Tuesday, 11 November 2008
Dáil Eireann Debate
condemns the decision of the Minister for Health and Children to abandon this programme as short-sighted and unjustifiable, and calls on the Minister for Health and Children to immediately reverse her decision.
Fine Gael has tabled this motion because we believe we are at a crossroads in terms of how we prioritise and spend our money within our health policy. This reaches to core values in health, namely, the saving of lives and the prevention of illness, pain and death. For background purposes, I mention that HIQA recommended that this vaccination programme go ahead and it produced figures which I put on the record of the Dáil last week. They are worth repeating because they are stark. Of the 7,259 cases of pre-invasive carcinoma type 1 of the cervix, known technically as CIN 1, 2,245 could be averted by the use of the vaccine. Of the 3,515 cases of CIN 2 and 3 which are also pre-invasive but more serious, 1,435 could be averted. More than one third of pre-invasive cancers which require treatment, time off work, distress, worry and anxiety could be averted by the use of this vaccine.
More startling are the facts that of the 200 cases of cervical cancer recorded in 2004, HIQA estimates that 111 could have been avoided as could 52 of the 93 deaths from cervical cancer in the same year. It is a wonder to many people, and to me, that we have been able to develop a vaccine against cancer. It is a dream come true. Now we will not use it because of a Government decision which will seem all the more stark and ludicrous as I speak tonight.
With regard to recommendations by experts, the members of the national immunisation advisory board are the experts on vaccination in this country. They recommended it and the Minister accepted this recommendation. HIQA conducted a cost-benefit analysis on it and recommended it, which the Minister also accepted because in August she announced the programme. Three months later, the Minister is trying to tell the Chamber and the people of Ireland that she cannot find €10 million out of €16 billion. In fact, it does not involve an amount of €10 million because I understand both companies are prepared to negotiate a deferral of any fees to be paid for the vaccine in the next year. All that is left to pay out of the €16 billion budget is a mere €900,000 because HIQA has put the cost of administration at €30 per dose. Last week, the Minister told the House the amount of the administration fee would be €5 million. However, for 30,000 children, the total is €900,000. Where would the other €4 million go? Is it to the HSE for administration?
I have discussed HIQA and the national immunisation board. Other voluntary organisations are deeply involved with this matter. I met with the Marie Keating Foundation which is incredulous that this will not go ahead. The Irish Family Planning Association cannot understand the Minister’s logic. The Well Woman Centre has expressed on the airwaves its disappointment and lack of understanding as to how the Minister could come to this decision. The European Cervical Cancer Association is equally incredulous that this will not go ahead.
The Minister states she cannot find the money. What about the cash for consultants to the HSE which amounted to €7.9 million last year for PPARS alone? What about the bonuses for the bosses in the HSE? These bonuses would pay for the administration of this. It might not pay for the cost of the vaccine but that can be deferred for a year. What about the redundancies which were discussed in light of the fact that a number of years ago Professor Drumm told us that at least 2,000 people in the HSE did not know what their job was?
Last week, the Minister mentioned that other countries in Europe did not have this vaccination. However, one must travel right across to the other side of Europe to Sweden to find one. They have it 50 miles up the road in Newry in Northern Ireland and we cannot have it here for our children. Why, if it was right in August, is it not right today? On many occasions, the Minister has spoken, sometimes passionately, about putting the patient first. However, her actions are the opposite. A good Minister would prioritise what is important. What is a higher priority than saving a life? Deputy McDaid, a Member of this House and a medical professional like myself, asked the Minister to remove what he described as a death sentence for these children. I ask her to do likewise.
Many decisions have been made but this is one of the worst, ill-judged and ill-thought out in a long time. It is easy to score political points and discuss taking money from the elderly and disabled children. All of these decisions have been reversed. The levy on the low paid has also been reversed as was the decision on the tax deductibility on in-vitro fertilisation. Is the Minister really prepared, for the sake of €900,000, to sacrifice the lives of 52 of our 12 year olds? Is she prepared to see approximately 111 of them suffer cancer and all of the pain and anguish that goes with it?
This is penny wise and pound foolish. HIQA calculates the savings in treatment costs per year due to disease avoided would be €2.7 million and the total cost of vaccination would be €9.7 million. This leaves the net amount at approximately €6.9 million. However, this fails to include the amount of income lost to industry and the Exchequer through people being out of work. This makes it cheaper again. It does not make any sense.
It is not too late for the Minister to put her hand up and admit she made a mistake. As the Minister of State, Deputy Sargent, told me and others at a meeting in Skerries, it was a rushed budget. The Minister rushed in and made a mistake. Sometimes it is great to be determined to carry on regardless and not to be for turning. However, this is when one is right. In this instance, the Minister is wrong. The Irish Family Planning Association, the Marie Keating Foundation and the European Cervical Cancer Association know it, as do we all. The Minister knows it herself and her colleagues on the backbenches know it. Will the Minister show real political courage, swallow her political pride and reverse this clearly wrong and obnoxious decision to remove the right to life from these children and let them live without the fear of at least one cancer?
Deputy Olivia Mitchell: I too urge the Minister to reconsider this decision. I support my colleague, Deputy Reilly, in all he has said. This decision is so irrational and so out of character for the Minister that I can only conclude it has not been afforded the type of rigorous assessment or consideration it merits and which I would generally expect of the Minister.
I was briefly Fine Gael spokesperson on health when the now Minister for Foreign Affairs, Deputy Martin, was Minister for Health and Children. I raised with him on many occasions the failure to roll out the pilot cervical cancer screening programme throughout the population.  The pilots were set up when my colleague, Deputy Noonan, was Minister for Health and Children. The issue at that stage was that there simply was not the testing capacity within the State, with some women waiting months for results. I was delighted when the then Minister for Health and Children, Deputy Martin, finally announced that the pilot scheme was to be rolled out nationwide, albeit with testing being outsourced to the United States.
In the intervening years, news of the availability of a new cervical cancer vaccine filtered through to the great excitement of all. For the first time, a cancer could be definitively linked to a virus, and prevention by vaccine was not only possible but feasible. Vaccination programmes have since been introduced in many countries, with a rash of states currently preparing to introduce such programmes. There has been such a strong take-up internationally because vaccination programmes are efficient and effective, representing good medicine and good economics. That is the reason the Minister supported the introduction of such a scheme. She has observed many times that the trend in managing population health is towards prevention, by keeping people healthy, disease-free and out of hospital through vaccination programmes and lifestyle changes, and, when people get sick, early detection through regular check-ups and screening programmes.
Not all vaccines and screening programmes justify population-wide delivery in terms either of improvements in the health of the population or health expenditure savings in the future. However, this is not the case with the HPV vaccine for which there is strong international evidence of its efficiency. It saves lives and can ultimately eradicate the disease. Moreover, it can obviate the need for invasive treatments that may render women who contract the disease incapable of having children. The vaccine is cheap, at a fraction of the cost of one day in hospital, and it will become cheaper over time as worldwide demand increases, as it inevitably will.
As I said, it is good medicine and good economics. This was accepted by the Minister, the Health Service Executive and the medical profession. In August, the Minister considered the introduction of a vaccination programme to be a good idea. What happened in the intervening ten weeks to make it a bad idea? It is not that the Minister was unaware in August of the poor condition of the public finances. She had already been asked by the Taoiseach to identify cuts in departmental expenditure as part of a penal budget. The Minister tackled that job with gusto. Nevertheless, she recognised that this vaccination programme was worth including in the proposed expenditure of her Department. She said at the time that the cost and take-up might cause a delay. However, neither the cost nor the take-up has changed. The Minister did not know then what the cost or take-up would be and she still does not know. Therefore, they cannot be the reason for her change of mind.
Will the Minister explain how this U-turn can be justified? The public demands an answer. If I were the mother of an 11 or 12 year old girl, I would be absolutely incensed at the prospect of the Minister refusing to take action that could prevent the possibility of my child contracting a serious illness that could lead to infertility and even death. The Minister must know that this is how people will react. How much more awful will it be for the Minister when some of the current cohort of 12 year olds develop cervical cancer? It is inevitable that some of them will given the current rate of 200 new cases per year. How could she live with herself? Knowing the Minister as I do, I honestly believe she would be unable to do so. I ask her, therefore, to change her mind.
Within the €16 billion budget for the health service, surely €10 million can be found to save these lives. At the very least, and I am, with great reluctance, offering the Minister something of a get-out clause here, she could make the vaccine available to those 12 year olds whose parents have a medical card and, for everybody else, ensure that tax relief is available at the marginal 40% rate. Many mothers will make sacrifices in order to ensure their daughters are vaccinated.
Deputy Catherine Byrne: As a parent of four daughters, I am constantly reminded of the deficiencies in health services. In my own area, many young people have died through drug addiction, suicide and cancers of all forms. Last week’s announcement by the Minister of the postponement of the commencement of a cervical cancer vaccination programme for 12 year old girls is beyond belief. It is only four months since the Minister announced that the vaccination programme would commence in September 2009. However, she has now discovered she does not have the €9.9 million needed to operate the scheme. How has the Minister, given her many years of experience in the Dáil, allowed this to happen? The health of children is not a budgetary matter. What about the long-terms savings arising from this programme as a result of fewer women requiring hospital treatment for cervical cancer? This is the worst type of penny-pinching.
I welcome the roll-out of the screening programme for young women, but it is not enough. The priority should be prevention, via a vaccination programme. This U-turn represents a major step backwards for young girls, many of whom are unaware of the risks and dangers associated with cervical cancer. It is the eighth most frequently diagnosed cancer in the State, with some 200 new cases diagnosed every year and 70 to 80 women dying from the disease. This vaccine was due to be given to more than 26,000 children between the ages of ten and 12 next September. This would have reduced the risk of these young girls developing cervical cancer by 70%. In the absence of this vaccination programme, deaths will occur which could have been prevented.
As a parent and on behalf of parents throughout the State, I urge the Minister to overturn this decision. The MMR vaccine, the meningitis vaccine and even the flu vaccine have led to significant reductions in those illnesses. The cervical cancer vaccine would have an equally successful impact and cannot be shelved. If the Government fails to introduce this vaccination programme, it will leave the less well-off in our society, who will be unable to afford the approximate €600 it will cost to obtain the vaccine privately, at a great disadvantage. I agree with my colleague, Deputy Mitchell, that the Minister should at least make the vaccine available to medical card recipients. My area of Dublin South-Central contains many pockets of disadvantage where parents will struggle even to afford the increased cost of bringing their children to accident and emergency departments. If the Government has the funding to include luxury drugs such as viagra in the medical card scheme, surely it can manage its finances adequately in order to proceed with a vaccination programme that will save lives.
I can only hope that none of my children develops cervical cancer in the future. It is every parent’s worst fear. This is a short-sighted decision. The Minister, who is highly regarded and has been in the Oireachtas for many years, must reverse her decision.
Deputy Joe Carey: I commend my colleague, Deputy Reilly, on introducing this motion on behalf of the Fine Gael Party. Cervical cancer is the eighth most common cancer in the State, with 240 new cases diagnosed every year and some 100 deaths. The development of the HPV vaccine represents significant medical progress. The Minister gave an assurance to the public three months ago that this vaccine would be provided to all 12 year old girls. Three months later, however, this lifeline has been taken away for no apparent reason other than to save a few euro. It is absolutely outrageous.
The Minister has been in office for a long time but she cannot see that it is her job to save lives, show leadership and make a difference for the public she serves. Here the Minister had an opportunity to do that, but she has removed that possibility. This vaccine can save the precious lives of young women — the mothers, sisters and daughters throughout the country — for the paltry sum of €10 million. One can refer to the amount of money that has been squandered by successive Fianna Fáil-led Governments. A total of €45 million was spent on non-medical consultancy costs over a three year period in the Minister’s Department. The Minister stood over this. A sum of €20 million was spent on PPARS, while Professor Drumm’s advisers cost €1.6 million. These are outrageous figures. In this case, however, the Minister is faced with a problem she can address with €10 million but she will not do it.
The Minister has presided over the squandering of all this money. She should hang her head in shame. I spoke to a constituent tonight who is also a close neighbour. She was diagnosed two years ago with cervical cancer. Her life was turned upside down; in her words, her life has been “wrecked” by the scourge of cancer. Her family life has been ruined. She cannot understand what the Minister is trying to do to the Irish people. The Minister has the opportunity to carry out another U-turn. I would applaud her for doing it for the sake of young people and their future. The Minister should swallow her pride and reverse this decision. If she continues on this course, I call on all Government Deputies to support the Fine Gael motion.
Deputy Dinny McGinley: There were many cutbacks in the recent budget and they affected all areas, including agriculture, health, social welfare and education. There were cutbacks across the board. This will cause hardship, suffering, loss of income and many types of discomfort. Of all the cutbacks that have been announced, however, this will cause devastation to families in the years ahead. It is probably the harshest cut of all. I do not like to use the term “merciless” but it is a merciless cut. I have no wish to use the term with regard to the Minister but that is how I see it.
I recall watching the television at home last August when it was announced that this immunisation programme against a particular form of cancer was to be rolled out nationally. I was delighted. Furthermore, being a lay person where medicine is concerned, I was delighted that at last there was a vaccine available against one form of cancer. I considered it a great medical breakthrough. If administered in 2009, as the Minister promised, it would save lives in the future. Each year 70 to 80 young women die of cervical cancer in this country. Consider the devastation such deaths leave in their wake. Many of them are young mothers with young children still at school. Consider the devastation visited on a family when a mother dies. There is devastation when a parent dies but it is particularly hard when a mother dies. It is unbelievable when somebody is left without their mother. Anybody who has experienced it, and there are many, knows how cruel and inhumane it is.
This vaccination programme was announced and everybody was looking forward to it. It was a great breakthrough. Now, however, it has been withdrawn, just to save less than €10 million per annum out of a budget of €16 billion. I have been a Member of this House for many years and I never had the privilege of being a Minister or Minister of State but I can guarantee that if I, a lay person who did some economics many years ago in university, had a half hour with the Health Service Executive, I would find savings of €10 million. It is certainly not beyond the competence of the Minister and the people in the HSE to achieve savings and proceed with the roll-out of this vaccine.
We will not see the results of this today or next year but in ten or 20 years, when few of us will still be Members of this House. Young mothers will make the ultimate sacrifice as a result of the vaccine not being made available to them. I ask the Minister to seriously re-examine this decision. We have addressed farmers’ meetings, meetings on education and other meetings but this is a core issue. For that reason I appeal to you, a Thánaiste——
Deputy Joe McHugh: Eight women died in County Donegal last year from cervical cancer out of a total national figure of 81. I will outline the difficulty I have explaining this decision to parents, particularly mothers. When a person leaves Donegal for Dublin they usually travel by car or bus. There is no train service from Donegal to Dublin. Take the example of a woman suffering from cervical cancer who is travelling by bus to Dublin. The bus will leave Letterkenny, cross the bridge at Lifford and travel to Strabane. When it reaches Strabane the woman can look into the lit up houses if it is the morning or late at night. The question that woman will ask as she travels from Strabane, through Omagh and into Aughnacloy is: “Why will the 12 year old daughters on these roads be entitled to a vaccination procedure, while my 12 year old daughter living in Donegal will not?”
On reaching Emyvale after crossing the Border, she is back in the country that is reactive, not progressive, has no forward vision, does not wish to undertake forward planning and has a stark history of making mistakes and looking at short-term targets. This is a short-term target. It is a disaster. I commend my colleague, Deputy Reilly, for proposing this motion tonight. It is a microcosm of where we are as a country and where we are as a nation. It is a microcosm of all the ills in this country. One need only consider Limerick. The people in Limerick are not different from the people in Donegal. There is a lack of intervention and a lack of building capacity in terms of intervention. Intervention is key, be it in health, the community or in education.
This country is now faced with cutbacks in all areas. School principals are listing the activities that can no longer take place in secondary schools, such as extra-curricular activities, sports and out-of-school activities. The intervention that was taking place is no longer available. Similarly, there is the situation with the health service, where lives could be saved. I am aware that the Minister personally has a genuine interest in saving lives, and she gets credit for that. However, as a Minister she fails to have the courage to take on a bureaucracy and administration that could make savings of €10 million. The people of Ireland will judge the Minister on her courage in taking on the administration.
We must focus on prevention. Following the release of another study on prostate cancer, Rory Hafford this week produced a document which states that 500 to 600 lives could be saved. We need intervention and a U-turn on this issue. I implore the Minister to do it tonight.
Deputy John O’Mahony: I welcome the opportunity to make a contribution to the debate on the reversal of a decision announced last August by the Minister, Deputy Harney. I commend Deputy James Reilly and the Fine Gael Party for proposing the motion. The latest announcement by the Minister is another ill thought out measure in a budget in which figures seem to be more important than people, especially the old, the young and the disabled.
If one considers the decision on economic grounds alone and if one is to be ruthless, uncaring and to think only about money, it is still a bad decision. The estimated €9.7 million cost of the scheme is only a drop in the ocean of the total health budget and will not save money in the long term. Prevention is better than cure. Money spent on prevention will save multiples of the same amount later on in the cost of treatment. If this decision proceeds the Government is being penny wise and pound foolish. Ireland is the only country in western Europe where the number of deaths from cervical cancer continues to rise. To put the decision in perspective, the amount of money involved is less than the cost of building a couple of kilometres of motorway per annum. It just does not make sense. Some 31,000 12 year old girls have lost the secure feeling that cervical cancer is off the agenda for them in years to come.
The Health Information and Quality Authority, HIQA, stated that this treatment, announced by the Minister in August, was cost effective, that it would in due course prevent more than 50 deaths per annum and it would prevent thousands from developing pre-cancerous cells. HIQA, a State agency, does not agree with the Minister’s decision from last week. While travelling in the car last Friday, I listened to the comments of Deputy McDaid from the Government side of the House. He is vehemently opposed to the decision made by the Minister and to the reversal of the announcement in August. Deputy McDaid suggested some of these children might have a case for suing the State in future years.
The chance of a person dying from cervical cancer can be significantly reduced by this drug. Cervical cancer is the most common cancer among women worldwide, and this is especially the case in Ireland where the figures are double those of other member states of the European Union. Will the Minister reconsider the decision?
Last August, when this decision was announced, the Minister, Deputy Harney, knew that the economy was in free-fall, as did everyone else in the Government and the House. How can the Minister suggest that the money would have been available last August if it is not available now, some two months later? This confirms that many of the decisions in the budget were not thought out. It would be a different matter if the original announcement was one year ago and the Minister could claim the situation had changed, but this is not the case. The announcement was made when the Minister knew that money was scarce. I urge her to reverse this decision.
Deputy John Perry: I thank Deputy Reilly for tabling this very important motion. Whatever about this Fianna Fáil and Progressive Democrats led Government, the rest of us live in the real world, not in the fantasy land of spin and propaganda. During these harsh November days reality intrudes and shows clearly that much of what passed for effective Government in the past few years was only an illusion. Now the reality of the Government’s incompetence bites back and eats away at the thin veneer of the spin that was passed off as representing substance and competence.
The Minister’s decision to stop the proposed cervical cancer vaccine programme is a perfect example of this incompetence. The programme was announced as a major publicity stunt. The emphasis was on presentation and style and perception became reality. The Government was happy to substitute spin for action and now it is clear that the Government is all spun out. It has rolled back on its commitment to introduce the vaccine. Fine Gael believes it is unacceptable that the Minister, Deputy Harney, should deny a life-saving programme for minimal savings. The decision of the Minister to abandon this programme is short-sighted and unjustifiable, and I call on her immediately to reverse that decision. Consider that €1.7 million is spent on consultants every week. If these costs were not paid for six weeks, the savings would amount to €10 million. The Government could find ten reasons not to implement this proposal, but it should consider the possible savings.
The Health Information and Quality Authority report, published three months ago, advised the Minister for Health and Children that it would cost €9.7 million to administer the plan to vaccinate 12 year old girls. The introduction of the vaccine would be cost saving because it would reduce the burden on hospital services in the long term. The cervical cancer vaccine is the first vaccine ever designed to prevent a cancer and, therefore, the impact of the vaccine programme will be significant. The tragedy of cervical cancer is that it often strikes when a woman is still young. Even with treatment, cervical cancer is an common cause of cancer death in women.
The vaccine is recommended for girls aged between 11 and 12 years. It allows the immune system to be activated and, given the recipient’s age, it also allows for the development of highest antibody levels. The higher the antibody levels, the greater the protection. Thus far the cervical cancer vaccine has proven to be safe. Researchers have observed in clinical trials that the antibody levels in women continue to increase with each of the three doses of the vaccine. Since antibody levels inevitably fall once the vaccine is no longer administered, the ideal vaccination programme is designed to start with high antibody levels to generate the greatest human papilloma virus protection for the longest possible time. In time, scientific research may find that three doses of the vaccine are unnecessary, or it may discover that a booster shot is needed some years later. We do not know the possibilities in such cases at this stage. Given this analysis, will the Minister consider the possibility of starting the programme as scheduled with just one vaccine shot per girl? This approach would at least provide some degree of protection from cervical cancer, even if it not the ideal level of protection. Then when the Minister finds the necessary additional funds, she can introduce the second and third shots of the vaccine.
The Minister’s basic argument is that the funds to facilitate the roll out of the cervical cancer vaccine are not available this year. I believe the funds are in the budget. Will the Minister examine all the costs associated with the proposed transfer of breast cancer services from Sligo General Hospital? A first-class breast cancer service is provided in Sligo General Hospital and there is a sufficient case load to justify retaining the existing service there. The hospital has the results to prove that the service provides one of the best outcomes for patients. It is a serious waste of public money to transfer breast cancer services from Sligo General Hospital. Why does the Minister not halt the transfer of services from Sligo General Hospital and use elsewhere some of the money this would cost?
Last week in the House I discussed the roll out and triple assessment of the programme. I have examined the matter since and there has been no difficulty expressed by Professor Tom Keane on the proposed roll-out of services. Considering there is a budget of €1,600 million in this area, a cost of €10 million for the programme represents a very small amount of money, especially given the preventative possibilities of the vaccine. It was reported yesterday that some €1.7 million is spent every week on consultants. Cancellation of these services for six weeks would save the required amount for the programme.
There was a debacle this weekend in the Defence Forces. Some €19 million was spent on helicopters disposed of for €300,000. Following rebuilding costs of €300,000 they were resold for €18 and €19 million. This is a clear indication of the Government’s incompetence when it comes to doing business. The helicopters were not tendered for on the world market and were purchased for a knock-down price. This proceeded regardless of the associated costs. Naturally, the Minister will not indicate that the Government was at fault in selling the helicopters. If different decisions had been taken there could have been a direct saving of €19 million. An expert stated on the radio yesterday that even allowing for a refit of the helicopters, there was still a profit margin of €10 million, which could have provided the funds for the vaccination service.
This treatment of the young and vulnerable in society is an appalling indictment of the Government, especially given that Ireland was reported to be one of the wealthiest economies in Europe. We were told money was never a difficulty, yet we cannot find the necessary €10 million, which is a sad state of affairs.
I welcome this debate, even though we had another debate last Thursday. In this debate, it is important that we are all fair and reasonable. I have a document in front of me which was published in January 2007. It was the health priorities of the Fine Gael Party and the Labour Party if they were in Government, and there is no mention of cancer in the document. I also have a document published by the Fine Gael Party during the election, which emphasis the importance of screening. There is no mention of vaccines. In the run-up to the budget, the Fine Gael spokesperson on finance suggested there should be a 3% cut in the health budget, totalling €700 million in cuts. I asked Deputy Reilly to tell me from where that €700 million would come.
In debates like this, it is important to take perspective into account. Unlike all the other countries mentioned by the Opposition Deputies, for example the UK which has had screening programmes for 20 years, we have only just begun to roll out a national screening programme for cervical cancer in September. By the end of the year, 100,000 women will have been screened. In the month of October alone, 30,000 women registered to be screened. Screening has the capacity to reduce cervical cancer by over 80% in terms of the population, and by 95% in an individual case, if a woman goes for all the screening. Therefore, in a country that does not have a national screening programme, the priority clearly must be to put in place a screening programme that will pick up women that have the pre-cancerous abnormalities, so that they can have treatment. Next year, €35 million is being assigned to the national cervical screening programme.
We live in a country where our cancer outcomes are not what they should be. The exception is in children’s cancer, where we do as well as any country in the world, as children’s cancer is organised and planned in one central location at Crumlin Hospital. However, we do not do well on other cancer treatments. That is why for the last two years we have been seeking to reorganise cancer services for the patients who currently have cancer, so that they can get a better outcome. Deputy Perry referred to Sligo. We do not have an appropriately organised service in Sligo, because we know from the expertise that in order to have a world-class service we need two surgeons with a specialist interest in breast cancer, two radiologists and two pathologists. We do not have that in the hospital in Sligo. We could not have that kind of resource and that level of expertise in hospitals with small volumes of patients.
The other priority is to resource the cancer control programme. Next year, an additional €15 million is being invested in that programme to recruit the skilled expertise that we need for the eight centres, so that the treatments we offer to cancer patients can deliver the best possible outcome that this country can afford. In that context, it was not possible to do everything. I do not need to be convinced about the vaccine. I am a strong proponent of the vaccine, but unfortunately we cannot do it this year. The Government could not engage with any company on the basis that we will not pay it this year, but we might pay next year.
There are over 100 different HPV viruses. Two particular viruses cause 70% of the cancers, and the vaccine can prevent those two particular strains. However, no 12 year old without a vaccine will not get screening with a 95% success rate. Equally, if a 12 year old got the vaccine, she would still have to be involved in the screening programme for the 30% of cancers that are not dealt with by the vaccine. We cannot start a programme this year that we cannot sustain next year and the year after. The decision not to proceed next year was made because we are seriously financially challenged. In the Department of Health and Children, we had to find €700 million worth of savings on planned expenditure for 2009. Since 75% to 80% of the costs are made up of payments to staff, the Deputies can imagine how challenging it is to find the sums of money in the remaining costs. If it were a once-off sum of money, it would not have been a difficult decision. It represents an ongoing sum of money for this year, next year and the year after.
Anybody who claims in this debate that we are sentencing girls to death knows that is not true. Every young woman who does not get this vaccine will be offered a screening programme. Any young woman who would get the vaccine would also have to be involved in a screening programme. The vaccine does not prevent cervical cancer, although it reduces its incidence in 70% of the cases. I accept that.
Deputy Mary Harney: The decision that we made was not to introduce the vaccine in 2009. I have heard phrases like “scrapped”, “changed her mind”, “U-turn” and all the rest. When I made the announcement in August, following the advisory group report and the report from HIQA, I made it in good faith. Following the advice given to me, I said that this vaccine was a good thing and should be introduced on the basis of an 80% up-take. There are two companies that make the vaccine and I wanted to make sure we got the most cost-effective version. However, things changed rapidly and there was no anticipation in August that we would have a budget on 14 October. Tax receipts deteriorated rapidly during the month of September. Small and all as the money may seem, the reality is that it is not possible to begin this programme in 2009.
A team of nurses were recruited to increase the take-up of the MMR vaccine. The childhood immunisation programme next year will cost €60 million. When the nurses have finished that programme, they will be available to introduce this vaccine. It was never the intention that it would be done through general practice, in the way pap tests are done. The intention was to do this through an immunisation programme using a team of nurses to carry it out. I wanted to do it in primary schools next year. It would be easier to do it this way, because we already have immunisation programmes under way in primary schools. We would know the children and would be able to obtain permission from their parents. We may now have to do it in secondary school. It is slightly less expensive to do it this way, although not by a huge margin.
There are many people in Ireland who do not realise that screening in a country that does not have it is far more important in the short term than a preventative measure that will take effect in 15 or 20 years. We do not have a good record on cervical cancer when compared with other European countries. The reason is our lack of a national screening programme. The programme is quality assured, and this was the most important criterion used in selecting the people to do the cytology. I was asked to delay that decision so we could reflect on it further. However, it is working incredibly well. About 1,500 smears are being taken every day and 79,000 kits were issued in October alone to doctors, Well Woman clinics and other involved parties.
Deputy Mary Harney: We anticipate that next year some 300,000 women will come forward. As the Deputy knows, this programme is geared to 1.1 million women in the State aged between 25 and 60. I emphasise that the screening programme can reduce the incidence of cervical cancer by over 80% and in an individual context by about 95%. I certainly hope that much of the publicity surrounding this issue will encourage people to participate in the screening programme. As regards BreastCheck, even though our screening rate at just over 70% is high when compared internationally, there are still too many people who do not come forward. We all have a role to play in that regard.
The Government must continue to put in place its eight designated centres and provide the resources in 2009 to do so. It is about choices; it is not about having money to do everything. If there are choices, they must be for treatment today and for having specialist centres with expert staff who we know can deliver better outcomes for patients, which is a priority. In addition, a screening programme has the capacity to reduce greatly the incidence of cervical cancer and, following that, a vaccination programme has a role to play. Seven other European countries, if not eight, have not yet introduced the screening programme.
Minister of State at the Department of Health and Children (Deputy Mary Wallace): Each year in Ireland there are between 250 and 300 new cases of cervical cancer, and between 70 and 100 women die from it. However, the figures hide the full impact of the disease. This is a cancer which affects younger women more than many other forms of cancer — younger women who have children, commitments and responsibilities. Worldwide, it is the second highest cause of cancer deaths among women.
In the context of the national cancer programme, I welcome the Minister’s decision to allocate an additional €15 million in 2009 for the programme of work under the leadership of Professor Tom Keane of the Heath Service Executive. This year, we have also provided 30 additional posts to the national cancer screening service to facilitate the roll-out of a national cervical screening programme. With an additional sum of €10 million provided in 2009, the full-year cost of the programme will be around €35 million, which is an immediate step towards reducing deaths from cervical cancer by over 80%.
It is clear that the roll-out of a national cervical screening programme is the most effective population-based approach to preventing and controlling cervical cancer. The programme will provide free smear tests through primary care settings to the 1.1 million women living in Ireland aged between 25 and 60. A successful national programme has the potential to cut current mortality rates from cervical cancer by between 80% and 90%.
The national programme provides screening in a primary care setting every three years for women aged 25 to 44, and screening every five years for women aged 45 to 60. It will deliver a national quality-assured cervical screening programme and will be implemented in line with best international practice. All elements of the programme will be quality assured. Call and recall, laboratory services and coloscopy will be managed to deliver a single, integrated national service. It must also be available to women within four weeks of their smear test. All smear test slides will be read twice by two separate cyto-technologists.
The Minister has covered the critical figures but it is important to repeat that up to 100,000 women will be screened by the end of this year. It is planned to screen approximately 300,000 women in 2009. It is also extremely important that women be informed and motivated to attend for screening when invited to do so, even if they have received a HPV vaccine. Vaccination and screening are complementary approaches to controlling cervical cancer. The national cancer screening service, which is rolling out the national cervical screening programme, is aware that it must make every effort to encourage women to attend for screening. The success of the programme relies on a take-up rate of at least 80% in the target group of women aged 25 to 60. Initially, women are self-registering for the cervical check programme, which commenced on 1 September. It is certainly impressive to see the number of women who have come forward for the self-registering process, either by phoning the programme or accessing its website. The programme has prepared a population database of the 1.1 million women who are eligible for screening. It will commence using this and formally calling women from the database when the number of self-registered people reduces. It is also encouraging to see that around 3,800 general practitioners have registered as smear takers for the programme. These GPs are located throughout the country.
The programme plans to cover 300,000 in 2009. The Minister is fully committed to keeping the introduction of the HPV vaccination programme under review, but all these decisions are taken in the context of implementing the overall national cancer programme and, as the Minister stressed earlier, the importance of rolling out the national cancer screening service.
Minister of State at the Department of Health and Children (Deputy John Moloney): While recognising the sincerity of the Opposition motion, I also recognise the Minister’s sincerity in explaining the thinking behind the postponement of the vaccination programme. In this context, I recognise the huge demands on this budget in continuing to support the national cancer strategy. No politicians go out of their way to become unpopular. I have seen the various quotations from newspapers that this Government decision will take lives, but I do not believe that. If we can ensure that people avail of the national screening process, it will go a long way towards assuring many people who may currently have doubts about it. A few minutes ago, Deputy Reilly quoted——
Deputy John Moloney: Recently an expert panel in the European Commission said that our approach reflects expert advice internationally. For example, they recommended that since no vaccine is 100% effective, national authorities should carry out organised population-wide, quality-assured cervical screening before introducing the HPV vaccine into the population. There is no doubt that experts differ.
Deputy John Moloney: I have the greatest respect for HIQA, but I am a little bit confused by the advice I get from experts. I have no difficulty in supporting HIQA when its representatives come before our committee. It is important to recognise certain points, however. First, while there is no doubt that the HPV vaccine is a valuable initiative, it is only one part of helping to prevent deaths from cervical cancer. Second, the vaccination is not and can never be a replacement for routine cervical screening.
Deputy John Moloney: No, but I want to clarify the position for people who have been upset by recent publications regarding the Government’s change of thinking on vaccination. It has been suggested that we are leaving people bereft with no support structure whatsoever, but the national screening process can give major protection. In addition, it is important to note that countries which have organised cervical screening programmes have substantially reduced the numbers of new cases and deaths from cervical cancer. It is not just a case of coming in here to talk about what HIQA or the European Commission’s expert group might say. The proven track record of governments abroad has shown how a national screening process can work, if properly implemented and taken up. The challenge is to do that. I also believe that the approach reflects best international advice. The Minister made it clear that when the decision was announced last August, nobody was aware of the decline in the national taxation returns.
It is worth noting that the Department of Health and Children was expected to cut expenditure by €700 million, yet €400 million was to be found for new services. I refer to the international audit of success rates for the treatment of many cancers, breast cancer in particular. We cannot put one specific cancer area above another. We must centralise the best cancer treatment in the eight centres, but in order to fund those centres every available euro is required. This year €15 million has been allocated in very tight budgetary times to continue the national cancer process. It would be wrong to say that because the Government is not proceeding with the vaccine programme it is not supporting the cancer programme as a whole. I refer to Professor Keane’s recent remarks about the additional cancer strategies and the proposals he intends to implement. It is also important to stress that the requirement for a population base for a cervical cancer screening programme is not replaced by the introduction of a vaccine programme. In other words, even if we had the wherewithal to go with the vaccination programme, the reality is that the first major check or safeguard is the screening programme.
Deputy Jan O’Sullivan: I am not quite sure how I am going to deal with that. I intend to share time tonight with Deputy Ó Caoláin and tomorrow night with Deputies Upton and Wall, with the permission of the House.
I compliment Deputy Reilly and the Fine Gael Party on tabling this motion. As the Minister said, we debated this issue last Thursday but it is very important to have an opportunity to return to it. Despite the three speeches I have just heard, I hope we can still persuade the Government to introduce this vaccine as intended in September of next year for 12 year old girls.
We must rescue this programme from the cutbacks. The cost is perhaps less than €10 million even though last week the figure of €14 million was mentioned. It is accepted now that it can be done for €10 million as a school-based programme, particularly with competitive tendering from the two companies concerned which can provide the vaccine. I will speak later about how we might save the money. I again ask the Minister to keep an open mind on the possibility of finding this money from somewhere within her budget for next year. I ask her not to let this programme go.
I believed the Minister was correct when she stated last August that she intended to introduce this programme. She said last August, “I accept the expert advice that the introduction of a universal high-uptake vaccination programme for young girls, in conjunction with population-based cervical screening, could significantly reduce overall cervical cancer rates”. This is very clear and we should not quibble about whether it is more or less effective than screening. The fact is that it is effective, as the Minister agreed last August. I acknowledge that she stated in her contribution tonight that she did not want people to think she had somehow or other changed her mind. I accept that she has not changed her mind. However, she has decided that the money is not there to introduce the scheme, despite the fact that within a health budget of approximately €16 billion this will amount to €10 million or less. I urge the Minister to find that money.
As other speakers have said, a wide range of people, experts and organisations who care about this issue have strongly condemned the decision to put the programme on hold, including the Irish Cancer Society, the Marie Keating Foundation, the All-Ireland Cancer Foundation, the European Cervical Cancer Association, the Irish Family Planning Association, the Well Woman Centre and many others. Probably more important, many ordinary people had expected that their 12 year old daughters would be offered this vaccine next year and regarded this as an important preventative measure. Of all the cancers, cervical cancer can be almost eradicated within our lifetimes if there is a combination of the screening and vaccination programmes. This is not the case with other cancers which, even with our best efforts, will still kill a percentage of our population. However, in the case of cervical cancer, we have opportunities which we should avail of. The publicity has created an awareness of the vaccine and many parents will purchase this vaccine for their daughters. However, it is regrettable that many families will be unable to afford to pay to protect their daughters. There is something obscene, in my opinion, about having to make such a choice and in the inequality of choice.
I urge the Minister to rethink her decision. It should not be presented as a competition between screening and vaccination or a competition between treatment and vaccination. We should not ration our health resources in that way. I fully support the screening programme which is very good and I am pleased it is being rolled out this year. However, the vaccine should also be provided.
As the Minister of State, Deputy Wallace, said, this is largely an illness affecting women in the younger age groups. Many cancers do not strike until later in life but half of all those who develop cervical cancer do so before the age of 50. We are talking about women whose lives will be considerably shortened if they develop this illness. All those factors must be considered and I ask the Minister to change her mind.
The cost of the programme was discussed last week and whether it could be done for less than €14 million. I believe it can be done for considerably less than that amount. The companies concerned will be willing to offer a lower price. I note there is competition between Aldi and Lidl and Dunnes and Tesco and prices come down as a result of competition. There is a competitive element to the tendering which I believe will result in a good price.
A top-up rubella vaccine is given in schools to girls of that age. Would it be possible to save on administrative costs by giving this vaccine at the same time as the rubella top-up? I do not know if this is possible but it is a suggestion worth investigating. This might also encourage an uptake of the vaccine. The Minister would hope for an 80% uptake.
There is an obligation on us to address the issue of finding the money and various suggestions have been made. The HSE farms out work to various private companies. In the case of the health repayment scheme which cost €15 million, the HSE paid a private company to write to all the people in the north east whose X-rays were reviewed, a total of more than 5,000 people. We all know there are many people working in the HSE who are unsure of what work they should be doing, including many people at the higher management levels. There are many grades pushing paper around. We were asked to be patriotic with regard to the budget. Will the Minister ask the HSE to find people within its organisation who can do this work and save money? We did not find out until afterwards that the €15 million was spent on the health repayments scheme. I do not know what else they are planning to farm out to various companies. There are many demoralised people among the Department’s civil servants and within the HSE who do not know what they are supposed to be doing. I ask the Minister to go back to the HSE to find whether it can save money in this area or otherwise find this money. The Minister should get to work with the HSE, her Department, the schools and the providers of the vaccine and seek to find a way in which she can introduce this programme at the time she had intended to do so. We should not give up on it.
Deputy Harney is the Minister for Health and Children, not the Minister for sickness. Prevention of illness is one of the most important jobs a Minister for Health and Children can do and this is a preventative measure. I urge the Minister not to close her mind to introducing it at the time she intended to do so. Not much has changed since August and I am sure what is a relatively small amount of money within the overall budget can be found.
The public was struck by the wrongness of this decision. With all of the various issues we were faced with in the budget, such as the medical card cuts for the over 70s, the education cutbacks and the variety of cutbacks outlined again today in the Social Welfare Bill, people were struck that the Minister could go back on a measure she announced in August that would prevent a deadly illness in the future. It is a preventative health measure that would cost relatively little within the overall budget. How could it become a victim of the cuts? People are genuinely shocked by this.
The Minister is a reasonable person, although I do not agree with her on many issues. It is possible to find this money. I urge that in this debate we should focus our minds on trying to find a way out of this and try to rescue the programme for next year.
Deputy Caoimhghín Ó Caoláin: Once again the Dáil has to call to account Deputy Harney in her capacity as Minister for Health and Children for what I can only describe as yet another disgraceful decision that will have a most negative impact on the health of the people. Last weekend the Minister’s party abolished itself but it is a great pity that the anti-people policies of her party, the Progressive Democrats, so long embraced fully by Fianna Fáil, were not abolished as well. Those policies unfortunately live on in Fianna Fáil and in this Government.
The decision to cancel the HPV vaccination programme arose from an ethos and a policy which puts public health in second place to petty book-keeping and a privatisation agenda. The Health Information and Quality Authority has estimated the total cost of introducing the HPV vaccine at €9.7 million. Allegedly to save this sum, a public health programme which would have saved women’s lives is being axed by the Minister, Deputy Harney, yet the budget left intact the tax breaks for the developers of private hospitals at far greater cost. In the year 2006 alone, the latest year for which figures are available, the Government gave tax breaks worth €10.6 million to the developers of private for-profit hospitals. In a budget that slashed public services, those tax breaks were left untouched, although they could have paid for this vaccination programme several times over. Also untouched in the budget was the Minister’s and the Government’s totally discredited private hospital co-location scheme.
I would remind the Green Party Members, if they were present, of what their current leader, then their health spokesperson, the Minister, Deputy John Gormley, said of the PDs in this Chamber in February 2007:
Deputy Gormley also said: “Ireland has one of the highest cancer rates in the world and with this Government refusing to deal with the problem, the statistics are likely to continue to grow”. Deputy Gormley and his colleagues will no doubt troop in to vote down this motion side by side with their Fianna Fáil and ex-PD colleagues tomorrow. I would advise the Green Party it might in these circumstances change its logo from a sunflower to a banana. When it went into Government with Fianna Fáil, it was undoubtedly green. It then turned yellow. Sadly, we are witnessing day after day that, as with bananas, the inevitable happens and they become rotten.
The Minister announced the HPV programme only three months ago and now it has been axed. The manner in which the cancellation was announced was typical of the sly management of bad news by this Government in that it was released on the day of the US presidential election. The Minister has made what I can only describe as pathetic efforts to defend this decision — I listened to her contribution earlier on the monitor. She has repeatedly tried to make people believe it was somehow a choice between continuing the rollout of the cervical cancer screening programme or introducing the HPV vaccination programme. This is completely wrong and deceptive on two counts.
First, screening is not a substitute for vaccination. The vaccination programme is to prevent the forms of cervical cancer concerned, whereas the screening programme is to detect cancer when it occurs. It cannot be a case of either-or. To save women’s lives, both programmes should be in place.
Second, the Minister’s argument is false on the grounds of cost. I have already identified one area where much greater savings could be made while allowing this programme to proceed. It has also been pointed out that the public procurement of the vaccine on the scale needed would entail significant price reductions, in which the Minister claims to be very interested. One estimate puts the cost as low as €7 million. In terms of the delivery of the vaccine, there is no reason it cannot be administered in conjunction with other vaccination programmes. This is to say nothing of the savings to the health service that will be made by preventing this cancer. Beyond the figures and the book-keeping, let us not forget that what we are talking about here are the lives and health of women in this country.
When the Minister first announced the programme back in August, it was widely welcomed. HIQA stated it was a welcome decision and that “a vaccine programme, together with a cervical cancer screening programme, will have a significant impact on reducing the incidence of cervical cancer for women in Ireland”. In June, HIQA published the Health Technology Assessment of the role of Human Papillomavirus (HPV) Vaccines in Reducing the Risk of Cervical Cancer in Ireland. HIQA pointed out that infection with HPV is the main cause of cervical cancer, the eighth most frequently diagnosed cancer in women in Ireland. In 2004 alone, 200 women were diagnosed with cervical cancer, while over 90 women died of the disease. HIQA continued, and I emphasise: “Vaccination against HPV therefore represents a new opportunity to reduce the incidence of, and mortality from, this form of cancer”.
Following a request from the National Cancer Screening Service Board, HIQA agreed in July 2007 to carry out a health technology assessment on the role of vaccination against HPV in reducing the risk of cervical cancer in Ireland. The authority asked the National Centre for Pharmacoeconomics to undertake the health technology assessment. The purpose of this assessment was to establish the cost-effectiveness of a combined national HPV vaccination and cervical cancer screening programme compared to a cervical cancer screening programme alone. The results of this cost-effectiveness analysis showed that universal HPV vaccination of 12 year old females would be cost-effective. The report also recommended a once-off vaccination programme for 13 to 15 year old females. At older ages, the vaccine becomes less effective due to an increased likelihood of females being exposed to the virus before vaccination.
The final report, the findings of which were approved by the expert advisory group which was convened by the board of HIQA, was submitted to the Minister for Health and Children, the National Cancer Screening Service Board and the National Immunisation Advisory Committee. On that basis, the Minister for Health and Children announced in August her decision to proceed with the vaccination programme. Now all that careful assessment and analysis and all the expert advice has been turned on its head by her. The chief executive of the Irish Cancer Society, John McCormack, has said the Minister’s decision to cancel the vaccination programme is “very disappointing” and added that “1 euro’s prevention is as good as 2 euro of cure”. The Dublin Well Woman Centre has said the Minister’s decision is both short-sighted, dangerous and an illogical move that will cost even more in the long term.
Savings could and should have been made on tax breaks for the private health industry, not on programmes that will enhance the health of women and prevent much greater cost in the future, both in the well-being of individuals and the cost to the health service of cancer treatment.
The Minister’s decision on the human papillomavirus vaccine shows that far from learning from the past, she and her Government colleagues are repeating the mistakes of the past. I appeal to them to reverse this decision. If the Government will not do so, then let those on the benches opposite, some of whom must share the Opposition’s incredulity at this decision, vote against the Government amendment tomorrow night. Sinn Féin fully supports the Fine Gael motion.
Deputy Mary Upton: I welcome the opportunity to speak on this debate and to support the Fine Gael motion. When the word “cancer” is uttered, it strikes fear into the heart of anyone who is conscious of the horrific consequences it can have on the individual affected and his or her wider family. A commitment was made in which the word “cancer” could have been included in a positive sentence with the words “vaccination” and “prevention”. It is a great disappointment to all Members that there has been an about-turn on this commitment. Instead, we must go back to worrying about the consequences in this lost opportunity for cervical cancer prevention.
When the vaccination programme was first mooted, there was a concern it could be controversial, particularly regarding the vaccination of young girls of 11 and 12 years of age. I recall debating this with someone who told me there may be concerns but realistically the positives would be more substantial. Interestingly, the telephone calls that I and some of my colleagues have received relate to the disappointment of those young girls who were told they would be the first to avail of this positive opportunity. The programme’s cancellation has become a great disappointment to people.
It is also a great pity that it has become an economic debate. This should not be about economics; it should be about good health and preventive medicine. Last year, a friend spoke to me about the magic €1 million and €10 million, these figures which can be pulled from everywhere and anywhere. I accept, in reality, that cannot be done in all cases. However, I propose we establish a set of priorities. While it is very well for me to say this will cost €10 million, so let us find it, it must be seen in the context of a much wider budget, and if necessary, the health budget. I accept there will be consequences but it has been outlined by my colleagues how important it is to set priorities in the overall budget, particularly the health budget. It is against this background that the Minister should look carefully at her decision not to go ahead with the cervical cancer vaccination programme.
The Government’s policy has been very remiss in not taking on board the value of preventive medicine. We are always chasing the story. This occurs with other illnesses such as, for example, diabetes. Diabetes is a common illness which is well-documented and the costs around its treatment and so forth have been worked out. If we were to put in place a preventive programme that worked on re-training and re-modelling, its impact could be substantial. We should be looking much more at prevention rather than constantly curing an illness. As a previous speaker stated, it seems we are focused on a Minister for illness and not a Minister for health. If people could only take account of the fact that certain illnesses can be prevented, we would have a much more positive approach to the whole health programme. As a consequence there would be much greater savings to the health budget in the long term.
This has become an economic debate rather than a health debate. While I spoke about the consequences and difficulties in finding the moneys to fund the cervical cancer vaccination programme, as they are relatively small they should be found. The effect of cancelling the programme has been damaging to people’s attitudes to the health services and health care. The programme was promised and was coming on stream. It was accepted it could be very valuable with long-term savings. In economic terms, we should measure the economic value as well as the health care value.
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