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

Vote 33: Health and Children (Resumed).

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

Witnesses should be made aware that they do not enjoy absolute privilege. The attention of members and witnesses attention is drawn to the fact that, as and from 2 August 1998, section 10 of the Committees of the Houses of the Oireachtas (Compellability, Privileges and Immunities of Witnesses) Act, 1997, grants certain rights to persons who are identified in the course of the committee's proceedings. 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 provisions within 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.

I invite Mr. Kelly to introduce his officials.

Mr. Kelly

I am accompanied by Ms Helen Minogue, assistant principal officer, finance unit; Mr. Dermot Magan, principal officer, finance unit; Mr. Jimmy Duggan, principal officer, services for older people; and Ms Roisin Heuston, higher executive officer, services for older people.

I invite Mr. Purcell to introduce the accounts, please.

Mr. Purcell

We are resuming on the Vote for Health and Children because, at the meeting on 18 December, the committee decided not to conclude on its consideration of the Vote in order to give members a further opportunity to inquire into matters which were of concern to them. At that meeting, the committee asked the Accounting Officer to furnish information in regard to certain issues which were of concern and he has done that. Those papers are before the committee. As I understand it, the purpose of calling the Accounting Officer back is that that information is now available.

We could spend a good deal of time on this issue because there is quite an amount of information available but I shall confine my remarks to some issues that jump out at me. On the previous occasion we met, great play was made of the fact that patients were kept in hospital for shorter periods. We have now got the figures which I requested for the number of patients readmitted to hospital after being discharged. We find that a staggering figure of 23,544 patients were readmitted in the week after discharge. Unfortunately, no figures are available for the month after discharge. That is a shocking indictment of somebody. Is it a judgment of the patient being rushed out of hospital and being sent home too quickly? Is it an indictment of the fact that there are no step-down facilities? Who takes responsibility? We are aware from our constituency work of people being discharged who, in some cases, are not fit to go home and many of whom have no families to take care of them. Many of these patients are not fit to go home and look after themselves. How does that compare with the rate of discharge in other years when people were kept a little longer in hospital?

Before Mr. Kelly responds, members of the committee have the information before them. Is it agreed to publish it so that it will come up on the other screens as well? Agreed.

Mr. Kelly

In relation to the Deputy's question, we should first try to get the figure in some sort of perspective. While there is a figure of over 23,500 discharges involved in this, it represents under 3% of total discharges. On the last day I referred to the decrease in length of stay in hospitals over a period of 20 years. I was at pains to point out to the committee that this trend was in keeping with the trend internationally in relation to the medical treatment of acute illnesses in hospitals. There is nothing extraordinary about the decrease in length of stay in the Irish context. It is totally consistent with the trend internationally.

We must also recollect that within the figure, as the note states, there are three categories of readmission. Some of these are planned readmissions. That is a case where a patient is not maintained in what is sometimes for them an alien environment of a hospital but allowed to go home for a period and to be readmitted, sometimes for a follow up procedure or a check on how matters have developed. There are also readmissions for unrelated conditions, which clearly could not be anticipated at the time of the patient's discharge, and then there are readmissions for the same condition. I cannot clarify the breakdown between the three categories in the data I have given the committee, but clearly those three categories are involved so I do not believe it is the case that there is a widespread practice of prematurely discharging people from acute hospitals.

My experience is different. Regardless of the percentage of the total number, the fact is that over 23,500 ill people had to be readmitted within a week. Those are the facts in the document so the case stands.

We have been supplied with the waiting list figures and it is interesting to note that in 1996, when this Minister came to power, there were 25,959 people on waiting lists. The figures available for 2001 show that the number has increased to 26,345 so, despite the waiting lists initiative, etc, this problem has not been tackled.

Another problem is that there is now a waiting list to get on to the waiting list. Is anybody addressing that problem? I can only speak from the Western Health Board point of view because I know the figures involved. We have six consultants in the orthopaedic section of Merlin Park Hospital to which people are referred for a hip operation or any other such operation. Those six consultants now almost exclusively deal with people on the waiting list rather than dealing with people who are waiting to get on to the waiting list. Only two or three cases a month are being seen by one or two of those consultants despite the fact that 2,000 people in the Western Health Board area are waiting to be seen at out-patient clinics in order to join the 26,000 people already on the waiting list.

Has the policy changed? Are consultants now being asked to see only patients on the waiting list so that the waiting lists will be reduced? Are the people waiting to get on to the waiting lists expected to continue to suffer? I know from contacting their doctors that some of the people involved are waiting more than two years to see a consultant to get on to the waiting list and many of them are in severe pain. Is there a policy now where consultants are being asked to deal with the people on the waiting lists and not those waiting to get on to the waiting lists?

Before you answer that question, Mr. Kelly, as you have been very kind in furnishing this information to us at our request at the previous meeting, I ask the committee's approval to publish the document in its entirety. Is that agreed? Agreed.

Mr. Kelly

I want to go back to the point the Deputy made about the waiting lists when he said the figure of 26,000 readmissions represents a serious problem in the system. The Department is not advocating a policy that would encourage hospitals to discharge people prematurely. I would make the point to the Deputy, and this is a problem about managing a system which is under strain in terms of capacity, that at the same time as those patients are readmitted, there is a figure on the waiting list data which indicates that 26,000 people are waiting for admission. It would not make sense for hospitals to retain people unnecessarily in hospital - they have to make judgments about this - at a time when we know there are queues of people waiting for admission to hospital. That situation has to be managed. Care has to be taken that each individual who presents and is treated in a hospital is treated fully and competently, but regard also has to be had for the people who are waiting to come in and that is difficult to manage.

In relation to the second question, there is no policy at Department of Health and Children level where people who are waiting for out-patients should not get attention. There is an acknowledged under-capacity in the system in relation to facilities in out-patient departments. That is something to which we are committed to trying to address but it will require expansion not just of out-patient departments, but of treatment facilities in the hospitals. My job as Secretary General of the Department is to provide information to Government in the first instance and then to implement decisions made by Government following on from that. The advice has been tendered in the strategy document put to Government late last year. The Government has adopted that strategy and according to how moneys are voted by the Oireachtas for implementation of that strategy, it will be my job to put the new facilities in place.

I am glad to hear there is no such policy, but what can we, as public representatives, say to the relatives of the 2,000 people in my area who are waiting for out-patient appointments when only two or three patients a month are being seen by one or two of the six available consultants? I have to write to those constituents to tell them they have no possibility of being called for treatment because I cannot even get information on when it might be possible for them to be called to the out-patient department to get on to a waiting list. From the point of view of someone who deals with the public, it appears that the system has broken down and that there is no health service for those who are waiting to have major operations or to get on to a waiting list so that their condition can be treated.

How can we address that problem? Should we appoint more consultants? Why is there such a bad system for appointing consultants to health boards? I know from the Minister's replies to parliamentary questions that he sanctioned the appointment of a consultant at University College Hospital, Galway, in January 2000. Two years later that consultant has not yet been appointed and he or she may not take up the position for another six months. Why does it take two and a half years for a consultant to be appointed from the time the Minister sanctions that appointment? Why must we go through all the red tape of getting approval from Comhairle na nOspidéal, the health board and then the Minister? Two or three months is needed for the approval of each body. Why can that red tape not be cut out? When the Minister approves the appointment of a consultant, the advertisement should be placed in the papers immediately rather than going through this chain of control in the appointment of consultants.

Comhairle na nOspidéal deals with the consultants aspect, but Deputy McCormack has made a valid point. In the context of the health document produced recently, the impact will be felt if more consultants are brought into the system. The Deputy pointed out the considerable delays occurring in consultants taking up jobs which is a problem in all health board areas. This document will not succeed unless the consultants are on board. Perhaps Mr. Kelly will elaborate on what the Department is doing to ensure the adoption of a speedier method than the current one.

Mr. Kelly

We had fairly extensive questioning around this issue at the hearing prior to Christmas at which I made a number of points in relation to our plans to improve the current process. In the meantime, we responded to the committee in relation to each of the areas in respect of which we were asked to provide additional material. I appreciate the effort made by people in the Department who worked under pressure to get that information to the committee. This was not one of the areas into which we made additional inquiries.

I acknowledge there is a general issue around medical manpower. This is related not only to the speed with which appointments are made but to the structure of the medical workforce and a considerably greater number of consultants appointments will have to be made. A task force is being set up to work through the implications of that change in the structure of the medical workforce. This is one of the issues that will be addressed in the course of its work.

Is Deputy McCormack happy with that response?

I am not happy with that response because we must deal with the reality on the ground. I am not exaggerating the position because I have followed this matter closely. It is now over two years since the Minister approved an appointment. While he was asked long before that to approve it, he did so in January 2000, but a consultant has not yet been appointed. I am dealing with the reality I encounter every day. I could go on about this all day but, in fairness to the other members, I had better stop now.

I wish to return to two points I raised with Mr. Kelly. I would be extremely concerned if we started to measure the standard of our health care system only on the basis of the number of people on the waiting list. We do not tend to attack Ministers or to say how good they are. Everyone does his or her best. On the last occasion I asked for figures on the number of patients involved and the number of procedures carried out. While we cannot measure the standard of our health care system only by the length of the waiting list, it is interesting to note that 462,000 procedures were carried out under 12 specialities in 1994 compared to 959,000 in 1999. The number of procedures carried out in that time has more than doubled. Some 497,000 extra procedures were carried out in 1999. The public must be made aware of that. We are here to find out if we are getting value for money. Members of the public are questioning the doubling of the finance being invested in health care, but those figures show there has been a doubling of the number of procedures carried out in that period. I presume that trend will continue.

We can measure the cut in the waiting list from year to year under five headings. From 2000 to 2001, the number awaiting cardiac surgery has fallen by 61%, the number awaiting ENT treatment has fallen by 30%, the number awaiting gynaecology services has fallen by 28%, the number awaiting ophthalmology services has fallen by 8% and the number awaiting orthopaedic services has fallen by 7%. Those figures show a major decrease in the numbers on the waiting list and that is only year on year. I accept that the people who are most concerned about the position are the 26,000 awaiting treatment. While there is a sense of despair concerning the number on the waiting list, it is important to point out the percentage decrease that has occurred and that the number of procedures carried out has more than doubled in that period and is nearing one million.

Like the Chairman, I would like to thank Mr. Kelly for the information he has provided. I was concerned that the increase in funding provided for health research was not reflected in the accounts, but I note that from 1999 to 2002 the Health Research Board, HRB, was given an increase in funding of 150%. On the last occasion, I asked for an assurance that the revenue collected from the increase in the price of tobacco products would be ringfenced. Is that revenue included in that increased funding? We sold the budgetary increases on tobacco products to the public on the basis that the revenue collected would be primarily allocated to cancer research and also to general medical research. There is an increase of 164% in funding for the HRB specifically and an increase of 150% for general medical research. I welcome those increases as we must implement preventative health care measures as much as possible. Does that additional funding include revenue collected from the budgetary increases in tobacco products that was ringfenced? It was a unique decision by Revenue to allow anyone to take revenue out of, or prevent revenue going into, the coffers.

In regard to the North-South cancer research programme, how successful is North-South interaction in research and in the general running of the health service?

Mr. Kelly

It is true that the funding made available for health related research has been increased over the past number of years but it needs to be further increased because investment in research yields new knowledge and information. Equally, this funding is a significant draw factor for medical graduates coming into the Irish health system. We are anxious to encourage the retention of Irish graduates in the system.

In relation to the ringfencing of funding, the funding that was made available through that particular tax imposition on tobacco products was in the order of £130 million. The commitment made at the time was that such funding would be applied within the health Vote to cancer related services. The funding made available for the implementation of the cancer strategy and the cardiovascular strategy impacts on many of the same factors and individuals. That would all come within that category, within which there was an amount available for research which is being protected within the research funding.

On North-South interaction in relation to cancer treatment and policy issues generally, I can confirm there is a constructive engagement at this stage between the respective Departments and Ministers and at health board level North and South. There is an active programme of work in terms of topics identified in the British-Irish Agreement on which there is ongoing work in areas such as the establishment of the Food Safety Promotion Board, accident and emergency services and emergency planning with cancer research having been identified as one of the particular areas of interest. The cancer research programme has been going particularly well. It involves a consortium between the research institutes North and South and the National Cancer Institute in the United States. Some good work has been done in that context in terms of the production of good data, analysis and research produced at this stage and the creation of opportunities for people to take up research fellowships in prestigious institutes in the United States.

Like Deputy O'Keeffe, I am a member of the Southern Health Board. A few years ago we changed the title of the regional hospital to Cork University Hospital. That was to reflect the training aspect and the attachment to the university. If individuals in, for example, the cancer treatment areas wish to get involved as individuals or as a team, is there any impediment to that? Is it done through the health board or do they go to the Department of Health and Children? What is the mechanism for interchange of individuals or of research?

Mr. Kelly

Depending on the nature of the project, it could be either the health research board, which funds research grants and fellowships, or in some cases the relevant health board, where a certain amount of funding is allocated by the boards to health services research in particular; they would be unlikely to fund basic biomedical research. A significant volume of funding within the boards is being allocated to research activity.

I realise the committee does not deal with policy issues but there should be an increase in the research area. It should be made as simple as possible for interaction and exchanges to take place so people do not have to go through myriad organisations, such as the health board and the research board. They should be able to take a direct route to get information about exchanges and interaction.

You spoke about the amount of money that has been put into research. I wish to refer to the shortages of personnel within the health service and to ask in particular about the new school of pharmacy in University College, Cork, which has been approved by the Department. Even though the submission has been approved and funding has been put in place, there is still a major difficulty in the implementation plan and getting it recognised so the pharmacy degree can be undertaken from October 2002. What is the current situation in that regard?

We are now asking the various educational institutions to send tenders to the Department in relation to training therapists. Obviously, the difficulty with putting these programmes in place is that there is a four year delay because we must wait four years for the therapists to come on stream. Has the Department looked specifically at Irish people who are training in universities abroad in the various therapies and targeted them by making grant aid available to them for their studies so that, in return, they give a guarantee to work within the Irish health service for a specific period? That appears to be an avenue that might, in the short-term, give us an opportunity to recruit additional people.

Mr. Kelly

With regard to the school of pharmacy question, I am not as au fait as Deputy O’Keeffe in relation to the impediment that seems to have arisen. To my mind the development of the school of pharmacy is roaring ahead with a determination both on the part of the university and of the Department to get on with it. However, I would be happy to look at it and to come back to the Deputy or the committee on it.

In relation to the recruitment of therapists generally, while the Deputy has made a useful suggestion as to what might be done to address critical shortages in the short-term, the work that has been undertaken on projecting numbers and seeking to source the right supply of training places in the third level sector is based on an analysis of this area carried out for us by Peter Bacon and Associates. That has projected demand over the period ahead and the required number of training places. Attention in the Department has been focused on trying to progress the implementation of that programme with the third level sector. Obviously, the employers, that is, the health boards and the voluntary agencies who also employ many of these therapists, have been busy undertaking special recruitment initiatives abroad, at home and in any place where there are suitably trained people. A number of people have been recruited from abroad and employed in the services here.

With regard to the Deputy's specific suggestion, the arrangements whereby people who are training in other systems could be encouraged to take up employment in the Irish system when they finish training certainly should be fully explored and I would encourage that. However, there is a difficulty in making payment to somebody in that situation on the basis that they may get other offers when their training concludes and so forth. My point is that it would need careful design to ensure that it actually had the result that was planned. However, it is certainly something we can look at.

What about the general health of the population in view of the figures you have given the committee since 1994 in terms of the number of procedures that have been carried out? For example, regarding diagnostics-therapeutic procedures, in 1994, there were 117,000 while in 1999 the figure was 408,000. For digestive system operations, the corresponding figures were 101,000 and 131,000. The figures for the nervous system have gone from 7,000 to 25,000. Is that an indication that the health of our people is deteriorating rather than improving despite the standards we have put in place and all the advertising regarding healthy living? Is there a concern in that regard?

Mr. Kelly

I would hesitate to make a generalised statement about the health of the population. Let us first see what the data are saying. The data are saying that the number of interventions that are made in the acute hospitals is increasing rapidly. However, that is due to a number of things. The demand that is presenting is increasing for a number of reasons. We have an ageing population and we know that illness rates and the need to intervene medically increase with age.

The other significant element in this is the rapid escalation in the diffusion of new medical technologies, particularly in the diagnostic area where there has been a particularly big increase in the number of procedures. The scope of what medical people can do now with new technologies, both in the diagnostic and treatment areas, has expanded and expands year on year. In a hypothetical situation, if we had no increase in demand due to age change or other factors on the demographic side, we would in any event have an increasing demand based on the expanding boundaries of what medical science can do year on year. There are a number of things going on there.

To look at the question of whether we are relatively healthier or relatively less healthy, one needs to look at the overall health statistics in terms of the health profile of the population. It is when one looks at specific areas such as the major premature killing diseases, particularly cancers and heart disease, and looks at those as age specific rates that one gets a view of what is going on. I do not want to keep pointing to the health strategy document, but in the opening part of it there is a good overview of where we stand in terms of international comparisons in the area of premature mortalities. We can see improvements, for example, in some cancers and in strokes. However, we are behind the game by international comparison when it comes to heart disease and cancers generally. That relates to genetic make-up, disposition, culture, our attitudes towards lifestyle factors and the quality of the treatment services which we acknowledged a number of years ago need improvement in the areas of cancer and heart disease. There is consistent improvement in terms of new investment in services in both areas.

As regards asylum seekers, is the Department concerned about the general welfare and health of some asylum seekers? I was told that four people attended one maternity hospital two years ago, but that figure has now increased to 50. We are talking about a dramatic increase in the number of people presenting with syphilis and other diseases. Is the Department concerned about the controls which are in place to monitor health care and the number of people presenting for screening? How can that be encouraged within the different health boards? The percentages seem to vary between health boards. The figure can be as high as 70% in one health board and as low as 40% in another. That is a matter of serious concern.

Mr. Kelly

As regards asylum seekers, the regime in place at present involves a voluntary screening process which we try to put into effect at the time the person is received into the country. Part of the reception process is to encourage asylum seekers to take up screening, particularly for various infectious diseases. There is a general concern, which does not only extend to asylum seekers, about the uptake of immunisation programmes for childhood diseases, for example, and the increasing incidence of sexually transmitted diseases, which is another category the Deputy mentioned. There is an acknowledgement by ourselves and by health boards that more effort needs to be made in terms of surveillance, the collection of data by the National Disease Surveillance Centre and the transmission of that analysed data back to the boards. There is a reasonably good recording and surveillance system in place now, but we have more to do to bring more people into contact with the services offered by the boards in these areas. We can do that by promoting the services and making them more culturally acceptable to particular population sub-groups.

Would it be possible to get some figures?

Mr. Kelly

As regards asylum seekers, the latest data I have are for the period January to September 2001. The uptake for the communicable disease screening, which was offered on a voluntary basis at initial reception, was 68%.

Is that nationally?

Mr. Kelly

Yes. While I am not happy with68%, it represents an improvement over time on the uptake of voluntary screening. It reflects the additional effort being put in by health boards to ensure that people——

Are there major discrepancies between health boards?

Mr. Kelly

I am sorry, Deputy, but I do not have the figures for each health board with me.

I would like to see the figures.

Mr. Kelly

We will get them and come back to the Deputy.

Mr. Kelly said he would give me the immunisation figures.

Mr. Kelly

As regards the childhood immunisation programme, the current uptake levels average 86% nationally for diphtheria, DTaP and DT, 85% for HIB and polio and 75% for MMR. However, the target uptake is 95%, which means we are falling short. There is an ongoing effort to increase the take-up rates. As regards MMR, for example, there are other issues in the background which militate against a higher uptake. We must continue our efforts to promote these programmes and to make it as convenient as possible for people to take them up.

As regards MMR, is Mr. Kelly aware that certain medical personnel have indicated they will give a single vaccine? When they appeared before the Committee on Health and Children, the general medical view was that it could have consequences. The recommendation from the Department of Health and Children and other agencies was that the MMR vaccine should be used. What is the Department's view of the trend towards single vaccines? Does it have the Department's approval?

Mr. Kelly

The Deputy summarised the overall policy position. The Department's view, which is consistent with the advice from all the expert bodies both internationally and here, including the WHO, is that the multi-immunisation shot which infants get confers certain advantages, namely, if they get one shot, they develop their immunity earlier than if they have to go back repeatedly to the GP. Any of us who have had the pleasure of having an infant attend the GP for these shots knows the distress caused to the infant in those circumstances. One shot is regarded as better than up to five shots which is the potential number that could be avoided with the latest development. On the basis that there is no proven link between the MMR vaccine and the health problems mentioned, the Department does not see any reason to change that view.

At the same time the Department strongly recommends the MMR vaccine. However, it appears that a certain percentage of medical personnel are allowing the single vaccine. Does the Department discourage that practice? Does it and the health boards have a policy on it? If medical personnel employed by the health boards give the single vaccination, what is the Department's view of their operation?

Mr. Kelly

I do not propose to go beyond saying that the Department's distinct preference would be to continue with the MMR, the multi-shot as I have termed it. The issue being raised by Deputy O'Keeffe is one of relatively recent vintage in this country. It is something that we are currently examining in the Department with some of the other agencies involved.

Has the Department statistics on smoking-related illnesses? If it has such evidence, is it a fact that such illnesses could be overloading the entire health system? Does Mr. Kelly have any evidence that that is the case?

Mr. Kelly

I do not. There are quite a wide range of smoking-related illnesses. Classically, we think of lung cancer but smoking-related illnesses embrace cancers of many body systems, not just the lungs. Some forms of heart disease are strongly associated with tobacco smoking. Given that heart disease and cancers of all types form a significant proportion of the illnesses treated both at primary care level and within hospitals, it is certainly part of the policy agenda to do everything we can within our power to reduce the incidence of smoking. That is not just because of the load it imposes on the health service but more importantly because of the premature mortality it causes for individuals and their families. The poor quality of life that many of these conditions impose can be disabling for people, particularly in advanced years. There is a very good health reason and quality of life reason for reducing the incidence of smoking.

Smoking-related illnesses account for about 7,000 deaths each year in Ireland and approximately half a million deaths each year across the 15 countries of the EU. What are we doing about it? First, we try to ensure that the right standard of service is provided. Smokers are the same as non-smokers when they are sick, and if they have a health problem it has to be dealt with. Second, we try to provide the right regulatory framework for tobacco, and the improved regime envisaged in the new Tobacco Bill advances that agenda. There are strong reasons for looking at the pricing of tobacco, particularly through fiscal policy. The Department will make those arguments at the appropriate time. We can also educate our people through public information campaigns but more importantly through reaching the attitudes of children at a young age. Various programmes are in place and campaigns have been run to give effect to that.

Has the Department any evidence that smoking among teenagers can pose a greater potential health risk than in older people? Smoking among youth seems to be on the increase.

Mr. Kelly

On average, 31% of the population smokes tobacco. For GMS patients the prevalence is about 36%. The survey of lifestyle attitude and nutrition, published in 1999, showed that 49% of children reported they had smoked a cigarette by the age of 15 to 17. One third of boys and girls were current smokers then, with 40% of girls in social classes five to six being smokers. Some 80% of all smokers become addicted between the ages of 14 and 16. While there is not evidence to support the proposition that young people experience greater health problems from smoking while they are young, the problem is that if they are addicted at that stage and continue to smoke during their lives, they certainly experience much more serious health problems in their later years. That is the significance of trying to influence people's attitudes at a young age.

The information you gave on bed closures was for the first half of 2001. In the final paragraph you indicated that you would let the committee know some statistical information you requested from the health boards for each quarter of 2001, including the reasons for closure, percentages and the number of bed-days lost. It would be very relevant and up-to-date information. Can you indicate when you will be likely to have that information from the different health boards?

Mr. Kelly

As of now, I cannot say that I have a definite date for it. In the normal course of events, however, I would expect to have it shortly. I would not expect an inordinate delay in obtaining it.

The other point you clarified related to questions that were asked about the nursing home subvention regulations. As the regulations were introduced in 1993, you indicated that it would be timely to have a review of some of the financial aspects, particularly with regard to paragraph 22 whereby if the principal residence is valued at £75,000 a subvention could be refused. The sum of £75,000 in 1993 would not be compatible with current prices. Have health boards been using their discretion on this aspect in recognising that, according to the consumer price index for houses, in 2002 they are not reflecting a value of £75,000?

Mr. Kelly

The value is set down in the regulation as £75,000 so, whatever the discretionary powers of the health boards, that particular provision is a discretionary one. If I recall correctly, it says the health boards "may" refuse to pay the subvention.

There are eight health boards in the country and there was a lack of uniformity in the original intention of the regulations' implementation. We are discussing with the health boards today why six of them did not carry out the regulations properly, while two health boards did. We have discovered that there are different aspects to the refunding of nursing home subventions. The regulation says that a health board may refuse to pay a subvention if a house is valued at more than £75,000. Is the nursing homes unit within your Department happy that all health boards are singing off the same hymn sheet in exercising discretion?

Mr. Kelly

Based on the information we have in the Department as to what the exact practice in each health board is, I am not in a position to give you a firm answer. The regulation provides for a limit of £75,000. As you point out, there has been a big difference in the value of property since the time that limit was set. We are reviewing that with a view to changing it. The provision itself is discretionary, so boards may review.

There is a general point to be made on these regulations. The word "may" is used frequently in the drawing up of them. This is to allow boards a degree of latitude in relation to how they make a judgment about individuals and their circumstances. This provision is one such provision.

I take the point that as we have discovered - it is not a new discovery - some boards have implemented the regulations one way and some another, there may be an argument to be much more prescriptive on the way they are expressed. However, against that a balance needs to be struck between the need for some local discretion——

Mr. Kelly, you are missing my point. The report points out that in 1993 the boards may refuse a subvention to a person if the principal residence is valued at £75,000. That may have been a valid criteria in 1993 but it is not compatible with the present residential values. You are revising matters because you are taking cognisance of the increases in house prices since then. In view of this there will be new values and new instructions to health boards.

In his report on the various health boards the Ombudsman found that the original regulations were not implemented correctly. That has been addressed and payments are being made at present. I would hate to think that the health boards are not exercising discretion on this issue in favour of the person who applies for a subvention and that they do not recognise that a value of £75,000 is not compatible with the present values. You cannot give me an assurance that they are exercising their discretion in this area. Would it be correct to conclude that we do not know if people have been rejected for nursing home subvention on the basis that 1993 rather than present values are used as the basis for making a decision?

Mr. Kelly

I cannot give a definite "Yes" or "No" answer to that on the basis of the information I have before me.

I suggest your officials should check this out with the health boards. An argument could be made that this is very unfair. We must make it more user friendly. I agree that you cannot act as a watchdog on all the health boards to see if they are exercising their discretion in this area. From my observations they operate a strict regime when determining the level of subvention that is required. Although the maximum nursing home subvention is £150, in many cases nursing homes are carrying people because they cannot get an enhanced subvention. I checked on the situation in the Southern Health Board, where 343 people are hoping to get an enhanced subvention on the basis that money has run out. In view of what happened with the reports by the Ombudsman and the Comptroller and Auditor General on the whole area of nursing home subvention, I hope the health boards will use a degree of latitude and discretion. There should be greater emphasis on the consumer rather than on protecting the health boards.

Mr. Kelly, given anticipated demographic trends, has the Department figures for nursing home provision and capacity in the public and private sectors over recent years and, if so, are their projections based on anticipated need over the next ten years or so?

Mr. Kelly

Taking the current level of provision, both in the public and private systems, we have made an assessment based on the demographic projections of the numbers of additional places that would need to be provided over the period ahead, whether in the public or private system. My recollection is that we explicitly put the data on that into this report.

Are you conscious that the various boards have reported to the Department an absence of capacity at present?

Mr. Kelly

Absolutely. We are conscious that there is a gap at present. There is a gap in relation to services for older people. The answer is not just additional nursing places, whether it be private or public. We would argue that a large part of the answer to the problem is to considerably strengthen the services provided at community level, both in terms of people who visit people in their own homes and day hospitals, day care centres and so on. There is a significant requirement for additional nursing care.

With regard to the numbers we have published in the strategy, on the question of community services we have referred to the recruitment of a range of staff in a number of disciplines to support the development of primary care services, domicillary care and respite services. We have called for the provision of 7,000 day care, day centre places and increased funding for home aids and appliances. At hospital level we have referred to the need for an additional 1,370 assessment and rehabilitation beds, some of them located on the acute hospital campuses and some in related facilities. We have also called for the associated development of acute geriatric medical services and the appointment of additional geriatricians In addition, we have called for 600 additional day hospital beds with facilities encompassing specialist areas, such as falls, osteoporosis treatment, fracture prevention, Parkinson's disease, stroke prevention, heart failure and continence promotion clinics.

On residential care we have referred to the need for an additional 800 extended care community nursing unit places per annum, including provision for people with dementia There is also a need for some of the existing units to improve staffing levels and ratios to provide a better quality of care for people.

To what extent are you reliant on the tax driven private sector provision as compared to public provision?

Mr. Kelly

The incentives provided for in the Finance Acts for the development of private nursing homes and, more recently, privately run hospitals are put in specifically to encourage development by private developers. The existing provision of what the public capital programme is supporting on the public side in terms of additional places falls short of what we believe will be required in future years to meet demand.

What are the prospects for a resolution of the carers' dispute? I presume the Department is aware of the acute hardship it is placing on parents of clients of some of the institutions affected.

Mr. Kelly

Absolutely. As Deputy Rabbitte would expect, I must be very careful about any comments I make about this dispute given the sensitive stage it is at. The scope for a solution lies within the Labour Court and it seems it is a question of persuading the parties involved that this is the case. On the employers' side, there is no need to persuade because they are more than willing to have the issues in dispute adjudicated upon by the Labour Court. I hope that the union involved can be persuaded, before the court begins its hearing tomorrow, that this is the best way to resolve the issue.

It is unthinkable that some of the parents who have been in contact with me and other Members would be left in the circumstances that beckon if the dispute continues. I do not want to make the resolution of the dispute any more difficult, but there is a fear on the part of many of the parents affected that there is not a full appreciation of the hardship being imposed on them in terms of trying to secure a solution to the dispute.

Mr. Kelly

The Department and health employers appreciate the position of many of the voluntary providers of service that are in close contact with the parents who are caught in the dilemma of having to care for their sometimes adult, sometimes younger children in this situation. It is most unfair that these people find themselves in this position. The Department, playing its role as the leader on the employers' side in this dispute, has done its utmost to try to have the relevant issues resolved, but those efforts have not been successful. The Labour Court is the court of last resort in situations of this sort because it has a track record of resolving matters of an equally difficult nature in the past. We hope the court and the industrial relations machinery will resolve the issues in dispute so that the people whose care is entrusted to us can be restored to their caring environment as quickly as possible.

Both the boards and the voluntary agencies providing services are working hard to ensure that the disruption to people affected and their families is kept to an absolute minimum. The Department is monitoring the situation closely and is in daily contact with the agencies affected to ensure that is the case.

I do not want to discuss this matter further with Mr. Kelly, but it would be unconscionable, from the point of view of the people affected, to allow this dispute to continue.

The matter will go before the Labour Court tomorrow and it is hoped that a satisfactory resolution will be arrived at. However, the court could take some time to deliberate on this matter.

Mr. Kelly

As I understand it, the commitment extended by the chair of the court last Sunday night was that the hearing would begin tomorrow and, from recollection, that a verdict would be delivered within a period of ten days. I am working from recollection, but I understand that the matter is being fast-tracked by the court in terms of reaching a finding.

If it takes ten or 11 days to find a solution, one would expect that the union will have to call off its dispute or matters will worsen for the parents of the people affected.

Mr. Kelly

I take the Chairman's point. Every possible avenue is being used at present to appeal to the union involved to take the matter before the Labour Court.

This dispute is different from many others, particularly in view of the heartbreak and strain involved for elderly parents caring for an adult son or daughter. Like Mr. Kelly and Deputy Rabbitte, I hope this matter can be resolved quickly.

I spoke to a parent of one of the people affected - the person in question is extremely distressed - before coming to the meeting and I hope all steps will be taken to resolve this matter. The parents to whom I have spoken have stated that this problem was flagged some time ago. Why is urgent action only being taken now rather than when the issue was first highlighted several months ago?

Mr. Kelly

I do not want to get into a recital of all the steps taken to address this problem over the past 12 months, although I certainly could do so. Information about those steps will become a matter of record at the Labour Court hearing tomorrow.

I am conscious of the fact that we are approximately one hour behind schedule and that we must proceed to our discussion with the health boards. I thank Mr. Kelly and his delegation for coming before us. I wish to place on record that I received a telephone call from one of Mr. Kelly's officials, Róisín Heuston, to the effect that he had taken constructive action in respect of the point I raised on the last occasion about nursing home subventions, issues of probate, letters of administration and allowing the health boards to use their discretion. I appreciate and acknowledge the Department's quick response on this issue. I am conscious that my local health board - I am sure this goes for other health boards throughout the country - is already following on this matter.

I thank Mr. Kelly for the information he has supplied. The committee requested some further information, but he has appeased us in that regard. We note the Vote. I do not believe there is any necessity for Mr. Kelly to remain for the rest of the proceedings. I am sure a number of his officials will be present to take note of what transpires.

Mr. Kelly

Thank you, Chairman.

The witnesses withdrew.

Sitting suspended at 1.38 p.m. and resumed at 1.45 p.m.