Dáil Éireann - Volume 653 - 24 April, 2008

Cancer Reports: Statements.

  Deputy Mary Harney:I addressed the House on the issue of cancer services on 12 March, following the publication of the reports on the misdiagnosis of nine women in the Midland Regional Hospital, Portlaoise. On that occasion I expressed my deep regret to the women and their families. Once again I reiterate this regret and offer sincere apologies to all those women and their families who are the subjects of the various reports we are discussing today.

We must never forget that our health system must have the treatment and welfare of the patient as its central focus. Health service staff must at all times strive to deliver quality driven, patient-centred care. In turn, staff must be supported by management in an environment where the highest standards of care are fostered, where there is teamwork and where roles and responsibilities are clear.

Of course, in the context of cancer care a prerequisite to a quality driven service is the multidisciplinary team providing initial diagnosis and treatment. Evidence has shown that where women are treated for breast cancer in a multidisciplinary quality environment survival rates can improve by as much as 20%. In each of the cases reviewed multidisciplinary teams were not present.

The key findings of the reports in Portlaoise were as follows. There were no multidisciplinary team meetings other than in oncology and consultant medical staff were not represented at the meeting that decided to suspend breast radiology services. There was confusion regarding roles [15] and responsibilities in the hospital and there were gaps in decision-making processes. There was a fundamental weakness in the management and governance of the review process because no authoritative co-ordination role was established for the process as a whole. Decision-making was fragmented, communications were inconsistent and there were too many individuals involved, which led to confusion about the status of the overall review process.

Since that date two other reports have been published. The review of the clinical care of patients who presented to the symptomatic breast disease service at Barringtons Hospital, Limerick, was published on 1 April, and the independent investigation by the Health Information and Quality Authority, HIQA, into the care provided by the Health Service Executive, HSE, to Rebecca O’Malley at the Cork University Hospital and the Mid-Western Regional Hospital, Limerick, was published on 2 April.

I received a report from the HSE on 31 July 2007 relating to the misdiagnosis of breast cancer in a woman who resides in the mid-western region. The patient, Ms A, had presented to Barringtons Hospital, Limerick, initially in 2005 and again in 2007. The HSE’s specific concern related to two pathology tests performed on behalf of Ms A that were carried out on behalf of Barringtons Hospital in University College Hospital, Galway.

On 7 August 2007, HIQA announced that it would undertake a review of pathology services at University College Hospital, Galway, which would include establishing the facts about this aspect of the patient’s care. It is anticipated that this review will conclude shortly. On 9 August, HIQA informed my Department’s chief medical officer about concerns relating to the adequacy of the management and care of ten women who attended the breast disease services at Barringtons Hospital within the past four years. On 10 August, the chief medical officer and deputy chief medical officer of my Department, on my behalf, met Barringtons Hospital and requested it to suspend the delivery of breast services, and it agreed to do so.

It was agreed by the hospital that an independent clinical review was required into the clinical care of patients who presented at the symptomatic breast disease service at Barringtons Hospital between September 2003 and August 2007. The review team was chaired by Dr. Henrietta Campbell, a former chief medical officer in Northern Ireland. As I said, the report was published on 1 April.

The report found that hospital records identified 331 patients falling within the remit of the review. Of these, 285 patients consented to the review. Following assessment of all available records, the review team concluded that in its opinion, the diagnosis and treatment of 139 patients was entirely appropriate and there was no need for further assessment. In a further 118 cases, it was the clinical and professional judgment of the review team that the level of clinical care was not always what it considered appropriate. However, in none of these cases was a diagnosis of cancer missed or delayed and in no case was a diagnosis of cancer wrongly given.

The report concludes:

whilst it is not considered that any of these patients have come to lasting harm, the review team is of the opinion that many of these patients could have been managed differently. In some women with benign disease, operative intervention would not have been required if appropriate investigations had been undertaken prior to surgery. In other cases where cancer was present, definitive surgery should have been undertaken as one procedure rather than in two stages.

In two patients, a diagnosis of cancer was delayed for a significant period from initial presentation, potentially causing serious harm. In 26 cases it was concluded that these patients should be referred for further investigations to exclude the possibility of breast cancer. In most of these cases the referral was regarded as a precautionary measure.

[16] The report emphasises the importance of triple assessment, that is, a joint assessment carried out on a multidisciplinary basis by a pathologist, a radiologist and a surgeon. Triple assessment was not available in Barringtons Hospital and as a result some patients may have undergone unnecessary surgery while others did not receive definitive surgery based on the results of normally expected pre-operative diagnosis.

The findings of HIQA’s first investigation into the care provided for Rebecca O’Malley by the HSE were published on 2 April. The main finding of the report is that the interpretive error made by a consultant pathologist that led to the initial misdiagnosis was a single mistake of human error. However, the report notes the absence of a triple assessment review in the centre, which led to missed opportunities to correct the error. The report is also critical of the HSE on governance, management and communications and the way in which Rebecca O’Malley was informed of matters relevant to her care. In total, the report contains 15 recommendations, including matters relating to clinical practice and management.

One of the most important things about any review is that we learn from the exercise and apply that learning throughout the service. All reports highlight the need for swift implementation of the national quality assurance standards for symptomatic breast disease services, which I approved last year under the Health Act 2007. The implementation of the standards will ensure that every woman in Ireland who develops breast cancer has an equal opportunity to be managed in a centre that is capable of delivering the best possible results. The standards need to be applied to all hospitals, both public and private, that provide symptomatic breast disease services. I strongly believe that symptomatic breast services should be provided only in hospitals that meet these standards in full.

My Department wrote to the Independent Hospital Association of Ireland and the private health insurers, on my behalf, last August, enclosing a copy of the standards, and I subsequently had discussions with them relating to these matters. The standards will clearly have implications for some private facilities. Some have already ceased providing symptomatic breast services. I continue to encourage hospitals in the independent sector to take the necessary steps to ensure that their breast cancer services comply with the standards.

The HSE has designated eight centres for symptomatic breast disease services. The HSE National Hospitals Office will shortly transfer full responsibility for symptomatic breast services to the national cancer control programme, which is being overseen by Professor Tom Keane. The programme recently completed a detailed review of resource requirements to create capacity for the progressive transfer of all symptomatic breast cancer services to the eight designated centres with the objective of completing 60% of the transfer by the end of this year and 90% by the end of 2009. Funding of €5.8 million has been allocated across the eight centres from the programme to support additional staff, including consultant, radiography, nursing and clerical posts. Funding has also been allocated for some necessary additional equipment.

Two other reports have yet to be published. One is the investigation by HIQA into pathology services at University College Hospital, Galway, which commenced in September 2007. While it is difficult to predict precisely at this stage when the work will be completed, it is hoped that the investigation will be concluded shortly and the report will be published as soon as possible thereafter. The other is the pathology review in Cork University Hospital, which is completed. A report is being finalised by the HSE in that regard.

Following the discovery of a small number of errors in the reading of X-rays, the HSE invited a panel of experts from the UK to assess the need for a review of the radiology services in Our Lady of Lourdes Hospital, Drogheda, and Our Lady’s Hospital, Navan. The panel recom[17] mended a review and work is progressing in identifying its full scope. It will be carried out in accordance with the HSE’s recently adopted policy on serious incident management.

If the recent reports and reviews have taught us anything, it is that we must fully support the establishment of the national cancer control programme and ensure it is established by the HSE without delay. The HSE has designated four managed cancer control networks. For the first time in Ireland, we have a national leader in cancer control. I have full faith in Professor Keane in delivering on this programme.

The decisions of the HSE to designate four managed cancer control networks and eight cancer centres will be implemented on a managed and phased basis. The HSE plans to have completed 50% of the transition of services to cancer centres by end 2008 and 80% to 90% by end 2009. Professor Keane is in discussions with the HSE to take control of all new cancer developments and progressively all existing cancer services and related funding and staffing.

The designation of cancer centres aims to ensure patients receive the highest quality care while allowing local access to services, where appropriate. Where diagnosis and treatment planning is directed and managed by multidisciplinary teams based at the cancer centres, much of the treatment, other than surgery, can be delivered in local hospitals. In this context, chemotherapy and support services will continue to be delivered locally. Cancer day-care units will continue to have an important role in delivering services to patients as close to home as possible.

Significant progress has been made on the implementation of the programme, including the appointment on a part-time basis of national clinical leaders in surgical, medical and radiation oncology; cessation of breast cancer surgery in 16 hospitals with low volumes; agreement with the surgical leads in the eight designated breast cancer centres on a transparent and evidence-based resourcing mechanism, benchmarked to best practice; the move to a common referral process, supported by the Irish College of General Practitioners, which will allow urgent patients to be seen within two weeks; the elimination of unnecessary follow-up of previously treated asymptomatic patients; agreement with the Irish Cancer Society on the administration of a grants programme to enable patients to be transported to designated cancer centres.

A new era of patient safety has begun in health care. We have started out on a path from which there is no return, the path of setting and implementing objective standards of care. It is a long road ahead, with many milestones yet to pass. It will involve all health care settings; the organisation of services between hospitals as well as within hospitals. We have taken some of the most important steps, that is, the first steps in the journey.

Three key milestones in legislation have already been passed. A statutory body responsible for standard setting and monitoring, the Health Information and Quality Authority, HIQA, has been established. A year ago, we enacted the first major overhaul in 30 years of the law regulating the medical profession through the Medical Council. A new Pharmacy Act has been enacted to regulate the pharmacy profession. All legislation has been driven by patient safety and the public interest.

The journey also involves honestly describing where mistakes and failures have occurred or do occur and to learn and improve from them. That requires a blame-free reporting and management culture. I am determined that we operate in an open way, that we implement improvements from mistakes and that the hue and cry of a search for blame does not undermine what really needs to be done in patients’ interests.

Patient safety and standards setting are powerful drivers of reform and improvement in services for patients. These are at least as powerful drivers of change as finance, staffing levels and working time issues. We are making patient safety — the best possible diagnosis and best possible outcomes — drive our decisions in cancer care. We shall see the results of this clearly. [18] The patient safety agenda will be implemented without distinction between public and private patients. My concern as Minister for Health and Children is for all patients in all settings.

The Government is aware of the significant issues relating to patient safety and is treating the matter as a priority. We are committed to ensuring the delivery of the best quality health service possible, doing so effectively and efficiently.

Some time ago I established the Commission on Patient Safety and Quality Assurance. Membership of the commission is made up of medical and nursing representatives, management and, importantly, two representatives of patients and carers. The commission is chaired by Dr. Deirdre Madden BL, a leading expert on medical law and ethics. The commission is due to report to me in the summer. Among the issues it will address will be the need for a licensing regime for health provision. Short of such a regime, we will not be in a position to enforce the standards on a mandatory or legislative basis in the private sector.

I have set out the broad policy framework that I want to put in place and the main findings resulting from the recent reports on cancer. Professor Keane has set himself ambitious targets for his two-year tenure as director of the national cancer control programme. He has quickly set about realigning cancer services to ensure a person can be assured of the highest quality service. He is receiving buy-in to the plan from clinicians across the country. The emerging clinical leadership will be the greatest guarantee that the plan will be implemented without delay.

  Deputy Alan Shatter:Today we discuss the findings of the Rebecca O’Malley report, the Barringtons Hospital report and the Fitzgerald, Doherty and O’Doherty reports into the Portlaoise cancer crisis. All these reports are a damning indictment of 11 years of Fianna Fáil-Progressive Democrats policy, now supported by the Green Party. In the past three years, we have had a health policy run by a Minister who engages in a semi-detached oversight, fails to accept responsibility and does not recognise the concept of accountability for the appalling failures in our health service.

Continued revelations of appalling mistakes in diagnosis and treatment of individual patients, discussed by the media on a daily basis, have totally undermined patient confidence in our health services. Excellent work done by so many nurses and doctors who save lives and improve the quality of lives gets lost in people’s consciousness by the increasing doubt created about the competency of our overall diagnostic and treatment services. It has reached a stage whereby many people genuinely in need of hospital care are frightened to enter hospital for inpatient treatment. Those reliant on diagnostic and inpatient services lack confidence in results furnished to them and feel compelled to seek second and third opinions to ensure they are not the victim of yet another error.

The legacy of 13 years of Fianna Fáil-Progressive Democrats Government is not only that we have a health service that falls scandalously below the standard expected in an EU-advanced economy but that a majority of people totally lack confidence in the capacity of the service to provide them with appropriate, timely, reliable and competent diagnostic and medical services.

As I have been allocated a short time, I can only draw on the more prominent aspects of the reports. I hope that as a result of recent events detailed in these reports real lessons have been learned and real reforms are implemented. However, considering the promises made by the Government in that regard, the Fine Gael Party has little confidence in the Minister or the current management and structure of the HSE.

The Fitzgerald report catalogued the systemic failures in the HSE’s response to the Portlaoise cancer crisis. Fitzgerald found “a fundamental weakness in the management and governance [19] of the process from the outset because there was no authoritative co-ordination and management role established for the review process as a whole.” Communication throughout the period was inconsistent and sometimes contradictory, too many people were involved from different levels and areas in the HSE who were unclear of their roles and responsibilities and they had differing understandings of what was going on. His report also found that the entire management process surrounding the Portlaoise cancer crisis has been a bungling mess from start to finish.

Fitzgerald found a lack of urgency from the HSE prior to the Oireachtas health committee meeting on 22 November 2007 when it was announced that 97 women reviewed under the ultrasound process needed to be recalled. These women were not contacted immediately but were treated like job lots and left until a sufficient cohort was accumulated before they were contacted.

The Minister for Health and Children was unaware of the ultrasound review until the day before the committee sat. In the intervening period, between the time she learned and the time the committee sat, she was unable to get detailed information from the HSE, a body which she created and which should directly report to her on health issues of national importance.

One would assume that when the issue broke last autumn this was the first time the HSE and the Department of Health and Children knew of the problems in Portlaoise General Hospital. We subsequently learnt that a consultant surgeon in Portlaoise General Hospital, Dr. Peter Naughton, had written a series of letters to the Minister, Deputy Harney, and her predecessor, the Minister, Deputy Martin, dated as far back as 2002, expressing his substantial concerns about the cancer services in that hospital.

In July 2005 he stated that radiological services were being provided by people who had no expertise in the area and that women were having unnecessary surgery because of a lack of decision-making. He described the services as a shambles. It is scandalous that nothing changed, no one took responsibility and no decisions were made. The correspondence was apparently ignored.

The frightening findings of the Fitzgerald report were echoed in the report published by the Health Information and Quality Authority, HIQA, into events surrounding the misdiagnosis of Rebecca O’Malley. The report catalogues a series of systemic failures in the organisation and the handling of the situation. Roles and responsibilities within hospitals and HSE management were not sufficiently understood, no one took lead responsibility for the situation, pathways of accountability and reporting at senior management level were not clear, there was insufficient understanding of risk management at all levels, communication between management and staff was not effective and there was a lack of confidence in the integrity of the communications process.

Of all the failings identified, it is particularly worrying that responsibility was left to Rebecca O’Malley to pursue her case. She made the hospital aware of her concerns in an incident form completed in November 2006, but it did not trigger an effectively managed action plan. There was no integrated system-wide approach, a lead individual to manage the overall response or a system to respond to her letters in a timely manner. It was left to her, through sheer frustration and determination, to pursue the issue, to raise questions regarding errors in her care and to bring this terrible error to the nation’s attention.

According to the report, there was a collective lack of accountability, cohesion and focus on the needs of the patient. This is the so-called patient-focused health system to which the Minister refers frequently. It is unacceptable that a person who suspects a misdiagnosis or has concerns about his or her health should be treated in such a manner. It is unacceptable that these concerns, which could reflect on the health of others, could be ignored. It seems almost [20] unbelievable that, in the construction and framing of the new HSE system for which the Minister is directly accountable and responsible, such policies and procedures were not considered and effective systems put in place.

The report found that major financial pressures demanded management time and energy, creating the potential for other priorities to be given less attention. Perhaps patient care and safety are a priority to which the HSE has, in the years since its establishment, failed to give adequate attention. They seem to be less important than the HSE’s bureaucratic and administrative priorities, which are occasionally more concerned with covering up or ignoring difficulties than with investigating them. Most damning was the HIQA findings on the HSE’s governance and management of the situation. According to the report, disillusionment with the role of the HSE was a consistent feature in most of the interviews. It found that the HSE network management system does not have the confidence of its staff and that the new system delayed decision making processes instead of facilitating them. This matter must be addressed. I am not reassured by the Minister’s statement, which we have heard previously.

HIQA found a disconnect between hospital management and the HSE’s National Hospitals Office in that the HSE expects hospitals to accept without question significantly increased workloads that are unmatched by resources or staff. This is a consistent theme across the health system. The sad reality is that patient-centred care is a low priority in the day-to-day workings of the health service and in the approach taken by the HSE. The report concludes that the HSE is designed in such a way as to delay and avoid difficult decision making and to prioritise emergency issues that have the media’s attention rather than to meet the local needs of patients and frontline staff.

Combined, the reports demonstrate that the Minister’s claim concerning her presiding over a health system that puts patients first is false. Instead of attributing responsibility to an individual, the reports refer to systemic failures. The Minister stated her desire for a reporting culture in which no blame is attached. The Minister, HSE management and those employed in the health service cannot be free of blame. They must be accountable for the service they deliver to the public and recognise their responsibility. If something goes wrong, there must be accountability. If there is none, there will be further scandals and tragedies as a consequence of the HSE’s failures.

For months, we have listened to the Minister’s plans for eight cancer centres of excellence. No one can disagree with the concept of excellence in cancer care or the proposals, but I cannot understand how the Minister can justifiably withdraw excellent cancer services from hospitals around the country when alternative and replacement infrastructure has not been put in place at the new centres. If the Government has a serious intent to establish centres of excellence, it must fully address issues concerning those hospitals where cancer services are to be terminated.

Back bench Deputies and, more importantly, Ministers should stop playing cynical local political games, namely, pretending to fight to keep cancer services in hospitals in their local constituencies while coming to Dublin and voting for closures. The conduct of the Minister of State, Deputy Devins, in this regard is particularly reprehensible. As a Minister for State at the Department of Health and Children, he can directly contribute to the decisions being made on cancer policy and services. His cynical and self-promoting presence at protests to maintain services at Sligo General Hospital when he is in a position as a Minister of State to ensure those services are maintained — if doing so is consistent with providing the expert medical care to which cancer patients are entitled — is nothing short of farcical. By his conduct, he is undermining any credibility vested in his position.

[21] We do not know when the cancer centres of excellence will be fully operational. The Minister, Deputy Harney, has given some indication of the general progress proposed by the HSE, but we do not know the details. For example, we do not know how much additional funding will be dedicated to these centres, how many extra beds will be needed, whether beds will be relocated or whether new beds will be created. How many staff are expected to move under the proposed plan and how many new staff will be recruited? What arrangements will be made for hospitals north of the Galway-Dublin line? What arrangements will be made to facilitate patients who cannot afford the cost of travelling to the centres of excellence? When will the national radiation oncology plan be delivered and by what method of financing? How can patient safety be prioritised when services, be they cancer or other health services such as those in the north east, are withdrawn without alternative services being put in place?

The reports published in recent months prove that patients are not put first, HSE management is anything but effective and, three years since its establishment, people are still unclear of their roles and responsibilities. The reports establish that there is not an appropriate, up-to-date and effective communication system between the HSE and its many segments and the Minister and her Department. At times, the Minister seems to discover difficulties or disasters more speedily via media reports than via direct communication between her Department and the HSE.

Discussing the establishment of the HSE in November 2004, the Minister stated:

It is a once-in-a-generation event. It is our generation’s chance to put patients first in the design of the management of health services.

She stated: “To achieve them we badly need clarity of roles and accountability — political responsibility for the Minister and management responsibility for the management” and “That will make a real difference to the quality of health services provided for our people”. In the years since the HSE’s establishment, the Minister has not only failed to deliver in this respect, but the situation has gone wrong. Members on all sides of the House lack confidence of any nature in the capacity of the HSE to deliver a competent health service. Our confidence is further diminished by the HSE’s tendency under financial pressure to cut frontline services while preserving an overwhelming, unnecessary and overlapping bureaucracy. We need a health service that is not about bloated bureaucracy and ineffective management structures, but patient values and how we cherish our people.

None of the reports reflects the worries and anxieties experienced by each of the women involved or the dreadful impact events have had on them. Some reactionary action was taken by the Minister in response to the situation, but the HSE has failed to create real public trust in its capability. The investigation team behind the O’Malley report stated that an urgent review should be conducted by corporate HSE of communications within its hospitals to ensure effective communications policies and procedures are in place to provide an efficient and co-ordinated response to the patient when a serious incident occurs.

The Minister should take heed of this and initiate such a review to ensure the appropriate and necessary changes are introduced as a priority. In addition, the Minister should finally recognise that the HSE, as created by her, is a failed organisation whose structure does not lend itself to the delivery of an appropriate and efficient quality health service. The present need for root and branch reform of the HSE and the manner in which it conducts its business must be recognised. Moreover, there is a requirement to ensure that the vast resources which are going into the health service are being used to provide frontline patient care and not to continue building an unnecessarily large administration and bureaucracy, which operates in a [22] world in which it seems on occasion that not only does the right hand not know what the left hand is doing but has not yet been introduced to it.

  Deputy Jan O’Sullivan:There is an old saying that sticks and stones may break my bones but words will never hurt me. However, the corollary is that words will not heal me either. Members again heard an eloquent speech this morning from the Minister for Health and Children. The version circulated to Members concluded with the line: “This is the framework and policy agenda that the Government is pursuing with the ultimate aim of delivering safer care and treatment for all who use our health services.” If eloquence could deliver a good health service, the Minister would be doing a great job, but unfortunately it cannot. The Minister, Deputy Harney, undoubtedly is a very elegant, or rather eloquent, Minister for Health and Children.

  Deputy Mary Harney:As opposed to elegant.

  Deputy Jan O’Sullivan:Well——

  Deputy Mary Harney:I do not expect the Deputy to reply.

  Deputy Jan O’Sullivan:While I do not know how elegant any Members are, I will talk about eloquence for the present.

  Deputy Alan Shatter:Articulate elegance.

  Deputy Mary Harney:I was more elegant when I first met the Deputy.

  Deputy Jan O’Sullivan:Although the Minister speaks eloquently, unfortunately eloquence and fine words do not deliver an excellent health service. It seems likely the Minister, Deputy Harney, will remain as Minister for Health and Children after the incoming Taoiseach takes office in two weeks. It is almost unbelievable that the reason she will remain as Minister for Health and Children is that no one else wants the job. No one else, in the very large Fianna Fáil Party or in the Green Party wants the job. They are leaving it to the Minister, Deputy Harney, whose party has the support of 1% of the electorate. This is an appalling indictment of the Government. The Minister is being left there because the others do not want the post rather than because they consider her to be doing a good job as Minister for Health and Children. Certainly, the Minister talks a good talk, but if she is as detached from the real reforming work as she appears to be in respect of the HSE or if she is as detached in respect of the delivery of the cancer strategy, the new Taoiseach will have failed unless he replaces her as Minister for Health and Children. This is the responsibility of the Government rather than of the Minister.

I will begin where Deputy Shatter left off in respect of the HSE. It is important to establish what the Minister said in November 2004 when the HSE was established. Again, fine words were used, but what has been delivered? If it has not been delivered with regard to the HSE, will it be delivered in respect of the cancer strategy? Members have a responsibility to ensure that what is stated and promised in this House is delivered and I take this duty seriously as a spokesperson for the Opposition and for the Labour Party.

Members need a Minister who does what the Minister, Deputy Harney, promised in the Dáil in November 2004 when the legislation setting up the HSE was being rushed through. She stated she would retain clear accountability for our health services. However, on a daily basis, one sees the Minister and her partners in government shirking their responsibility for the health services, as well as blaming and criticising the HSE. I refer to the words used in 2004, not the [23] action. The Minister promised that the HSE would bring efficiency, value for money and a scaling down of bureaucracy. One of the guiding principles was to be a move away from care in hospitals and institutions to care in the community.

However, a nationwide litany of evidence has emerged this week that the opposite is happening and that those vital supports that make the difference between a family being able to care for a loved one at home as opposed to in a hospital or an institution are being reduced. This week alone there have been accounts of the closure of respite and rehabilitation beds in Leopardstown Park, Dublin, which is located in Deputy Shatter’s constituency. I visited the north east last week and was informed that St. Oliver’s, Dundalk, must close its respite and rehabilitation beds. One hears of reduced home help throughout the country and yesterday I learned of the ending of the hospital in the home scheme, which had been operating in the Dublin area. There is a failure to fill vacancies in occupational therapy, physiotherapy, speech and language therapy posts and a wide variety of other support services within the community, while waiting lists of two years and longer exist for some of the aforementioned therapies.

Last night I discussed a family in County Kildare with one of my colleagues. The father is blind and has a series of health complaints and there are three intellectually disabled young adults in the family. Incredibly, the family has had its home care support service withdrawn. The events I have just recounted demonstrate that matters are going in the opposite direction to what was promised by the Minister in this Chamber in November 2004 before the establishment of the HSE. It is becoming increasingly difficult for families to keep their sick relatives out of hospital and this piles on pressure in an acute system that is bursting at the seams.

If eloquence and promises could deliver a good health service, Ireland would have one, but unfortunately they cannot. I make this point in the context of this debate on cancer services because Members again have heard an eloquently presented and convincing verbal picture of a vision of what should be put in place. The most important question is how to get from the present position to such a point. The Minister provided that fine line about the ultimate aim of delivering safer care and treatment for all who use our health services. She also referred to Professor Tom Keane and what he will do during his two-year term. Moreover, she referred to the establishment of the cancer strategy and noted that the HSE has designated eight centres. She stated: “The HSE National Hospitals Office will shortly transfer full responsibility for symptomatic breast services to the national cancer control programme”.

This constitutes further long-distance management from the Minister. As Minister, she is responsible. She set up the HSE and appears to have washed her hands of how it operates. The HSE now intends to set up the national cancer control programme and, presumably, it will be given a budget. However, in two years’ time, Professor Tom Keane will have returned to Canada. How will Members then ensure the recommendations contained in the reports before the House today are implemented? Will Members then be informed that, regrettably, it was not possible to implement all the recommendations of the Rebecca O’Malley report because the national cancer control programme did not use its budget wisely? Will they be informed, for example, that triple assessment in Waterford, appropriate equipment in Limerick or the provision of a service for the people of the north west cannot be ensured? Members require an absolute assurance from the Minister that in contrast to her actions regarding the HSE, she will take responsibility for this programme. Otherwise, a new Minister is required. The most important issue pertains to delivery of this programme rather than to the painting of a fine picture with fine words.

How does one move from the reality of what was described in the three reports on Portlaoise to the failure to diagnose cancer in nine women and informing 97 others over the airwaves and through the Oireachtas Joint Committee on Health and Children, instead of personally, that [24] they could have cancer? How does one deal with the reality of the systematic shortcomings and inadequate resources that led to the misdiagnosis of Rebecca O’Malley and Ms. X in Limerick and Cork, respectively, or the reality of misdiagnosis in Barringtons Hospital and UCHG? How does one move from such issues to a reliable, safe service that is trusted by the people of Ireland?

The Minister referred to hue and cry and a search for blame. This is not a hue and cry or a search for blame, it is a search for responsibility and accountability and an ongoing process to monitor and ensure that what is planned will be put in place. I welcome the comments of the Health Information and Quality Authority, HIQA, representatives of which appeared before the Joint Committee on Health and Children last Tuesday, that it intends to visit all the aforementioned centres and set out standards in respect of what should be available. Ultimately, however, HIQA does not have the teeth to ensure the resources are put in place to make this happen. The Minister should give a commitment that she, or whoever succeeds her, will come into this Chamber on a regular basis to outline progress on these reports. She should ensure ongoing monitoring and that the requisite resources are available. It cannot operate like the HSE, where everything is blamed on the executive but no responsibility is taken in this House.

I ask the Minister for precise answers on how she will be accountable for implementing the recommendations in the various reports on her desk. The public must be informed of the timeframe, staffing, governance systems and resources and who will have responsibility and authority to ensure that what is needed at all levels is in place. Rebecca O’Malley stated at the press conference to launch the HIQA report on her misdiagnosis that the system to protect the patient did not fail because there was no system. We will have failed Rebecca and many others if the fine words which were uttered in this Parliament are not translated into action. We need to hear precisely how each of the 15 recommendations of the HIQA report will be implemented and the timeframe for doing so. The system for monitoring progress on each element of the recommendations needs to be explained and the person with responsibility for ensuring each step is taken must be identified.

The Opposition has agreed to support the cancer strategy but our support is not uncritical. We do not agree, for example, with the plan to leave the entire part of the country north of a line from Galway to Dublin without a specialist centre. We insist that the money is delivered to fulfil the promise made by the Taoiseach to the people of the south east in advance of the general election that Waterford Regional Hospital would be developed and resourced sufficiently to provide everything required of a proper centre of excellence.

I will misquote the Ceann Comhairle by saying this debate is not the end of the focus on the reports on cancer misdiagnosis, it is the end of the beginning of an ongoing process of providing a safe and comprehensive cancer screening, diagnosis and treatment service. That is why I want an undertaking from the Minister that she will take a hands-on and focused approach rather than operate at a distance of three steps from the HSE, the cancer control programme and the various centres. Otherwise, nobody will take responsibility for implementing these reports.

The BreastCheck programme has not yet been rolled out in my county and we do not expect it this year because we are being serviced by a mobile unit. Several other counties in the south and west also lack BreastCheck screening. I want an assurance from the Minister that the programme will be rolled out as quickly as possible because we are at risk currently. There is no mammography service in my own region except where patients are referred to the symptomatic breast centre by their GPs but even in that case patients face a long waiting list unless their symptoms are urgent.

[25] I also want an assurance that the cervical screening programme will be rolled out within the indicative timeframe. I have concerns about the plan that appears to be on the cards for sending cytology abroad. At least two centres in Ireland are undergoing the process of accreditation and I urge the Minister to give them the resources they need to meet the requisite standards so that we do not lose their expertise.

The cancer control programme is meant to be full and comprehensive but a full hospice palliative care service is not yet in place throughout the country. I want a commitment that the resources will be made available so that the care can be provided. People should not be disadvantaged merely because they live in a certain part of the country.

The OECD recently highlighted statistics that suggest Ireland is at the lower end of the scale on a range of cancers, including breast, prostate, cervical and colorectal cancers. It is important that all aspects of cancer are included, not just the areas highlighted in our deliberations.

In regard to the late Susie Long and the importance of a system that is fair to everybody, irrespective of whether one is a public or private patient, I want an assurance from the Minister that public patients will not have to wait so long that their health and lives are put at risk. There should be no discrepancy between public and private patients and, for that reason, the Labour Party has put forward a proposal for universal health insurance so that everybody will be on the same waiting list.

Ultimately, responsibility must be taken for implementation as opposed to the vision of the cancer strategy. Due tribute would be paid to the women whose lives were put at risk from misdiagnoses by implementing in full the recommendations of the reports before us. The current Minister for Health and Children and her successors should take responsibility for implementing the reports and we will hold them accountable for doing so.

  Deputy Caoimhghín Ó Caoláin:Last month it was revealed that public patients are still facing waiting times of up to a year and a half for vital tests on suspected cancers, including colonoscopy examinations. This is in spite of the false promises made by the Minister and the Taoiseach on improvements in cancer care, especially in the area of diagnostics. Last October, Susie Long died of cancer after her diagnosis was delayed for months because she was on a waiting list for a colonoscopy. The Taoiseach admitted at the time that Susie Long had been let down by the system.

Deputy Harney has been in this Government for over a decade and has been Minister for Health and Children since 2003.

  Deputy Mary Harney:The Deputy is ahead of himself.

  Deputy Caoimhghín Ó Caoláin:Am I?

  Deputy Mary Harney:I have been Minister since October 2004 to be precise.

12 o’clock

  Deputy Caoimhghín Ó Caoláin:It just seems much longer. I feel weary thinking back on every day of the intervening period. She bears direct responsibility for a situation whereby public patients with symptoms which might indicate cancer have to wait as long as 18 months for vital tests. There is no excuse for this. The Minister says it is unacceptable, and she is correct. However, if it was unacceptable when she became Tánaiste in 1997, she has had a decade to address it. She has failed and, while her Fianna Fáil colleagues in Government like to hide behind her skirts, they share her responsibility. That is the context in which we discuss the latest reports on failures in cancer care delivery.

[26] The reports on the cases of Rebecca O’Malley and Barrington’s Hospital can only be described as an indictment of the Health Service Executive and its management of cancer services. Basic principles of patient care were violated by the HSE. The right of patients to information about their cases and to prompt and meaningful responses to their concerns were denied. In the report of its inquiry into the Rebecca O’Malley case the Health Information and Quality Authority stated: “The impression gained was of a system that delayed or avoided difficult decisions”. The report reveals that when Rebecca O’Malley raised her concerns about her misdiagnosis no real effort was made to assist her and inform her of the facts of her case and how it had been handled. It was up to the patient to pursue the case through the system, which she did with great difficulty. Publication after publication has documented the arduous and difficult steps that she had to take all along the way to try to establish the factual position and the “why” behind her particular experience. No one within the hospital system or the HSE took the lead in responding to the patient.

The HIQA report found “a collective lack of accountability, cohesion and focus on the needs of the patient”. When the report was issued, Rebecca O’Malley stated, and it deserves to be recorded again on the record of this House:

I asserted myself and demanded answers to my reasonable questions. The system responded to my efforts by erecting, through ignorance or inertia, a wall of deafening silence that is so typical of the walls that patients regularly have to climb in an arduous effort to make the health system accountable to the very people it exists to serve.

The HIQA report demonstrates that the system failures with regard to patient care and properly informing patients who were exposed in the Portlaoise breast cancer scandal are replicated across the hospital system for which the HSE is responsible. The Barringtons Hospital report illustrates the lack of proper regulation and accountability of the private hospital system. One media commentator put it very well when he said that “by over-centralising decision-making the HSE has emasculated regional managers to the point where front-line services are compromised”.

There is a point we must acknowledge. Human error will occur in the delivery of health care — that is a fact and is inevitable. No one should try to fool the people into thinking otherwise. No system is perfect and better management cannot eliminate all instances of human error. However, the system must be open and transparent. It must be prepared to admit its mistakes and, above all, it must give patients full and frank information. Clearly, we are looking at a substantive body of evidence that shows this is not the case with the current system.

The question to be posed is whether lessons will be learned. With respect to the Minister, the signs are they will not. As far as the HSE and the Government are concerned, ruthless centralisation is the name of the game in both the management of our health services and the delivery of care, particularly hospital care. The Minister, Deputy Harney, and the HSE are about to put in place a plan which will concentrate cancer care in just eight so-called centres of excellence, four of them in Dublin, leaving large swathes of the country without proper access. Even in advance of this, services at local hospitals are being cut. As was said earlier by Deputy Shatter, none of the proposed eight centres is located north of a line from Dublin to Galway.

The term “centres of excellence” is and has been bandied about and something needs to be said about it. We should start from the premise that every centre where cancer care of whatever type is delivered — I emphasise “of whatever type” — ought to be a centre of excellence. They should all be centres of excellence. By placing the emphasis on eight centres only, the Govern[27] ment and the HSE promote the belief that care delivery at other sites must be inferior, which is a dangerous fallacy. It would also be a travesty if the reports under consideration today were to be used to promote the policy of over-centralisation, to which the Minister is clearly heavily committed.

I want to make the following point in regard to cancer care as I have made it in regard to a raft of acute hospital services, time after time in this Chamber and in other fora. No one is arguing for radiation oncology facilities in every hospital in the country. However, eight centres with such facilities are too few, and they are, as I and others have repeatedly pointed out, totally unbalanced in terms of regional spread, leaving much of the population very badly served or not served at all in real terms in my part of the island. What is needed is a truly all-Ireland and regionally based cancer treatment service — I commend this approach to the Minister once again.

Radiation oncology should be delivered within the regions. I have a very close and dear friend in St. Luke’s from Monday of this week until Friday. She will return home for the weekend and will return to the hospital for five days of each week for the following four weeks. She is a very special and lovely person. I know first-hand the terrible trauma she has suffered in terms of the preparation for this long absence and disconnect from her family and friends. As in her case, other cancer sufferers are being subjected to long and painful journeys for treatment. Many patients feel too ill to travel and choose not to avail of radiotherapy as a result, which is a terrible situation. The resources are there, even in current straitened times, to deliver radiotherapy on a regional basis. The Government needs to go back to the drawing board with its plans.

Cancer patients have been denied life-saving treatment because successive Governments have failed to provide the radiation oncology facilities required. The Government has had ample time and a booming economy over many years to plan and budget for the provision of radiotherapy centres. The State could and should have taken the lead and provided these centres directly as public facilities open to all and available and accessible on the basis of need alone. Instead, the Government has committed itself to public private partnerships to deliver them, although it was then found these would take too long and a review was ordered. The Minister, Deputy Harney, told us the planned centres may have to be provided entirely by the private sector. Professor Drumm, on the other hand, has told us the public sector can do it. I agree with him, at least on that.

The disconnect and the lack of clear management and timely and effective decision making that has been exposed in the reports we are considering comes as no surprise. It is replicated at the very top with the Minister and her Government colleagues, and at the highest level in the HSE. There is clearly no agreed cohesive, cogent approach to all of this. There are serious differences in the utterances of the Minister, Professor Drumm and others.

It was a cancer patient, the late Susie Long, to whom Deputy Jan O’Sullivan referred, who most recently and starkly highlighted the injustices of our two-tier health care system. It is a system that does not provide adequate care for cancer patients. It is a system where one can get a faster life-saving diagnosis if one is a paying customer. Public patients like Susie Long have to wait. In her case, that wait in the second-class queue proved fatal.

This Fianna Fáil-Progressive Democrats-Green Party Government is attempting to shirk its responsibility for the chaotic state of our cancer care services. The mammography issue at Barringtons Hospital in Limerick has exposed the failure of the Government to ensure that private hospitals are properly accountable. The Health Information and Quality Authority was established in legislation in these Houses in 2006 but was empowered only to monitor services provided by the Health Service Executive. It does not have powers to hold private hospitals [28] fully accountable. That is something I and other voices in this House pointed out at the time of the HIQA Bill but the Government ploughed on regardless.

Through the infamous co-location scheme the Government is encouraging the development of more private for-profit hospitals without proper accountability. When we last addressed cancer care here I recall asking the Green Party Members in Government if they remembered their opposition to co-location. I am still awaiting their answer.

  Deputy Mary Harney:What about the Deputy’s opposition last year to the hospital in the home service? That appears to have changed.

  Deputy Caoimhghín Ó Caoláin:I am sorry, I did not hear the Minister.

  Deputy Mary Harney:The Deputy opposed the hospital in the home proposal last year, as did the Labour Party.

  Deputy Caoimhghín Ó Caoláin:I am sorry, I cannot hear what the Minister is saying.

  Deputy Kathleen Lynch:The Deputy should conclude.

  Deputy Mary Harney:I am talking about inconsistencies, that is all.

  Deputy Caoimhghín Ó Caoláin:It will be of no comfort to the Minister but Fianna Fáil-led Governments for the past 11 years have presided over what is a catalogue of failures and delays in cancer care. What is urgently needed is comprehensive public cancer care, provided in the public health care system and available to all citizens on the basis of need alone, regardless of their ability to pay or where they are geographically located. I commend that approach to the Minister or, more hopefully, to her successor and at the earliest opportunity. I would wish the Minister, as I did the Taoiseach yesterday, peace and contentment for the years ahead of her.

  Acting Chairman:I call Deputy Flanagan who has ten minutes.

  Deputy Charles Flanagan:Am I sharing with Deputy Ring?

  Acting Chairman:Deputy Ring can have ten minutes later but if the Deputy wishes to share——

  Deputy Mary O’Rourke:Was I not next?

  Acting Chairman:I beg your pardon, Deputy. Of course, Deputy O’Rourke is next. She has ten minutes.

  Deputy Charles Flanagan:When I looked across at the Government benches I did not see anybody but the Minister but, of course, Deputy O’Rourke can make her contribution.

  Deputy Michael Ring:She is sitting on the Opposition side.

  Deputy Mary O’Rourke:The Chair signalled to me that it was my slot.

  Acting Chairman:I apologise. The Deputy has ten minutes.

  Deputy Mary O’Rourke:Members are very kind. This is my allocated slot for voting; it was hard earned and I am very pleased to be here.

[29] I am glad to speak on the cancer reports. I thank the Minister for coming into the House, as is her duty, because Members often bewail if Ministers do not come into the House to speak on such reports.

I attempted to listen to the Minister’s contribution in my office but my telephone kept ringing. Did the Minister say that the money allocated to Professor Keane for cancer care will be kept safe from the Health Service Executive? It will be a separate budget. It would have to be kept safe from the HSE because if it gets its bumbling — and that is a kind word — hands on it, it will be dissipated with no responsibility. I hope the cancer care budget remains with Professor Keane and his secretariat under the Minister’s guidance and not of the HSE. The Minister might clarify that matter when replying.

The Minister has come into the House to report on the various mishaps, which were major, that happened to women. It is not just women who speak here today but men also who feel deeply about the women who were misdiagnosed or had to wait their turn in that regard, to quote Deputy Ó Caoláin, because they were second class citizens but we must look forward. I have found in life that we should always look forward and not be forever looking back.

I very much approve of the centres of excellence outlined by the Minister. That is the purpose of my speaking here today even though Mullingar, which is in my constituency, had one such good cancer care centre. The centres of excellence make sense. That is the reason they should be encouraged. A previous speaker said they should be located geographically where they are needed. It is not possible to give the complete level of care, including multidisciplinary teams, that is needed to treat cancer in a comprehensive way. To think we can have cancer care units anywhere we want them is ridiculous.

I approve of the proposal for centres of excellence. They are the signpost for the future not just of cancer care but I hope also of heart and stroke care and the care of other prevalent illnesses. These centres would embody the multidisciplinary teams, research and development, training and the outlook needed to conquer and keep pace with developments in illness. We will always face illness in our lives and I strongly agree with these centres.

I take the opportunity to talk about hospice care because while we propose to have centres of excellence there is a need for hospice care throughout the country. Somebody asked me recently if hospice care was only for people who, sadly, have terminal cancer. I would have thought hospice care was for those who need it in their dying days or who need palliative care of a certain kind. The Minister has kindly agreed to meet with a hospice care group from south-west Meath whose members are doing great work on a voluntary basis to set up a hospice for those who come to use it.

As well as giving my support to the centres of excellence I wish to refer briefly to the issue that has riven this country recently, namely, Nuala O’Faolain’s interview on the “Marian Finucane Show” on a Saturday morning. I am not aware if it was mentioned in this House already but I have not met a man or woman who listened to her speak who was not instantly struck by her searing honesty. We know her, and I know her in a peripheral way, as I am sure the Minister and others in this House, from meeting her as she went about various assignments here and listening to her broadcasts from the United States where she followed the Hillary Clinton-Barack Obama campaigns. We know her always as a very forthright person. I do not believe she spoke in despair but out of a wish to let people know what it is like to be in that dark place and to wish to find an echo with people. I found her searing honesty tremendous and I applaud it, as I have often applauded statements she has said or written. Throughout her writing life she has forced us to examine issues in a way we did not know we were capable of doing and that made us face up to issues. In this way, as she has faced up to her own, she is true to her career and to the way she has managed herself throughout all those years. She was [30] met with strong, dignified probing by Marian Finucane. There is no doubt it was a very difficult interview but both women, and I do not wish to sound in any way patronising, should be applauded for the way they conducted themselves. Ms O’Faolain has given inspiration to all people who suffer from cancer.

It is interesting to note the way she was told the news in a New York hospital. She was told by a young functionary going by that she had secondaries all over her. That was the way the knowledge was imparted to her.

Her first impulse was to get back to Ireland, which was very telling. To return home is, I suppose, an animal instinct in everyone who is out of sorts, so she returned to her beloved County Clare. I understand she is now in a hospice in Galway, or at least that is what we garnered from the interview. It had an emotional impact throughout the country and it is only proper we should talk about it and face the issue.

Those of us who studied and taught students thought immediately of Dylan Thomas and his poetry:

Do not go gentle into that good night,

Old age should burn and rave at close of day;

Rage, rage against the dying of the light.

That is exactly what she is doing and were ever words more appropriate? She does not want to leave life, but who would? I would not have regarded her debate as a case for euthanasia, far from it. She wanted to stay with life. It clearly shows what people with a terminal illness are going through, as well as the need for properly developed hospice care throughout this country.

I expect the Minister will make a reply at the end of the debate. I would be glad if she could respond to the points I have made. One concerned whether the budget for these centres of excellence would be kept separate from the marauding hands of the HSE. It could later indicate it does not know where the budget has gone or it has been allocated to some other subhead. This must be kept with Professor Keane, whom I have not met, for its purpose in setting up the centres of excellence. He sounds utterly sensible.

There cannot be a centre of excellence at every crossroads in Ireland. How could this happen as we would not have the required expertise? Will the Minister in her reply give some details of plans for hospice care, now and in future? Will they all work through voluntary effort? People, both those who raise money and those from whom they expect to raise it, must be worn out sometimes through voluntary effort.

I am sure in some sections of the Department of Health and Children there are some plans for hospice care, and perhaps various care centres could be placed right throughout the country. These would of course be centres of excellence, although not in the same vein as what we need for cancer diagnosis and care. They would rather provide care for the dying with dignity, strength and humanity.

Will the Minister explain if hospices are solely for cancer care, or if anybody with a terminal illness can call upon palliative or hospice care? I am aware of a wonderful palliative care nurse who came to a home on our road every day where a young woman died recently. She cared for that woman throughout the night. I hope to get replies on these issues.

I do not share the sentiment of the previous speaker, despite what I say about the HSE. I have no time for that body, as nobody appears responsible for anything when we call them. We are passed from Billy to Joe to Jack to Mary, and in the end we do not get a reply. Answers [31] to parliamentary questions are disgraceful. I sometimes forget the question by the time I get an answer because the matter has been going on so long.

I wish for the Minister to stay in her Department because she has guts and competence. Those two qualities are very necessary for the stewardship of the Department of Health and Children.

  Acting Chairman:The Deputy’s hard work was clearly appreciated by those who re-elected her. I apologise again.

  Deputy Mary O’Rourke:Indeed, and to think the Acting Chairman was going to do me out of my slot.

  Deputy Michael Ring:Senator Donie Cassidy could not even do that.

  Deputy Charles Flanagan:I apologise to Deputy O’Rourke if, for some reason, I stood in my place intending to speak before her.

  Deputy Mary O’Rourke:The Deputy is all right.

  Deputy Charles Flanagan:It is just that I did not see her.

  Deputy Mary O’Rourke:We are all human.

  Deputy Charles Flanagan:I was called upon by the Chair in any event. I am pleased to have the opportunity to make a contribution, however short, on these important matters. This is the fourth opportunity we have had since last October to discuss cancer services, particularly in the midlands, and cancer reports. We can dwell on the past but it is an exercise in futility. I agree with Deputy O’Rourke that we must now look forward to see what lessons can and will be learned, and how the learning of these lessons will affect the people of the midlands.

The Doherty and O’Doherty reports represent a litany of failures in mammography services in Portlaoise. These reports outlined the grave and systemic weaknesses that led to nine women from the midlands being erroneously given the all-clear for breast cancer. I join with other Deputies who wished these women and their families well in their recovery.

It is now some weeks since these reports were published and the hospital community in Portlaoise, and the people of Laois, are still reeling in their aftermath. Services have been suspended indefinitely and the women of the midlands are being referred to Dublin hospitals, which have neither the capacity nor the resources to cope with the additional demand for services. At one stage we were told people in the midlands were being transferred to St. Vincent’s, on other occasions they were going to St. James’s; there appears to be a lack of clarity about which hospitals are providing services to treat the women in the midlands. There is also the question of transport and arrangement of schedules. The position is far less than satisfactory.

With regard to other cancer services, Portlaoise currently has the longest waiting list for colonoscopies in the entire country. The people of the midlands are left waiting a full 18 months for a vital routine procedure. I ask the Minister to address the matter. In regard to other services at Portlaoise, the maternity unit is grossly understaffed, to the point where health and safety is in jeopardy. I call on the Minister to direct officers from HIQA to visit the maternity unit in Portlaoise and publish an early report, as there are health and safety issues of a significant degree where women are having children in waiting rooms and conditions far less than satisfactory.

[32] A new unit which does not even provide the necessary capacity has been mooted but there has been no progress. The accident and emergency unit at the hospital is a national disgrace. A new unit has been provided but remains under lock and key, inaccessible to staff and patients. The position is of grave concern. In short, Portlaoise hospital has been exposed as one where a range of factors resulted in a shocking series of misdiagnosis in the past, and now both the hospital and the people of the midlands are being punished.

It is regrettable that the Minister has not visited Portlaoise hospital since the issue arose last autumn and it is even more regrettable Professor Drumm has not visited the hospital. I ask both to visit the hospital as a morale-boosting exercise and to at least talk to the staff and people, seeing at first hand the type of service available to the Laois population.

All units of the hospital remain dangerously underresourced. Staff morale is at an all-time low and the HSE has done nothingto assure the people of the midlands it has made changes to ensure better services are available. What has been done to assure people that consultants’ letters to Ministers will not be ignored in the future to the same extent as they were in the past? What has been done to put the mammography services at the hospital back on track?

Where is the old equipment featured in the reports and is it still being used for the provision of vital readings? Has the equipment been replaced and if so, where is the new equipment? The CT scanner that was under-resourced for such a long period now operates on an nine-to-five basis. What is the position at weekends? People are referred to Waterford, Dublin or Tullamore. These issues should have been addressed in the context of the reports, particularly if confidence in the services is to be restored.

What strategic plan, if any, is in place for Portlaoise hospital? Will it be the whipping boy as regards the closure and downgrading of regional services throughout the country? Will mammography screening and maternity services be restored? Will resources be provided in respect of the mammography service? Will the HSE continue to scale down all aspects of hospital services at Portlaoise? I want to know what is the plan and the Minister should seek details of it. The plan is less than certain and the proposals are less than definite and highly unsatisfactory because we simply do not know what is the position.

Neither do we know to where the women and other people of the midlands are to go under the new regime of regional centres. I do not have a difficulty, in principle, with regional centres for cancer care, notwithstanding the fact that it is not proposed to situate such a centre in the midlands. I have no problem with that provided the people of my constituency and beyond are given assurances that they will have access to the type of vital treatment services which they deserve and which are necessary.

The Health Service Executive and the Minister for Health and Children have conspired to create an information vacuum in respect of what is happening, particularly in the context of the hundreds of thousands of people in the midlands who are going to lose their services. Parliamentary questions tabled by Deputies remain unanswered. I recently experienced a farcical situation where I left a meeting in Tullamore stating that I would be obliged to progress a particular matter by way of parliamentary question and where said question was referred by the Minister’s office to that of Professor Drumm and, in turn, sent back to the gentleman with whom I had originally been dealing. The latter was asked to reply but indicated that because the matter involved funding it was not proper to him and he had no information in respect of it. What I experienced was a complete affront to the entire democratic process. Neither the Minister, the HSE nor the hospital appear to be accountable to the people or their public representatives.

[33] Some time ago I called on the HSE — I do so again today — to introduce a structured schedule of public meetings to be attended by senior hospital personnel in the midlands. Such meetings are essential if public confidence in the hospital services available to the people of the region is to be restored. Service providers and hospitals must be able, at all times, to institute clear lines of communication with their patients and prospective patients. Patients and their families offer a very valuable resource to hospital managers who wish to improve their standard to care and address deficiencies.

I am suggesting that the general manager, medical director and director of nursing of each hospital in the region should be prepared to meet elected representatives and members of the public on a regular basis. They should be prepared to discuss their hospitals and the plans they have for them, put their service plans in the public domain and talk to the local media. Information is vital and the restoration of the confidence of the people of Portlaoise and the midlands is an essential task which, regrettably, has been ignored since the publication of these reports six weeks ago.

Nothing less than a schedule of public meetings will be appropriate, particularly if the hospital in Portlaoise is to have a vibrant future. Despite the fact that they are currently being treated as such by the HSE and the Department of Health and Children, people in Laois-Offaly and the wider midlands region are not second-class citizens.

The Minister likes to refer to the powers she does not possess. As a result, I sometimes wonder about the Department of Health and Children and the role and function of the Minister. She has powers to ensure that the lines of communication between the people of the midlands and the hospital in Portlaoise are opened and kept that way. The current situation is a complete farce. People are rightly frustrated, fearful and angry. They believe they deserve better from the Minister and the HSE and they are right to do so. They want answers and they want to know that lessons will be learned and an action plan put in place.

The consequences of the Doherty and O’Doherty reports cannot be that Portlaoise hospital is condemned to limbo on an indefinite basis. It needs a strategic plan and a schedule of structured funding. People must be informed as to what is happening, which is the least they deserve. The Minister must provide leadership in that regard.

  Deputy Chris Andrews:I welcome the opportunity to contribute to the debate on this issue, which is vital to me, my constituents and people throughout the country. I met Professor Tom Keane who came before the Joint Committee on Health and Children and what he said made me confident that he can deliver the required changes. I spoke on previous occasions in support of the national cancer strategy. I am of the view, now more than ever, that said strategy will be delivered upon by the Minister and Professor Keane.

We need to focus on survival rates among cancer patients. It has been proven that these rates are 20% higher where patients are treated at centres of excellence. Such centres are key to improving survival rates.

There is no doubt that reform of the health service will be difficult. All the more reason then that we should drive such reform and change. By definition, reform means change. Reform alters people’s boundaries and takes them out of their comfort zones. It also leads to people seeing themselves as winners or losers in some sort of battle.

Each hospital forms part of a jigsaw. The Government is obliged to consider the whole as opposed to merely focusing on individual pieces. The ultimate goal as regards reform of the health service is the improvement of standards of patient care, an increase in survival rates and the provision of the most up-to-date treatments. We have started out on that road. Our journey will be long and difficult but, ultimately, it will be effective and results will be delivered.

[34] Early diagnosis is the key to delivering improved survival rates. When early diagnosis becomes the norm, multidisciplinary teams must be in place to deal with the large throughput of cancer-related illnesses. Doctors must be familiar with the broad range of cancer treatments and the side effects thereof. They must not work in isolation from others involved in the care of individual patients. Everyone dealing with a particular patient must work together and communicate with each other. It should not be the case that medical teams treat different parts of illnesses in isolation. Patients will suffer unless an approach that is all-encompassing is taken.

Hospitals will lose services as the latter are transferred elsewhere. However, we must ensure the needs of cancer patients remain to the fore. In my constituency of Dublin South-East there have been proposals for a transfer of services from St. Luke’s to St. James’s. St. Luke’s is a wonderful facility with excellent staff and the environment is positive for anyone who is ill and recovering from cancer. If we are required to transfer services to St. James’s to improve matters and if more people will survive as a result of such a transfer, we must go ahead with the move. The transferral of services to St. James’s will allow St. Luke’s to develop other services on the existing site, which is clearly in the interests of the health service.

Deputy Charles Flanagan said that we must learn lessons, but the establishment of HIQA and the appointment of Professor Keane are examples of learning from past mistakes. The recent Barringtons and O’Malley reports were distressing. I also extend my sympathy and support to those involved in their recovery. These reports have highlighted the real need to bring about change by establishing these centres of excellence as soon as we can.

  Acting Chairman:I thank the Deputy for his co-operation. I call Deputy Ring who has ten minutes.

  Deputy Michael Ring:I wish we were debating a motion because then we could vote on it. Fine Gael Deputies decided that we would no longer have debates such as this, but motions on which we can vote. I am surprised that we are having statements again today because we cannot have a vote when they conclude.

As somebody who comes from a family whose sister died at 45 years of age, and a sister last week had her breast removed, I know all about the cancer services that are available. The services in County Mayo are excellent and there is an excellent team working there. Mayo General Hospital is seeking a managed clinical cancer treatment network to connect with Galway. We have an excellent team of surgeons in Castlebar. However, there was an announcement recently by the hospital manager, although not with the good wishes of the consultants or the people of Mayo, that services would be moved from Mayo General Hospital to Galway. This battle is not over. It is easy for the Minister, Deputy Harney, Deputy O’Rourke and Deputy Chris Andrews to speak when four centres of excellence will be located in Dublin. We will have one in Galway but there will be none in Mayo, Sligo or Donegal, and that is a disgrace.

It is fine for Professor Keane, great man that he is, and everybody says he is, but the same professor is getting €600,000 for a two-year contract. Professor Keane will be like the Minister, he will walk away after two years, whether the system works. He will be like the Minister, saying that he has no responsibility for the HSE. He will have no responsibility for what is left behind him. He has taken away an excellent service from Mayo. Last year, 79 women were operated on. Some 10,000 people came on to the streets of Castlebar to state that they were happy with the service there.

We do not trust the Minister, the HSE or Brendan Drumm because they cannot deliver services. They have made a mess of the HSE. They will make the country’s cancer services worse rather than better. People living in Blacksod or Belmullet are 100 miles away from [35] Galway city, which means they must make a 200 mile round trip for an appointment. There are no parking facilities because the hospital is overcrowded.

I will give an example of how they are operating in Galway already. A gentleman wrote to me and to the Connaught Telegraph in Castlebar. The newspaper contacted the HSE and I tabled a parliamentary question. The HSE responded to the Connaught Telegraph but I am still waiting for my reply. It informed a woman that she would have an appointment for oncology services on 23 September 2008, but the problem is that the woman has been dead for 17 years. The HSE went on to say it regretted sending out the appointment letter and blamed a junior member of staff. A senior member of staff should have taken responsibility for that, however. It is outrageous that the HSE does not have its records up to date. It is also outrageous that the HSE expects people in Mayo and Sligo to have confidence in that hospital. How can one have confidence in a hospital that gave an appointment to a woman who has been dead for 17 years? I have no confidence in that hospital.

I oppose the withdrawal of services from Mayo General Hospital, which we are happy with and want to keep. That battle is not over yet. Deputies Beverley Flynn and Dara Calleary, as well as the Minister of State, Deputy Jimmy Devins, and other Government Deputies will soon have an opportunity to vote in this House on cancer services for the north west. I am sick and tired of such people speaking out of both sides of their mouths. In Mayo they are all for it, while in Dublin they are all for the Minister, but they will have to make a decision here shortly. When we put that motion on the floor of the House we will see if they vote for the people of Donegal, Sligo and Mayo, but they will not be speaking out of both sides of their mouths. We will bring the women from Sligo and Mayo to the Visitors Gallery to show them what these politicians are made of.

We are proud of our cancer services in Mayo, including the team of consultants there. The women of the county want them so why should a service be taken away, at least until the service in Galway is up and running? People should be allowed to decide for themselves.

Recently, I came across the case of a woman who went into a private hospital to have her breast removed. She has private health insurance. She should have been receiving chemotherapy for the past five weeks but is not fit to because she got an infection in that hospital. That is the kind of health service we have in this country, yet we are told there have never been as many financial resources as at present. We are told that this is the way forward, but is that not what the Minister told us about the HSE? She said there were too many health boards with too many people on them and they were not working. She said the HSE would be the answer to everything but it has destroyed the health service. We have never had so many problems and nobody is taking responsibility for anything. In the past two or three years, we have been paying more money for consultants and less money for doctors, nurses and attendants. Something is wrong. Ireland is only a small country with a population of 4.5 million. There are as many people in Manchester, yet their health services are able to cope while ours cannot. What has gone wrong with the health service here?

Yesterday, a man in Mayo General Hospital was waiting to be called today for a bed in Galway, but no such bed is available. A young man in Erris with a serious head problem has been waiting four weeks for a bed in Beaumont Hospital. His mother and sister contact me every day looking for the best service for their loved one, but it is not forthcoming. What is going wrong?

The Government talks about decentralisation to bring services from Dublin to the regions, but the opposite is being done with the health service. Services are being transferred from rural areas to the cities. That is not acceptable and something must be done about it. I plead with the Minister to leave the services we have in Mayo General Hospital, including the excellent [36] staff, Kevin Barry, Mary Casey and Ronan Waldron. These are excellent consultants and surgeons. I will support the Minister if she wishes to set up centres of excellence. The women of Mayo, Sligo and Galway will make a decision and go to the best places. I plead with the Minister to leave the services in place for the women of Mayo and to have a satellite service between Mayo and Galway. The Minister should not take away a service that is working from a county that needs it. Ours is a rural, disadvantaged area and circumstances are very difficult for people living there.

People in my constituency cannot get hospital appointments because the HSE has no funding to bring them to the hospital. People will die because they cannot get to appointments and the Minister wants to remove services from Mayo. It is not right and it should not happen. The services are working but what the Minister tried with the HSE is not working. I say to Professor Keane that he is entitled to his €600,000 but he is not doing any favours to the women of Mayo.

  Deputy Mary Harney:I thank the Deputies who contributed to the debate. I will begin by responding to Deputy Ring, although he was the last to speak. Theodore Roosevelt said that successful leadership is about speaking softly but waving a big stick. I do not know about Deputy Ring’s big stick but he certainly does not speak softly.

  Deputy Michael Ring:I am passionate.

  Deputy Mary Harney:I sympathise with Deputy Ring on his family experience of breast cancer and wish his sister a speedy recovery.

  Deputy Michael Ring:I thank the Minister.

  Deputy Mary Harney:However, Deputy Ring’s comments on Professor Keane are unfortunate. We have procured the services of Professor Keane and other services from the British Columbia Cancer Centre for a two-year period and the sum of money is €600,000. That is not the salary of Professor Keane. Most surgeons working in this city earn substantially more than that in one year. This man is incredible value for money, though I hate using the term. We are very fortunate to have someone of his competence, experience and expertise to implement the cancer control programme. Everyone who has met him, including clinicians, nurses, managers and administrators are deeply impressed with the speed with which he sought to implement the cancer control plan. He came here last November and he tells me that, in respect of breast cancer, he is ahead of schedule, which is very reassuring. He is working with clinicians around the country to get clinical buy-in. Just a few weeks ago he addressed 200 surgeons at the Royal College of Surgeons. He left the room with everyone agreeing that his methodology and his plan was the way forward.

Regarding Mayo, the clinicians support Professor Keane, particularly Dr. Barry, the breast surgeon there. I have publicly saluted Dr. Barry’s courage.

  Deputy Michael Ring:No, he does not. I can tell the Minister he does not.

  Deputy Mary Harney:That is the case. I am assured of that. I hope to meet Dr. Barry next week, when I go to Mayo——

  Deputy Michael Ring:The Minister can ask him.

  Deputy Mary Harney:——to launch BreastCheck. I am sure Deputy Ring has seen the mobile unit in Castlebar.

[37]   Deputy Michael Ring:I am delighted it is there.

  Deputy Mary Harney:I welcome the fact that the service is being rolled out to Mayo. Deputy O’Sullivan asked about the complete roll-out. That will take place by the end of next year in respect of BreastCheck.

Cervical screening will be rolled out to the entire population base this summer. It will not be done in the same manner as BreastCheck, county by county.

The outsourcing of cytology is done for two reasons. One is quality, because it will take at least two years to bring our facilities to the standard required. The second reason is cost, but it is mainly a quality issue.

Before I address the points raised about cancer, on the broader issues of health, between 1999 and 2003 life expectancy in Ireland increased by three years, the fastest increase in the developed world. That happened because of better treatments. Today, a child born in Ireland will live longer than a child born in the Netherlands, Belgium, Denmark, Germany and the United Kingdom. Fewer than half the number of people who used to die from heart disease die from it today. This is one of the biggest success stories that has dramatically impacted on life expectancy.

The OECD reviewed cancer performance here in 1994-98 and 1999-2003. Comparing the second period with the first, the survival outcomes had improved by 31% for pancreatic cancer, 24% for prostate cancer, 13% for lung cancer, 10% for leukaemia and 9% for breast cancer, which was one of the best performances. We are top of the class on children’s cancer, ahead of the European average.

I say these things because we hear constant references to shambles and disaster. Some 400,000 more people are treated in our hospitals this year than was the case 12 years ago, as day cases, outpatients or in-hospital treatments. For the top 20 procedures, instead of people waiting two to five years, as was the case some years ago, it is an average of two to five months.

Regarding cancer services, we know that volume equals quality. Some 250 publications state that if one is not treated in a centre with a high volume of cases on an annual basis — a minimum of 150 — the chances of surviving are diminished by 20%. That means that one in five women, who would otherwise survive, would die. This is compelling evidence and if we are interested in patient safety we are compelled to implement that.

1 o’clock

Deputy Ring referred to 79 cases, which falls far short of 150. When BreastCheck is rolled out and that is integrated into the hospital in Galway, the new cases in Mayo will be substantially reduced. The same applies to other counties. We have made an exception for Donegal, for geographic reasons and because of dialogue and discussion we are having with the authorities in Northern Ireland on cancer care. There will be a satellite centre from Galway in the hospital in Letterkenny and, hopefully, there will be radiation and oncology facilities. The Minister for Health, Social Services and Public Safety in Northern Ireland announced last week that radiation oncology services are being rolled out to Altnagelvin. I have discussed with the Minister for Health, Social Services and Public Safety, Michael McGimpsey, our interest in jointly providing radiation oncology for the patients in the region. The Irish Government will be prepared to fund capital investment or procure services and the Minister there is very interested in that.

One of the first people I met when I became Minister for Health and Children was Margaret Murphy from Cork. I met her in the UK at a World Health Organisation, WHO, patient safety conference. Her son, Kevin, died long before I became Minister from errors in a hospital in this country. She wanted to find out what happened to her son and why, but no one gave her [38] answers. She litigated and when she received compensation she donated it to a charity. That era is over. If mistakes occur we will investigate them, painful as it is, publish the findings and learn from them.

Deputy Shatter referred to blame culture. I have learnt from domestic expertise and international conferences I attended under the auspices of the World Health Organisation that if there is a blame culture, a doctor or nurse will not put up his or her hands if they think they will be penalised. That is what happens in patient safety cases. The countries that do best are those that encourage reporting the error to ensure the mistake does not happen again or that the capacity for the mistake can be minimised.

I do not have time to respond to all the issues raised by Deputies. The health reform programme is in its infancy. The previous organisation of services did not work, which is why we have a new regime. The new regime is in its infancy and is slower than I or Professor Drumm would wish, but progress is being made. Deputy O’Sullivan referred to my HSE, but it is my HIQA too, if she wishes to be personal. This House passed the legislation and it had the support of all the parties on the establishment of a unified system.

  Deputy Jan O’Sullivan:There was no time to debate it.

  Deputy Mary Harney:There were debates on it for weeks and months, as the Deputy knows. There is an onus on all of us, particularly people who work in the public sector, to support the developments. One never hears somebody from a private hospital moaning about it and running it down. We constantly hear people criticising their place of work. People working in the public sector do not seem to have the same affinity with their institutions as their private sector counterparts. That is a great pity.

  Deputy Jan O’Sullivan:That is very unfair.

  Deputy Mary Harney:That is a great pity and it is a fact. Can the Deputy tell me when she last heard somebody say anything to the contrary, anywhere, on “Morning Ireland” or any other show or in the media? If she can point to one example, I shall correct what I am saying. The fact is that our public health system is providing outstanding care for thousands of patients and the reform programme is about improving access issues and dealing with deficiencies. We are getting there. We are not there yet, but we are certainly on the road to success.