded up. Medics, clinicians and their nursing and other colleagues can be innovative and can put forward proposals for funding to get that through. We agree that the NTPF should not just be simply one diagnostic tool based. In fact, the NTPF fund might be better spent if it was spent on an entire episode of care to clear the backlog rather than on a suite of diagnostics and low-complexity, high-volume work.

Mary Fogarty, a nurses' representative, says there is no social distancing taking place in the hospitals. On Monday, 13 July, there were 56 patients on trolleys in one area in the regional hospital with a capacity of 20 patients. This has increased now to 40 patients. Some patients are sitting on chairs. There is no social distance and staff are exposed. The Irish Nurses and Midwives Organisation, INMO, has asked for an internal investigation into full controls for nurses to reduce the risk of spreading infection. Looking at hospitals across the country we see that some of them are struggling with the pandemic and some are not. Perhaps it is time to start examining the management system in some of the hospitals that are not being managed properly. The front-line staff deserve to be protected, but so do the patients. Why is it the case that in certain situations some hospitals are running well and some are not? We must look at how we can assist in this from a structural point of view and at the reason that certain hospitals are coming under that regime. An additional 96 beds were allocated, but staffing at the hospital has depleted by 20%. Is this not something we should examine from a management point of view? This question is one I asked at a previous meeting of the committee in respect of the meat factories. It is down to the fact that there are management problems in certain areas. If there is no good management, there is no good structure. Every person who goes into the hospital goes there to help, but if the structure in place is not right they cannot help.

Dr. Peadar Gilligan

I share the Deputy's frustration about the crowding of emergency departments because it has been my experience for many years of my career.

Things around the country are challenging, and that is because, essentially, unscheduled care is just that. Patients arrive when they feel their problems require urgent assessment. For that reason departments that cannot move those patients who require admission onto the wards will become crowded very quickly indeed. That is reflective of the capacity issue.

In defence of my management colleagues, they have undertaken a Herculean task in the context of Covid. They have reassigned resources and helped in the reallocation of spaces for clinical use and the reallocation of staff to work in various areas. Of course, there are always areas that can be improved on, but our colleagues in management are as clear on this as I am. They do not have the capacity they need to provide the care they wish to provide. Fifty-six patients on trolleys is a situation that should never happen. It happens because patients are not moving through the system quickly enough since there are no beds immediately available for them.

Deputy Bernard Durkan took the Chair.

My second question is: why is there such a high turnover of nurses in certain hospitals compared with others? In certain hospitals around the country there is a massive turnover of nurses who are not staying within the hospital system. Is this not a clear indication that in some of the hospitals there is a breakdown of management or communications to let the nurses do their job properly? They are also frustrated that they cannot carry out their duty of care. We should look from that point of view at how we can help. If there are clusters of areas where there is a high turnover of nurses in hospitals, we should look at that to see why that is. Is it because the nurses are frustrated that they cannot carry out their duty of care?

Dr. Peadar Gilligan

Again, absolutely. I acknowledge there remains huge frustration in the system when people feel that the level of care they would wish to offer they cannot offer because of the constraints of the system. The entire system needs to work towards facilitating the doctor, nurse or healthcare professional in delivering the care he or she wishes to deliver. We have not been in that space, but what Covid has shown us is that when the system pulls together it can achieve amazing things regarding the delivery of safer care. Some 8,000 healthcare professionals in Ireland contracted Covid in the course of the delivery of care to patients, which is a significant number of people who became unwell as a result of the work they do. We have too many multi-bed wards in the hospital system still. We need to move towards more isolation facilities. We have too few critical care beds. We need more of those as well. I share the Deputy's frustration and that of the nursing staff, but we need a system that facilitates us in delivering care.

The submission and the evidence we have heard from the Irish Cancer Society is probably the most concerning that has come before the committee to date because, essentially, the premise of it is that in the efforts to save lives from Covid-19, other patients' lives have been put at risk. Following on from Ms Morrogh's previous responses, I think she indicated to my colleague, Deputy Cullinane, that if urgent action is not taken, lives will be lost avoidably. Looking at the waiting times as outlined in her submission in respect of access to colonoscopies, for example, there is an indication that 1,000 people have been waiting longer than 28 days and 329 people have been waiting longer than 90 days. Is it a fair assumption to make that lives have already been lost as a result of the restrictive measures put in place in respect of cancer screening services, whether they have been lost or put at risk or will be lost?

Ms Rachel Morrogh

I do not think we are at that point.

Cancer takes a while to develop. That is why what we do next will chart the future of the people we mentioned earlier and those 450 cancers that have not been detected yet, or that we would have expected our screening programmes to detect during a four-month period under normal circumstances. We are worried that Covid was layered on top of a system that was not even meeting normal demand. Non-urgent services were postponed for a considerable amount of time because of the need to deal with Covid and we are now facing the choice of whether to fully resource, fund and look at what we need to do across the health services to meet the backlog, as well as the normal demand. The number of cancer cases in Ireland is increasing annually and we need to make choices that will build a sustainable cancer system because, as Deputies outlined, there will most likely be a second wave. What we do now is going to be critical.

I apologise for cutting across Ms Morrogh but the responses required are contained within her submission. Putting measures in place that will save the lives of those who go through the trauma of a cancer diagnosis will be a significant test for the new Government.

I have a brief question for the IMO. It has outlined very effectively some of the deficiencies within our services, but I refer specifically to wards, trolleys and overcrowded waiting rooms. Did the IMO have concerns about fire and health and safety prior to Covid? In November 2019, for example, patients on trolleys were transferred from University Hospital Limerick's emergency department due to an unannounced visit from a senior officer from the Limerick Fire & Rescue Service. Is that a broad concern and is it affected by the knowledge of the restrictive measures that will need to be in place during the pandemic?

Dr. Peadar Gilligan

It has been a major concern for us in the IMO and everyone involved in healthcare that crowded environments are more difficult to decant from in the event of an emergency like a fire breaking out. That fire has broken out but it is now called Covid. Crowded situations would allow the spread of this disease. We can never go back to a situation where the UHL emergency department, or any other hospital or emergency department, has crowded wards. We have been saying this for many years, and many Deputies have noted it as well. We now absolutely must have the capacity and bed numbers in place in order that we can safely provide care and safely remove patients from potential risk in the event of an emergency.

I have one very short follow-up question. I come from County Monaghan, which had a very well-developed local hospital from which services were removed. Should those hospitals be utilised and some of those services be restored to ease the pressure on other centres?

Dr. Peadar Gilligan

What we need to do is utilise the system we have to its optimal effect. That does not mean occupying every bed in the system because clearly we cannot do that. We need to have a facility for surge, so we cannot have an occupancy level above 80% in any of our acute hospitals, nor, indeed, in our elective hospitals. The IMO's position is that we need to move to certain hospitals only providing scheduled care, in order that that scheduled care is not interrupted by the delivery of unplanned or emergency care. That would be a very important initiative and part of that capacity requirement.

The next slot is my own. I agree that we have a capacity issue. It has been there for a considerable time and has been growing. We also have a staffing issue and the added complication of people being paid at different levels within the system.

That has been a result of issues largely outside the command of most people.

I have some questions. Do the witnesses support the concept of a short, medium and long-term plan? That is Sláintecare, effectively, and the implementation of such a plan is vital now. If we must wait a long time before putting into operation the things we need now, we will be waiting forever. I refer to physical buildings and staffing levels. Which of the witnesses would like to answer?

Ms Susan Clyne

I can answer on behalf of the IMO. We have been supporting short, medium and long-term plans for many years. Unfortunately, the funding has not accompanied those plans. Regardless of whether one is a supporter of Sláintecare, it does not have the funding to accompany those plans. We are stating, however, that there are things we can do in this crisis. We do not need another plan, we need to see action on contingency and building of capacity.

We also need to see action regarding manpower resources in hospitals. We have to state as well that we have been hearing much from the system about shifting care into the community and into general practice. That is good, where it can happen and where it is resourced. We need a great deal of joined-up thinking now to get things moving. Working with colleagues in management, the HSE and the Department of Health, staff showed during this crisis how agile and flexible they were and how they adapted to new ways of working. That was done, however, in the context of a crisis and it was not evaluated as to how it is going to work in the long term and what new supports need to be put in place for that to happen. I ask Dr. McCauley to talk about the shifting of care to the community and how that could happen in the next several months.

Deputy Michael McNamara resumed the Chair.

Dr. Denis McCauley

The shifting of some care to the community is a valid concept. Not all care can be transferred to the community but the care that is transferred has to be planned and it also has to be resourced. I alluded to chronic disease management earlier. That will be a positive development. It only started this year and it has been hindered slightly by the onset of Covid-19, but we have adapted it. We were innovative in adapting it so that we can look after a group of over-70s in a Covid-19 situation.

For this to work, we need to have the required capacity and consultants. General practice is always adaptable, innovative and flexible. However, we need a plan and it needs to be resourced. If care is being transferred just for the sake of it, without it being proven to be useful, that is a bad thing. If it is being done just to save money without any view of the actual benefits, or lack thereof, to the patient, then that is a bad thing.

If, however, certain parts of care can be transferred and if it has been clinically proven that GPs can at least match that care and, as a GP would say, at times even improve that care and if that is feasible and the resources are provided, then general practice will stand up. If the transfer of such care is incoherent, however, and if it is not planned and resourced, it could actually have a detrimental effect. The system is now in flux and the last thing we want is for that flux to result in a decision to transfer care to the community without all the personnel being in place in the primary care teams, as well as the GPs. It is a laudable concept but it must be effective and it must be resourced.

There was a talk earlier about the flu vaccine. Any raised temperature that occurs in the community now will have an emotional and financial effect. We will not know if a raised temperature is Covid-19 until we test people. The flu is one aspect, however, where we can step up. The previous Minister spoke of vaccinating children. Once again, if that programme is planned properly, and we would like to get the planning done as quickly as possible so we can implement it, this will be a service that will show it can be effective.

I referred to the short, medium and long-term plan because I have been associated with the health services for generations at this stage.

It is only in recent times that we heard of the lack of capacity of physical buildings and, obviously, the follow-on in staff. It is only in recent years we were told there were too many beds. Yet, it was obvious to most of us that this was not the case. I welcome the change in the system and the change in emphasis as well as the need for extra capacity. It is obviously a matter for Government to provide that.

The other point I wanted to raise relates to attracting staff and making the health services an attractive place to work. Job satisfaction should be part of the entire system. Will the Irish Medical Organisation identify the issues most urgently needed? What is needed to restore morale and public confidence in the system as well as remove the inequalities within the system?

Ms Susan Clyne

I will answer on behalf of the IMO. I must make the point that for over a decade now the IMO has been highlighting the capacity deficits within the system. This goes back to many previous Governments. In 2008 capacity first began to be reduced. Then it was severely impacted and reduced at the time of the financial crisis. The IMO warned at that time of the negative impact that would have on future generations.

The Deputy asked what we need to do to attract staff into the system. We need to value and respect them. We need to listen to them and allow them to do their jobs in a well-resourced environment. We cannot have two-tier pay systems for medics or doctors. That is a disgrace. The basic principle of equal work for equal pay holds. Yet, we are asking doctors, who are being head-hunted from every part of the globe, to come and work here because we value them so much that we will pay them 30% less than the person they will be working beside. Then we are surprised that they will not come and work here. We are asking our non-consultant hospital doctors, who are currently being asked to work 24-hour or 26-hour shifts, to come back to this health service and work here while claiming that we value them and respect them.

We have an issue with the general practitioner population. Up to 600 GPs are due to retire over the coming years. Retirement is a major issue not only because of the normal issues of retirement but because of Covid-19. Some of these GPs may be at a vulnerable age or have underling health conditions themselves. Yet, we say to our newly-established GPs that we have no supports to help them and we will not help them to set up. We tell them they are on their own.

Government must address the absolute fundamental basic inequalities in the system. Government and the health service must value the staff they wish to recruit. It is not enough to say "thank you very much" occasionally or in a pandemic. That is welcome and it is good to be recognised, but that culture must continue. There has to be a culture of respect, of paying people properly and of listening to them.

Dr. Denis McCauley

One grouping which is important in the context of the pandemic is the public health doctors. Public health doctors have basically been working night and day during this period. All healthcare staff have put their shoulders to the wheel. Public health doctors have been in the background working non-stop to try to ameliorate the effect of the Covid-19 emergency.

Up to 50% of these public health doctors are due to retire. We need to attract public health doctors back into the system. There have been two reports. The last one was the Scally report, which recommended public health doctors be considered for or given consultant status. We have been advocating yearly for this. During the Covid-19 emergency these people have been working night and day, possibly to the detriment of their personal health. We are asking the Deputies to show respect for these people for two reasons. The first is that they deserve consultant speciality status. If they do not get that, we will have great difficulty getting replacements for the 50% of public health people who will retire.

The developed nations that have good public health systems have done better in the pandemic. They do a great deal of extra work, but for a safety valve, for future pandemics and even for the evolution of this pandemic we must have an effective public health service. The fact that public health doctors have not been given consultant status, as recommended over the past decade, is wrong.

To add to all that Ms Clyne said, in the context of the public health emergency, public health doctors should be respected with that contact so that we can ensure that service not only remains even static, but develops.

I thank Dr. McCauley and Deputy Durkan. I thank the Deputy also for stepping into the Chair.

The next speaker is from Fianna Fáil. The Deputy is coming back in.

To come back to the point, Dr. McCauley or Dr. Gilligan mentioned the issue of the flu vaccination. Obviously, in the fight against Covid, a comprehensive and more widespread flu vaccination programme will be needed. I wonder if both organisations, particularly the IMO but also in terms of cancer patients, might comment on what they would like that vaccination programme to look like and the issues which they may see arise.

Ms Susan Clyne

I understand the HSE will make some proposals to the committee this afternoon in relation to the flu vaccination but it has already been announced that the flu vaccination will now be extended to children between the ages of two and 12.

The IMO had called a number of months ago for Government to look at a total population vaccination programme and to sit down and talk to us about that. What we are concerned about is that we are now coming towards the end of July. We need to sit down and talk about the flu vaccination programme now. Respiratory illnesses will start circulating in early September. We need to have a plan. We need to understand what is going to happen so that GPs can prepare. We have to acknowledge the fact that the days of a full waiting room in general practice are long gone. There are no more walk-in clinics. Everything is by appointment. Therefore, GPs will have to prepare to a certain extent for some vaccination clinics and we need to sit down with the HSE. We are due to meet them next week, but we would have been in favour of a total population vaccination programme delivered in general practice.

Can we hear from the Irish Cancer Society?

Ms Rachel Morrogh

As the Deputy will probably know, cancer patients are considered an at-risk group. Therefore, they are encouraged to get the flu vaccine every year. Certainly, the Irish Cancer Society will be playing its part in that regard and encouraging cancer patients to get vaccinated.

It is important as well that, while I would expect there to be probably a high uptake among cancer patients, we encourage people at a population level to go and get vaccinated this year. When we think about the impact of flu and seasonal diseases on the treatment of cancer care, and we know that elective surgeries have decreased by 15% during the winter months because of the impact of flu on the hospital system, with the reduced capacity that we are now experiencing as a result of Covid we need to do everything we can to ensure that people will not end up hospitalised and to keep capacity for the urgent cases.

Ms Susan Clyne

If I could make one further point, we must have a strong campaign to give people confidence in vaccinations. We can see from surveys the anti-vax movement is quite strong. It is operating strongly on social media, with much of it around the potential of a Covid vaccine. The system needs to be sending out a very coherent message about the vaccination programmes and the safety of the vaccination programmes.

That point that vaccination saves lives needs to be underscored later on with the HSE as well. We have seen social media used positively, but during this pandemic we have also seen it used negatively in terms of misinformation. I support Ms Clyne's comments on the vaccinations.

In terms of the other services the Irish Cancer Society provides, fundraising is a huge component, particularly in regard to research. Has the society put a figure on how much it will be down this year as a result of not being able to avail of funding activities or has the society found alternative methods?

Mr. Donal Buggy

The Irish Cancer Society operates largely on fundraising from the general public, and from corporate supports also. Ninety-eight per cent of the €24 million income of the Irish Cancer Society last year was fundraised. We expect to see a significant deficit this year. Everyone knows our flagship Daffodil Day event which takes place at the end of March every year.

Unfortunately, it was not possible to run that event on the streets this year as we normally do. It raises approximately €4 million every year but we were able to pivot and transition that fundraising effort online and raised €2 million. That is half of what we would have expected to raise.

We are working very hard to ensure we can continue to raise the funds needed to support the front-line services we provide. We have always had the support of the public who have been putting their hands in their pockets and supporting us as we have changed our fundraising methods over the past 6 months. We will run a significant deficit in 2020 and expect to also run a deficit in 2021 and 2022. We have reserves in place to address that and ensure the front-line services we have can continue and we can enhance them to address the needs of cancer patients over the next number of years.

Research has been significantly impacted by Covid-19. All clinical trials for cancer in Ireland stopped in February and no new trials have opened since. That has a significant impact on the potential outcome for many cancer patients. It also has a significant impact on the psychological well-being of patients who are not being given access to novel clinical trials or potentially life-saving new treatments.

There are also issues with regard to our research infrastructure. Many of our researchers are on precarious contracts. They have only been able to do a proportion of that work over the past five or six months. Will they be able to extend those research grants? Will they have the funds to be able to continue the research programmes they hoped to deliver?

The society is committed to and will continue to invest in research, particularly, research that is closer to the patient which allows us to really understand the quality of life issues and patient impact issues faced by people who are diagnosed, not just now, but into the future.

Some 65 people today will be told that they have cancer and 25 people will die from cancer today. If we do not invest in research, those numbers will increase. If we do not invest in research in Ireland we will not be able to access the world-class cancer doctors that we need to deliver a world-class cancer system.

Mr. Buggy said there will be a significant deficit. Is he prepared to put a figure on that?

Mr. Donal Buggy

I may have to revert to the committee on that. I would rather give an accurate figure. I have a figure in my head but I am not sure it is 100% accurate.

I had the great pleasure of launching the volunteer driver service for the ICS last year in Beaumont Hospital. What impact has the pandemic had on recruiting volunteers for that service throughout the country?

Mr. Donal Buggy

One of the first steps we took after the shutdown of the country was to ensure services such as our volunteer driving service could be maintained. We have drivers who are over the age of 70 and who are in the extremely medically vulnerable category. Of the 1,000 volunteers the society had going into the pandemic, approximately half of those temporarily stood down to protect them from the Covid-19 virus.

We were able to develop new online training and recruitment programmes for new volunteer drivers and, thankfully, we were able to take on board more than 100 new volunteers, which allowed us to maintain the level of that service. Approximately 98% of all requests were met over the pandemic period. We were also able to connect with services such as Lifeline Ambulance Service, Order of Malta Ireland and the community and county committees that were set up to ensure any cancer patients looking to access chemotherapy services were able to do so. We are totally indebted to a cohort of magnificent volunteers who, when no one was travelling anywhere in the country, brought cancer patients to and from their appointments.

All members would urge people to support the society in meeting both the financial deficit and the deficit of volunteers in order that it might try to continue to support cancer patients. I thank both organisations for being with us.

I thank Mr. Buggy and Deputy McAuliffe. Deputy Funchion is next.

I want to ask the Irish Cancer Society about cervical screening specifically. I am one of the final speakers so I apologise if this has been raised already. Does the society have any information or figures on how many women are waiting for retests, particularly in the Carlow-Kilkenny region? These would not be initial tests but retests in cases where there were symptoms. Given the delays and everything else caused by Covid, does the society know how long the backlog is for that region specifically? If Ms Morrogh and Mr. Buggy do not have that specific information, maybe they could comment in general on the issue of the cervical screening and the delays relating thereto?

Ms Rachel Morrogh

I am afraid that we do not have those data. I think that representatives from the screening service will be before the committee this afternoon and they may have the data. If they do not, we can certainly ask them for the information through our own channels.

On the resumption of screening, as I said earlier, we do welcome the resumption of CervicalCheck but we are disappointed that BowelScreen and BreastCheck have not resumed. We do not have sight of specific data in respect of backlogs. For the official figures, the screening service may be able to talk to the Deputy about what they are specifically. We have done our own calculations on the number of cancers and precancers that we think have gone undetected during the period that screening has been paused. Regarding cervical cancer, we think that in the past four months approximately 1,000 precancers would not have been detected and in the region of 33 cervical cancers. That is obviously of major concern to us and it underscores the need for screening services to resume as fully as they can as soon as it is safe to do so.

I thank Ms Morrogh. My second question is also for the society. This was obviously a very serious situation and everyone must take all the public health advice and measures seriously. However, does the society believe that it was necessary to cut the services to the level that was done? Was there not some safe way of carrying out some of these cancer screenings? Covid is extremely serious but there are so many illnesses, cancer being one, that affect so many people and early diagnosis is key in everything. Was there not a way to carry out some of those screenings? I would like to know the society's opinion on that.

Ms Rachel Morrogh

The advice that was taken by the screening services and by the health services generally was from NPHET. That was the evidence base on which screening was paused. I am afraid that I cannot answer as to whether that was the right decision, but that was NPHET's advice.

The only reason I ask is that many women contacted myself - I am sure other people too - about their frustration at seeing certain shops and retail outlets being allowed to open in circumstances where they knew they needed a second test and were being told that it was too risky. I am conscious of the irony of that for people who are in that situation and who are worried. Maybe some of the screenings could have resumed earlier than they have. As Ms. Morrogh said, a lot of them have not resumed.

Mr. Donal Buggy

I can perhaps address the Deputy's question. We did not know in March what the pandemic was going to bring to us in the context of the effect it was going to have on hospital capacity. As a result, we supported the decision to pause screening services at that time. Similar decisions were taken right across the European Union. Many countries shut down their screening services. However, many have also resumed services more quickly than we have in Ireland. What we need, or what we are lacking, is that ambition to get those screening services up and running and link them into the hospital capacity that is required to manage patients who have not gone through the screening programme and who need further diagnostics and treatment.

Ms Clyne said the IMO called for a total vaccination programme. When did it call for that total vaccination programme and what has been the response to date? I do not mean to limit the possibility to respond to Ms Clyne. It is open to all witnesses.

Ms Susan Clyne

It is in our submission to the committee, and the IMO has indicated this before. We are not saying that we are looking for a mandatory vaccination programme, we are saying that the HSE should fund a total population vaccine programme. At the moment the HSE funds the vaccine only for at-risk groups and for those within the at-risk groups even on the General Medical Services, GMS, scheme. The HSE funds the actual, physical vaccine but not the administration of the vaccine. In light of the need to limit respiratory illnesses and flu in the community the IMO has called for the vaccine to be available on a total population basis, but available voluntarily. We would encourage the total population but we do not want to get into the debate on whether it should be mandatory to get the vaccine.

Has the IMO received a response on that yet?

Ms Susan Clyne

No. The HSE has indicated it wants to talk to us next week about the winter vaccination programme. We note there has already been an indication announcement that it is looking at expanding the at-risk group to include children aged two to 12 years. We would not believe that this is sufficient.

Does the IMO believe it should be free to everybody in the population?

Ms Susan Clyne

Yes. We believe it should be free to everyone in the population and not just the vaccine. A properly delivered vaccine programme within general practice should be free to everyone in the population so we can improve the uptake, maintain records and have a real understanding of where we are with a total population covering.

In response to Deputy McAuliffe and to me, Ms Clyne said that it would be administered within general practice. Is the vaccine currently administered by pharmacists?

Ms Susan Clyne

The vaccine can be administered by pharmacists but it is the IMO's view that it is better done through a general practice because the person's health record is more complete and it is a more holistic approach. Very often when people come in for a vaccine there is an opportunistic consultation where other issues are addressed. In the current circumstances it is also safer in general practice.

Would Ms Clyne accept that it is safe to have the vaccine administered by pharmacists or does she think there is a particular danger at the moment posed by pharmacists administering the vaccine?

Ms Susan Clyne

No. I do not think we ever said there was a danger caused by pharmacists.

So, you do not think it is dangerous for pharmacists to administer it.

Ms Susan Clyne

No. I do not think it is in the best interests of the patient. I believe it is better to have the person's healthcare needs met within general practice.

Which would be the priority, that there be a total vaccination programme or that the vaccination programme be administered by general practice?

Ms Susan Clyne

That there be a total vaccination programme. Pharmacists do administer vaccination programmes. The IMO is not saying that they should not. We are calling for a total vaccination programme for the population, which is not a mandatory vaccination programme but a total vaccination programme.

I thank Ms Clyne for clarifying that. I am not a medic but I know that certain levels of vaccination are particularly beneficial once a certain, required level is reached such as the vaccination for mumps and so on. I have a child who was recently vaccinated and I am aware that certain levels are beneficial. Do the witnesses know what level offers a particular benefit?

Dr. Denis McCauley

It depends on the age group. With the flu vaccine, for example, it has been found that if there is lower coverage in children the rate of spread of flu is actually less. A level of 65% is necessary in the older age group to prevent it from spreading quickly. The evidence of the English research shows that if one gets a smaller proportion of children the spread is less. The cover varies depending on which population one looks at. This is the first year they are planning to do it with children and it will be a different mode of administration; I understand it will be a nasal drop. The evidence in England is that the spread is less, but it depends on which population one looks at.

When the sea of snot starts in September, while one might feel that children are not particularly sick with the flu, they spread it quite a lot. That is unclear with regard to Covid. It varies with the flu. If one has to administer to fewer children, one gets greater results. Those are the English data. We do not have any comparative data in Ireland.

I missed what Dr. McCauley said about something starting in September.

Dr. Denis McCauley

The kids go to school and mix, and there is the issue of social distancing. There is a thing called the winter plan which has started. The crèches are open and a number of childhood infections are beginning to come in. We had essentially no childhood infections at all since March but now with crèches open, we are seeing children with temperatures. Even within the pod system, there will be a certain amount of mixing. With regard to the flu, children are thought to be significant vectors. They are not that symptomatic but do seem to spread it.

Is Dr. McCauley referring to children presenting with Covid or children presenting with influenza?

Dr. Denis McCauley

It is a completely separate issue. At present, we are awaiting adjudication from NPHET on whether children need to be tested when they present with a childhood illness, a temperature of 38°C and a cough. I know that there are different data. Data from Israel show that they could spread infections. There is evidence from Finland and Denmark that opening schools did not cause an increase in infections. Those are two diametric facts. The European guidelines on infection control are to be published at the end of August. I cannot answer that question at present.

Ms Susan Clyne

On the subject of vaccinations, while it might be 65% for the flu in that age group, it is different across the population. We would look for everybody to participate in the HPV vaccine for girls and boys in schools. For the childhood vaccination programme, one would need herd immunity of over 85%. We are always pushing for the maximum number of people to be vaccinated to give herd immunity.

Do we know what percentage of the population would have to be vaccinated against the flu to achieve herd immunity?

Dr. Denis McCauley

Going by the present system, it has to be above 65% or 70% to be effective. That is going by the Irish situation. The flu vaccine is available to at-risk groups and people over a certain age. That is what is necessary with the Irish dynamic. When one extends it to the whole population, that effective figure could change. As Ms Clyne said, the higher, the better. As I said earlier, any temperature that occurs in the community now will cause a lot of psychological worry and will cause economic effects. If a child or an adult has a temperature, the need to stay in quarantine at home will have economic effects as well as health effects and psychological effects. The fewer temperatures we have, the better.

When does the flu season typically start?

Dr. Denis McCauley

It varies. It came early last year. Generally, it is any time from September to January. The flu came on time in Australia so we imagine it will come in late October, but last year it came early.

If we are to achieve herd immunity from the flu by having the required percentage of the population vaccinated, while everybody is stressing that it will be a voluntary vaccination, time is ticking.

Dr. Denis McCauley

That is why we have been advocating for the past two months that we engage with the Government about this, since the then Minister for Health, Deputy Harris, announced that the vaccine would be extended to children between the ages of two and 12. We have been interested to liaise with the Department about the matter and our first engagement will be next Wednesday.

After the Minister, Deputy Harris, made that announcement, was there a follow-up consultation with those who would be administering the vaccine?

Ms Susan Clyne

We have had some preliminary discussions with the HSE on the matter. We will meet further with representatives of the HSE next week in the context of the roll-out of the programme. It is important to note that we will always encourage everyone to get the flu vaccine. We encourage employers to make it available to their staff. It is not the case that the vaccine is not beneficial after the end of October. Even while the flu is circulating, vaccinations keep on going.

The specific question I asked was, after the Minister, Deputy Harris, announced that he was going to extend the programme, was there a consultation with those who were going to be implementing it?

Ms Susan Clyne

There was not a detailed consultation. We are expecting that to happen.

I thank Ms Clyne. Obviously, Covid-19 is a virus with serious consequences in terms of mortality, and even many of those who survive it suffer debilitating and lifelong conditions. The response to Covid-19 has had the effect that some people are not presenting for routine medical procedures and screening programmes have been put into abeyance. That is also going to result in excess mortality. My question might be overly simplistic, but which is going to result in a greater mortality, Covid-19 or the response to it?

Ms Susan Clyne

The excess mortality rate is not that high at the moment. That is something we will only be able to evaluate as the evidence comes in. I am concerned that we are looking at our health services as if this crisis is because of Covid-19. We already had a crisis that Covid-19 has made worse. That is why we must take significant steps in investment at the moment and not more planning. Myriad plans exist for the health sector but we just want some investment based on clinical evidence and patient need.

I do not think we can answer the question about mortality. We are of the view that mortality will increase at a higher level than it would otherwise have done. Mortality is increasing within our health services because of the capacity issue anyway.

How does the Irish return to cancer screening compare internationally? The representative of the IMO may be able to answer that question but I particularly direct it to the representative of the Irish Cancer Society. How does Ireland compare with other western European states with regard to screenings currently being carried out and the plans that are in place for a return of screening programmes? If the comparison is unfavourable, why is that so? What is causing any differential?

Ms Rachel Morrogh

We have tried to find out that information. We have been using our European networks to get good information but it is a bit patchy. We know that screening has resumed in The Netherlands, though on a priority basis. The Netherlands has colon, breast and cervical cancer screening up and running. Its first case of Covid-19 was diagnosed on 27 February. The invitees for screening are being prioritised on the basis that clients who received their initial invitation before 16 March but had their appointment cancelled have been re-invited and will be followed by clients who should have been invited after that date.

The information from Portugal is not entirely clear.

In the central and southern regions of Portugal, breast screening has resumed since mid-June and bowel and cervical screening has also returned but we do not know on what dates that happened. In Ireland, we have said previously that we want breast and bowel screening to return as soon as possible. If the reason that cancer screening has not returned is because of the capacity issues then this underscores the point that both organisations have been making today, which is that there needs to be real, substantial and sustainable investment in capacity so that we are able to ensure that people get access to health care and cancer services as soon as they need them. That will ensure that we limit the number of excess deaths and give people a really good opportunity to live a healthy and good quality life.

Does Deputy Durkan wish to come back in?

No, I am in the hands of the Chairman.

If there is a question that the Deputy wishes to ask, he can ask it otherwise we will-----

I have already raised the question on capacity, the priorities and the manner in which we should set about achieving the necessary capacities. The IMO stated that it had been putting this issue for the last ten years. I have been at health meetings in the last five years where the suggestion that we had an overcapacity in beds came up again and again. I did not believe that at the time.

I wish to put another issue before the witnesses. As our population expands, and it is expanding, and if we recover and hopefully we will fully from the pandemic economically as well as in health terms, the demand will then get bigger again. The question then obviously arises as to whether we are well-placed to provide the level of services required to that greater population. I am not referring to the ageing population to which everybody refers but to the influx of young people who are employed in this country. That has been the pattern for many years and will continue to be the pattern. There are children and family issues as well as older people’s issues. I would like to know if that issue is in hand and if those people at the coalface, on the front line, are prepared to push for the necessary facilities there.

Ms Susan Clyne

The Deputy can be assured that all healthcare workers at the front line are not only prepared to push but have been pushing for a long time for the facilities. The short answer is “No”, we are not prepared for an increase in services. We cannot even meet the demand on our services now. Capacity and recruitment are the issues.

At the end of the session I want to make a special appeal that it is absolutely immoral that our public health doctors, who for many years have been advised on foot of a report, as Dr. McAuley said earlier, that they should be treated as consultants, have been the ones who have been asked to manage the country through this pandemic which is not over and yet their issue remains to be resolved. I make a special appeal that this issue be resolved once and for all. Most people do not think about public health from one end of the decade to the next. It is something like this that shows the value and absolute necessity of a well-staffed and valued public health system.

I thank Ms Clyne and all of our witnesses for coming in today and for answering all of our questions. I will suspend this meeting until 2.30 p.m. when we will meet with the Department of Health and HSE officials.

Sitting suspended at 2 p.m. and resumed at 2.35 p.m.