COMMITTEE of PUBLIC ACCOUNTS debate -
Tuesday, 18 Dec 2001

Vol. 3 No. 29

2000 Annual Report of the Comptroller and Auditor General and Appropriation Accounts.

Vote 33 - Health and Children.

Mr. M. Kelly (Secretary General, Department of Health and Children) called and examined.

Chairman

We will deal first with Vote 33 for the Department of Health and Children. We will then discuss the Comptroller and Auditor General's report on nursing home subvention.

Witnesses should be aware that they do not enjoy absolute privilege. The attention of members and witnesses 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 identified in the course of the committee's proceedings. Notwithstanding this provision in legislation, I remind members of the long-standing parliamentary practice to the effect that they 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. They are also reminded of the provisions of Standing Order 149 that the committee should refrain from inquiring into the merits of a policy or policies of the Government, or a Minister of the Government, or the merits of the objectives of such policy or policies.

I ask Mr. Kelly to introduce his officials.

Mr. Kelly

I am accompanied by Ms Helen Minogue, assistant principal officer, finance unit; Mr. Dermot Smyth, acting assistant secretary; Mr. Tom Mooney, deputy secretary; Dr. Jim Kiely, chief medical officer, and Mr. Dermot Magan, principal officer, finance unit.

Chairman

Also present are officials from the Department of Finance, including Mr. Joe Mooney, principal officer, public expenditure division. I ask the Comptroller and Auditor General to introduce our study of the accounts of the Department of Health and Children.

Mr. Purcell

My annual report does not contain any paragraphs on the Vote for the Department of Health and Children. This is unsurprising as the Department is mainly concerned with policy and strategy. The vast majority of voted health funds go to health boards, agencies and hospitals which are subject to audit and accountability requirements in their own right. I hardly need to say that health spending constitutes a major portion of the public finances. In the year 2000 over £4.6 billion was spent on voted health services, out of total Vote expenditure of £20.6 billion, which means that health accounted for 22% of the total. The recently published health strategy envisages large increases in allocations in coming years. It is important that this level of expenditure is subject to an effective value for money regime. In this regard, my staff have discussed how best to co-ordinate efforts with senior staff in the Department. The recent Deloitte and Touche value for money audit of the health system should serve as a useful input to the development of performance measures and indicators for the health sector.

I would like to mention for the information of the committee that members of my staff are conducting a value for money examination of waiting lists. It will be some time, however, before I am in a position to finalise my report on the subject.

Chairman

As the committee has received a written statement from Mr. Kelly, we will go straight to questions.

Deputy Bell

The nursing home subvention is to be discussed separately. A substantial amount of money is spent on the health service and most people are totally dissatisfied with it, excepting those who can afford private care. There is now one system for those who can pay and another for those who cannot, such as those on medical cards. I receive a constant stream of complaints to my office as I am sure do my colleagues. People are put on trolleys in hospital waiting areas while there are empty beds and there is a lack of nursing and medical staff. If we took all the foreigners out of the hospitals, the entire system would collapse. Mr. Kelly is the Accounting Officer and is charged by the State and the Oireachtas to tell us what he proposes to do about the two-tier system and our ragged health service. Can he explain why all these problems have arisen?

Mr. Kelly

I will do my best to respond, but some of the comments made in the framing of the Deputy's question relate to policy which I do not want to get into. The overall theme running through the question was that of levels of dissatisfaction arising from the pressure on all aspects of the health system. I am happy to indicate to the Deputy and to the committee what is required to address that. I do so against a background of consultation undertaken by the Department, among stakeholders in the system, the wider community and voluntary and community groups which have a very direct interest in the system. We have spent a year studying the very questions Deputy Bell has just raised and that has culminated in the preparation of an agenda which is set out in the Government's health strategy document entitled Quality and Fairness: A Health System for You. What comes through from the analysis in that document is that there is no single quick fix solution to the immediate pressures on the system. We can, for example, try to relieve pressure on accident and emergency departments and long-term waiting lists for elective surgical procedures and we are making progress on those issues.

Based on the scientific market research and surveys of public opinion there is, in fact, a very high satisfaction rating with some aspects of the system. I do not, therefore, accept the sweeping statement that every aspect of the system is in tatters. For example, the general practitioner service has an 80% to 90% satisfaction rating among users, which is an exceptionally high rating for any service, public or private. Similarly, surveys of the opinions of those who have accessed the health system on the quality of care and treatment they received document a high level of satisfaction. Clearly, those who do not have such a view of the system are those who do not get to access it because they are waiting for procedures or services, such as orthodontic services where there are considerable weaknesses in the system. We are not happy about this and are trying to address the problem.

It is a question of capacity in terms of the available numbers of beds, doctors, nurses, paramedics and other support staff. Are they sufficient to address the demands on the system now in addition to projected demands in the years ahead? We have put together a developmental programme to cover the next seven to ten years which addresses capacity in the acute hospital system and the need to dramatically and radically develop primary care. The programme addresses the need for a build-up in the services available to older people, the disabled and children and it identifies the considerable price tag involved.

There are structural problems in the medical workforce. The huge amount of evaluation carried out clearly indicates what needs to be tackled and a task force is being assembled to proceed with the job of restructuring the workforce and to make the health system more attractive to Irish medical graduates although we will still welcome graduates from other jurisdictions into our health system. As long as they meet training and visa requirements, there is no reason we would not employ people from European and non-EU countries. These people are a valuable resource. If the committee wishes I can list 20 ongoing initiatives to measure and address the demand for nursing, to upgrade education and to improve pay and career structures. There are also improvements in further training and development for nurses. Measures have recently been taken to introduce family-friendly work practices to attract nurses back into the workforce.

Chairman

Is it not true that 1,700 nurses are not EU citizens and are, therefore, on a two year contract? Is it not true that there are about 1,750 vacancies for nurses, some 1,000 of which are in Dublin? A programme has been put in place, but how is it alleviating the shortage? All the components of the health strategy go out the window if there are insufficient resources to carry out its aims.

Mr. Kelly

In terms of nursing, I can talk about what we have already done and about what is already producing results. You refer to the increase in the number of nurses working in the health system. This year, up to 31 July, an additional 1,702 nurses were employed in the system. In the year ending 31 July 2001, 1,500 nurses were recruited abroad and, at the end of October 2001, the total number of nurses from abroad working in the system stood at 2,054. Every day, 417 nurses work in hospitals as agency nurses and some of the vacancies are filled in that way.

Chairman

What is the actual nursing shortage? Is the figure of 1,750, of which 1,250 are in Dublin, correct?

Mr. Kelly

I will produce the figures shortly.

Chairman

That is the most pertinent point.

Mr. Kelly

If one takes the gross number of vacancies, the figure will be of that order, but when one takes into account the amount of overtime being done and the number of vacancies covered by agencies, contract nurses and so on, the figure is in excess of 300. Although we are trying to recruit 1,200 nurses, many of the vacancies reflected in the figure are filled by way of overtime and agency employment.

Chairman

That is 1,200, but one must allow for turnover because many nurses from European Union countries will move to countries which offer better pay, whether the United Kingdom or otherwise. There are shortages elsewhere. Are you allowing for the labour turnover factor? Will it not further compound the figure?

Mr. Kelly

Yes. There is an annual attrition rate for nursing caused by nurses retiring or moving into other careers, both inside and outside the health system. There are also nurses who leave employment in general and the fact that the system is expanding. These factors increase the demand for nurses each year. I characterise our activities as having done everything possible in terms of improving the employment and training regimes, increasing the numbers entering training by a very significant factor and, as employers, looking after staff, in particular, nurses. I have asked my own staff working on this matter what additional measures we can take.

I do not claim that we are ahead of the problem. There is, Chairman, as you have remarked, an international shortage of nurses, particularly nurses with specialist qualifications. Until very recently there was also a very heated labour market for skills of all kinds and nurses were attracted from nursing into other careers. As Secretary General of the Department of Health and Children, I cannot alter these environmental factors. What I can do is ensure everything possible is done in terms of the factors under our control. We have done so.

Deputy Bell

I thank you for your detailed reply. I understand your problem and do not envy you. No one would want your job because your Department is in a shambles. When I first entered politics there were queues of mothers outside my clinic trying to get their daughters into nursing. I live within the shadow of Our Lady of Lourdes Hospital, the largest hospital, the flagship, of the North-Eastern Health Board. No one comes to me now asking to get them into nurse training. I would like to know the reason for this. I suggest one of the reasons is that the level of expenditure and taxpayer's money being spent on the administration of the health service, for example, running the health boards, has created a lack of funds for the coalface where staff are needed. There is a lack of money going into opening beds and wards which have been closed. Far too great a percentage has gone into the administration of the health service which your Department is directly responsible for organising.

How many beds and wards paid for with taxpayer's money are idle at present? Medical card holders who want a hip operation have to wait two years. If one can afford to pay at the Blackrock Clinic or somewhere else, one can be treated within a week or two. Could you explain this to the committee? I apologise if I sound angry, but it reflects the anger of the people I meet every day.

Mr. Kelly

I share the Deputy's sense of frustration about the length of time patients have to wait for certain services. I regard it as one of my direct responsibilities to address the matter. However, I wish to return to how we achieve this. While a certain amount can be done in the short-term, some aspects will require a sustained programme of development and reform over a period of years.

I ought to comment on a couple of remarks the Deputy made in his preamble. The first relates to applications for nurse training posts for which there is no shortage of applicants. The reason applications do not come to notice in the way they perhaps once did is that there is absolute formality now about the ways in which people apply for nurse training. It has been drawn into the Central Applications Office process just like other forms of education and training, which is a reflection of the ongoing development of moving education and training into the university sector. That policy objective has now been realised.

As regards administration, I do not accept the point the Deputy made in passing. I have examined in some detail, by reference to other similar types of enterprise, the assertion that the numbers in clerical administrative grades are too great a burden. In fact, an examination of the figures reveals that from a total of nearly 90,000 employed in the health system, taking account of the increase which would have taken——

Deputy Bell

How many are in administration and how many are doctors and nurses?

Mr. Kelly

The figure I have in my head relates to administration. However, I am sure we have the figures here and will be able to clarify them. From recollection, the figure for administration is 12,000. When one looks at its composition, two thirds are working in positions which directly support patient services. Having deliberately removed administrative duties from those with professional training and skills in order to allow them to spend time on their professional duties, it would make no sense to remove those working with patient records or looking after out-patient appointments or the nursing administrative requirements and tell hard-pressed professionals they must spend their time performing administrative tasks. The statistic is thrown around rather loosely in some of the public commentaries and justifies clarification. I recall it is dealt with in some detail in the health strategy document. I can give the Deputy the figures if he wishes.

Deputy Bell

I do not mean to be too critical. I wish to give you the opportunity to tell the public the reasons they have to wait on trolleys for beds, wards have been closed all over the place and there is no money. Could you tell us what changes the Department has initiated with regard to the training programme for nurses? I welcome your comment that there is no shortage of applicants. Is it possible that we have a similar position to the one we discovered during an examination of another Department, namely, that it takes too long to process applications? My daughter applied for a public service job in the Department of Health and Children. Three months later she had not received a reply, yet having attended an interview on a Saturday morning with Aer Lingus, she started the following Monday. I suggest that appointment procedures within the health service be investigated. We are spending hundreds of thousands of pounds every month on advertisements. The biggest earner for Independent Newspapers is the amount spent on health board advertisements.

Mr. Kelly

This is something we are looking at. We are trying to modernise the ways in which we recruit by increasing the amount of electronic advertising which is more efficient. Most of the health employers now have website access in addition to newspaper advertisements. That does not suit everybody and so we must use normal access routes as well.

We asked the health boards to look critically at the way recruitment was carried out and a number of improvements flowed from that in terms of how they advertise. Electronic developments, in particular, have emerged from that. I appreciate it being brought to my attention again but it is not something we are unaware of as an issue.

Returning to the training and education improvements in nursing, fees for back to nursing courses have been abolished. An advertising campaign aimed at attracting nurses back into the workforce and back to the country, which ran from 30 November to 31 December 2000, generated a significant number of inquiries. During 1999-2000, 16 new post-registration programmes were developed. In 2000, there were 660 places on post-registration courses in specialised areas of clinical practice. In response to an identified need, 11 of the 16 new programmes are located outside the Dublin area.

Nurses are being encouraged into specialised areas of clinical practice and will be given full pay while doing so. Course fees will be paid in return for a commitment to continue working within the public health service in this specialist area for one year following completion of the course.

Swift progress has been made on the implementation of the agenda for change mapped out by the Commission on Nursing. The agreed priority action plan is being put in place. A total of £12 million in additional revenue has been made available for the continued implementation of key recommendations of the commission, many of which relate to the area of training.

From the current academic year, nurses working in the public health service who undertake public health nursing and certain other undergraduate degree courses on a part-time basis will have their fees paid in full by their employing authorities. Fees will be paid in return for a commitment on the part of the nurses to continue to work in the public health service for a period of up to two years after the completion of the degree course. This fees initiative will continue until at least 2005 at an estimated annual cost of £3 million. From the current academic year all students studying for the higher diploma in public health nursing in UCC and UCD will be paid a salary while studying and will have their fees refunded. This, again, is in return for a commitment on the part of students to work as public health nurses for at least two years with the sponsoring health board after training. From the current academic year, all nurses studying for the post-registration higher diploma in sick children's nursing will have their fees paid by their employers.

Chairman

Mr. Kelly, we welcome all of that as a step in the right direction but will you answer Deputy Bell's question as to how many wards and beds are out of circulation at present?

Mr. Kelly

I am not sure I have a figure for that.

Chairman

Can you give an approximation because it is a very important question?

Mr. Kelly

The information I have is that the vast bulk of beds are in operation and that any closures are of a temporary nature and are to do with refurbishment or other purposes. There are not, to our knowledge, any significant closures at this stage due to staffing shortages.

Deputy Bell

Mr. Kelly's and my information is substantially different. I have to question the practice of some health boards which close wards and send patients home during the Christmas period. We should have the figures in regard to each public hospital as to how many beds are vacant and for what period. While they may not be closed for the entire year, they are closed for certain periods of time probably due to staff shortages. That is the information I have but perhaps my colleagues would disagree with it.

Chairman

Are there any operating theatres not functioning at present in Dublin?

Deputy Bell

Some of my Dublin colleagues may have different experiences. I do not have any more questions at this stage.

Mr. Kelly

I will come to that question in a moment. The statistics on hospital activity in the current year do not support the notion that there are lots of beds closed down. Hospital activity has increased this year. The number of patients going through hospitals has increased by 6%, which reflects an increase of 50,000 additional people being treated in the public hospital system in the current year.

I take the point made by Deputy Bell that there are seasonal closures to cope with annual leave both in the peak periods during summer and again around Christmas. That is not something I attribute to staffing shortages or nursing shortages. I do not have the facts with me today but I will make a written statement to the committee on the issue of bed closures and theatre closures attributable to nursing shortages, if they exist.

Chairman

We would like that. Deputy Bell's question is a very pertinent one.

Deputy Dennehy

Can Mr. Kelly say if we only measure the delivery of service by way of waiting lists? Regardless of changes of Administration over the years, I remain concerned about this. Can Mr. Kelly give a ballpark figure for procedures carried out over a period of ten years? The area of orthopaedics has changed radically; in the past one had to be over a certain age to qualify for a hip replacement. Are we doing more or less procedures now than we did in the past?

Mr. Kelly

Again, I do not have the specific statistics Deputy Dennehy requests, but I have statistics comparing 1980 with the year 2000 which might illustrate the trend. If one looks at either the volume of activity or, more particularly, the efficiency of the system over that period, it is very instructive. In 1980, there were 17,700 beds in the acute hospitals and in 2000 there were 11,980 beds.

Chairman

That is a very long timescale.

Deputy Dennehy

I want to nail this down; the number of beds will not satisfy me. I want to follow a train of thought.

Mr. Kelly

The corresponding figure for 1990 would have been around the 12,000 mark. If we just work on the 1980 figure I can give statistics. Beds per 1,000 population reflected by those statistics are 5:1 in 1980 and 3:1 in the year 2000. The number of in-patients in 1980 was 544,000 and in the year 2000, 549,000. There was a massive explosion in activity related to day cases. In 1980 there were 8,000 such cases and in the year 2000, 320,000, involving a massive increase in efficiency in the system. The average length of stay in 1980 was 9.7 days and in the year 2000, 6.6 days. Again, this indicates a very significant improvement in efficiency. In 1980 there were 1.46 million out-patients and in the year 2000, two million. I do not have a figure for 1980 for accident and emergency departments, but the figure for the year 2000 was 1.2 million attendances throughout the country.

The Deputy asked if waiting lists accurately reflect the state of the nation in respect of acute hospitals, to which the obvious answer is that they do not. The waiting list figure accounts for about 3% of overall hospital activity. It is, nonetheless, a significant statistic.

Waiting time concerns us very much, the reason we have identified the things that need to be done in the health strategy, of which one is increasing overall capacity. Second, we wish to improve the way in which existing capacity has been used because we believe there are opportunities for further efficiency gain through investment in equipment etc. Third, we need to address an imbalance between public and private patients in terms of the distribution of elective surgical facilities in public hospitals. Each of these three legs of the strategy has its own agenda.

Deputy Dennehy

I do not want to rewrite the strategy document, but we have no method for measuring value for money. As there obviously has been a huge increase in population, the figures could be questioned in that sense. Am I right in saying there are 22 or 23 specialties or disciplines?

Mr. Kelly

Yes.

Deputy Dennehy

I accept the extent of the procedural changes 20 years ago, but the changes in the past ten years have not been very radical. We should do an evaluation of the changes between 1990 and the year 2000, examining neurosurgery, orthopaedics etc. to give a ballpark figure. I am sure you receive annual figures for the various disciplines.

I am concerned that we are not measuring output or product. We can take on ten more consultants for some discipline and nobody says, "We produce ten times as much." I would like the committee to see value for money in respect of measurement which is separate from future policy. I want to see what we are doing because I am concerned about the matter. Will you enlighten us further? The figures should be available for annual and national returns. We need not break them down in terms of regions as that would complicate the matter. I would like to know the figures available pertaining to the various disciplines.

Ten or 12 years ago there were four or five orthopaedic surgeons in the Southern Health Board area. Now there are probably eight or nine, since the unit was established in County Kerry, but we still seem to have waiting lists of the same length, although that may not be fair to the consultants concerned who now treat knuckle joints and elbows and recap knees. I want to know the number of procedures performed. I was chairman of the board when we sent patients to Belfast by helicopter in which people thought they would all die. Thank God, they did not - they all survived. There was a change from there on. It was a watershed in terms of pricing. However, we need the figure for the number of procedures performed.

Administration was referred to by Deputy Bell. Are public health nurses, for instance, included in the administration grade?

Mr. Kelly

No, they are not.

Deputy Dennehy

How about community welfare officers, CWOs?

Mr. Kelly

CWOs are. I indicated I would get the precise figures which I now have in front of me.

Deputy Dennehy

I do not want the percentages alone. If CWOs are being described as administrative officers, we are in big trouble. The methodology is wrong. I do not care what anybody says. Like Deputy Bell, I am concerned that we do not have somebody in a warm office, but at the coalface. A CWO is now as much a coalface practitioner as anybody else in a hospital.

I would like to analyse what is described as an administrator. While I do not want to juggle the figures, the public should know how its money is spent. It will believe we are counting managers only. Obviously, that is not so. I would like to know the composition and how it is measured. The composition of what is described as the administrative group in critically important. We could be counting door porters and such staff as administrators. It was a lazy way of doing things 20 years ago, and we are still doing it. Will you give us a note on the breakdown of the figures?

Last year we were fairly supportive of the increase in the price of tobacco for the sole reason that it would be ring-fenced. We also spoke of cancer research and the extra money that should be spent in this respect. However, the grants to research bodies under subhead B.6 are lower than I expected. Was the extra money ring-fenced? Did Revenue hand it up? Did it go towards cancer research? If not, to where did it go?

Mr. Kelly

I will supply the committee with the data relating to the breakdown of the clerical administrative grades. We should be able to produce a table or statement on the analysis of activity by reference to procedure. The yield from the additional excise on tobacco amounted to £132 million which was applied to the overall health Vote.

Deputy Dennehy

I understood it was to be geared for cancer related research. Was I correct in that assumption?

Mr. Kelly

I did not know there was a specific commitment in respect of cancer research. The overall Estimate would have included a significant sum for the cancer and cardiovascular strategies, each of which is directly related to smoking related illnesses. There would have been a specific cancer research programme in respect of the overall national cancer strategy, involving North-South collaboration, working with the National Cancer Institute in the United States and also drawing in the Health Research Board. There would have been an increase in funds for research as part of the overall national cancer strategy.

Deputy Dennehy

The full £132 million was obtained. Was that the first time in the history of the State that Revenue gave up anything of that order?

Mr. Kelly

Yes. It was a very strong gesture in terms of the tax yield from a particular product, which leads to a lot of health problems and difficulties, being applied to various services which address those problems. The polluter pays principle was applied.

Deputy Dennehy

Bearing that in mind, is B6 the only subhead under which grants to research bodies are allocated in the order of £7.6 million? Should there have been a higher figure?

Mr. Kelly

That is a figure that has been increasing gradually, admittedly from a low base, over a number of years. The figure for the Health Research Board and the National Cancer Registry Board reflects an increase, although I do not have the percentage increase with me. That can be clarified. In the current year, the Department has published a strategy on health research which projects a significant increase in research in coming years. We recognise it is important, not just in terms of health problems and finding new ways of addressing them, but also as part of the environment that medical graduates in particular look for when they come to work in the Irish health system. The availability of a strong research base and environment is part of the agenda in attracting medical graduates. The research itself obviously has an intrinsic value both in relation to particular diseases and the health services that are provided.

Deputy Dennehy

I would like to get an explanation of where the £132 million went. Had it not been for the fear of smuggled cigarettes and the black market I think the same increase would have applied. There was an argument that we would have lost more in the long run although there would have been public support for it on the basis that the money was being very carefully directed.

How big a problem is the provision of medical services for non-nationals, particularly in maternity services?

Mr. Kelly

Clearly the increased numbers of people from different parts of the world, particularly those from eastern Europe and parts of Africa, have put additional stress on public services generally. We have tried to cope with that in a number of different ways. The first place to do that is at the point of reception. As part of reception arrangements we have incorporated a voluntary system of health screening for asylum seekers. That involves screening for a number of infectious diseases and checking immunisation status. Once people have come past reception stage, they are treated like any other person by the health system. Once they present themselves for treatment, they receive services in the same way as others. There are some special arrangements required such as translation services.

There is a very visible increase in the number of births occurring, particularly in the Dublin maternity hospitals. It is estimated that 3,000 births involving asylum seekers will take place in Dublin maternity hospitals this year. That has created its own pressures in those hospitals, some of which have recently received publicity.

Deputy Dennehy

It is critically important that health services are provided so that we do not end up with problems at a later stage. There was some argument about the local health boards being responsible. I presume all funding spent on the voluntary screening is refunded. Is it a demand-led scheme? Wexford and Cork are obvious points of entry and one could envisage three or four health boards having difficulty in funding the screening.

Mr. Kelly

We have tried to address this point in our negotiations with the Department of Finance in terms of the overall health allocation. We have also addressed it in the way in which we allocate funding to the health boards; it is now part of the overall allocation which we make to them. We hope that we have done this reasonably well. We have tried to take that into account where the pressures are greatest, namely, the east, south and south-east.

Deputy Dennehy

It is very important that this is done. If, for financial reasons, health boards stop being as enthusiastic about this as they should be, that could have a knock-on effect. Besides yesterday's decision in the Supreme Court, what has happened facilities for children at risk? Is the provision of these facilities on target?

Mr. Kelly

An analysis of needs in that area was undertaken some time ago. The cases which come to the attention of the court involving young people who are at the end of the line in terms of care and therapy represent one part of a continuum in the care of children at risk. There has been a very significant investment in the implementation of the Child Care Act, 1991. One part of that has been the investment in high support and special care facilities. The numbers of high support and special care places has increased from 17 in 1996 to 93 today. Included in this is a 24 place purpose built special care unit at Ballydowd which is being opened on a phased basis, and a seven place special care unit for girls at Cork. An additional 41 places are planned for 2002. There will be a high support facility at Portrane providing 24 places in the eastern region, the construction of which will be completed early next year. The Midland, North-Eastern, North-Western and Western Health Boards are co-operating to provide 12 high support places on a single campus in Castleblaney. The Mid-Western Health Board will provide five special care places for adolescent boys. Places in these facilities are due to become available in mid-2002. That level of provision resulted from an assessment exercise undertaken at the beginning of this development programme. As far as the Department and the health boards are concerned, we will have sufficient special care high support places available by the middle of next year. That is something we will have to look at again next year. Our experience with every type of service we provide is that further pressures arise.

Deputy Dennehy

Can a cost be put on that? I presume it is not like providing places for the elderly and is substantially more expensive.

Mr. Kelly

The capital investment is £30 million.

Chairman

I was curious about the location of the unit in the Mid-Western Health Board area.

Mr. Kelly

I do not have it to hand.

Chairman

Where is the location?

Mr. Kelly

Again, I do not have it. I will clarify that for you, Chairman. I am sorry I do not have it.

Deputy Dennehy

It is very expensive to run these places. We are not comparing it to 70 places for the elderly or anything like that.

Mr. Kelly

They are the most intensively staffed facilities that we provide for any type of client in the health and childcare system. The ratio of staffing is very high. I am trying to recollect what it is, but it involves intensive, one to one therapy from a range of different care providers as well as the resources needed to provide a secure environment.

Deputy Dennehy

From what Mr. Kelly says, I assume he is satisfied that no Minister will have to go to the slammer and that sufficient progress is being made. Is the single funding agency approach due this year? Will the health boards fund the voluntary organisations? Is that on track?

Mr. Kelly

In relation to the southern area, where that is being examined, we envisage the arrangements being put in place in 2002.

Deputy Dennehy

Is that going back from the original plan?

Mr. Kelly

No. We got the report from the group chaired by Professor Michael Murphy which looked at the arrangements that would be required to do this and we have been in intensive discussions with both the health board and the various hospitals, as the Deputy is aware, in order to put those arrangements in place. The actual formal funding arrangement will go into place in 2002.

Deputy Dennehy

There seems to be a fear among voluntary bodies that they might not get a fair share. There was a glitch where people over 70 years received medical cards but were patients of non-GMS practitioners. Has that been resolved? Can they now go to the doctor of their choice if they are not within the GMS?

Mr. Kelly

Yes, by virtue of the special arrangement that was introduced to enable them to do so.

Deputy Dennehy

Has it been addressed?

Mr. Kelly

Yes.

Deputy Dennehy

Is Mr. Kelly happy with the method of appointing consultants involving multiple agencies? Is it generally the case that people must wait until almost the day consultants are retiring before an application is made to Comhairle na nOspidéal and it spends a year before it decides to advertise the vacancy. There is often two or three years' delay. Are there plans to change the method of making such appointments? It seems to be archaic and designed for times past when there was a financial saving in not replacing a retired consultant.

Mr. Kelly

It is something we have been looking at. When one starts to examine it, as the Deputy said, there are probably four different parties to the appointment of a consultant. There is the employer - sometimes one can have a shared commitment where there is more than one employer - the Department of Health and Children, Comhairle na nOspidéal, in relation to the approval and structuring of the appointment, and sometimes the Local Appointments Commission if the appointment is to a health board. Potentially, there are four or five parties. We have tried, by getting the various parties together, to telescope the processes so we can shorten the total time it takes between when a decision is made to make an appointment and the appointment actually being made.

Even with some improvement in the position in the last 12 months in relation to those arrangements, I cannot say I am satisfied with the length of time it still takes. One of the areas we have identified in the health strategy as requiring attention is an examination of the manpower requirements in hospitals as part of the overall hospital planning process. This will lead to a review of the role of the health boards as against the role currently performed by Comhairle na nOspidéal. We are now talking about the insertion of a new agency into the system which will examine the planning arrangements for hospital services. Overall, I am not happy and more work needs to be done to improve performance in that area.

Deputy Dennehy

We must apply a professional approach to the waiting lists, which Deputy Bell raised earlier, especially in the area of single handed practice. It has been badly handled but I am glad that, at least, somebody is examining it.

Deputy McCormack

I will confine my comments to University College Hospital, Galway, with which I am most familiar. I am sure the situation there reflects the circumstances elsewhere in the appointment of consultants. This is a factual case about which I have tabled parliamentary questions on several occasions in the last two years. The appointment of a consultant neurologist, sanctioned by the Minister for Health and Children in January 2000, has not yet been made and probably will not be made until the middle of next year. This is two and a half years after it was sanctioned. The single consultant neurologist at the hospital was due to retire last January and because of the red tape that Mr. Kelly has acknowledged, this delay has ensued. The board had to look for an appointment from the Minister, then go to Comhairle na nOspidéal and then back to the hospital. The consultants and the board have to be consulted and then it goes back to the Minister again.

At the end of two years one gets to make the appointment by which stage the consultant applying for the post may have already received a better offer because, as Deputy Bell said - his daughter applied for a job on a Saturday and was working on the following Monday - how can one expect someone capable of filling a consultant's post to be around two years after the job was first sanctioned by the Minister? Even if he or she was around, he or she has to give notice to their current employer which will add a further three or four months to the process.

Why has something not been done to remove the red tape? I have been asking this question for two years because I have been following this case. It is scandalous. I can supply all the facts and figures because I am very familiar with the case.

Mr. Kelly

I am not sure I can add much to what I have said already. I have acknowledged that there are a number of stages in the appointment of a consultant. I have also said that we are looking at how the process can be improved with the various actors. Each of the actors is an independent statutory——

Deputy McCormack

"Actors" is the right word.

Mr. Kelly

——authority in its own right. I can influence a certain amount as Secretary General of the Department, but I cannot influence precisely the ways in which each of these bodies, which have their own statutory remit to perform, goes about its job. There is a need to improve performance on this and it is something we are examining and will continue to do so.

Deputy McCormack

Do not continue for too much longer because, if it has been looked at since I first raised a question, it is time we had some progress.

Deputy Bell

Nothing is being done.

Deputy McCormack

I raised it with the Minister two years ago and he was able to tell me the wonderful news that the appointment had been sanctioned. That was a January 2000 parliamentary question and we are still waiting for the appointment. Mr. Kelly used an apt word, "actors"; much acting is involved but without results. I cannot understand all the red tape involving Comhairle na nOspidéal, consultants coming back and so on. Are consultants holding up progress? Where do they come into the picture?

Mr. Kelly

No, I do not think it is fair——

Deputy McCormack

I am only asking, Mr. Kelly. I did not say——

Mr. Kelly

Chairman, do you want me to comment?

Chairman

The Deputy has a valid point if this is the length of time it is taking. This document is weighted on the basis of getting nurses and consultants on board. If I remember correctly, when Comhairle na nOispidéal was dropped, it was intended to replace it with a new body. Massive recruitment will be required to achieve the aims in this document, yet there are roadblocks within the system at present. How are the consultancy resources to be provided in order to realise these objectives?

Mr. Kelly

I take the point. There is a bottleneck in the system in relation to consultant appointments in particular. That is something we are trying to work on.

Chairman

Deputy McCormack has given one example. There is a bottleneck in the current system and the document is weighted on rapidly increasing the number of consultants and attracting them back into the country. If that bottleneck exists, and we are not assuming that there is a massive number of consultants at present, it could mirror the position Deputy McCormack outlined in other health board areas with regard to long delays in appointing consultants through the process which is being replaced. How are we going to track resources in the future if we have these problems now, when not as many are required?

Mr. Kelly

One of the issues we are facing at the moment in relation to the arrangements that are there is that we have seen an unprecedented growth in the number of consultants appointments being made. Looking at the statistics, over the past three years, there have been 324 additional consultant appointments. That is a net additional figure so it does not take account of retirements and so on. There is actually a rapid movement of consultants into the system. It is also the case that in many situations, before the permanent appointment is made, a person can be appointed on a temporary basis. It does not follow that if there is a delay in the permanent appointment, which I am not excusing at all, the service is not available or there is not a person in the post providing the service.

There is a need to improve significantly the performance of the system in relation to the speed at which we can move through the various stages of appointing a consultant. It is something we have already tried to improve. We have not done enough on it to date and it is an area in which we need to do more work.

Deputy McCormack

I do not accept that. I do not know where the 324 went but I am only seeking one and I cannot find one. That is all I know about it; these are the facts. I know that there is a person in that post. There is one in University College Hospital, Galway. He is due to retire but by the time this new appointment is made, we will not have filled any posts. We will simply have replaced a person who, in the interval since this post became empty, has become due to retire. Two years ago we needed two. If one person had not stayed on, there would be nobody now. He stayed on but we cannot get the other one appointed. I asked the question because I am not making any progress with the issue and I hope that something will be done about it.

Deputy Bell mentioned waiting lists. I had a letter recently from the CO of the health board which told me that the person who has been longest on the waiting list at University College Hospital, Galway, has been there for ten years. Another person, who was very distressed, came into my office a few months ago. She had a letter stating that a relative was being called for an appointment, but the relative had been dead for seven years. That is the position at University College Hospital, Galway. The records are not even up to date. It is no wonder waiting lists appear to be shrinking when people are on them for ten years and some of them are already dead.

Deputy Bell

They are dying.

Deputy McCormack

Let us get real about this. What is a solution for reducing the waiting lists when this is the current situation? I can back up my comments with relevant facts.

Mr. Kelly

I am afraid I cannot comment on individual cases.

Deputy McCormack

I am free to do that.

Mr. Kelly

However, I accept that we tend to talk in terms of statistics on this matter. Each statistic represents a real person who is waiting for a procedure and I accept that totally. It is not acceptable and it is something we are trying to work on. When we look at the progress we are making, to which I would like to make reference, the number of people on public hospital waiting lists as of 30 September 2001 was 26,345. That represented a decrease of 3,312 or 11% on the figure for September 2000. From September 2000 to September 2001 the number waiting, for example, for cardiac surgery, was down by 61%. The number waiting for ENT procedures was down by some 30%. The number waiting for gynaecological procedures was down by 28%. Considerable progress was made in the reduction of waiting times between September 2000 and September 2001. The number of adults waiting for cardiac surgery for more than 12 months decreased by 77% and the number of children waiting for cardiac surgery for more than six months decreased by 80%.

In terms of overall activity, because waiting list activity is just one part of what is happening in the hospital system, 870,000 in-patients were discharged in 2000. The provisional figures for the first eight months of this year indicate that the figure for 2001 will be 920,000. The number of people currently on waiting lists represents 3% of all in-patient discharges in 2000, a very important 3% in terms of our priorities. The new health strategy I referred to earlier will provide a framework for the reform of the acute hospital system and improved access for public patients and includes a plan covering the action required to address the issue of waiting lists. The strategy places a new focus on waiting time, which is perhaps a more relevant indicator for a person who is in need of treatment. By the end of 2004 the target is that all public patients will commence treatment within a maximum of three months of referral from an out-patient department.

Chairman

We have read the health strategy document and we know the targets. Deputy McCormack is talking about the reality.

Deputy Bell

Mr. Kelly cannot really believe that. We must be living on a different planet from him.

Deputy McCormack

I have no confidence in the health strategy, judging by the past record of the Department. To clarify the issue, the waiting list is now is 26,345 according to the figures given there. It is no good telling me how it has been reduced since September 2001. By how much has it been reduced in the last five years? The waiting lists have shot up in the last few years. The Department guidelines, for example, say that no adult should be on the waiting list for more than 12 months and that no child should be on it for more than six months. The last time I obtained a reply to a parliamentary question on this issue, between 68% and 85% of people on the list had spent more than 12 months waiting. Let us not fool ourselves about the numbers being reduced in the last year. They were reduced for some of the reasons I gave earlier, but if the waiting lists now were compared to the waiting lists of four or five years ago it would be possible to see whether there has been a reduction.

Chairman

When a health board submits waiting list information and there is a reduction in numbers, does it qualify the reduction? Does it offer information about how many people have died, or moved to other hospitals because of frustration, since the last period it submitted figures? Are these numbers factored into the equation so that the figures are honest? Can the figures be massaged to make them look better?

People have come to us after trying to get, for example, a urology appointment and been told they must wait for up to two years. Is there any figure, within the health board system, for people who are waiting to get on the waiting list?

Deputy McCormack

How many people have been taken off waiting lists in the validation of lists carried out by the health boards? That, also, has only taken place in the last two to three years. People are written to and asked if they still wish to remain on the waiting list. Perhaps 32, or 45 in the case of the Western Health Board, will be dead and some will have gone to private hospitals. It is very easy to reduce a waiting list in this manner. Let us get real about what is happening. I will drop that because I believe I have made my point.

Mr. Kelly gave figures, for which he compliments the Department of Health and Children, on the average stay of patients in hospital which is reduced by an average of two days from eight to six days. How many of those patients have been readmitted to hospital because of cross infection and other complaints and because in some cases they were sent home when there was nobody to look after them? It is easy to reduce the length of time patients stay in hospital when extreme pressure is put on their families to take them out of the hospital before they are ready to go home. How many have been readmitted to hospital within, for example, a month?

Mr. Kelly

There were a number of questions from the Chairman and the Deputy. With regard to whether the figures are massaged, I hope not.

Chairman

Are you sure? People who died are not factored in, nor are people who leave the waiting lists voluntarily. The health boards write to people to check if they are still available and some might say they have moved on or something similar. Is the information you are getting factually correct?

Mr. Kelly

The Department and particularly the health boards have put a lot of effort into validating the waiting lists. That involves distilling the waiting lists in terms of people who are genuinely in need of a particular procedure and are available for it, both in the sense that their doctors say it is a suitable time for them to have the procedure and they are physically fit enough to have the procedure carried out.

Chairman

Therefore, the health boards would report that since it last produced this quarterly information - I believe they produce this information quarterly - so many people have died, so many have moved on to another hospital and so many are not interested. The position is, therefore, such and such. Do they do that?

Mr. Kelly

No, I do not get the data from the health boards on that basis——

Chairman

How can you be sure then that the information is factual and correct?

Mr. Kelly

I rely on the health boards because we have emphasised to them, time and again, the need to validate the data.

Chairman

We will have the health boards before the committee later in January to discuss nursing home subventions. We will raise some of these questions with them.

Deputy McCormack

What about my last question?

Mr. Kelly

I wish to acknowledge a failure on our part in relation to people waiting to get on to the waiting lists. We do not currently have a count in relation to that, but that is not to say we are not conscious that significant numbers of people are waiting for an out-patient appointment or an out-patient procedure. It may sound as if I am repeating myself but we have set down plans to improve the operation of the out-patient service because we recognise that there are bottlenecks.

Chairman

From when will it be improved? It is very frustrating. A doctor or GP generally contacts a politician out of frustration when his patient has, for example, a urinary condition and he cannot get a urological appointment, because the patient has a medical card, for up to two years. Can you imagine his reaction? He contacts the politician, who contacts the health board and the health board justifies it by pointing out that it is the earliest time it can offer the appointment. The health boards should produce a true figure for the number of people waiting for appointments under the different specialities. It would be very interesting.

Mr. Kelly

You asked when it will happen. One of the initiatives taking place in 2002, the treatment purchase fund, should produce an immediate impact once we can get——

Chairman

When is it due to start?

Mr. Kelly

In 2002.

Chairman

That is 12 months. When in 2002?

Mr. Kelly

As early as we can get the arrangements in place.

Chairman

Do you think it might be before March or April?

Mr. Kelly

I hope so, yes. There is an allocation of funding.

Chairman

There is something else happening at that time too, although it is nothing to do with you. Please continue.

Mr. Kelly

Just to make it clear, the agenda to which I am working is the implementation of the Government's health strategy.

Chairman

We accept that. I am asking when it will be introduced. That is all.

Deputy McCormack

How many patients who are discharged from hospitals are readmitted within one or two months? Are such figures available?

Mr. Kelly

I do not think we have data on that. It might be available at hospital or health board level.

Deputy McCormack

Is it possible to get those figures? We will then know whether the reduction from eight days to six days is working.

Mr. Kelly

If you look at international experience with regard to length of stay, we are not markedly out of line if one studies it by reference to particular specialities and procedures. If it was the case that we were markedly out of line by reference to practice internationally, I would accept there was some validity to the point with regard to patients being discharged. I am talking about the aggregate figure. There might be situations where individual patients are discharged before they are ready, but I hope not. I hope the system responds sensitively where that does happen.

Deputy McCormack

The last question was about the waiting list for orthodontic treatment, which is five years in the Western Health Board area. The Eastern Regional Health Authority proposed to the Department nearly two years ago that parents of children on the waiting list for orthodontic treatment who have the work carried out privately should get 50% of the money refunded and should receive a 100% refund if they are medical card holders. After considering the proposal for about a year, somebody decided it would be illegal. I do not know if it was the orthodontists who made that decision. Why is such a system not adopted when health boards are failing to deal with the waiting list? Why is there not a system where families of children on the waiting list who have the work carried out privately are reimbursed 50% of the cost in the case of non-medical card holders and 100% where the families hold a medical card?

Deputy Bell

They have to go to Northern Ireland to get it.

Deputy McCormack

Why can that system not be adopted?

Mr. Kelly

The straight answer is the existing legislative framework on eligibility. The Northern Area Health Board is the board that tried to introduce it and was determined to go ahead with the scheme. When we examined the proposal fully, we discovered that the eligibility legislative framework at present does not allow for it. That is not to say that we intend to leave it there. We will, as part of our work programme arising out of the strategy, look at the eligibility legislation in a deep way over the coming year. That is one of the issues we intend to look at in that context.

Deputy McCormack

There is a great deal of looking to be done.

Deputy Bell

This issue is important in my constituency. Credit unions are lending more money for orthodontic treatment than for holidays. People have to borrow and go to Newry, Belfast, Derry or elsewhere in Northern Ireland for treatment because the price there is about 50% less than the price in the Republic. It appears to be a case of restrictive practice which must be dealt with by the Department.

Mr. Kelly

It is not. This was one idea which was attempted during 2001 that did not work. On the other hand, there are many other ideas and initiatives that are ongoing and are working. I know there are huge waiting lists for orthodontic treatment——

Deputy McCormack

The waiting time for treatment for those on the waiting list has increased to five years. The system is not working.

Deputy Bell

It is non-existent in the health boards.

Chairman

Is Mr. Kelly as frustrated with the delay in the provision of orthodontic treatment as we are?

Mr. Kelly

Yes.

Chairman

It is a matter of major frustration for parents. The Department of Health and Children is based in Hawkins House in Dublin, but in recent times politicians have been kicked all over the place on health issues, whether in respect of orthodontic treatment, people trying to get appointments or people on the hospital waiting list. What Mr. Kelly is reflecting today is the frustration of many politicians with this issue.

Mr. Kelly

We are not sitting on our hands and not dealing with this issue. We invested an additional £5.3 million in the system under an orthodontic initiative in 2001. The idea behind that is to enable boards to recruit additional staff, to use private specialist orthodontic practitioners and to develop facilities. We have done preparatory work on the structural changes required. This is a deep problem; it is not amenable to a simple overnight solution. Changes need to be made. We are introducing a new grade of specialist dentist in orthodontics and there are new specialist training programmes, which have commenced. The idea is to improve the supply of skilled people in the health boards to provide the assessments and treatments required. I accept there is a significant unmet need in this area and that the progress we are making needs to be accelerated rapidly to make a real impact on tackling the problem.

Chairman

The investment of £5 million will not make a great impact, given that the scale of the problem is massive in every health board area.

Deputy Rabbitte

I presume Mr. Kelly can recognise that there is a huge gulf between his side of the table and this side of the table in terms of his conviction that progress is being made, which I am sure must be the case given the additional amount of money being put into the service. However, compared to the experience of colleagues on this side of the table, it is immensely frustrating and difficult to deduce from what he said or from reading the health strategy, which carries financial commitments, that matters will be addressed. Some of the issues my colleagues raised have existed for many years. What happens in a situation where there is a health strategy but the public finances are in a pretty alarming state of decline? The reversal is enormous in terms of the propitious circumstances we were in more than a year ago and the situation now. What happens if a new Minister for Health and Children or the same Minister for Health and Children cannot continue to support this rate of investment? Where do we stand then?

We could focus on any number of matters, but it seems that the consultants point is an important one. The extraordinarily cumbersome appointment procedure knits into many of the other problems in the service that have been advanced here. I know of consultants who are available to do procedures that are badly needed and require the patient to have an intensive care bed, but they cannot be done because there is no intensive care bed available, perhaps because there is no intensive care nurse or whatever.

To take up the points made by Deputy McCormack and Deputy Bell, Mr. Kelly said that we must have regard to the statutory remit of the various bodies involved. I understand that, but if we can appoint a Taoiseach within two or three weeks of a general election, why can we not address this problem of consultants? We set up the National Roads Authority because we could not build a stretch of road from one county to another without Uncle Tom Cobbleigh objecting to it. The National Roads Authority is not perfect but it is in place. Why can we not set up a consultants appointment authority centrally? If there is a need for a consultant in Galway regional hospital or a consultant in a different discipline in the Adelaide/Tallaght hospital, given the small number of people involved in total, why can the appointment not be made centrally? It seems so important in terms of delivering the service, given the pyramidal structure of consultants that is currently in place, that when a vacancy becomes available that at least it is filled.

I am not reassured as a result of what Mr. Kelly said. He has presented the best possible case given the hand of cards he has to deal. I am not sure there is a commitment to tackle the problem. Regarding the specific case of consultants, the position has been like this for years. Appointments are made through the cumbersome Comhairle na nOspidéal procedure and there are all the different other interests to which Mr. Kelly referred. There is no sign that the procedure will be dramatically improved.

Deputy Bell said that we are not being confrontational; we are just at our wits end. It is difficult to deal with some of the people we meet. We meet people, not statistics. It is difficult to explain to them, when they waited 20 years for a hospital in Tallaght, why they cannot get a bed in it now that the hospital is there. These are people we meet in our clinics. I am prepared to accept the improvements Mr. Kelly enumerated. Given the rate of investment in the service, one would expect that. I take it that people are applying themselves seriously to addressing this problem, but there is huge frustration on this side of the table about the issue.

Mr. Kelly

At the heart of the Deputy's statement is a question about the consultant appointments. I have already tried to reply twice to the questions around that.

Deputy Rabbitte

I do not mean to cut across Mr. Kelly but he has told us of the difficulties. I accept they are not made by him and that there are statutory requirements, but can we not cut through them? The law can be reformed. If the law needs to be refurbished or changed, that can be done. Is he saying that consultants would not permit it, that hospital managers want to have their say or that the health boards would be horrified if some central body was making the appointments? I am sure the problem is complex. All we are concerned about is that it does not seem as if it is being tackled. I am not one of the consultant bashers. I know some excellent people in the area who are primarily concerned about delivering a professional service and so on. Are there interests that impede progress?

Mr. Kelly

Genuinely, I do not think anybody has as his or her objective, either directly or indirectly, the slowing down of consultant appointments. The current arrangements are certainly not perfect, to put it mildly. We have already had one look at the set of arrangements. Various legislative changes are coming up. One is the review of the Medical Practitioners Act, which is at a fairly advanced stage. It will have implications for a number of the bodies concerned with the regulation of the medical profession in Ireland. I do not want to get into the detail of that legislation at this stage, as it has not yet been published or presented to the Government. We are committed in the strategy to examining all the organisations at work in the health system. We need to examine how the functions of various bodies are aligned with the ambitious agenda we are setting for ourselves. We acknowledge that there are imperfections that need to be addressed.

As regards the rational planning of hospital services, we need to power up considerably what we are doing in that area through the establishment of a new national hospitals agency. Within that agency we should not just plan for bed numbers, but also for appointments at consultant level, non-consultant level and other areas such as nursing. By moving forward in an integrated way we could think through the implications and address the bottlenecks in the system.

Some of the current arrangements date back to 1970, and others even earlier - for example, the Local Appointments Commission. We have not given sufficient attention to modernising the processes around consultant appointments in particular. We are now setting out to do that as part of the overall work agenda.

I may have picked it up wrong, but I think the Deputy suggested that in some way the procedure for appointing consultants might be a factor in people having to await treatment. I am not sure that is a significant factor because it is the practice to fill approved vacant posts at consultant level on a temporary basis so the service can get moving. In the case of replacement appointments, it is the practice to have somebody in place, or to keep somebody on, so that the service is not interrupted. Having said that, I am not satisfied with the pace at which appointments are currently being made. We have more work to do in that regard.

Deputy Rabbitte

As it is late in the evening, Chairman, I will finish because we have been over this territory a lot on different committees recently. Is there clarity and uniformity about the circumstances in which a health board can require people to sell their homes to help fund their stay in a nursing home?

Mr. Kelly

Could the Deputy elaborate a little on that?

Deputy Rabbitte

If, for instance, the family of a senior citizen in a nursing home looks for assistance, the health board may require the sale of that person's home to help fund his or her stay in the nursing home. Has Mr. Kelly never heard of that happening?

Mr. Kelly

Does the Deputy mean a health board requiring, as in obliging, somebody to do that?

Deputy Rabbitte

That is one of the areas that might be looked at. All I know is that it has happened, although I am not alleging it was done under duress or anything like that. I know of cases where the domestic dwelling has been disposed of to help fund residency in a nursing home. I am querying whether there are centralised, uniform departmental guidelines, or whether each health board does its own thing.

Mr. Kelly

I am not sure it answers the specific point raised by Deputy Rabbitte, but in the Second Schedule of the Nursing Home Regulations, 1993, there is a series of provisions in relation to how assets are dealt with in looking at the means of a person who is to be subvented for nursing home care. To be honest, I am not familiar with the detail of those provisions. However, health boards are working to those regulations as the best central guidance.

Deputy Bell

Old people have been forced to sell their homes to subvent not only nursing homes but also beds in public geriatric units. They are being told by the health boards to sell their homes.

Deputy Rabbitte

If Mr. Kelly is not familiar with the detail, it would be best if he could furnish us with a note before the meeting with the health boards. Is Mr. Kelly expressing surprise at this practice?

Mr. Kelly

No, it was in relation to how it came across to me - as an obligation being put by health boards on people seeking subvention to sell their homes. There are provisions in relation to how assets are dealt with by health boards in calculating the means of a person seeking a nursing home subvention.

Deputy Rabbitte

For the purposes of the note, the question I asked was whether there was clarity and uniformity of procedure. Deputy Bell used the word "forced", which I did not want to use. I know of cases, however, where essentially the people concerned consider themselves to have been obliged to dispose of their domestic dwellings to fund their stay in a nursing home. I am trying to establish whether there are clear guidelines, and if they vary from one part of the country to another and from one kind of service to another. I am looking for clarity of information, rather than expressing any opinion at this stage.

Mr. Kelly

Okay. I will be happy to supply a written note to the committee on that matter.

Chairman

Thank you. We have had a long discussion on this issue. It is sad that in many cases cancer treatment is often cancelled at short notice for various reasons, and that inflicts psychological damage. Does Mr. Kelly have any observation to make on that? Perhaps he would like to comment on what is happening with regard to the development of a cancer strategy. At one stage, it was proposed to have centres of excellence around the country. What is happening with that programme?.

Mr. Kelly

In relation to the first point, Chairman, I have personally come across cases where appointments have been cancelled at short notice. It is absolutely devastating for the person concerned, their relatives and their family. It is very difficult to excuse and in cases where I have had the opportunity to make an inquiry about it, what came across was that it only happened under extreme duress at hospital level. The people concerned, those making that decision at hospital level, were equally conscious of the impact it would have on the person and were sensitive to the trauma it would cause.

In the round, it goes back to the capacity problem in the acute hospitals, about which we started to talk at the beginning of this meeting, particularly during the winter months. I am not saying incidences of cancellation only occur in winter, but they seem to be concentrated during periods when the hospital system comes under pressure from the numbers of acute medical admissions, especially of older people, which arise particularly over the winter period. The answer is to ensure there is sufficient capacity in the acute hospital system to deal with the workload arising.

In relation to the cancer programme overall, we have been working steadily towards the vision set out in the national cancer strategy some years back of putting in place centres of excellence involving a mix of various specialities - medical, surgical and pathology - in the various centres. In fact, on a number of fronts, we can point to very significant progress, for example, the number of additional consultants in cancer specialities who have been appointed in the meantime. There have been 60 plus such appointments since 1996 when the cancer strategy was developed. These have been in areas such as medical oncology, haematology, histopathology and palliative care. There has been very significant funding investment of €79 million over that same period. There have been developments in services to cope with symptomatic breast disease, breast screening and cervical screening. We are awaiting the expert advice on radiotherapy services which we expect shortly.

In relation to the numbers of additional treatments taking place, I have recently seen data from the eastern region which can actually point to a reducing death rate from various types of cancer over the past five or six years. Again, that is evidence that the services which have been developed are producing an impact at this stage.

Chairman

People in the eastern region are close to the centres of excellence when it comes to cancer treatment. Would the same pattern emerge in the other health board areas - for example, the Western Health Board, the Southern Health Board and the Mid-Western Health Board? I accept what has been achieved is laudable. When do you think these centres of excellence will be in place on a national basis?

Mr. Kelly

We are making steady progress. In 2001, significant funding for the symptomatic breast disease services has been put in place. That has centred on developing the service in a number of identified centres, largely one in each health board area. We are steadily making progress on the development of centres. It is not just an eastern region phenomenon but one right around the country.

Chairman

Your success is probably greater in the Eastern Regional Health Authority area because one has access to what I would classify as top cancer treatment. The same pattern would not emerge around the country because, as you know, a lot of people have to travel long distances to receive cancer treatment. I have encountered situations where people have had appointments cancelled at short notice. You agreed with me on the psychological stress caused and the unfairness of the situation. We often produce strategy documents but do we have a time frame for implementation, that is, that it will conclude by December 2002? You must set objectives.

Mr. Kelly

It is in the nature of the way we work. The way we tend to work is that we set a strategy which sets out the right things to do. The pace at which we manage to do those things depends on the level of additional investment that flows each year for that service. On cancer services, we have been making steady progress in developing the high quality and very high standard service the cancer strategy envisaged. We need physical infrastructure and specialised equipment in some cases but the scarcer resource is perhaps the numbers of highly skilled specialised people to support these very high standards of services. We have been moving as fast as the system is capable of absorbing additional funding. We have more road to travel in seeing full completion of this.

Chairman

It is often stated in newspapers that we spent £2.5 billion on health in 1996 and £5 billion in 2001. The amount has doubled in five years. You have listened to members illustrate the frustrations people experience. You have been pinpointing your successes and have been talking about what is a fine document. It comes back to what Deputy Rabbitte said originally in regard to looking ahead and economic resources. We have had some very good years but we are worried about the future, whether what you set out to achieve can be achieved and whether there will be financial impediments to achieving it.

Mr. Kelly

I would not disagree with your assessment, Chairman. We had a responsibility in setting out a programme such as that to cost it and put a price tag on it so that any public discussion on it would, if you like, embrace the realities of what it would cost to put in place. I cannot see any way to provide the type of service we want without that sort of investment.

Chairman

We will not note the Vote today because we hope to have the health boards in on 22 January next. Some of the questions asked today are ones we will take up with the health boards. With the permission of members of the committee, we should circulate the transcript of this discussion to the various health boards so they know the type of topics likely to emerge in addition to nursing home subventions.

Deputy Bell

We might consider sending that letter from Deputy McGrath. The questions contained in it apply to most health board areas.

Chairman

I thank Mr. Kelly for being so frank in his responses to our questions. It is probably not easy, but we would like to put date on getting the information and suggest 15 January on the basis that at least we would have the various bits and pieces together for our meeting on 22 January when we intend to bring in all the health boards to discuss the nursing home subvention.

Mr. Kelly

We will do our best.