Beaumont Hospital Board - Annual Financial Statements 1995-98.

Mr. J. Purcell (An tArd Reachtaire Cuntas agus Ciste) called and examined.

Acting Chairman

We are dealing with the annual financial statements for Beaumont Hospital Board for 1995, 1996, 1997 and 1998. I wish to make witnesses aware that they do not enjoy absolute privilege. I draw their attention to the fact that 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. I also remind members, notwithstanding this provision in legislation, of the long-standing parliamentary practice that members should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I welcome Mr. Pat Lyons, chief executive officer of Beaumont Hospital and I ask him to introduce his official.

Mr. Lyons

I am accompanied by Ms Evelyn Hempenstall, financial controller of Beaumont Hospital.

Acting Chairman

Mr. Fergal Somerville and Mr. Niall Staunton from the Department of Health and Children are present. I ask the Comptroller and Auditor General to introduce the contents of the accounts.

Mr. Purcell

Four years' accounts of the hospital are before the committee for its consideration, the latest are for 1998. The audits have been satisfactory with the exception of the length of time it has taken the hospital to develop and implement the comprehensive assets register which would enable it to maintain an acceptable control framework over its equipment in particular. Attention is drawn to this matter in each of my audit reports for the four years. The audit of the 1999 accounts is almost complete. The audit was contracted out to a private auditing firm and on the basis of contact with the firm, considerable progress appears to have been made in the development of the register in the interim. A definitive statement on this must await my review of the 1999 audit papers.

In the 1995 audit report I refer to inadequate stock control in the pharmacy. I am glad that problem has since been addressed to my satisfaction.

Apart from these matters I have no specific observations to make on the accounts.

Mr. Lyons

I agree with the Comptroller and Auditor General that the question of fixed assets was raised by him regarding the accounts of a couple of years. We have been putting much effort into endeavouring to develop a fixed assets register, to computerise it and to validate all the assets in the hospital, which originally cost £93 million 13 years ago and now has an equitable value of £51 million. We see the importance of maintaining a fully integrated fixed assets register which accounts for all the procurements, disposal, depreciation and useful life and which can be used to maintain a service record of all equipment, particularly in the current climate when we are upgrading and renewing much of the equipment which is now 12 years old.

Acting Chairman

Thank you. I now invite Members to ask questions.

In all four years' reports the Comptroller and Auditor General has mentioned the serious matter of the fixed assets register. What is the exact position with regard to it? I understand the hospital is doing something about it but I would like to know exactly what is being done. If £93 million worth of equipment has been provided by the State we would like to be sure it is safeguarded, accounted for and controlled in every way possible.

Mr. Lyons

A substantial proportion of the £93 million, £52 million, relates to buildings. The rest relates to equipment, furniture and fittings. In the early part of 1997 we started a process of identifying a computer system, quantifying the assets throughout the organisation and bar coding all the assets. We seconded two members of staff to itemise each item of equipment, furniture and fixtures within the organisation. That was quite a task and continued into 1998 and 1999 when it was almost completed. We used that register to facilitate the validation of the assets for their compliance with Y2K and during that period the progress in the fixed assets register fell to one side for some months. In 2000 we completed the validation and verification of all assets. We have implemented procedures linking the procurement and tendering of assets with the register itself so that the register is automatically updated. The disposal policy in relation to assets was also updated. Notwithstanding that we needed to update the register we also updated the procedures and policies surrounding the maintenance of the assets register. The updating began in 1997 and was completed in 2000.

Is it complete now?

Mr. Lyons

It was completed in the current year.

I thought Mr. Lyons said he was working on it.

Mr. Lyons

The assets register must be maintained continuously with procurements and disposals on a month-to-month basis. The full register has been completed and needs to be revalidated continuously.

On the overall allocation for the years heretofore, has the hospital operated within the initial allocation from the Department or have additional allocations been sought in any of the years?

Mr. Lyons

We have had negotiations with the Department in the early part of each year on shortfalls or service developments. For example, two years ago we developed an oncology service and we budgeted for £2.4 million annual revenue cost. Part of the negotiation in the first year was to validate that requirement as genuine. We received supplementary payments from the Department in the first year. The actual spend was validated and a supplementary was given. In previous years we had overruns in the course of the year. The bulk of these related to that type of development, through which we negotiated supplementary funding appropriate to fund those shortfalls. In this year to date, we do not have an accumulated deficit on revenue account.

Does the hospital have money in the bank at the moment?

Mr. Lyons

My colleague, the financial controller will tell us what is in the account.

Ms Hempenstall

At this point in the year, the third quarter, the hospital is in an approved overdraft position with our bankers. What tends to happen is that for the first two quarters of the year we are in a positive cash balance and for the last two quarters in negative cash balance or approved overdraft. The value and level of the overdraft is approved by the board and sanctioned by the Department of Health and Children. We operate within those limits at all times.

The length of time patients have to wait in accident and emergency departments before being treated is coming to the fore. While I appreciate there are staffing and physical problems in every hospital, are there problems in Beaumont Hospital which need to be addressed to ensure a superior service is provided in the accident and emergency department?

Mr. Lyons

Because of population growth and demographic trends in the north Dublin area we continually have a problem in maintaining capacity to meet increasing demand, particularly in wintertime. Admissions through the accident and emergency department have increased at a substantial rate. Seventy per cent of patients are admitted to the hospital through that department. Elective work accounts for the remaining 30%. Twenty-five per cent of patients are admitted through our national and regional specialities.

Because of our inability to accommodate all demands on the hospital, at times patients haveto wait on trolleys in the accident and emergency department prior to admission. We have taken as many initiatives as we can to reduce length of stay and improve staffing levels in the accident and emergency department, in which the facilities have recently been upgraded - both equipment and space. We have introduced nurse triage and nurse practitioners and there is direct liaison with general practitioners to try to improve the flow of patients through the hospital. Most pressure, however, is exerted by the fact that the occupancy rate is running at 99%. Statistics in the United Kingdom and elsewhere indicate that it is very difficult to manage capacity if the occupancy rate is 100% continuously. Unfortunately, to alleviate the pressure in the accident and emergency department at weekends we sometimes have to cancel booked admissions for elective surgery for Sundays or Mondays, but we try to minimise this as much as possible. We have recently appointed a new accident and emergency consultant who, with physicians and general practitioners in particular, is looking at ways in which some of the patients referred to the accident and emergency department can be referred back as quickly as possibly. While at times there are inappropriate attendees at the accident and emergency department, our inability to accommodate very sick patients who require admission when the hospital is full presents the biggest problem. The nursing crisis does not help but I hope our endeavours to recruit nurses, both at home and abroad, will alleviate the situation in two to three months time.

In recent years there has been an incessant problem with demand versus capacity. The hospital has 640 beds. While the short-term strategy is to link with community services and general practitioners to improve throughput, the long-term strategy is to increase capacity, as emphasised in the recent report produced by the ERHA. We have produced and submitted a plan to the ERHA for the development of day surgery and day care facilities on site. This is an important development. The upgrading and development of community services, particularly step-down and convalescent facilities and support systems for patients who require re-admission, will do much to reduce demands on the hospital, but these developments will take time. In the meantime we will have to manage patient throughput as best we can and give priority for admission to those who are acutely ill, while maintaining a service for health boards, both national and regional.

What are the national and regional specialities in Beaumont Hospital?

Mr. Lyons

Our national services are principally neuro-surgery, renal transplantation - kidney transplantation - and cochlearimplant. We provide a regional ENT, vascular and gastroenterology service.

How many patients are on the vascular waiting list?

Mr. Lyons

Approximately 250, of whom 80 approximately have been waiting in excess of nine months.

Is there any way this can be remedied?

Mr. Lyons

We recently reached agreement with our neighbouring hospital - the Mater Hospital - on a rota for vascular surgery. Each hospital in Dublin but principally Beaumont Hospital provides a service for the health boards. With the Mater Hospital, we will now focus on a rota basis on the North Eastern Health Board and the North Western Health Board. The remaining hospitals in Dublin will develop a rota for the other health boards. This will ease substantially the pressure on Beaumont Hospital, which in 1999 treated 380 vascular cases approximately, mainly aneurysms, referred through an accident and emergency department, mainly in the North Eastern Health Board and the North Western Health Board regions.

A point which I have made over and over again at committee meetings is that we are examining the accounts of Beaumont Hospital for the years ending 31 December 1995 to 1998, inclusive, which have no relevance to the matters under discussion. This is unacceptable. It is not fair that this committee and the Houses of the Oireachtas should be asked to examine accounts which are five years old. It is not possible for us to deal with them. We need a guarantee that we will examine the up-to-date accounts of Beaumont Hospital and other activities to ensure we will deal with fact, not fiction.

Acting Chairman

On that point, I mentioned in private session that it was not a reflection on Beaumont Hospital that we would be dealing with the accounts for the years 1995 to 1998, inclusive. I mentioned 28 reports, all of which relate to either 1998 or 1999. This represents a substantial improvement on the position which prevailed three or four years ago. Given the establishment of the new bodies, we will always be catching up on reports. We will not be able to examine every report every year. It will happen therefore——

While I accept that across the board reports are running behind, the position has to be corrected. I address this question to the Comptroller and Auditor General.

Mr. Purcell

It has nothing to do with the Comptroller and Auditor General. The accounts for 1995 were available to the committee for examination the following year. I signed my audit report on the accounts for 1996 in July 1997. I signed the 1997 accounts in July 1998. It is not therefore a matter of Beaumont Hospital not having the accounts - it had the accounts ready for audit - or of my staff not carrying out the audit or me not reporting on them in a timely manner, it is simply a matter for the committee. The Acting Chairman pointed this out at the beginning of the session, but I would hate anyone to take an inference from what the Deputy said, that the fact that these matters have not been scheduled until now has anything to do with me or with Beaumont Hospital, which can speak for itself. It has nothing whatsoever to do with us.

Will Mr. Purcell accept that in principle we should be regularly updated on current accounts?

Mr. Purcell

That is clearly desirable but it is up to the committee to regulate its own business.

Perhaps we should deal with that as a separate item.

Acting Chairman

We have referred to this matter over the past 12 or 14 years. Very often we dealt with matters that were seven or eight years out of date, but that has changed. Before we went into public session I complimented the secretariat, the chairman and others on the change that has taken place. Every report we received was either 1998 or 1999 vintage, which was not the way up to last year, when we lit a fire under certain persons in certain areas and change came about. On the workings of the committee, if we wish to work more days in the week we will have to discuss that in private but it is imperative to note that, as the Comptroller and Auditor General said, it is not a reflection on Beaumont Hospital that we have——

I am not saying that. I am simply saying that it is ludicrous that we are sitting in Dáil Éireann tonight examining accounts that are effectively five years old.

I want to ask Mr. Lyons a number of questions. What concerns the public with regard to financial expenditure in all of our hospitals is the question of staff shortages. I know Beaumont Hospital fairly well because it deals regularly with the North Eastern Health Board area and I know, for example, that the waiting lists for medical expertise at the hospital are getting longer. I understand the reasons for that. For example, there are 1,200 vacancies for nurses in the city of Dublin and I am sure Beaumont Hospital has its share of that problem. I note also from reports I get from the North Eastern Health Board that many of the problems are caused by a shortage of doctors and consultants. Could Mr. Lyons indicate to the committee the position in Beaumont Hospital on staff shortages including nursing vacancies, junior doctors and consultant vacancies that have not been filled? Also, is that problem having an effect on the growing waiting lists?

Mr. Lyons

We do not have a staffing shortfall in junior doctors and consultants. All our junior doctor posts are filled. There will be an issue in anaesthetics and accident and emergency posts come 1 January. There is a reduction in the applications for posts for the Dublin hospitals but we feel we will be able to resolve that problem and maintain a full complement of junior doctor staff. We do not have any vacancies for consultant staff except what may arise through retirements, and they are filled on a routine basis. In fact, we have increased the number of consultant posts over the past five to six years through service developments and expansion of existing services.

The critical point for Beaumont, like many hospitals, is a shortfall in nursing staff. Currently we have 110 vacancies in nursing out of a total complement of 900 nurses. There are a number of factors, which have been debated in various forums, in regard to what is causing that shortfall but as far as we are concerned, we have taken an initiative of recruiting in the Philippines to fill those vacancies and over the next three to four months, our nursing complement will be back up to its full complement of 900 staff. We have recruited 165 Filipino nurses. We will not require all of those nurses but we will have them on a panel and they cover all specialities within the organisation. The current effect of the staffing shortfall is that we have more than 60 beds out of the system, out of a total complement of 640. We are down on average one and a half theatres and we are trying to manage the situation by having extended hours in theatre and by using locum nursing staff wherever possible to deal with increased demand. We try to maintain the five day wards to deal with the elective work and the referral patterns the Deputy referred to but we are confident that by December/January, all of the capacity that has been closed because of staff shortages will be reopened. Notwithstanding that, the demands coming on the hospital from the North Eastern Health Board, the north west, etc. are increasing and even with a full complement of beds and theatres, the demands can far outstrip our ability to supply. However, we will be back to full complement in January.

The other areas that are marginally affected would be in the lower grades such as catering and cleaning. Cleaning, which we contract out, has been recontracted. We had to adjust the rate because of the minimum wage and competitiveness in that area. In regard to portering and catering, we constantly have to keep our eye on the ball to ensure that we deal with the high turnover in that area because opportunities exist elsewhere. We can only pay people in accordance with national guidelines but we are at full complement in those services.

In a nutshell, the nursing shortages have been the key pressure point for the hospital and have taken up a great deal of management time in ensuring that we get back up to complement. We endeavour to promote staff retention in every area possible and to make Beaumont, like any other hospital, a good place to work and to be motivated. Outside of the pay elements to the reward system, to try to motivate people in a non-pay area as best as possible. We have a forum in which we consult with all department heads on a regular basis, visit departments, etc. Obviously that is not unique to Beaumont but we do our best to try to retain the staff we have.

I fully understand and appreciate that but in simple terms, has the waiting list in Beaumont Hospital increased or decreased over the past two years and, if so, to what extent?

Mr. Lyons

The waiting list has increased in the past two years and we are currently in the process of negotiating with the private hospitals to try to deal with our capacity shortfalls. The waiting list has increased by more than 500 cases in the past year. Our current waiting list is approximately 3,400 cases across all specialities. ENT particularly is one of the major areas and we are currently going through the ENT waiting list to see what elements of that list need to be prioritised. We are negotiating with our neighbouring hospital, St. Joseph's, to try to deal with urology, ENT and vascular cases that can be referred on.

Thank you. I do not want my comments to sound like I am critical of the hospital. I am very familiar with the hospital and I would like to record compliments from the North Eastern Health Board because I know the hospital deals with many people in my constituency and in the North Eastern Health Board area. If Mr. Lyons were to ask this committee to recommend a measure to the Minister to help the situation, for what would he ask?

Mr. Lyons

What we have requested has been reflected in submissions to the Eastern Regional Health Authority which I understand is in detailed discussions with the Minister about the capacity requirements in the eastern region. The Eastern Regional Health Authority has been considering a bed capacity review that was undertaken on its behalf. Obviously we would like to have support for that initiative which will help alleviate the capacity problems currently in the system. Within that, we have our own application for developing day surgery facilities andcapacities at the margin that will alleviate our own pressures.

Of the 3,400 cases on the waiting list, how many of those would be medical card holders and how many would be private patients? Does the hospital have a helicopter landing pad facility and, if not, does it have any plans to acquire such a facility?

Mr. Lyons

We estimate that 70% of those on the waiting list would be public patients and 30% private patients. We do not discriminate on admission - public versus private. We take people off the waiting lists on the basis of medical need. That is controlled by the hospital in consultation with the clinicians. Although we have a few private wards, the majority of private patients who end up in those wards come through theA&E department so they are not elective cases. We deal with the elective cases principally through the five day wards.

The Deputy's second question related to the helipad. We sent a submission to the Department of Health and Children and the Eastern Regional Health Authority for the development of a helipad on site, principally because we are a major trauma centre and with neurosurgery, orthopaedics and maxillofacial on site, we get a substantial proportion of the trauma cases from around the country. We have managed at times to land a helicopter on site but with the new equipment of the Air Corps that is now no longer possible so the airport is used. As a result we have made a submission which involves a rooftop landing site.

That is a complex and expensive facility, costing in the region of £750,000 to £1 million. We have recruited engineering consultants to deal with the overall hospital upgrading, which the Minister announced during the year, and we are using those consultants to make specifications for the facility so we can get a fix on the cost. The hospital would like to have that facility. It is a facility that obviously improves on the transport time and the golden hour that clinicians refer to in relation to time from pick-up to drop off in the hospital. It would certainly be a plus in the neurosurgery, orthopaedics and trauma service in the hospital.

On a number of visits to a friend who was in Beaumont Hospital, I discovered last year that there was some type of cleaning problem in the hospital. The public corridors and the lobby did not seem to be up to standard. That is just a personal observation but other people who were with me also thought it was a problem. What happened with the cleaning contract? Has it improved?

Mr. Lyons

We went through many difficulties in the past 12 months because the cleaning contractor, like many such contractors - it was a reputable company - had a staff retention problem. With cleaning contractors one relies very much on the supervision and training of staff but due to high turnover and absenteeism, the service deteriorated. Clinical areas are obviously a priority but the public areas showed deterioration. We put the contract out for tender, we operated the number of hours applicable to the contract and, as I mentioned earlier, we had to increase the hourly rate for contracts of that nature. Security and cleaning were the two principal ones. Thankfully, the new company has fulfilled our requirements from a standard and specification point of view within the first six weeks of the contract and we are very encouraged. People will see a substantial improvement.

The other thing I noticed was that the lighting was poor in the evening when I visited. Is it policy to turn down the lights in corridors or was it to cover up the lack of success on the cleaning front?

That was before the cleaning improved.

Mr. Lyons

The lights in the wards at night are obviously dimmed but I will certainly look into that, Deputy. The front entrance is not conducive to the traffic that comes through the hospital and one part of our plan is to upgrade the front entrance and bring more light into it.

Presumably there is an internal audit control system in place in the hospital. On the question of the Filipino nurses, is it correct that you have recruited 500?

Mr. Lyons

We recruited a panel of 165, of whom we will draw down about 100 nurses between now and December. They have to go through a verification process and that will take two or three months.

Will there be further recruiting to meet your task of filling the full requirement for nurses?

Mr. Lyons

Yes.

How many patients does the hospital deal with annually?

Mr. Lyons

Referring back to previous questions, 70% come through A&E and 30% through elective admissions and transfers. That accounts for a total of 20,000 to 21,000 in-patient admissions per annum. In addition we would treat 55,000 to 60,000 patients in the A&E department as attendances and we would deal with more than 100,000 in the out-patients department. On a day care basis, we deal with 15,000 to 17,000 day cases, principally nephrology and dialysis and obviously day procedures. We are talking about total patient encounters on an annual basis of between 200,000 and 220,000.

Is that the largest number in the country?

Mr. Lyons

Of the acute hospitals, St. James's and Beaumont are probably equal in dimension.

What percentage of your patients are from outside Dublin?

Mr. Lyons

Twenty per cent. We operate at 98% to 99% occupancy so every area in the hospital is used and every bed is occupied each day.

Are there any big plans for the general expansion of the hospital?

My. Lyons

The development of the psychiatric unit on the site has finally been approved. That will involve a 60 bed unit which will complement and replace some of the acute services in St. Ita's. We are now going through the process of selecting a design team. That has been tendered for and, I hope the unit will be in place in two and a half to three years. I have mentioned the day surgery facilities. We have just developed the oncology unit in the hospital and that has worked very well. That continues to develop. We have upgraded the A&E department and we are refurbishing the entire hospital. A total budget of £27 million for equipment and building is being invested over a period of three years. We see the development of geriatric services, particularly a day hospital on site, as well as a long stay facility in the environment, as important to improve early discharge of patients.

Orthodontics is being spoken about and we have been approached by the Eastern Regional Health Authority to assist in the development of that on site. Dialysis facilities, which are currently overcrowded because of the increase in the number of people requiring dialysis, necessitate us expanding our facility to a larger unit accommodating 30 stations and 30 beds but migrating to 40 beds over a period.

I understand you have a unique arrangement with general practitioners on site. Is that correct?

Mr. Lyons

With the new A&E consultant we are trying to improve the liaison with GPs by bringing them into the department but we are only at the early stages. St. James's Hospital has pioneered this.

Have you brought GPs on site?

Mr. Lyons

We have regular liaison with GPs and on each aspect of the interface with A&E we discuss and agree protocols. However, the involvement of GPs in the A&E department has not yet started but we envisage progressing towards that direct involvement in association with our A&E consultant.

In what time period do you hope to implement that?

Mr. Lyons

Over the next six months we will work through that process. However, it is up to the A&E consultant to agree exactly how he envisages that operating. Also the development of GP clinics on site is something we wish to explore and we wish to take what has been best in the experience at St. James's and apply it to the hospital campus.

Will that be attended by the medical profession?

Mr. Lyons

It will be an out of hours service to take some of the pressure from attendances at the accident and emergency department and deal with the out of hours GP service in the area.

Is there a figure for the target reduction in the A&E department?

Mr. Lyons

The reduction in attendances could be quite small but it obviously improves the service from the general practitioners in the area. Five per cent to 10% would be quite a high target for reductions in attendances at A&E.

Will Mr. Lyons explain briefly why the nursing shortage crept up on us to the acute extent it apparently has?

Mr. Lyons

There are a number of factors contributing to the nurse shortage. In the recent past the diploma programme was introduced for student nurses which effectively took the students off the shop floor. That component of manpower was unavailable to the hospitals over the training period. We have studentsen bloc but the number of hours or man days available to us is substantially reduced from what was available previously. An endeavour was made by all hospitals in the eastern region to facilitate that by the introduction of more recruits to the nursing area, working with the Department of Health and Children and the nurse planning unit in bringing more students into the frame.

In parallel, what was not envisaged by anyone was the Dublin phenomenon and the fact that nurses began to leave the system two or three years ago because of the cost of living in the Dublin area, the attractiveness of working in the private sector, the stress levels of working in a major acute hospital and the rewards available elsewhere for not working in that type of environment. Although the Department of Health and Children responded to the pay issues substantially following the nurses dispute, there are substantive reasons nurses are leaving Dublin and going abroad, whether personal or otherwise. We must face that reality and introduce other grades of nurses to replace qualified nurses who leave the profession or area at an earlier age than they would have left in previous years.

The diploma and degree programme has had an impact as well. All these factors must be taken into account, together with the fact that all hospitals, particularly in the Dublin area, have developed services substantially and the complement of and requirement for nurses in the system has increased, so we are not dealing with thestatus quo of a steady complement of nurse requirement on a year to year basis. We have developed oncology and many day surgery and day care facilities and that necessitated an increase in the complement of nurses. However, the principal problem is that Dublin is not an attractive place. People are also leaving in other professions, hence the reason we must go abroad and recruit. We are doing everything to create incentives in the system to retain staff.

Is there on-campus accommodation for nurses? As regards Filipino nurses, does the hospital arrange their accommodation?

Mr. Lyons

We do not provide on-campus accommodation for nurses. It was not in the original hospital design. As regards the Filipino nurses, we facilitate their short-term accommodation locally until such time as they organise accommodation for themselves. We have accommodation arranged for 45 nurses.

They are in for a shock. They will be heading back to Manila.

Mr. Lyons

They are contracted for two years. Like any group or grade of nurses, we will do our best to retain what we have recruited. Unfortunately, we have little choice.

Acting Chairman

A financial aspect has cropped up in each of the reports, namely, a term loan which is payable within one year. It was £500,000 in 1996 and 1997 and £593,000 in 1998. A one year loan suggests it should have been cleared at the end of the year. Is there a revolving credit system or a shortage of capital?

Ms Hempenstall

As regards the outstanding balance of the term loan shown under two headings in the balance sheet for each year, the accounting policy is to split the liability and to reflect separately what will be paid in the following 12 months. For example, at a particular point if there were four years to go on the repayment of a term loan under the heading, "term loan repayable in one year", one would reflect one year's repayments. The balance of the figure would be reflected in long-term bank loans. While that figure looks to be a similar figure for each year, it is not the same £500,000. The original term loan which was approved by the Department of Health and Children a number of years ago was for an investment in computer assets in the hospital.

Acting Chairman

On behalf of the members, I thank Mr. Lyons and Ms Hempenstall and the officials from the Department of Health and Children for their attendance and co-operation. Is it agreed to note the reports? Agreed.

The witnesses withdrew.