Martin Daly: Radiotherapy Machines Failing Cancer Patients

Thank you to Professor Ashton-Barrie and her witnesses as you outlined and Mr. Stephen Dempsey from the Irish Cancer Society. It's simply incredible that for such a critical form of treatment for cancer that you're telling us here at this committee this is not a matter of money, this is actually a matter of planning and it's a matter of having an ongoing rolling procurement programme which is a predictable model. Is that right? So, coming to some of my questions, some of the machines are so old they break down regularly. So how much does a new machine cost? Approximately? Approximately 3 million. Okay. Plus or minus half a million. If a machine breaks down, how much does it cost? How much would a part, for example, cost to replace in a machine that's 18 years old? It's very difficult to say, the parts, there can be small parts or there can be very significant parts. But how, you must have a ballpark. The maintenance contracts are around about 10% of the cost of a LINAC per year. So that's 300,000 euros? In and around that, yes, that's right, for maintenance with parts. In an 18-year-old machine, are the comparative machines in close jurisdictions where we can get parts for, or do we have to go further afield for them? No, in fact, parts are, the supply is a real problem because the manufacturers base their rotation on around about 10 to 12 years, the replacement program. So there are no similar machines in the United Kingdom, there's no similar machines in the European Union. Where would you have to go for parts like that? Well, the companies do have parts when they can access them, but they do not guarantee beyond 15 years, they will not guarantee the supply of parts. So they get it on a best effort basis. So, on average, how long does it take to put a machine right, if it breaks down? And again, it depends on the nature of the breakdown. On average? We've seen breakdowns that last a week, we've seen breakdowns that can be replaced or repaired in about a day. And what happens when you have a booked patient with cancer who have already had a delayed access to treatment? What happens to those patients? Yes, so the challenge is that the machines don't break down in a predictable manner, that's the big problem. And as Brendan alluded to, it can be a variable time frame to get that part in, to get the machine fixed. Very often it happens, it could be first thing in the morning time, you've got a machine booked full of patients, that machine has to be offloaded, those patients have to be redistributed, we have to cancel other patients that are less urgent. So there's this massive urgency inside the department, day in, day out, to re-sort these patients, and make sure the patients whose treatment are time critical have to get treated that day. For your unit, where are those patients travelling from? So they could be travelling anywhere from Donegal to Waterford. I'm mainly based at St Luke's Network in St James. We treat lung cancer patients all the way from Waterford to Donegal. So they could be travelling some distances for those treatments, and that'll be delayed. Their treatment could be delayed several hours. We then have to get the staff to try and stay behind. This is an impact, and I know it sounds very minor, but we have challenges recruiting or training staff, and that's a really big issue for us. And there's a morale issue too, but if you suddenly have people in the family say, you know, we can't finish at 6 or 7 tonight, we have to get you to stay on till 9, that's a huge impact to them, let alone the tremendous impact to the patients. And as you heard in the letter that Ashley read out, it's awful for patients. They're anxious to begin with. If you're coming up with your first treatment and the machine is suddenly broken down, your confidence in that system is just... But if you've come from Donegal, for example, you may have flown down and expected to go back in an afternoon flight. Yes, something like that. So what happens to them? We may have to try and admit them somewhere or get them accommodation. It can be that big of an impact. So there's huge, and this is all about the patient, by the way. So there's huge anxiety for those patients. Already they've had delayed access to treatment. Now they've arrived at a center where a machine is broken down. We've heard it could be a day to a week to have that machine. There are other patients waiting for treatment on the other machines. Absolutely, and if you can imagine trying to restore that day and day. I know we're really keen to deliver the most efficient, timely service, but it's impossible to do that if we're actually constantly re-assorting these patients at short notice in an unpredictable manner. I mean, if you take Dublin Airport and there's a storm, it takes days to recover. We're exactly the same as that. The flights get delayed. Our patients all get re-assorted. And it is very, very disruptive, and it takes a long while to catch up. So we do our very best to cope with that, but at a great cost. And it's not just those re-assortments. I take it that we have a very old machine. It's 15-year-old in St. James's that delivers our stereotactic program. It delivers accurate treatment, but it breaks down very frequently. So a treatment that might take, say, 20 or 30 minutes when it's working really well, if the machine is constantly breaking down and tripping, that could take an hour. So that per patient is stuck on the bed for instead of 20 minutes. And it's not a comfortable position necessarily. They're there for an hour. There's the knock on. We're running late then by 40 minutes. These minor things all add up to delays in the system, but huge patient impact. I can't understand how distressing that is. So for someone with lung cancer, on average, how many treatments would be required? It can be, if it's lung cancer, it can be as short as three treatments with our stereotactic program, but they're very long treatments. They're very often 45 minutes ago. Or it can be 33 treatments. Some of our head and neck cancer treatments take up to 35 treatments over seven weeks, and some of our prostate treatments are seven and a half weeks with 37 treatments. So, again, someone coming from Donegal or somewhere else at a distance for 33, 35 treatments, ending up in a situation where they arrive where there isn't treatment available, they may have to be admitted. They may have to be sent home. They may have to be rescheduled. This is a huge, huge... And don't forget, we don't fund transport for patients, just to be clear. I know. But this is at the patient's cost. They're very often relying on friends and family to drive them up. And you can imagine, if you're not familiar with coming to, say, an urban environment, that journey is made all the more fraught by these delays here. So, I mean, access affects outcomes. I just want the messages to need to be simple and clear. Access affects outcomes, and access is a problem. Reliability affects outcomes because if people are being put off and their treatments aren't being conducted in a cyclical manner the way they're planned, that also affects outcomes. It can potentially... We really work very hard to mitigate that, but it's at a huge cost. And our worry is we've never had... We are very at risk if we had, say, in all our centres, say, our Beaumont Centre where we have four machines, if all four broke down tomorrow, we would be in a difficulty. And they are breaking down so regularly that that will happen within the next year. It's only a matter of time. Our Beaumont Centre where we have four machines, if all four broke down tomorrow, we would be in a difficulty. And they are breaking down so regularly that that will happen within the next year. It's only a matter of time before that happens. The precision of newer machines, then, is important as well in terms of outcomes as well. Can someone make a comment about that? Because that's really important. Thank you for that because you're absolutely right. The disruption is, of course, very important and is a huge human cost. But the real thing is the precision of machinery. When you have very old machines, they're less precise. So if we take a throat cancer, if you want to radiate a cancer, say, sitting in the voice box, if you've got a very old machine, the beam has to be opened wider. And that means you get more collateral short-term side effects and long-term side effects that the patient lives with for the rest of their lives. If you've got a more precise machine, you can focus the beam in more and you improve what we call the therapeutic ratio, the balance between benefit and damage. And that's what we lack. When all our machines are old and are all going to be replaced sometime in the future, we get ten new machines altogether. We don't have the capacity. I'm on a clock there and I just want to say this, that I asked a parliamentary question on the floor of the Dáil and I will take the Minister at her word, but she must have been briefed by her officials, either in the department or by the HSE, and none of this is congruous with the witness statements you're giving here today. And I think that is a big, big ask of the Minister to decide.