COMMITTEE of PUBLIC ACCOUNTS debate -
Tuesday, 22 Jan 2002

Vol. 4 No. 3

Nursing Home Subventions - Special Report No. 3 (Resumed).

Mr. D. O'Shea (Regional Chief Executive, Eastern Regional Health Authority) and Mr. P. Robinson (Chief Executive Officer, North-Eastern Health Board) called and examined.

Chairman

The Eastern Health Board last appeared before the committee in respect of the examination of its financial statements on 9 March 2000. The North-Eastern Health Board last appeared on 12 March 1998. We have received correspondence from Mr. O'Shea, regional chief executive, Eastern Regional Health Authority, and Mr. Robinson, chief executive officer, North-Eastern Health Board.

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 who are identified in the course of the committee's proceedings. Notwithstanding this provision in the legislation, I remind members of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable. Members are also reminded of the provision in Standing Order 149 that the committee shall also refrain from inquiring into the merits of a policy or policies of the Government or a Minister of the Government or the merits or the objectives of such policy. Will you introduce your officials please, Mr. O'Shea?

Mr. O’Shea

As everyone is aware the Eastern Health Board was abolished at the end of February 2000. It has been replaced by a new arrangement of the eastern region with the three area boards replacing the old Eastern Health Board and a new authority, the Eastern Regional Health Authority, with responsibility for co-ordinating, making arrangements and overseeing the services, not only of the three area boards, but also of the 36 voluntary hospitals operating in the eastern region. Pat McLoughlin and myself are representing the ERHA. We are accompanied by the chief executives of the three area boards: Maureen Windle, chief executive officer of the Northern Area Board; Pat Donnelly, chief executive officer of the South-Western Area Health Board; and Michael Lyons, chief executive officer of the East Coast Area Board.

Pat McLoughlin, former chief executive officer of the Eastern Health Board, is director of planning and commissioning for the Eastern Regional Health Authority. He was chief executive of the board during the period for which the accounts are currently being examined. Also present is the ERHA's director of audit, Geraldine Smith and the co-ordinator of services for the elderly in the Northern Area Health Board, Eddie Matthews. We also have Liam Woods, the ERHA's director of finance.

Chairman

Paul Robinson is the chief executive officer of the North-Eastern Health Board. I invite him to introduce his officials.

Mr. Robinson

On my far left is Mr. Geoff Day, assistant chief executive officer in charge of regional services, Mr. Aidan Browne, assistant chief executive officer in charge of community services and Mr. Seoirse O'hAodha, our finance officer. On my right is Mr. Jim Reilly, senior administrative officer. I apologise to the Chairman as I had notified him of the attendance of Dr. Ambrose McLoughlin, our deputy chief executive officer, but he is unavoidably absent due to a visit by the Minister to the north-east today.

Chairman

We are sorry to drag you away from that visit.

Mr. Robinson

I will not comment on that.

Chairman

Are officials from the Department of Finance also present? No. Will the Comptroller and Auditor General introduce the financial statements?

Mr. Purcell

As was noted earlier the Eastern Health Board, as it then was, and the North-Eastern Health Board were spared criticism in the Ombudsman's report in regard to the pocket money issue. I am not quite sure whether they were spared in regard to the family circumstances part of that report, but that is not something that was within my remit when finalising my report and the follow-up report on pocket money issues, so I will leave it to the committee to deal with that.

As the chief executive officer of the ERHA has just stated, the Eastern Health Board finished up its business at the end of February 2000 and the accounts before the committee today relate to the 14 month period which ended in February 2000. I am glad to say there was a clear audit report on the final account of the Eastern Health Board.

There are three years of accounts for the North-Eastern Health Board before the committee. The 1998 and 1999 accounts have a clear audit report but the 1997 report draws attention to a problem I mentioned in Our Lady of Lourdes Hospital relating to the failure by consultants to sign claim forms to enable the hospital to claim recovery of the charges for private patients directly from the VHI. This is similar in character to that mentioned in the previous session regarding Waterford Regional Hospital. In this case, it led to a situation where some £450,000 was not being claimed from the VHI. There was an additional twist in the case of Our Lady of Lourdes Hospital in that patients themselves were remiss in not signing the claim forms, which was also holding up recovery under the direct payment system. I can confirm that both aspects have been addressed long ago by the board and do not constitute a significant problem at present.

Chairman

Mr. Robinson, would you read through your opening statement please? At the request of the committee, I am charged to publish that statement.

Mr. Robinson

I welcome the reports of the Comptroller and Auditor General on the annual financial statements of the North-Eastern Health Board for the years 1997, 1998 and 1999 and I thank him and his team for their advice and courtesy during the course of the audits. I also welcome the special report of the Comptroller and Auditor General on nursing home subventions and note his acknowledgement that this board correctly interpreted article 8.2 of the Nursing Homes (Subvention) Regulations, 1993.

I estimate by reference to comparable boards that in the correct application of this regulation from the beginning of the scheme, the North-Eastern Health Board was required to find in the region of £150,000 to £200,000 from its general allocation for elderly services to meet the additional costs of subventions. The comptroller's certificates on the board's annual financial statements for the years 1998 and 1999, do not include any reports under section 6(4) of the Comptroller and Auditor General (Amendment) Act, 1993.

The comptroller's certificate on the 1997 annual financial statement includes a report on the collection of patients' accounts in Our Lady of Lourdes Hospital, Drogheda. The issues raised in this report have been dealt with by the board and this has been acknowledged by the Comptroller and Auditor General's team. A new accounts receivable system was introduced in Our Lady of Lourdes Hospital in 1999 and this has facilitated the streamlining of the billing system. Hospital management works closely with the private health insurers to ensure that issues relating to patient accounts are dealt with as speedily as possible. Payment is now made directly by the insurers to the hospital and this results in a faster collection of the income due on the accounts.

Deputy Bell

I am particularly pleased that the North-Eastern Health Board came out on top in the report on nursing home subventions. I am pleased that the points made by myself and others were listened to when we pointed out in the Dáil over a number of years that the scheme was being illegally operated. I am sure it is not a coincidence that Mr. O'Shea, who has now left for another area, was also the chief executive of a health board during part, if not all, of this period, as well as Dr. Ambrose McLoughlin. I pay tribute to both men and to the health boards for interpreting the law correctly. I ask both chief executive officers to explain to the committee how they could interpret the scheme correctly when all of the other health boards were not doing so. It took the Ombudsman to point out that it was being operated incorrectly and illegally. Only then was legal advice sought by health boards. The advice received was that the health boards were wrong, as indicated by the Ombudsman and by public representatives in the Dáil and at committee level. It pleases me as a senior public representative and former member of the North-Eastern Health Board that you have the facts right.

Mr. Robinson

The legal position was examined at that stage. The board saw different interpretations could be applied to the legislation and to the circulars that were coming out. The decision was made at that stage to work on the basis of the legislation as the core issue.

Mr. O’Shea

There has always been a high level of dependence on nursing home beds in the east. There is a dearth of long-stay beds for the elderly within the region and, therefore, long before the introduction of the Nursing Home Act, there was a high dependence on nursing home beds as a means of delivering mainline services in the east. For that reason, there was a high level of sensitivity and much work was being done within the board area with the nursing homes. There was a greater awareness of the situation and the Eastern Health Board implemented the regulations according to the book. The Comptroller and Auditor General mentioned that we fully complied with the regulations under article 8.2, in the context of article 9.1, but the interpretation of the regulations was changed last year and, as a result, we are working on the issue of family circumstances.

We must go over 12,000 files. We have already gone through 2,500 of them and have identified in the three boards a total of 46 refunds. By the time we have completed the exercise, there probably will be another 150 cases pro rata to be repaid. We have increased the number of people involved in the process to seven and we plan to have the project completed before the summer. As article 8.2, the pocket money issue, was interpreted correctly, we are not involved in any repayments under that heading.

Deputy Bell

We have talked enough about this issue. We are pushing an open door in this case, as opposed to those cases we examined earlier. This brings us to item seven regarding the report into the North-Eastern Health Board patients' property accounts.

This is a cousin of the nursing home subvention and paragraphs one and two spell out how accounts are held and administered. Again, I ask the chief executive officers to note that there is a great deal of mystery attached to the question of patients' property accounts. In some geriatric homes, some patients are paying two or three pensions. Private pensions earned by his or her late spouse for a lifetime's work have to be given in as well as the State pension. There are two types of patients. One might pay around £100 per week and another might be paying three times that amount from three pensions. There are no policy guidelines for this. I could not find any criteria from the health board when I queried this or when I asked about the matter in the Dáil by way of parliamentary questions to successive Ministers for Health and Children. Could the representatives tell us where the guidelines are to be found and could they give a copy of the criteria for patients' accounts to the committee? Are there regulations set down by the Department of Health and Children or do they exist on a health board by health board basis?

Many of these patients pay into these funds for years. I met one person who had been paying in her pension for almost 30 years simply because she did not know what was happening. No one was coming to see her apart from the voluntary agencies. She did not know - she was very elderly - to what she was entitled or who controlled it. There should be accountability. If a relative goes into a hospital, the matron should be able to produce a record of the money being held by the health board on behalf of that patient. If a person goes into a bank and asks for a balance of account, it is given immediately. If a person tries to get the same information about what is held on his or her mother's behalf from a health board, it might take months. That must be standardised.

What efforts are being made by the health boards to apply a better system for children needing orthodontic treatment? Why is it possible to cross the Border and receive the treatment for less than it costs in Drogheda or Dundalk? Surely there is an interconnection between chief executive officers and senior executives in the dental service. Why does this cost so much in Border areas and in Dublin?

Mr. Robinson

In long-term accommodation operated by the board, patients are assessed on the basis of their total income in accordance with the institutional assistance regulations. The charge can range from nothing for patients with no means up to the full cost, subject to the patient being allowed to retain a certain amount of money for his or her own use. The economic cost is calculated in relation to the board's hospitals on an annual basis. We do not have a single patient in the north east who would receive payment for the full cost.

We keep a record of how much is in each patient's account in each of our long-stay institutions and it is audited annually by independent auditors. It is clear how much is in the total account and how much applies to each patient within that total. There is a process for patients to withdraw money from their accounts on a regular basis similar to a post office account. The independent accounts, as audited, are made available to the Comptroller and Auditor General. Indeed, even though it is not queried in the accounts, the debt was queried by the Comptroller and Auditor General, as was the appointment of the independent auditors during the audit in question, and we responded to those queries.

In relation to orthodontic treatment, the North-Eastern Health Board was in the fortunate position during 2001 of being able to open a second orthodontic unit in Dundalk. We had been operating the regional unit in Navan for a number of years. As a result of opening that and the fact that we will be taking on an extra specialist in orthodontics very shortly, the number of patients in treatment during 2001 was just over 1,400. We have targeted this to rise to 2,400 for the current year. The waiting period for patients to receive treatment is approximately 20 months. We hope that, by the end of 2002, we will have reduced this substantially.

As regards charges, I presume Deputy Bell is referring to patients and clients who seek private orthodontic treatment. We do not have any control over the prices charged by private practitioners. We are aware that there is a very big disparity between what private orthodontists charge in the Republic and what they charge in Northern Ireland. However, as already stated, that is the private market and we do not have control over it. We have developed the practice of using our own orthodontic service and we do not use a mixture of public and private orthodontists to provide treatment. I do not have an answer for Deputy Bell with regard to the difference between prices charged in the Republic and those in Northern Ireland.

Deputy Bell

I appreciate Mr. Robinson's reply. However, one often finds that people who have medical cards cannot afford to pay for treatment for their children in the Republic. Medical card holders in my constituency have obtained credit union loans in order to bring their children across the Border for orthodontic treatment.

In my opinion, the estimate of 20 months for the waiting period is conservative and it only applies to certain categories. Will Mr. Robinson indicate what he intends to do to reduce the length of time people must wait and by when this will be achieved?

Mr. Robinson

It must be made clear that those who qualify for treatment in the north east are not charged by us, so they do not pay the health board for orthodontic services. We are operating the national scheme of assessment which, I believe, was revised during 2000 or 2001 as regards the categories of children that would qualify for treatment. That is what is operated by our orthodontic service. The process is that the children are seen first by the primary dental care service and are then referred for assessment to the board's orthodontic service. They are seen by a consultant orthodontist or a specialist and if they qualify they are put on the waiting list for treatment. The 20 month waiting period to which I refer relates to the date from which they are placed on——

Deputy Bell

That is if they get on the list.

Mr. Robinson

Yes, if they get on the list.

Deputy Bell

The point I am making is that this does not take account of the thousands of children who are not on the waiting list and who cannot get on to it. I am not blaming the health board for this because it probably lacks the money to allow it to alter the position.

Mr. Robinson

It is not a question of money, as such, it is really the categories that qualify automatically for treatment that are included on the list. If people do not qualify because they do not meet the requirement regarding the level of severity laid down in the Department's guidelines, they will not be put on the list at that stage. Those are probably the people who would then tend to seek private treatment. If they do qualify having been assessed, they are put on the list and the 20 month waiting period comes into play.

To deal with the second part of Deputy Bell's question, we are taking on an extra specialist who is being trained in Belfast and who will complete that training in 2002. There will, therefore, be an additional post at just below consultant level.

I cannot give a precise indication at present with regard to the level to which we hope to reduce the 20 month waiting period. Part of the difficulty is that once a waiting list begins to be reduced, the number of referrals seems to increase. As a result of the extra staff we will have in place, we will be able to increase the number of clients in treatment this year compared to last year by just over 1,000. The figure will rise from just over 1,400 to just over 2,400.

Deputy Bell

The flagship hospital in the region is Our Lady of Lourdes in Drogheda, in the shadow of which I live. A substantial programme designed to cope with the services in the region, not merely those for the hospital, was put in place by a previous chief executive officer. Unfortunately, we are dealing with accounts that go back four years and we do not have the accounts for last year or the year before. As far as I am aware, the Eastern Regional Health Authority is the only board that has produced a return for 2000. We are, therefore, not able to measure the health boards' capital programmes or see what is contained in their accounts vis-à-vis funding from the Department of Health and Children for capital development programmes. Will Mr. Robinson outline the position with regard to the substantial capital programme that was announced by the North-Eastern Health Board?

Mr. Robinson

We have recently been able to announce a number of substantial developments at Our Lady of Lourdes Hospital. These are the first priorities which will include improving the coronary care and high-dependency units. We have appointed architects and the contract will be going out to tender during the course of the current year. The really major development at Our Lady of Lourdes Hospital will cost several million pounds. The board has submitted and updated the hospital programme that was prepared in 1998. This has been submitted to the Minister and I am pleased to state that he has given us approval to appoint architects to draw up a development control plan for Our Lady of Lourdes Hospital. The new development will be extremely complex and will have to be built in phases because, as Deputy Bell knows, it is a restricted site and we will have to build around the existing hospital. The key will be getting architects to design not just additional accommodation but also a plan on how this should be completed in phases over a period of years.

I do not have the precise figures with me regarding the overall cost, but we are projecting that it will run to something in the region of £75 million. However, until the development control plan is prepared by the architects, that is the best estimate we can provide based on standard costs on the project brief that has been submitted to the Department. Once the architects cost the project in detail, the final figure will be subject to variation.

Deputy Rabbitte

I wish to ask Mr. Robinson about the only note on the accounts with which we are dealing. This appears on page 2 of the 1997 accounts for the North-Eastern Health Board in respect of the problem highlighted regarding hospital charges and the fact that a residual problem exists. What is the current position in respect of this matter?

Mr. Robinson

The position at this stage is that the outstanding accounts have largely been completed and finalised. Total claims outstanding at December last amounted to £680,000, which reflects the increased workload on the hospital and the number of consultants in place. This represents a two month period at this stage. At that time there was a figure of £263,000 related to the period prior to 1997. The finance officer updated the Comptroller and Auditor General on the pre-1998 claims as a result of the audit. The balance has been significantly reduced with the result that there was only a figure of £6,000 at March 2000 in respect of that period.

The updated position regarding the 1998 claims at the end of December 2001 was that there were 7,666 still outstanding. An amount of about £5,700 had been written off which related to pre-1997 cases. In respect of current issues, the figure I gave earlier is £680,000, which represents two months of bills submitted. As we are now in a direct payment system, we expect the bulk of that money to come in within the next two to three months.

Deputy Rabbitte

Does that mean that the lapse will not be more than two months or so in the future?

Mr. Robinson

That is the way it has been going over the past number of years. We have put processes in place regarding the issues concerned. The two issues identified by the Comptroller and Auditor General were long delays by patients in submitting claims and delays on the part of a number of consultants which have now been overcome. We are using direct payments for all consultants.

Deputy Rabbitte

Unlike Deputy Bell, I have not had the privilege, if that is the correct word, of being a member of a health board, but I still cannot get my head around the question of nursing home subventions with which we have dealt all day. However, I wish to inquire about the disposal of properties. Do we have a note about this in the paper we received today? Is there uniformity throughout the country?

Mr. Duggan

The short answer is that I am afraid I do not know. I am appearing before the committee in the context of the nursing home subvention scheme rather than the wider issue. However, if it would be of any help, I will arrange to have a note supplied to the Deputy regarding this situation. I am afraid that is the best I can do.

Deputy Rabbitte

I would be obliged if we could obtain a note in this regard from the Department which addresses the question of uniformity of application across the country. I am disturbed by some cases which have come to my attention. Allowing for the fact that there are usually two sides to every story, I am still concerned about this issue. Does Mr. O'Shea wish to comment?

Mr. O’Shea

I take it the Deputy is referring to assets held by someone in the context of the nursing home subvention. Is that the issue? The regulations are in place and stipulate that the health board "may" rather than "shall." Therefore, from the outset there is an element of discretion in the matter. The regulations are now interpreted by the three area boards and I may ask one of the chief executives to give the details to the committee. However, the overall position is that pragmatically in the east, an asset held by someone would usually be a house. If someone has a house over the value set out in the regulations, the application is still processed. Initially the house is ignored while the family sorts out what will happen to it. In other words, a person is given six months of subvention without taking the house into account. At the outset the family is advised of the options under the regulations - the disposal or renting of the house, or doing nothing with it. It is advised of the consequences. At the end of six months the position is reviewed to see what has happened to the house in the meantime. At that stage the regulations are imposed. Nevertheless, because of the valuation of the house——

Deputy Rabbitte

Precisely what do the regulations being imposed mean?

Mr. O’Shea

Each case has to be taken on its merits. There is still an element of discretion, but if it is clear that there is a house of high value which is not being handled in any way to the advantage of the client, then the subvention will be withdrawn. However, it is obvious that each case has to be taken on its merits. The benefit of the doubt is given to the client, not necessarily the family, to ensure the client does not suffer any hardship. I might ask Ms Windle, chief executive officer, Northern Area Health Board, to give the committee more detail as she is dealing with this matter on the ground.

Deputy Rabbitte

I can see the reason there should be an element of discretion and so on. However, I am concerned that different applications can apply and that inequities arise. There are circumstances where an elderly person is in a domestic dwelling or whatever and the entire family has fled to different parts of the city or country. I have some difficulty understanding the reason a house has been sold in some cases to comply with the regulations while it has not been necessary to do so in others. I am sometimes mesmerised as to the reason it is necessary in one case and not necessary in another.

Ms Maureen Windle (Northern Area Health Board)

The regulations are set out in the nursing homes regulations, 1993. The regulations state that the health board may refuse to repay the subvention where the residence is valued at over £75,000. However, they also state that where the residence is occupied by a spouse, son, daughter or someone with a disability pension and a raft of such things, this must be taken into account, as must the person's income, which has to be over a certain level, in other words, those on low incomes, which would be greater than £5,000. All these criteria are taken into account.

When elderly people go into nursing homes the first priority is to try to get them back home as quickly as possible. In certain cases we cannot do so. In cases where the principal residence is not occupied by such people, the situation is explained to the person regarding ability the pay. The house can be rented in that period which generates an income or the value of the property can be used to derive an imputed income. In some cases people may have means by which they augment the cost of the nursing home. We have a flexible approach in that the valuation of the house is determined by the individual, not by the health board. We have an independent appeals system whereby an individual can appeal an assessment. These are two safeguards for the client.

It is often a decision of the family or the individual to dispose of the house. The main criterion is that the cost of the nursing home is £X, the health board pays a certain amount and the balance can be made up by renting or disposing of the house. If the family or relative chooses to do so, the interest is used to augment the total cost of the nursing home.

Deputy Rabbitte

I wish to ask Mr. O'Shea about the issue of capacity in the nursing home sector in terms of current and perceived future needs. Is there an alarming gap? Are we narrowing it? To what extent are recent tax driven measures contributing? To what extent is there a downside to the private sector in terms of keeping pace?

Mr. O’Shea

We have carried out an assessment of capacity in the east since we were set up which we have published and has given rise to discussion about the shortfall in the acute hospital sector. We have also carried out an assessment of our needs in services for the elderly in the context of long stay and intermediate stay beds. The difference between the east and the remainder of the country is that there is a whole raft of beds which are quite common in the rest of the country in the context of district hospitals or local community hospitals where there is short stay accommodation, usually for elderly patients, which obviates the need for them to go into large teaching hospitals. They can be treated at general practitioner nursing level and they do not have to go into large teaching hospitals. In Dublin, in particular, that whole layer of beds is missing. We have identified it as something which is urgently required so that patients, particularly elderly patients who suffer from respiratory illnesses and so on, who do not need to be admitted to a large acute teaching hospital, but who still need medical care at the level of general practitioner can get it, often for two or three weeks. The absence of that has led to huge pressures on the acute hospital sector.

There is a dearth of continuing stay geriatric accommodation in the ownership of the health boards themselves to a level which is much below that in the rest of the country. Traditionally this has been augmented by utilisation of nursing homes, not just in the context of nursing home subventions with which the committee has been dealing up to now, but also contract beds where the health board contracts nursing homes to provide beds for which the health board pays and which are used to augment the health board's stock of beds for people who require continuing care. The difficulty is that in the context of the health board stock it is usually not just residential accommodation which is involved, there is also a large element of therapeutic activity such as physiotherapy, occupational therapy, day activity, socialisation programmes and so on which help to get elderly patients back into the community. Generally these are not as common in the private nursing home sector. These beds are contracted for accommodation and not for all the other range of activities. In the east we need to augment district hospital type beds. We also need a significant number of community hospital beds to provide this combined residential and therapeutic care. All these aspects have been identified in our programmes and in the new health strategy. We are looking forward to the implementation of the new health strategy because the east will have the fastest growing elderly population in the country. At the moment we are starting from a base which is below the average for the number of elderly in the east. Over the next ten to 15 years the rate of growth of the elderly will out-pace any other rate of growth for the rest of the country. We will need significant additional accommodation and facilities for the elderly in the next ten to 15 years.

Deputy Rabbitte

There are no notes on the accounts of the Eastern Regional Health Authority by the Comptroller and Auditor General. Looking at the accounts, Mr. O'Shea, it is a bewildering range of services for someone who is not a health professional. It is a very onerous range of services that must be provided. One of the glib answers - or is it - in terms of the increased investment in the health services is that investment is not commensurate with an improved health service. The view of many members of the public is that there are too many people involved in administration and too few people at the coalface. Given that you are at the pinnacle of the administration side, is that merely a glib partial answer to why we are swallowing up more money and not reflecting it in tackling the queues that featured during the early stage of these discussions?

Mr. O’Shea

I will answer that question in two ways. First, it is not true that there is no measurable or tangible improvement in the health services in recent years. For example, if one adds together in-patient, out-patient and day hospital services, the number of patients treated in acute hospitals in the eastern region in 1999 was 1.8 million; in 2000, 1.9 million and last year it was two million. That is a 5% increase in throughput in the acute hospital sector over the last few years. This is at a time when we had already identified that we are significantly short of actual beds and consultants in the region. This has been acknowledged in both the strategy and the recent budgetary decisions. It is significant that that level of throughput has been achieved.

I would like to draw the committee's attention to the recent report of our director of public health, published approximately two weeks ago. This shows a significant drop in mortality for both breast cancer and cancer generally. While the level of activity of treatment has increased significantly, the actual level of mortality has decreased. This is due to the re-organisation of cancer services, the increase in activity in that area and the fact that we have a much better range of hospitals specialising in particular aspects. Perhaps we are not as good as we should be in articulating the benefits in the service and how much the service is improving. Nevertheless, we must admit there are still major deficiencies. There are waiting lists, even though they have improved, on which we are working very hard. There are difficulties in regard to A&E, on which we are working hard. This is related to bed capacity and consultant capacity.

The other aspect relates to how one counts administrators and managers. A report in the last three or four months indicated that the number of managers in the system was increasing much faster than the number of nurses. That is where much of this debate sprung from. There were two elements to this. First, administrators were counted as literally anyone who was not a nurse or doctor. It included people like community welfare officers, consultants' secretaries and support services for dentists. Literally anyone involved in work which was not hands-on clinical work was regarded as a manager, which is nonsense. On the other hand, the number of nurses was artificially decreased because during the period of comparison all the student nurses changed from being employees of the health boards and hospitals to being students through the CAO and university system. All of those nurses fell out of the count, therefore, the actual increase in nurses during the period was approximately 40% but it only showed something in the order of 15% because student nurses were not included. This gave rise to newspaper headlines.

Deputy Rabbitte

I heard a similar point being made last night about the waiting lists. It must be a nightmare being Minister and trying to track down what is going on. One cannot rely on one report published today because there are exceptional arguments such as have been advanced now in terms of the reliability of the statistics. Last night you explained that waiting lists do not necessarily mean what they say. Even when someone has the required procedure in one hospital, one may find that he or she is still listed in a different hospital for the same treatment. Should we not be able to get to the stage where we at least know what is happening?

Mr. O’Shea

We are back to what the ERHA has been doing since it was set up. The reason it was set up is to do exactly this job. There was no regional overview of what was happening in the eastern region. Prior to our being set up the Eastern Health Board and each of the 36 hospitals were dealing directly with the Department of Health and Children, as was the rest of the country. The Department of Health and Children is structured to deal with the whole State, not individual regions. There was no regional focus on events in the east. We have begun to put together significant information about what is happening in the east and the pressures that exist there. We can measure the shortfall and identify that 40% of all elective work done in hospitals in the eastern region is done for patients from outside that region, even though many of these patients are not coming in for tertiary or highly complex work. Of all patients coming through eastern regional hospitals for all purposes, including accident and emergency patients, 20% are coming from outside the region. Until now the hospitals were not gathering that information.

Equally, we found that patients could be on the waiting list for two or three hospitals and, if they were from outside the region, they could also be on a waiting list at their home hospital for the same procedure. We are working closely with the hospitals to put together more information about what is happening. This is essential so we can plan properly.

The committee is right; we do not have comprehensive, State-wide information about the detail of what is happening in our hospitals. This was identified in the National Health Strategy published in late November. This is an indication of the significant investments made in the IT and information gathering systems necessary for what we are doing. I agree with the committee that it is unacceptable we do not have this information. It is also unacceptable that we would allow this situation to continue for much longer.

Chairman

It has been a long day and a unique experience for the Committee of Public Accounts to have all the health boards and their chief executive officers appear before us. Our main objective was to discuss the nursing home subvention. We heard pleas of mea culpa from the six previous health boards and minime culpa from Mr. O’Shea, but the legal advice being received in that health board is wrong. We found it surprising there should be different interpretations in different health boards. The Ombudsman’s and the Comptroller and Auditor General’s reports into the nursing home subvention helped everyone to focus on the issue. Hopefully the health boards that still have a small level of subvention to be paid will have that matter resolved in the near future. Mr. O’Shea has given an assurance that he hopes to have the family circumstances part sorted out by September.

I thank the chief executive officers and their officials and the Department of Health and Children officials. There are lessons the Department could learn from this exercise. It strikes me that there are still differing interpretations of the main part of the nursing home guidelines. One board today said that it would not take 5% of a house into consideration. Another board stated that it would take it into consideration if it was over £75,000. There is a loose interpretation. I agree with flexibility but it would be easier to implement it if there was a corporate guideline. The Department of Health and Children has recognised that the £75,000 stipulation with regards to the value of a house in 1993 needs to be considerably amended to be compatible with today's values and we welcome that.

We note the financial statement of the Eastern Health Board for the 14 month period to the end of February 2000, and thank the North-Eastern Health Board for its annual statements from 1997 until 1999.

The agenda of the meeting on 29 January 2002 contains the 2000 Annual Report of the Comptroller and Auditor General Appropriation Accounts, Defence - Vote 36 and Army Pensions - Vote 37. We will adjourn until Tuesday, 29 January 2002 at 2 p.m.

The witnesses withdrew.

The committee adjourned at 5.05 p.m. until2 p.m. on Tuesday, 29 January 2002.