Speech by the Minister for Health and Children on the Private Members Motion on Cancer Services
I am pleased to have the opportunity to describe and put in context the extensive investment and reform programme which this Government has been promoting under the National Cancer Strategy and particularly since the launch of the Health Strategy in November 2001 and to set out the current position in relation to cancer services nationally.
The opposition motion fails to appreciate the broad recognition among health service providers of the changes that have taken place in recent years in improving cancer care. Cancer care is too important a service to have it subjected to the type of “all kinds of everything” motion which the opposition has put together.
In the middle of this century, the chances of surviving cancer were low and showed little improvement from year to year. Over the last few decades, however, there have been some striking changes. In childhood leukaemia there has been a dramatic improvement in survival. Similar improvements have occurred in Hodgkin’s disease, testicular cancer and melanoma. In many other cancers, improvements, though less dramatic have been taking place. This has greatly changed the experience of cancer. We must, therefore, begin to view cancer not as a death sentence but a condition from which people can expect to survive. Nowadays, there is real hope for patients and families. My focus is to ensure that there is access to services which deliver this experience for each and every person who is diagnosed with cancer. Effectively tackling the problem of cancer means achieving consistently high quality, specialist services for patients, their carers and their families.
Policy Context- Health Strategy
This Government is committed to the development of co-ordinated and patient-focused cancer treatment. The Health Strategy provides a highly ambitious and challenging agenda for the delivery of major improvements in health services throughout the country and signifies the clear and high priority which I attach to cancer and cancer care as part of the overall health system. The first national goal of better health for everyone contains a number of critical objectives in relation to cancer care and I have already made significant progress on many of them.
I propose, a Chathaoirleach, to outline the substantial developments that have taken place in recent years in all of the main elements of a comprehensive cancer policy. Health Promotion, Prevention, Primary Care, Acute and Palliative Care Services have all benefited from investment and improvement.
The key goal of the National Cancer Strategy 1996 was to achieve a 15% decrease in mortality from cancer in the under 65 year age group in the 10 year period from 1994. I am happy to advise the House that this figure was achieved in 2001, which was 3 years ahead of target.
There is no doubt that cancer is a major challenge to our health services. Approximately 21,000 new cases of cancer are recorded annually in this country and one in three of our citizens will develop cancer in the course of their lifetime. Cancer is more common in older people and as the population gets older, we can expect cancer cases to increase accordingly.
Our age standardised mortality rates are higher than the EU average and there is scope for improvement to bring our rate in line with other EU countries. The reduction since 1994 in cancer mortality rates is as a result of improved diagnosis, earlier interventions and improved and more widely available cancer treatments. I expect these trends to continue as a result of developments in cancer services and continued improvements in treatments.
Improving Cancer Services – Investment to date
A particular feature of health policy development over recent years has been the development of highly focused disease specific action programmes. The National Cancer Strategy is a leading example of this.
Since the implementation of the National Cancer Strategy, a cumulative figure of €400 million has been invested in the development of cancer services, well in excess of the£25million initially envisaged in 1996 to implement the National Cancer Strategy.
Cancer Prevention Programmes
The National Cancer Strategy acknowledges that the cause of most cancers is multifactorial but that there is strong evidence that lifestyle factors, in particular smoking, alcohol and diet play an important role. The promotion of healthy lifestyles is a key element of the work of the Department´s Health Promotion Unit and spending by the Unit since the launch of the National Cancer Strategy on these topics is in excess of €17m.
Following the signature by the President of the Public Health (Tobacco) Act, 2002 on the 27th March 2002, I established the Office of Tobacco Control on a statutory basis. This indicates my commitment to a range of anti-smoking measures. In this regard, I announced on 30th January last, my decision to ban smoking in all workplaces from the 1st January 2004: this ban will include the hospitality industry where many workers are exposed to passive smoking.
For all health behaviours, there is a shortage of national data representative of the various social subgroups in the Irish population. To combat this, the Health Promotion Unit commissioned the National Surveys of Lifestyle, Attitudes and Nutrition (SLÁN), which were carried out by the Centre for Health Promotion Studies, National University of Ireland, Galway.
The first SLÁN survey was commissioned in 1998 to provide baseline information on a range of lifestyle related health behaviours in the Irish adult population, with sufficient power to detect differences across age, gender and social strata.
SLÁN Top Line Indications
In 2002 the HPU re-commissioned the next phase of the National Health and Lifestyle Surveys, with a larger population sample. I am pleased to announce that some positive trends are emerging from this 2nd Survey, which I will be announcing in full tomorrow. The top line indications show that:
- Across almost all demographic categories smoking rates have fallen but this trend has been most marked among girls and young women, a key target for our recent anti -smoking initiatives.
- The overall rate of smoking in school-going children has fallen.
- While overall exposure to tobacco smoke is down, the rates of exposure at work and in pub and clubs remain high.
- Alcohol once again proved to be a problem, despite an increase in the number of school children reporting to never having consumed an alcoholic drink.
- One of the most positive findings in the Survey was the increase in the adherence to the recommended consumption levels of fruit and vegetables, in all social groups and men in particular.
While these trends in both smoking and diet are positive much work remains to be done especially in the area of alcohol consumption and I will be elaborating more on these issues at the launch of the 2nd National Lifestyle Survey tomorrow.
There is increasing recognition internationally of the importance of primary care in the delivery of cancer care. The Primary Care Strategy will provide us with the capacity to ensure that people can experience a well co-ordinated and integrated package of services appropriate to their needs in their own communities and in their homes. It will broaden the focus of services to include health promotion, prevention and supportive care for those who have recovered from cancer, are living with cancer or are dying from cancer.
Secondary and Tertiary Care
Investment to date under the National Cancer Strategy has enabled the funding of 80 additional Consultant posts, together with support staff in key areas such as Medical Oncology, Radiology, Palliative Care, Histopathology and Haematology throughout the country.
- For example, prior to the National Cancer Strategy, there was a total of four Consultant Oncologists in this country. Since 1997, an additional 12 Consultant Oncologists have been appointed nationally, including three in the South Eastern Health Board alone.
- Other appointments under the National Cancer Strategy include an additional 21 Consultant Surgeons, an additional 13 Radiologists and an additional 13 Histopathologists.
The benefit of this investment is reflected in the significant increase in activity which has occurred. For example, the number of new patients per annum receiving radiotherapy treatment has increased from 2402 in 1994 to 3809 in 2000. This means that an additional 1407 patients are accessing these services, representing an increase of 58% nationally. The number of new patients per annum receiving chemotherapy treatment has increased from 2693 in 1994 to 3519 in 2000, representing an increase of 30% nationally.
Symptomatic Breast Disease Services
Breast Cancer is the individual site specific cancer which has received the most investment in recent years. Indeed, since the implementation of the National Cancer Strategy, approval has been granted for an additional 39 Consultant posts with a special interest in breast disease across the modalities of Surgery, Radiology and Histopathology.
Since 2001, there has been a cumulative investment of €30m in the development of symptomatic breast disease services. The benefit of this investment is reflected in the significant increase in activity which has occurred, with in-patient breast cancer procedures increasing from 1,336 in 1997 to 1,839 in 2001. This is an increase of 37% nationally.
As the Deputies are aware, I announced the national extension of BreastCheck, the National Breast Screening Programme on 27 March last.
BreastCheck currently provides breast screening services to women in the 50 to 64 age group in the Eastern Regional Health Authority, North-Eastern Health Board and Midland Health Board areas. This programme is proving extremely successful in identifying breast cancer among women in this age group and also provides for the necessary surgical care of women who require breast surgery. To the end of December last year, 110,636 eligible women had been called for screening and 83,000 women had been screened, representing an uptake rate of 75%.
BreastCheck has ensured that their programme is externally reviewed and validated. Last year a team from the European Reference Centre for Quality visited the programme. The key strengths of the programme identified by the Reference Centre are outstandingly high levels of professional expertise, team working and commitment to the programme, with all disciplines working to an internationally recognised standard. The BreastCheck clinical unit in the Western area will be at University College Hospital Galway, with two associated mobile units. The area of coverage will be counties Galway, Sligo, Roscommon, Donegal, Mayo, Leitrim, Clare and Tipperary N.R. The BreastCheck clinical unit in the Southern area will be located at South Infirmary/Victoria Hospital, with three associated mobile units. Counties covered include Cork, Kerry, Limerick, Waterford and Tipperary S.R.
Under the extension, approximately 130,000 women in the target population 50 to 64 years of age will be eligible for screening. The programme expects to diagnose approximately 400 cancers per annum among this population.
Under the Business Plan submitted by BreastCheck to the Department, the national expansion of the programme to the West and the South has been costed at €27 million, including€13million capital costs.
Discussions are on-going involving officials of my Department, BreastCheck and relevant health agencies and indeed meetings took place the week before last in both Cork and Galway in relation to the detailed roll-out of this programme. The objective is to prepare an effective and cohesive model which is in the best interests of the women concerned and which builds on the quality standards applied by BreastCheck and develops effective linkages with the Symptomatic Services.
My commitment and that of my Department is evidenced by significant funding which has been provided. There has been a cumulative investment of €40million to date in this programme. In addition, I have also made available approximately€6million for the construction of a new state of the art screening unit at St. Vincent´s Hospital to replace the current Merrion Unit.
In relation to the development of services for women with cancer, the commitment of this government is further evidenced by the introduction of the Irish Cervical Screening programme. Cervical Screening is a valuable preventative health measure when delivered as an organised screening programme.
As part of an examination of the feasibility and implications of a roll out of the national programme, the Chief Executive Officers of the health boards are making arrangements to have an external review of Phase One carried out during 2003.
To meet the additional demand for cervical cytology laboratory services, additional resources have been made available in recent years to develop both the laboratory and colposcopy services. In 2002, additional ongoing funding in the region of €2.5m was provided and in 2003 a further €1.4m has been allocated to health boards and the ERHA for ongoing development of these services.
I accept that we do not have sufficient radiotherapy capacity at the present time to meet existing and future demands for radiotherapy. The provision of radiotherapy requires significant medical, scientific and support expertise and resources, in addition to extensive capital investment. That is the reason I established an Expert Review Group on Radiotherapy Services to ensure that we effectively plan the current and future development of this key element of cancer care.
The current debate on radiotherapy services is extremely narrowly based and is confined to geographic location without any real discussion on the principles that should underpin the national provision of services.
In establishing the Expert Review Group, I ensured that it would be multi-disciplinary and include the various modalities of care, including radiation oncologist, medical oncologist, physicist, academic, public health and patient advocate representatives. I also ensured that we would have expert input from outside the jurisdiction.
I consider it premature for the opposition to engage in political opportunism even before it has had an opportunity to examine the Report, see the essential principles that underpin its work and appreciate and reflect on the extensive benchmarking they no doubt have undertaken in relation to the provision of radiotherapy services in other countries.
One example I would like to refer to concerns the centralisation of services as referred to in the opposition motion. Northern Ireland has a population of 1.7m citizens and it has decided to centralise its radiotherapy services in Belfast with the construction of a comprehensive radiotherapy facility on the site of a major teaching hospital which will treat all cancer patients in the six counties who require radiotherapy.
There is considerable optimism in Northern Ireland in relation to this development as it represents the best and most effective way of organising services that ensures a quality and equitable access to radiotherapy. In contrast we have a population of 3.9m and the debate to date is about geography and not about the quality of services. I fully expect that the Expert Review Group will address the competing demands of quality and geography.
International evidence is that radiotherapy is a service that can best be provided in a limited number of centres. I am certain that the future demands to provide a comprehensive service that is quality and equity driven will be extremely expensive. For my part, my objective will be to develop proposals on foot of the Report that will provide us with a model of radiotherapy services that is patient centred, that attracts and retains the best medical and scientific expertise and that ensures comprehensive radiotherapy treatments in a timely and quality manner. I am determined to plan to achieve this objective.
I wish to advise the House of a number of developments in radiotherapy. In recent years, significant investment in new radiotherapy services has taken place in Dublin, Cork and Galway. St. Luke´s Hospital has seen considerable renovation and upgrading. In excess of €25 million has been invested in St. Luke´s enabling the purchase of significant additional equipment including six new linear accelerators. This investment ensures that St. Luke’s continues to meet the demands placed on it as a world class centre for the delivery of radiotherapy.
Almost €9 million has been invested in Phase 1 of a substantial new building project development at Cork University Hospital for Radiation Oncology Services which was completed in 2002. This involved the commissioning of two new Linear Accelerators as well as other equipment.
A new Radiotherapy Department is currently under construction at University College Hospital Galway. It is proposed that this supra regional centre will provide services to the Western and North-Western areas. This development is part of the Phase 2 Project at University College Hospital Galway. In excess of€100 million has been allocated to this project which is due for completion in Autumn 2003.
The Report of the National Advisory Committee on Palliative Care was approved by this Government in the Summer of 2001 and I launched it in October 2001. The Report describes a comprehensive palliative care service and acts as a blueprint for its development. This Government has agreed to the implementation of the report´s recommendations over a 5 to 7 year period. The implementation of the Report will be undertaken as part of the implementation of the National Health Strategy.
Additional revenue funding of €2.5m was provided in 2003. Since September 2001 almost €11m has been allocated to the health boards and the Eastern Regional Health Authority to begin implementing the Report’s recommendations.
Cancer Clinical Trials
In February of this year, the first all-Ireland Cancer Network was launched under the auspices of the Ireland-Northern Ireland-National Cancer Institute Cancer Consortium. The network is being formed by the Irish Oncology Research Group in Dublin, the Clinical Research Support Centre in Belfast, nine cancer centres in Ireland and one in Northern Ireland.
The new cooperative group will be jointly funded by the Health Research Board in Dublin and the Research and Development Office in Belfast. The group will receive €1m over the next two years to carry out its work. Its principal role will be to initiate and coordinate clinical trials in cancer hospitals in both parts of the island.
My own Department has demonstrated its support by investing significant resources in this trilateral programme. Under this scheme, awards to the value of €3.5 million have been made available to allow hospitals to recruit and train staff, improve facilities and take part in world class clinical trials.
Organisation of Services – New National Cancer Strategy
International evidence is that better clinical outcomes are achieved in hospitals with specialist staff, high volumes of activity and access to appropriate diagnostic and therapeutic facilities. Best results in treatment are achieved where patients are treated by staff working as part of an integrated multidisciplinary specialist team. This core principle must inform the current organisation of services and how we plan future services across the various modalities of cancer care.
I wish to refer to the work of the National Cancer Forum, a multidisciplinary group of experts appointed to advise on cancer services, including hospital services. The Forum, as part of the development a new Cancer Strategy has examined oncology surgery between 1997 and 2002 in respect of a number of site specific cancers, including lung, breast, pancreas and colon.
The Forum has concluded that there are too many Consultants performing oncology surgery in too many hospitals given the total number of procedures that are performed in our hospitals. We simply do not have the patient caseload to support the current broadly based organisation of oncology surgical services. The Forum has advised me that the current organisation of these services is not in line with international best practice. The Forum will be reflecting further on this issue as it prepares the next Cancer Strategy, which I expect to receive later this year.
International evidence is that technically challenging surgery, for example, can best be supported if it is concentrated in a relatively small number of centres. This is a message that is evidenced based and needs to be directed at and pursued at a number of levels in our society.
Primarily, at medical level there is a clear responsibility on the profession to respond to this reality in a balanced and adequate manner. As major stakeholders in our health services, I also expect the profession to lead medical and public opinion on this subject and challenge contrary views. I am convinced that the medical profession on a more organised basis also needs to articulate to politicians on matters of this importance. Too often, it is left to politicians to respond to pressure to pursue the organisation of services that is based on sectional interests and not on best practice.
It must be understood that having a service is no longer sufficient. It must be a service that is organised in such a way that it is capable of delivering quality in line with international standards and practice. We must face the reality that we cannot continue to expect that we can deliver the highest quality of cancer services across over 30 acute hospitals.
I am not prepared to stand over a service that is designed in a way that limits the potential of cancer care to maximise outcomes for our population. To do so would be to create an apartheid system that is simply not acceptable. These are major challenges for politicians, the medical profession and society generally. While we must continue to invest in quality, we must also organise for quality. Best cancer care must be benchmarked against quality indicators and not indicators based on geography.
In terms of our achievements in improving cancer care, I have presented information here today in terms of increased manpower and increased activity. These are an important measure of improvements in cancer care. However, we also need to develop further our understanding of the process of care.
The ultimate objective in terms of the delivery of cancer care is that those in receipt of services experience outcomes on a par with best international standards. Health information is fundamental to assessing and implementing quality programmes. The National Health Strategy provides for the establishment of an independent Health Information and Quality Authority to lead the development of health information to support these requirements.
The Health Information and Quality Authority will exercise a pivotal role in relation to a number of key information functions. It is only through focusing on specific information developments such as this, to build on the excellent work of the National Cancer Registry, that we will be able to continuously demonstrate the positive impact that cancer services are having and also to identify the areas which may need to be addressed to further strengthen our cancer care system.
Patient Survey: Perception of Quality of Healthcare
Last month, the Irish Society for Quality and Health Safety in Healthcare launched the results of the latest survey undertaken on their behalf into patient perception of the Quality of Healthcare. The Health Strategy contains a great many commitments associated with both people centredness and quality issues. It clearly identifies the need for healthcare providers to put the patient at the centre in the delivery of care and to take into account the views of patients in relation to the care they receive. The results of the 2002 survey are positive in many respects. Patients perceive the quality of the care and service they received to be very high. Some of the findings mentioned in the Survey include:
- 92% of patients reported being satisfied or very satisfied with the overall quality of care they received during their stay in hospital;
- 85% of patients reported being satisfied or very satisfied with the standard of service they received in the A&E Department;
- 90% of patients who experienced a procedure reported having it adequately explained to them;
- 92% of patients expressed a high level of overall satisfaction with the hotel aspects of the hospital’s service.
We are extremely fortunate in this country that those involved in cancer care provide a professional and high standard of care that is broadly appreciated by those with cancer and their families. I wish to recognise this dedication and commitment here today. My objective as Minister for Health and Children is to ensure that the substantial investment is reflected in improvement in health outcomes for cancer patients.
The developments which I have outlined here today describe an overall framework through which cancer services can be developed and provided in the most co-ordinated and effective manner.
In conclusion, a Chathaoirleach, I am glad of the opportunity to place on the record of the House the substantial developments that have taken place in cancer services. It is appropriate that this House should commend the Government for its positive and demonstrable commitment to cancer services. I do consider that while we have achieved a lot, more needs to be done.