Annual Financial Statements 1994-1998: Midland Health Board.

Mr. D. Doherty (Chief Executive Officer, Midland Health Board) called and examined.

Acting Chairman

We are dealing with the annual financial statements, 1994, 1995, 1996, 1997 and 1998 of the Midland Health Board. I wish to make witnesses aware that they do not enjoy absolute privilege. Members' and witnesses' attention is drawn to the fact that as and from 2 August 1998, section 10 of the Committees of the Houses of the Oireachtas (Compellability, Privileges and Immunities of Witnesses) Act, 1997, grants certain rights to persons who are identified in the course of the committee's proceedings. The rights include the right to give evidence, the right to produce or send for documents, the right to appear before the committee, either in person or through a representative, the right to make a written and oral submission, the right to request the committee to direct the attendance of witnesses and the production of documents and the right to cross examine witnesses. For the most part these rights may only be exercised with the consent of the committee. Persons being invited before the committee are made aware of these rights and any person identified in the course of proceedings who are not present may have to be made aware of these rights and provided with a transcript of the relevant part of the committee's proceedings if the committee considers it appropriate in the interests of justice. Notwithstanding this provision in the legislation, I should remind members of the long standing parliamentary practice to the effect that members should not comment, criticise or make charges against a person outside of the House or an official, either by name or in such a way as to make him or her identifiable. I welcome Mr. Denis Doherty, chief executive officer, and I ask you to introduce your officials.

Thank you, Chairman. I am accompanied by Mr. Diarmuid Collins, the board's director of finance, Mr. John Cregan, the programme manager for hospital services, Mr. Derry O'Dwyer, the deputy chief executive officer and programme manager for community care and Dr. Patrick Doorley, the board's public health director.

Acting Chairman

I welcome Mr. O'Toole from the Department of Health and Children. Perhaps you would introduce yourself and your officials.

Thank you, Chairman. I am John O'Toole, assistant principal, finance unit, and I am accompanied by my colleague, Mr. Ronnie O'Sullivan, assistant principal, hospital planning office.

Acting Chairman

I call on the Comptroller and Auditor General to introduce the content of the accounts.

Mr. Purcell

Thank you, Chairman. As you said, there are five years of accounts and reports before the committee today in respect of the Midland Health Board. It might help the committee's deliberations if I distinguish between issues reported, which tend to be common across health boards generally, and those issues which are particular to the Midland Health Board.

The common issues over the years include poor recording of fixed assets, especially equipment, the need for better control over pharmacy stocks and problems associated with the administration of patients' private property accounts. The passage of time has meant that these issues have largely been resolved and there is not a lot to be gained in my opinion at this stage in going over that old ground again. A new financial system was finally implemented last October in the Midland Health Board and this should help in providing a framework for improving the financial management of the board.

With regard to the most recent audit reports, that is, those covering the accounts for 1997 and 1998, I would draw the committee's attention to three main items. First, in my audit report on the 1997 accounts I was critical that no bills had issued for out-patient charges in Mullingar General Hospital between July 1996 and December 1997, that is a period of approximately 17 to 18 months. Although the bills were issued retrospectively, when the matter was brought to the chief executive officer's attention, it is likely - I think it is fair to say - that the belated billing had an adverse effect on the charges collected.

Having brought the matter to notice on the 1997 audit, I was surprised when I found that there had been a recurrence in 1998 when there were no bills issued for out-patient charges in the second half of that year. The chief executive officer attributed the lapse to staff shortages but pointed out that the introduction of the new financial system in 1999, to which I have just referred, would ensure that the issue of bills could not be overlooked in the future.

The second point to which I wish to draw attention is the 1997 report. It refers to the delay in bringing a new orthopaedic theatre in Tullamore General Hospital into operation. The construction was completed in 1995 and the equipment installed in 1997. The total cost of providing this facility was almost £2.5 million. Even then the theatre was only being used when maintenance was being carried out on another theatre. The Department allocated money in 1997 for bringing the theatre into use but due to financial pressuresmost of this money was diverted to meet day to day running costs of the board and the theatre was finally brought into general use in 1999. As I understand it, it is now being used four days a week on average.

The last point, which can be found in the 1998 report, concerns the drawing down by the board of capital grants from the Department before it was in a position to use them. This practice contravened the Department's rules in this regard, which stipulate that grant claims should only be in respect of matured liabilities. The chief executive officer acknowledged that the draw downs were not in accordance with the rules while outlining in each case the circumstances which led to this particular situation arising. In response to my concerns, the Department wrote to all health boards emphasising the importance of claiming only for matured liabilities in drawing down capital funding.

Acting Chairman

Thank you. Mr. Doherty, would you like to make an opening statement?

Thank you, Chairman. Perhaps it would be helpful if I referred to the matters the Comptroller and Auditor General alluded to. I agree with him in relation to a number of the issues raised in the earlier reports in that the passage of time has, in effect, permitted these to be remedied. For example, the register of the fixed assets is now very comprehensive. It is one of the benefits of the investment in the compliance for Year 2000 for equipment in that resources and facilities allowed us to do that, so it is completely up to date.

I think there is an ongoing concern about the register of assets of buildings. We currently have a man working half time in bringing that up to date. He is about half way through it at this stage and soon we will be in a position to say categorically that all property is fully registered and that the files will be available to demonstrate that. With regard to the pharmacy stocks, we now have systems in the three general hospitals and in the two psychiatric hospitals which record the stocks.

With regard to the drawing down of capital funds in 1998, I would maybe deal with that in two ways, first in terms of compliance with the requirements of the Department of Health and Children and, second, in relation to the financial implications - two matters the committee would be concerned about. With regard to the drawing down of the funds, I would say at the outset that I agree with the report of the Comptroller and Auditor General in relation to that. Perhaps I may say by way of explanation the circumstances that gave rise to that. I think it was a concern on our part that capital funding which became available and where we made a judgment call at the time it was offered, that we would be in a position if allocated that money to spend it by the end of the year, the expectations we had in that regard did not materialise in all of these cases.

One of the larger cases related to a transfer of land between Tullamore Urban District Council and the health board. By mid-December we had done all the difficult work in that the board had dealt with the resolutions required and the matter was, in effect, in the hands of our solicitors to finalise things. That really should not have taken very long because the property was registered in the name of another public body. What appears to have happened then is that when the contract came through it contained a great deal of typographical errors which needed to be corrected. In effect, our eyes were off the ball for a period and it took some time for the legal details to be dealt with.

In the case of the other items, much of it related to the acquisition of property for community type facilities for the physically and mentally handicapped. Our expectation that we would be able to acquire and secure the ownership of property by year end frankly did not materialise and there were delays arising from that.

In relation to the financial implications, if any, of that, I must emphasise that the board operates a single bank account. Therefore, even though it was in receipt of capital funds earlier than required, that favourable balance was taken into account in calculating our revenue requirements from the Department of Health and Children. There is an ongoing advantage in that regard in that in the year in question we realised over £3 million from the sale of assets, particularly the sale of lands at St. Loman's Hospital, Mullingar. Ever since, we have had a favourable balance on our capital account - this stands at approximately £1 million at present - which has the effect of reducing the draw on the revenue side by that amount.

Acting Chairman

I thank Mr. Doherty for his presentation. I am sure Members will want to put a number of questions.

Many of these accounts seem only to have historic value because they relate to things which occurred long ago. Why did it take so long to produce these accounts?

There was no delay in actually producing the accounts. In all cases, they were produced within the statutory timeframe and audited promptly as well. It is no more than the ordering of them in terms of the business the committee, etc., had to do.

Acting Chairman

I am informed by the Comptroller and Auditor General that, as a result of the way the committee operates, we were not in a position to deal with these accounts at an earlier date.

Will Mr. Doherty expand on the statement in paragraph 1.2 that delays were caused by typing errors, etc.? That seems to be a trivial matter.

Indeed it is, Chairman. All of the difficult work associated with that transaction, which involved the board acquiring a piece of land adjacent to the campus of the general hospital in Tullamore from Tullamore Urban District Council which was the registered owner of the land. We obtained approval for the funding of that transaction in August and for a subsequent additional amount of money in October. We completed all of the formalities between the two public authorities in that the statutory notice required to acquire the property was given and the internal process we have for our land purchase committee to view the property and recommend it was undergone. All of that had been dealt with by the middle of December.

All that remained was for the legal contracts to be executed by the respective firms of solicitors dealing with it. The draft contract came our way in December but it contained a large number of minor typographical errors which had to be corrected. The delay occurred for no more reason but that the Christmas and new year period arrived and the contract did not receive the attention it deserved. There was an inordinate delay having regard to the type of work that had to be done in completing it.

The next paragraph refers to physical and sensory disability services in 1998 and indicates that total expenditure was £702,000 but that there was a delay in drawing down £100,000. Has that money since been drawn down?

It was earmarked for the services for which it was allocated and in the locations in which it was provided for. In the case of a number of those, the projects have been completed and commissioned. There is one amount for a facility in Durrow, County Laois, where unanticipated difficulties arose which involve identifying and commissioning another property. However, the money allocated is reserved for that purpose.

In 1997 it was discovered that out-patients had not been billed by Longford and Westmeath general hospital in the period July 1996 to December 1997. Will Mr. Doherty comment on that matter?

I am disappointed with the subsequent history of that matter in that there was a staffing difficulty which gave rise to the problem in respect of the billing for out-patient services not being acted upon and then dealt with, subsequently, in bulk. It was brought up to date but, subsequently and largely for the same reasons, went out of kilter again.

I am satisfied that, at the second attempt, the arrangements that were put in place are unlikely to give rise to problems in the future. There are a number of reasons for this. First, it is unacceptable that accounts are not issued promptly, second, we have a better financial system which is less consuming of staff time and, third, we have strengthened the financial expertise available to the programmes. For example, in the current year we have appointed a qualified accountant to work full-time in the acute hospitals programme. It is the responsibility of that person to ensure that the financial services are attended to in the way that is necessary to make sure that we collect the money owning to the board.

The Comptroller and Auditor General also commented that details relating to fixed assets were poorly recorded. What is the position in that regard?

I am pleased to say that currently that problem has been comprehensively resolved in that we have a completely up to date register of fixed assets. It was possible to do that as part of the work involved in ensuring that all our equipment was compliant with the year 2000 requirements. We have a comprehensive computerised system that is up to date and we will maintain it in that state.

What is the position in Mr. Doherty's health board area on the problems associated with patients' private accounts?

The amount of money we handle is declining because there are fewer long stay patients. That applies particularly to the psychiatric hospitals where traditionally there was a big volume of work. At the beginning of the period the committee is looking at, the amount of patients' private property would have been £1.1 million. That has reduced to approximately £700,000. That is partly because of the reduction in long stay patients but it is also related to the fact that last year we paid more than £218,000 to the Chief State Solicitor's office in respect of dormant accounts where the holders of the accounts died intestate.

The other issue is the cost of administering these accounts. That has become a loss maker for us in recent years. Traditionally, the higher amount and the interest rates that used to prevail were sufficient to meet the administration costs. However, lower volume and what we generate with current interest rates are not sufficient to cover the administration of these accounts which is time consuming because many of the account holders are dependent people. In addition to the weekly pension transactions, there is also the need to look after the pocket money element on their behalf. That involves a great deal of time by nurses and other staff to keep that right.

I am concerned about the Comptroller and Auditor General's report on the 1997 accounts, particularly in relation to the orthopaedic theatre at Tullamore General Hospital. The theatre was built in 1995 and equipped in 1997. According to the report, it seems to be only partly opened and to be used when the other theatre is being repaired. In 1997 a large sum of money was diverted from capital funds for the theatre to day to day administration. The money was used for the day to day running of the health board rather than for the purpose for which it was intended. Perhaps Mr. Doherty could clarify that. It is a serious matter if, coming towards the end of the year, we use that type of money for administrative and other staffrather than providing a theatre for patient operations.

I am happy to clarify that. As regards the current status of the theatre, it is used virtually full-time now in that it functions four of the five days a week core time. We have four theatres, of which two are specially air conditioned for orthopaedic type work. The existing spare capacity is what we need to be sure we will be able to have a theatre in emergencies. It is in full-time use.

As regards the transfer of funds, we aretalking about revenue solely. There was no transfer between capital and revenue. Revenue funding was provided in that year for commissioning the theatre. However, because of the financial situation that year and the pressures on the board arising from other increases in demands in the acute sector area, we sought and obtained the approval of the Department of Health and Children to use a large portion of that for the ongoing acute servicesrather than for commissioning the theatre which we delayed until we were able to get the fourth orthopaedic surgeon on the staff. We also needed an increase in orthopaedic capacity. We concentrated more at that time on out-patient activities which was gearing up for the day when we had the additional surgical capacity.

When did the theatre open on a four day week basis?

That is four years after the building was complete.

The building was equipped in 1996 so 1997 would have been the first year in which it could have been used.

There is a two year lapse. The purpose of providing capital funds for theatres was to reduce the number of people on waiting lists for operations, etc. How many people are on the waiting list for such procedures in the Midland Health Board area?

As regards the period we are talking about in relation to in-patients, although there was a delay in commissioning the theatre, we were able to increase activity significantly. In-patient activity increased from just under 2,000 in 1995 to 2,276 in 1998. Day patient activity increased from 8,500 in 1995 to 12,500 in 1998. There was a big shift from in-patient to day patient activity which was also more economical.

As regards the theatre situation, we have two areas of difficulty in relation to waiting lists. The first is ear, nose and throat and the second is orthopaedics. The total number of patients on the waiting list for orthopaedics at the end of March was 607. The total number for ear, nose and throat was 1,155. They refer in all cases to patients who were waiting longer than three months.

There are more than 2,000 people on the waiting list. How does that compare to the figures for two years ago?

The figures have been declining in the past year.

That is not the question I asked. I want to know how the figures compare to the figures for two or three years ago. There are 2,162 people on the waiting list.

The figure for all in-patients in the period from December 1998 to December 1999 came down from 2,200 to 1,700. Some of that would have been due to validation of the waiting lists. There has not been a dramatic reduction in numbers during that time. One of the main reasons for that is that the capacity of Tullamore General Hospital is way below what is required to meet the need. We will not make proper impact on that until the new hospital is commissioned.

I am trying to establish what the numbers on the waiting list were in 1997 when this theatre was fully equipped compared to the numbers now. I have the current figures; perhaps Mr. Doherty could give me the figures on the waiting list for ear, nose and throat and orthopaedics at the end of December 1997.

The figure I have for orthopaedics at the end of December 1997 is 899.

What is that for?

That is the figure for orthopaedics. The figure at the end of March for orthopaedics——

The figure I want is that for the end of December for ENT.

The figure for ENT in 1997 was 1,081.

In other words there has been no decrease in the number of people on the waiting list between 1997 and the present. Therefore we are not solving the waiting list problem in the Midland Health Board area - maybe it is not the fault of Mr. Doherty - any more than in the other health board areas. Some people who come to us are between three and five years on the orthopaedic waiting list and the figures are not being reduced.

Throughput is increasing but the numbers on the waiting lists remain high.

This is despite the fact that many on the waiting list have either gone to a private hospital or passed through a general ward before being called for their procedure.

Yes, some would. The overall number we are dealing with year on year is very much higher, not just in relation to elective work but work which arises because of the huge year on year increase in calls on the accident and emergency services which has a consequential knock-on effect for orthopaedic departments. Part of the difficulty in making a real impact is that if trauma and emergency work is growing, there is not an opportunity to deal with more of those on the waiting lists.

Acting Chairman

I wish to raise the issue of finance for the theatre and such things - I appreciate the Department of Health and Children gave permission in that case - and the drawing down of money for projects which are incomplete or which are maturing. In the past year we had a difficulty with different agencies in this regard, and it was taken very seriously. In the case we are now discussing it was down about £3.5 million and work to the value of £2 million was completed. What was the outcome of that? Were there complaints from the Department or what was decided as a result of it being drawn to your attention? The procedure was fairly strict. Drawing down funding has to be signed for by way of certificate——

Acting Chairman

——in terms of local authorities. Was it the same in the case of health boards? Was it necessary to certify the £3.5 million?

Yes. The forms required by the Department were completed in mid-December in order to avail of the funds in the course of the year. This issue arose in one year and has not occurred subsequently and steps have been taken to ensure it does not occur in future. Allowance was made for it in calculating our cash flow from the Department so there was no financial implication for the overall funding by the Department in that sense.

Acting Chairman

In the past, if one agency was drawing down cash, similar agencies may have been left behind to some extent. Is the Department of Health and Children happy that the procedure has been tightened up?

We are happy that the letter has issued to the Midland Health Board and the other health boards stressing the importance of only drawing down capital when the liabilities have matured for payment. When the matter was raised by the Comptroller and Auditor General we wrote to him explaining the situation. In the past the Department got invoices and certificates from architects from health agencies, but in recent years we have moved away from that because the Office of the Comptroller and Auditor General examines accounts locally and it was felt it would be a duplication to have this documentation coming to the Department. We now have a form where it is certified that the work has been done, the liabilities have matured, the equipment has been bought, or whatever. That is the system and we are quite happy with it. We have written to all health boards reminding them of the requirements in relation to the system. Some health boards are good and some are maybe not so good, but the Midland Health Board is very efficient in terms of filling the forms which include several columns with figures. They are very accurate and we are very pleased. We are happy that the system is on the rails.

Acting Chairman

I think it was presumed that when a certificate was signed by an official it was taken in good faith to be accurate. Now there is a second counter-signature and there is a mechanism to ensure people are aware of the implication of signing a certificate of completion.

Mr. Purcell

I think the Chair is referring to the case of the National Roads Authority when local authorities were drawing down grants. There issome provision for a counter-signature, perhaps by the county engineer as well as one of the senior administrative personal. In the case of health boards, only a certificate from the chief executive officer is necessary.

Acting Chairman

Is the Department satisfied with the process? Our primary objective is to ensure the process in place is foolproof.

Yes, I think the Department is satisfied.

Under-capacity was mentioned in respect of various disciplines. To what extent is full capacity being utilised in all areas, for example, surgical medical beds in all the institutions within the remit of the board?

On the medical side the problem is that the capacity of medical beds is not sufficient to meet current need, even in what we traditionally call the off-peak season. We find that throughout the year there is encroachment on surgical beds in order to deal with that need. It tends to be a very serious problem in the winter period. In fact, we are currently looking at bed capacity throughout our acute hospitals. Beds per population in the Midland Health Board area is low relative to the system as a whole. Much of that is related to what had to be done in the period 1988-9 and that has not been recovered. We have introduced new services such as geriatric services into our acute hospitals in Tullamore and Mullingar without any increase in bed capacity. Of course, the older population in absolute terms has increased a good deal in that time. Even though we have significantly increased the amount of day surgery and day activity in other departments, the issue of capacity merits particular attention at this time.

Regarding theatre surgical capacity, that is influenced to some extent in our case by the pressure on the diagnostic departments, particularly radiology at the regional centre in Tullamore, and also to an extent by anaesthetic cover which can be a problem at times. Overall we feel the new hospital in Tullamore, which will give us a big increase in day capacity, will allow us do much more with the same level of resource. Regarding the future we feel the number of acute beds is not sufficient for the growing demand on our services.

When will the new hospital be commissioned?

We expect it will be commissioned in about three years. Preliminary works will begin this autumn. The overall project will take approximately three years.

To what extent will the capacity be increased?

There will be increased capacity.

Roughly what percentage?

In bed terms, in-patient beds will increase from approximately 208 currently to 233. The number of in-patient beds for most specialties will be much the same but the number of day beds will increase substantially. There will be a dedicated day procedure unit a facility for renal dialysis and oncology.

As a former member of a health board, my problem in relation to medical and health planning generally is that while there is an under-capacity which is currently manifesting itself, forward planning does not seem to incorporate a greatly increased capacity. I cannot understand how these two aspects measure up and I have yet to see how it will work out. This relates to other areas also. If you increase capacity by 5% it should have a beneficial impact in terms of reducing waiting lists, administration work within the hospital services, anaesthetist services and the availability of medical and surgical beds and so on. If there is a snag within the system where one area cannot cope, obviously this will have a knock-on effect. I am not sure what has been outlined will be catered for.

It is a fair point that the bed capacity has been at its present level for more than the past decade. This may indicate a need to increase that capacity. During the period the committee is considering, the average length of stay in medicine, surgery and orthopaedics has declined. Patients are being kept in hospital for shorter periods which allows more people to be put through the system. Even though the numbers are increasing, they are not keeping pace with the increase in the demand for services. I believe this will continue.

Are there any wards or facilities in institutions closed at present?

Have you any difficulty in relation to the availability of nursing and medical staff?

Not really. A competition was held last week for permanent nurses in Mullingar and we set up a panel of 54. It is more difficult to recruit temporary staff now than in the past. We are trying to fill all the permanent posts we can justify. We are benefiting to an extent from our proximity to Dublin in that some people are relocating to towns in our area which are close enough to Dublin.

Are all permanent consultant posts filled?

We do not have vacancies which cannot be filled. There are probably a few vacancies at present as a result of retirements and filling but I cannot recall a post which has not been filled because we are unable to do so.

Could Mr. Doherty clarify the figures at the end of 1997 for ENT and orthopaedic services?

At the end of 1997 the figure for orthopaedic services was 899 and for ENT 1,081.

That must be compared with the figure of 2,162 at the end of March 2000 which is greater than it was at the end of December 1997.

That is correct.

Apart from the numbers on waiting lists, what is the average waiting time for various procedures for adults and children in your area?

We are paying special attention to the tail of the waiting list, so to speak, in the current year. The policy of the board is one year waiting time for adults and six months for children. The number of children on the waiting list for three to six months is 11 and for more than six months 42. I will give the Deputy the numbers at the end of 1998. We have particular difficulty in relation to general surgery in Portlaoise where the number was 519 at the end of 1998 and the average waiting time was 2.75 years. The waiting time for gynecology services was two months. There was no waiting list for surgery, medicine or gynecology in Mullingar. In Tullamore the waiting time for general medicine services was three months, for surgery 1.25 years, for orthopaedic services two years, for tonsils and adenoids it was 1.4 years, for grommets 1.4 years, for others 1.4 years and for adults 1.5 years. The waiting list situation has improved since then.

Government policy is the same as health board policy which is one year for adults and six months for children. Within what period will your health board be fully compliant across the various procedures?

In terms of the volume we handle, it would be easy to deal with this problem by dealing with those longest on the waiting list. Consultants do not agree with us in all cases that it is best to deal with those who are longest on the waiting lists. There is merit in that from the point of view of equity but often some patients who are a shorter period on the waiting list may have a greater medical or surgical need. They would tend more towards bringing in those whose need is greatest. What we are negotiating with them at the moment is a protocol where we can deal with the medically urgent cases while at the same time recognising there is an equity issue in relation to those who are longest on the waiting list. We are satisfied in relation to children that this is not a problem and in the course of the current year we expect to have dealt with those longest on the waiting list.

Given that within the consultants' contract they have total control over clinical priority, how are you negotiating this, because at the end of the day consultants are not very keen to relinquish control in that area? While I agree that you must balance equity with medical priority, I do not think it is fair that a person must wait five years on a waiting list for an orthopaedic examination just because he or she is not regarded a medical priority. Are you progressing in this regard with the consultants?

The Deputy is correct that if consultants wish to stand on their dignity the contract allows them to do so. However, it is our experience in virtually all cases that when we invite consultants to look at the issues around equity together with medical need, they are amenable to coming to arrangements that suit the priorities of the Government and the board. This year we attempted to extend that to general practices with a lot of patients. We tried to bring them into the loop to help those who have been on waiting lists for a long time.

Part of the problem is that if patients are on a waiting list for a year and a half the consultant will not have seen them for that length of time. By virtue of the fact that they are on a waiting list, it is likely they are attending their GP on a fairly frequent basis. It seems to us that a way of introducing equity into the system is to involve GPs in the process of prioritising until we reach a stage where the waiting lists are much shorter. The GPs we involved are interested in the system and the consultants see merit also in it because it is difficult for them to manage long waiting lists. We expect consultants to be in theatre and outpatient departments rather than going through lists of patients. Medical secretaries and waiting list managers are important in this respect. Consultants do not want to have long waiting lists which are the subject of debate and controversy. In our experience they are helpful in attempting to come to terms with them.

Is there any statistical information available on the number of procedures performed by each consultant each year?

There is. We produce statistics for every consultant monthly. These are furnished to all consultants. Let us say we have eight surgeons. We produce coded information monthly. Each consultant knows his or her number. They do not know the numbers of the other consultants. In this way they are in a position to compare their performance with that of their colleagues.

How many members of staff in the finance department conduct audits? On information technology, are you completely up to date? Do you have access to teleconferencing facilities to conduct meetings between hospitals?

On the latter point, while we do not have access to video-conferencing facilities - there is, however, a central facility - we do have access to teleconferencing facilities. This is sufficient for most of what we have to do. In relation to audits, we have an approved staff complement of four. Two of the posts are filled. An offer of appointment has been made in respect of another. On wider audit activity, we are also increasing staff numbers to conduct clinical and risk management audits, areas in which we were short-staffed. On computerisation generally in the financial area, we installed the SAP system last October. It is being rolled out. We are in a position to say for the first time that we have a good system on the financial side.

Are you fully compliant with equality legislation, in particular in the achievement of a gender balance in recruitment?

We have done a lot of work in that area. For a number of years we have had an active equality committee working specifically to a strategy and a policy, which is resourced. In that regard we are as good as the public service generally. Recently we were the first health board to be awarded the accreditation of disability friendly.

Are there any female programme managers among your executives?

We have a 22 member corporate team, some of whom have a region-wide remit while others are general managers. Eight of the 22 are female.

Acting Chairman

To my knowledge Mr. Doherty is the only official who has managed two boards simultaneously during the past 20 years. I often wondered how he managed to do this. He is probably the most experienced official around. On waiting lists, Deputy Cooper-Flynn raised the question of comparisons between consultant-led teams. The relevant aspects are the number of patients waiting, the facilities and staff available and the level of efficiency. You said that comparisons are now being made between consultants. Is this being done nationally or just within the health board?

Just within the health board.

Acting Chairman

Perhaps I should address this question to the officials of the Department of Health and Children. I am aware that there is a case mix programme in place to identify efficiencies generally. Has any attempt been made to evaluate output and efficiency per unit?

Yes, considerable work has been done in recent years by way of the waiting list initiative to try to reduce waiting lists. This week the Minister announced the allocation of an additional £10 million to combat the problem.

On the question of comparisons between health boards, you mentioned the case mix model of diagnostic related groups in which emphasis is placed on the measurement of quality and quantity. The Department is working with chief executive officers nationally to develop performance indicators to be included in the annual service plans drafted by health boards.

Acting Chairman

It seems Mr. Doherty's board has taken a different initiative. Do you know if any of other seven health boards have taken a similar initiative? Would you be inclined to replicate it?

Other health boards have similar arrangements. As Mr. Doherty said, each consultant can identify himself or herself and compare his or her performance with that of his or her colleagues. He also raised the question of clinical independence and each consultant auditing his or her performance against that of his or her peers. That is the most important point.

Acting Chairman

Thank you. Is it agreed that we should note the accounts and the financial statements for the years 1994 to 1998, inclusive, of the Midland Health Board? Agreed. I thank Mr. Doherty and his officials for attending and bringing their wisdom to bear.

The witnesses withdrew.

Sitting suspended at 11.17 a.m. and resumed at 11.22 a.m.