COMMITTEE OF PUBLIC ACCOUNTS debate - Thursday, 15 Jan 2004

Department of Health and Children — Value for Money Report on The Waiting List Initiative.

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

Chairman

I welcome everybody to the committee. Witnesses should be aware that they do not enjoy absolute privilege. 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 granted certain rights to persons who are identified in the course of the committee's proceedings. These rights include the right to give evidence, produce or send documents to the committee, appear before the committee either in person or through a representative, make a written and oral submission, request the committee to direct the attendance of witnesses and the production of documents and the right to cross-examine witnesses. For the most part, these rights can be exercised only with the consent of the committee. Persons invited before the committee are made aware of these rights and any person identified in the course of proceedings who is not present may have to be made aware of them and provided with the transcript of the relevant part of the committee's proceedings if the committee considers it appropriate in the interests of justice.

Notwithstanding this provision in legislation I should 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 House 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 that within Standing Order 156, the committee should also 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 policies. I invite Mr. Kelly, Secretary General of the Department of Health and Children, to introduce his officials.

Mr. Michael Kelly

The officials with me are Pat O'Byrne, who manages the national treatment purchase fund; Mr. Robbie Breen, assistant principal in the hospitals division in the Department and Dr. Tony O'Holohan, deputy chief medical officer.

Mr. Michael Lyons

I am the chief executive of the Eastern Regional Health Authority. May I introduce my colleagues, Mr. Jim Breslin director of planning commissioning and change at the authority, who is responsible for the contracting and commissioning of waiting list initiative work; Mr. Liam Woods, director of finance in the authority and Ms Angela Fitzgerald, director of monitoring and evaluation who is involved in the monitoring and reporting on waiting list initiative work.

Mr. Joe Mooney

I am in the public expenditure division of the Department of Finance, and my colleague, Mr. Larry Dunne, is an assistant principal in the same division.

Chairman

The Comptroller and Auditor General, Mr. Purcell, will introduce the value for money report.

Mr. John Purcell

The waiting list initiative was introduced in 1993 to deal with the persistent problem of significant numbers of patients waiting long periods of time for elective, that is non-emergency treatment in acute hospitals. In launching the initiative the Department for the first time set targets for the maximum length of time patients had to wait for treatment in nine specialties. These are set out in figure 1.1 of the report and represented surgical procedures which had the longest waiting lists at the time. The maximum waiting time set for the initiative was 12 months for adults and six months for children. Between its introduction in 1993 and the end of 2003, a total of €290 million was provided under the initiative. These funds were intended to be kept separate from the normal core funding of the acute hospitals and to be used to increase the number of elective surgical procedures being undertaken, thereby reducing the number of patients waiting longer the target maximum times.

The money provided under the initiative took a long time to make a significant impact on the number of long waiters and it was not until 2000 that meaningful reductions began to be seen. Since then the numbers of long waiters in the selected categories have generally been falling and the latest figures for September 2003 show that 6,530 patients were waiting for treatment in those categories for longer than the target maximum times. This represents a big improvement over previous years and is attributable not only to the effect of the initiative but also to the impact of increased funding generally for acute hospitals and, latterly, to the operation of the national treatment purchase fund. The residual problem is mainly in the eastern region with four Dublin hospitals accounting for over half the reported long-waiting patients at the end of 2002 but even there the situation is improving. Based on the latest figures at the end of September 2003, estimates of average waiting time show meaningful reductions over 2002 figures.

Our examination concentrated on the period 1998-2002 when most of the money, that is €172 million, was spent. From our examination we found that there was a lack of clarity about what the waiting list initiative money was intended to cover. For example, for a long time, there was confusion at hospital level as to whether day cases were to be included. While the targeted money appeared to have been applied to activities designed to achieve the general aims of the initiative, there was a lack of traceability in the hospitals we visited as to how the funds were used. By 2002, almost half the funds were being used to pay for staff posts that had been made or were about to be made permanent. While this was a legitimate way of using the funds and as human resources were required to improve the listing, it had the effect of restricting the flexibility to channel funds to the most problematic areas. We also found that systems needed to be developed to gather and analyse information which will help to assess the effectiveness of the money spent in this area. For example, information on comparative waiting times for public and private patients would be useful as would information on the time spent by individuals awaiting a hospital out-patient appointment with a consultant, which historically has not been taken into account in calculating the overall waiting times for patients waiting for elective treatment.

The advent of the national treatment purchase fund in 2002 gave a much needed boost to activity geared to shortening the waiting lists. The way in which it operates provides a clear link between the money granted and the effect of the money being applied. I am glad to note that the Minister in his response to my report has stated that waiting list funding will in future be channelled through the national treatment purchase fund, that is money that is not already committed to permanent resources which will become part of the core funding of acute hospitals in the future. At a minimum, this should help to refocus the initiative to the attainment of its primary objective of ensuring that no one should have to endure an excessive wait for an elective procedure.

Mr. Kelly

The Department of Health and Children welcomes the publication of the Comptroller and Auditor General's report on the waiting list initiative. Since the waiting list initiative was introduced in 1993 many thousands of patients had elective treatments more quickly than would otherwise have been the case. As the report has acknowledged and documented, the initiative has resulted in a significant number of important achievements. There has been a reduction of 54% in the number of patients waiting longer than the target times between 1998 and 2003 from 14,100 to 6,530. There has been a decrease in waiting lists for many specialities, particularly cardiac surgery which decreased from around 1,000 at the start of 1998 to 55 by the end of 2002. The number waiting for vascular surgery has been reduced by 60% and in the speciality of gynaecology the numbers were cut by half.

I am conscious, however, that while we tend to discuss this topic in terms of statistics, each case represents a person who has been judged by his or her consultant as needing a specified medical procedure. In an ideal world, one would not wish to see significant waiting time for any health service that was needed but, as pointed out in the report, this would require maintaining a level of spare capacity which could be expensive and wasteful.

Over the last two or three decades there have been numerous important advances in hospital services, particularly surgical technology, and in anaesthesia. These advances have improved greatly the range, safety and effectiveness of the surgical procedures that can be offered by modern health systems. However, as a consequence, there have been dramatic increases in the demand for surgical procedures, especially elective procedures. This is a dynamic situation which changes each year.

The nature of our health care system is such that not all treatments can be made available to patients immediately. The committee will be aware that there are two streams to hospital activity, emergency and elective. Pressures on the hospital system due to identified capacity constraints hinder its ability to provide elective activity in a planned way because of the urgent and unpredictable needs of emergency patients. This is a complex area and compounded by difficulties relating to the less than adequate availability of long-stay beds and other supports in the community. Patients who require elective treatment may have to wait because beds, staff and operating theatres are being used to treat emergency cases. Eliminating waiting lists entirely would mean having spare capacity in the system to deal with peaks in demand. The balance to be achieved is to ensure that the available resources are used efficiently and that treatment can be delivered to patients in a reasonable time.

The waiting list initiative contributed to a 25% increase in acute hospital activity in the period 1997 to 2002, while day case work increased by 60% in the same period. There has been a rapid movement in the last few years towards day case work. As a result, a variety of routine and complex treatments, surgery and diagnostic tests can now be performed with the patient being admitted and discharged from hospital on the same day. More than 50% of all elective surgery is now performed on a day case basis. This was one of the targets set out in the health strategy and it is a deliberate objective of policy to move in that direction.

In the statistics on acute hospital discharges, it is notable that of 957,997 discharges in 2002, over 400,000 were day cases. It is also notable that total activity in the acute hospitals between 1993 and 2002 increased by 35%. The Comptroller and Auditor General's report noted that between 1998 and the end of 2002, and particularly from 2000, the reported number of patients waiting longer than the target maximum waiting times for elective treatment decreased by 39% from 14,100 to 8,700. The latest waiting list figures for the quarter ended 30 September 2003 show that the reported number of those waiting a long time has decreased to 6,530, representing a 54% reduction since 1998. The health strategy contains a commitment to reform the organisation and management of waiting lists. While the waiting list policy has been the subject of regular review, the analysis carried out during the preparation of the strategy indicated the need to take further measures to reduce waiting times for patients. This led to the establishment of the national treatment purchase fund, NTPF, which has proved to be successful with over 9,700 patients treated up to the end of 2003.

The introduction of the fund has had other beneficial effects. In particular, the NTPF estimates that a significant percentage of patients could be removed from the waiting lists because they no longer required or wished to have treatment. Similarly, the NTPF has shown the benefit of using private sector input where appropriate. It has been suggested that the Department was reluctant to indicate that long waiting patients be targeted by the waiting list initiative. The Department acknowledges that a particular focus of the initiative was to deal with those waiting longest in the nine target surgical specialities. However, there was more than one objective to be addressed under the initiative, which is acknowledged in the report. It had four distinct objectives. It aimed to achieve a significant reduction in the number of public patients awaiting elective procedures; increase the number of persons receiving elective procedures; reduce the times persons are waiting for elective procedures in the target specialities to a maximum of 12 months for adults and six months for children; and improve the management of elective procedures, waiting lists and waiting times. To focus on one of these at the exclusion of the others would be a mistake in an analysis of the initiative's overall impact.

Attention has been drawn to the fact that substantial amounts of waiting list initiative funding were spent on staffing costs. It is inevitable that a significant proportion of spending under the waiting list initiative would relate to staff costs. There is no other way of delivering activity. Many hospitals use waiting list funding to employ extra waiting list staff and bed management staff. In this context the report notes that the hospitals visited during the course of the review have a more active management of waiting lists and waiting times and better hospital bed utilisation. This suggests a gain in efficiency in the overall management of patient throughput, apart from the direct improvement of waiting list management.

With regard to permanent consultant posts, once services were put in place and were successful in dealing with local need, there was a compelling case to transform the short-term and temporary nature of these appointments. Furthermore, Comhairle na nOspidéal, the statutory body responsible for consultant appointments, has stated that it is undesirable to allow temporary consultants to become a continuing feature of the health landscape. Accordingly, a number of long-term temporary posts have been made permanent, for good reasons.

There are a number of other problems associated with continually employing additional skilled staff for short periods. That may yield results in the early stages but over the longer period it creates uncertainty for skilled staff with unpredictable short-term contracts. They are much more likely to go where there is a chance of permanent employment and therefore their skills will move with them.

I wish to comment on references in the report to the prioritisation of patients and I deliberately involved Dr. Tony Houlihan in the delegation today so that if the committee wishes, he may comment further on this aspect. It is a complex question. Ultimately, the decision to admit a person to hospital is the responsibility of the consultant concerned who must decide on the relative merits of each case. He or she must make that clinical decision based on experience and training. Urgent cases will always get priority over non-urgent cases and it is very difficult to interfere with this clinical judgment.

While the rate of progress in achieving the targets set out in the health strategy for the reduction in waiting times has been slower than anticipated, the targets remain as goals to be achieved. There is nothing imprecise or aspirational about them. All health hoards outside the eastern region now report that, in general, adults currently reported to be waiting more than 12 months and children reported to be waiting more than six months have either been offered treatment under the national treatment purchase fund, NTPF, or have conditions that are complicated or are outside the remit of the NTPF.

The Comptroller and Auditor General has commented on the fact that some hospitals were able to benefit more than others from resources received from the waiting list initiative. This reflects the fact that there were inbuilt incentives related to performance. In fact, some hospitals were not able to take up waiting list initiative funding because of capacity constraints. We learned during the early years of the initiative that allocating in proportion to the size of the waiting lists primarily was not a good solution. Quite deliberately, the 1998 review adopted a performance based approach and we continued that to 2003.

The existence of lengthy waiting lists is one manifestation of the capacity issues in the health service. Capacity was recently identified by the OECD as a particular factor in long waiting lists. The acute bed capacity problem in the hospital system has been well documented. The Government has accepted the need to provide additional acute beds and has decided to provide an additional 3,000 beds in acute hospitals by 2011. More beds have been already commissioned in this context, of which 253 are in the ERHA region.

The report points to a number of information system deficiencies at hospital level regarding the output attributed to the waiting list initiative. This is something the Department is conscious of and intends to address in the forthcoming health information strategy. For 2004 there has been a 100% increase in the allocation for information systems over and above the original allocation for 2003. The committee will be aware from previous hearings that this is a priority of the Department and one on which we can move urgently and actively in 2004. The Department has adopted a policy of enterprise-wide systems with a view to standardising information and the provision of significantly improved management information systems.

Waiting lists will continue to be an indicator of how the overall system is performing. It is important that the public, politicians, the media and the wider health system have access to information on where the pressures are in the hospital services. The Department already publishes information on its website showing the national and local picture and we would encourage hospitals to publish more detailed information so that patients and their doctors can make informed choices about their care. That issue is being addressed by the ERHA and the health boards.

Against the background of the health strategy commitment on waiting lists, the success of the national treatment purchase fund and the report of the Comptroller and Auditor General, the Minister for Health and Children decided in the context of the 2004 Estimates to give a significant lead role to the NTPF in tackling waiting lists in the future. This announcement heralded the end of the waiting list initiative in its existing format. A substantial element of the funding is now being included as base or core funding for those health agencies in recognition of the staff and resources that have been put in place over the years to support the increasing elective workload. Additional resources will be made available to the NTPF to target those waiting longest for treatment. Discussions on that matter are ongoing.

In conclusion, the Department maintains that given the four objectives set out for the waiting list initiative, it has been broadly successful in increasing the level of elective activity in acute hospitals and in achieving an overall reduction in waiting time. Without this additional elective activity supported by the waiting list initiative over the past decade we would undoubtedly be faced with much longer waiting times than currently prevail. However, I would not argue that any part of the health system is beyond improvement, so I welcome the conclusions and findings of this report as an input to our ongoing efforts in the health system to address waiting lists for a variety of health and personal social services. I assure the committee that the Department will work closely with the national treatment purchase fund and the relevant health agencies in continuing to identify improvements which can be made in this area.

Chairman

Can we get permission to publish that report?

Mr. Kelly

Yes.

Mr. Lyons

The ERHA welcomes the report of the Comptroller and Auditor General and is pleased to have the opportunity to discuss the findings with the committee. I have provided the committee with a detailed opening statement which I hope will assist the members in their deliberations on the report. I propose to make a few brief summary points which are included in the statement I have submitted.

The ERHA has put in place a framework to implement the waiting list initiative in its region since it commenced commissioning waiting list initiative work in the second half of 2000. In that context it is interesting to note that the period examined by the Comptroller and Auditor General ranges from 1998 to 2002. The framework put in place by the ERHA consists of contracting with individual hospitals using strict commissioning criteria and the benchmarking of unit and marginal costs for individual procedures against comparative costs such as case mix, private sector prices and the national treatment purchase fund. Monitoring and reporting arrangements have been put in place to ensure that the waiting list initiative work commissioned has been delivered and differentiates between waiting list initiative work and core activity and between in-patient and day case work.

We also routinely validate the waiting lists and we place patients in nursing homes and other appropriate services outside the acute hospitals to ensure that acute beds are freed up and that patients are treated in the most appropriate setting for their care. Details of the various components of the ERHA's waiting list initiative framework are set out in the statement submitted. Critical elements of the commissioning process are the targeting of long waiters and the skewing of funding towards hospitals with a proven track record in delivery and available capacity. This has struck an appropriate balance between addressing the needs of long waiters and the capacity of the hospitals to deliver on waiting list initiative work. As a result, the introduction of perverse incentives for maintaining long waiting lists has not arisen in the region.

In addition, the ERHA operates a policy of supporting hospitals with their waiting list initiative implementation plans, including recovery plans in cases where targets are not being met. However, in the event of a hospital not achieving its targets, the ERHA has decommissioned the work contracted for and transferred the funding to other agencies who have the capacity to deliver. In implementing its strategy on the waiting list initiative, the ERHA is working closely with the Department of Health and Children to increase capacity in the region. This is particularly relevant in the case of bed capacity in the acute sector and in regard to step down and rehabilitation places for persons who have completed the acute phase of their treatment.

The capability of service providers in the region to deal more effectively with waiting lists is constrained by bed capacity, which is inadequate to meet the demands for elective work. Other constraining factors in the region are delayed discharges from acute hospitals, changing demographics and the impact of referrals from outside the eastern region, which reduced the bed availability to residents from the region to below the national average as well as artificially increasing its waiting lists by about 20%. The high occupancy levels of up to almost 100% in acute hospitals in the region is another constraining factor, as is the impact of emergency admissions on elective work, which accounts for 20% of admissions to the region's acute hospitals on a consistent basis.

Despite those constraints, since the authority first commissioned waiting list initiative work in 2000, and, as the Comptroller and Auditor General said, up to September 2003, there have been improvements in the authority's performance and the service provided in the region. For example, total elective activity in the region increased by 34% to 54,176 cases. Emergency activity increased by 20%. The total number of long waiters in the target groups was reduced by 46.3% when the number reduced by 3,700 cases. The total number of long waiters in all specialities was reduced by 36% when the number reduced by 3,750 cases. A total of 382,000 cases were treated in acute hospitals altogether, of which approximately 24,373 were waiting for treatment. That represents 6.4% of total cases treated in the acute hospitals in the region.

When the impact of referrals from outside the region, which represent about 30% of all patients, and the fact that the reporting of day cases has always been a feature of the authority's reporting arrangements is taken into account, the percentage of persons waiting in the target group could be reduced from 70% to 39%. In addition, there is scope for discussion about the average waiting times referred to in the Comptroller and Auditor General's report. Fifteen months and 8.9 months for adults and children respectively have been referred to, but that relates to a cohort of patients who make up just 8.3% of total activity in the acute system. In that context, in 2003 almost 270,000 patients in the region accessed selective treatment very quickly, compared to 24,373 waiting more than three months. In addition, some of the patients waiting in those time bands are not medically fit for surgery and in that regard there is a need to address such issues as criteria for suspension or removal from waiting lists and the introduction of the unique patient identifier to avoid persons being on several waiting lists and facilitate their validation. That is currently being piloted and the evaluation should be completed during 2004.

The private system does not deal with an emergency workload, which is the difference, in fairness. In single specialty hospitals, of which we have a number, that are not on emergency "take", of which Cappagh Hospital would be one, as it deals with orthopaedics, or in private hospitals that do not take emergencies, one can exactly plan activity and manage it with precision. That is not the case in public hospitals which are taking 70% of their admissions as emergencies.

Deputy Boyle

I thank the officials from the Department of Health and Children for visually demonstrating what a waiting list looks like.

Perhaps Mr. Kelly could respond to a few observations on the value for money report. The waiting list initiative was introduced in 1993 and is now in its 11th year. It was initially seen as a short-term initiative, which begs the question of how long a short-term initiative should be. For the first half of its existence it was not seen to be very successful at all. In fact, in the targeted group the numbers increased significantly until 1998 and I have noticed that a lot of Mr. Kelly's statistics on the decrease are from 1998. However, if one takes the year 1993, when the initiative was introduced as the benchmark and 2002, when the value for money report was compiled, in the targeted group there was no significant decrease in numbers. The decrease since then, in 2003, is, I suspect, only a marginal decrease on the 1993 figures. There may be a number of factors to explain that, such as the initial funding being subsequently lowered. It then decreased until 1998, when it started increasing. Perhaps the greater amount of money was having more of an effect from 1998 onwards. Nevertheless, even from 1998 to 2001, the decrease in the targeted group was just in line with the decrease in general waiting lists.

There are questions about the first eight years of this initiative and its general effectiveness. There are further questions about the ability to measure value for money. That can be examined in a number of areas, first of all the differences between the different procedures — why some increased and others decreased — the differences between health board areas and the differences between hospitals, on which I will ask specific questions as I proceed.

We are talking this through in the Department at the moment so I cannot give a definitive answer. It is clear that the funding, which has become part of core base funding in the health boards, about €23 million of the total allocation for the initiative in 2004, has been allocated to the relevant health boards on the basis that it is necessary to continue with the level of activity that the posts and so on that are in place will support. As regards the balance of that funding, we are currently in discussion with the management of the national treatment purchase fund, and will discuss with the health boards when we see them regarding their service plans, how the balance will be struck in terms of allocating that funding between health boards and the national treatment purchase fund. However, it will involve an increase in the allocation to the fund during 2004.

This is not the first co-ordinating piece between the operation of both initiatives. For example, the assistant secretary of the hospitals division in the Department is a member of the steering group for the national treatment purchase fund. Similarly, there is liaison with chief executives and other representatives of health boards on the steering group. So, the initiative and the fund have operated with a degree of co-ordination over the last two years. We are now moving on from that and are, in part, informed by the analysis in the report and, in part, by our own analysis, having seen the success of the fund in contracting with the private system, and to some extent with the public system. They have gained that additional activity level and, in particular, have developed this transparency between funding and output. In 2004, we are putting them in a lead role in this respect.

Deputy Boyle

My final question also relates to Mr. Kelly's presentation when he talked about the Department improving its information systems for collecting statistical data for comparative purposes. He did not seem to respond to the suggestions made by the Comptroller and Auditor General in the value for money report, which referred to the need for new and different indicators that might be more effective in measuring the value for money aspect. The Chair has already sought statistics on private hospital patients but there is also the question of waiting times for outpatient facilities for consultants. Does the Department intend to act on these recommendations and will they form part of the review of new information systems the Department will have in place in future?

Mr. Kelly

Yes.

Deputy Boyle

In both areas?

Mr. Kelly

I have not commented on it because at this stage we have not got to the point of specifically setting out what the IT developments will address in 2004. We know broadly what the systems will be but not what reports they will produce. There is an ongoing engagement both by the Department and the health boards concerning a suite of performance indicators on the health system. We have developed a set of performance indicators and are applying them in many areas at present. We will certainly address the recommendations that have been made here in that context, in looking how we could build the indicators in this particular area.

Chairman

Mr. Purcell has a point of clarification.

Mr. Purcell

I do not think we should get hung up on the four objectives and I am not really taking issue with what the Accounting Officer has said. However, I think it is fair to say on the basis of documentary evidence — and that is what an audit has to rely on — that these did not emerge until after the review group reported in July 1998. They emerged in a clear fashion in the guidelines issued by the Department in 1999 and 2000. Even in the set of guidelines that were sent to the chief executive officers of health boards and hospitals in 2000, the Department did point out in a covering letter that the overall objective of the initiative was to ensure that the target maximum waiting times were not exceeded.

Maybe the Chairman misunderstood me. I am just asking simple, basic questions.

Chairman

I am not trying to divert attention. The Comptroller and Auditor General is well able to stand over his report. I wish to make that point clear, Deputy Fleming.

Mr. Purcell

There are a couple of issues. To cast doubts over the veracity of the document is inappropriate because the final document is sent to the Department and the relevant health boards to confirm the factual accuracy of the items and figures in it. There will always be differences of opinion about particular aspects of the report and where they are relevant and material, they are reflected in the report and the Accounting Officer or the chief executives of the health boards, as the case may be, have the opportunity at that stage to state them. If they are material, they will be included in the report to show both sides of an argument.

On the value of the report, that is for many people to judge. However, there is certainly a value in getting much of the data which was not there beforehand and presenting it in a public document for people to make up their own minds. As the Deputy said, he was able to look at the hospitals in his region to see whether they were good, bad or indifferent relative to others.

As to whether one can come to an absolute conclusion in a single line in the same way one does in giving an audit opinion in an audit report on accounts, it is not possible; it is as simple as that. The Deputy said there were no conclusions but I see conclusions at the end of sections two, three and four. If the Deputy wants to look at the conclusions, they are there. They are not in a single line as one would see in a set of accounts. I have studied the work of my counterparts in the developed world and they have not managed to do so either. If the Deputy can come up with a formula which would enable us to do that, I would be delighted to hear it through the committee or on an individual basis.

Deputy Fleming

I want to come back on two points. I fundamentally reject the Comptroller and Auditor General's comment to a Member of Oireachtas Éireann that it is inappropriate to discuss the veracity of a report laid before Dáil Éireann. The Comptroller and Auditor General commences the report and sends it to the Department and to the Minister who lays it before the Dáil. The Dáil is entitled to consider or discuss the report and that function has been delegated to the Committee of Public Accounts. Its function is to discuss the report and to agree or disagree with it, to note it or to report on it to Dáil Éireann.

The record will show whether those words were used. I wrote them down.

Deputy Dennehy

What was the suggestion about having an agenda, Chairman?

Deputy Fleming

My agenda is black and white. As a member of the Committee of Public Accounts, my agenda is to——

Chairman

We are here to study this report.

Deputy Fleming

——take my responsibility seriously, to study the report and, when I have studied and understood it, to put it to the witnesses. As of now, I have not got to that stage. I have not studied it. I did not suggest there were no conclusions. There are several conclusions throughout the report but the overall conclusion, which would be helpful to Dáil Éireann as to whether there was value for money for the taxpayer, is not addressed. Several points of detail are addressed but the big question is not. I will address the question of getting out the data in the report, but I will move on.

There is a simple answer to that and the Deputy alluded to it. We could not rely on the figures because there were not reliable records in the hospitals in which these procedures were undertaken. It is clear that many elective procedures were undertaken but the extent to which they were paid for under the waiting list initiative targeted funding was difficult to establish. My view in that regard is reinforced because the Department attempted to arrive at some figures. However, there are significant differences between the figures it supplied in April 2002 and those it will report this month. This bears out the point.

I accept Mr. Lyons's word in good faith. The Comptroller and Auditor General must have some view about the sum of €172 million. Did it pay for 10,000, 50,000 or 100,000 procedures? Neither Members of the Oireachtas nor the general public know the answer to that question. The Comptroller could have taken the information provided, qualified it and given a plus or minus range, based on accuracy. We would then have been able to identify a range of procedures that may have been carried out. I have no idea of the number of procedures, to the nearest 10,000, that were carried out.

We are going to have difficulty concluding our discussion on this report. I know how much it cost but the report provides no information regarding the number of procedures involved. Some of that information might be available and if we estimate it to the nearest 10,000 we might then gauge whether particular procedures cost €1,000, €2,000, €5,000 or €10,000.

Mr. Purcell

When discussing the reliability of figures, I refer to the procedures in, for example, the Midland Health Board area, with which the Deputy will be familiar. In April 2002 it was reported that 867 procedures were carried out under the waiting list initiative in 2000. In January 2004 that figure has been reduced to 560. Those figures are, therefore, fairly unreliable because there is a large percentage difference between them. In the case of the Mid-Western Health Board for 2000, in 2002 it was reported that 991 procedures were carried out under the waiting list initiative, while this month that figure has risen to 1,724. In the round, it would be difficult to give overall figures in which one could have confidence.

I take the point Mr. Lyons made. When the Eastern Regional Health Authority was established — I acknowledge this in my report and state that some of the other health boards could follow its example — it arrived at figures which are consistent. However, having visited some of the hospitals I am aware that while the figures provided by St. James's hospital were fairly reliable, the position at St. Vincent's was somewhat different. Until recently, Tallaght hospital was not in a position to distinguish between day cases carried out under the waiting list initiative and other cases involving elective surgery. There were problems there and in that situation I might have been accused of misleading the public and the committee if I were to put those figures into a report.

Deputy Fleming

The report should be helpful to the reader and no information is completely unhelpful because one does not know where one stands. While acknowledging the questions over the available information, there were two reasonable options, one of which was to include the information and qualify it by stating they were best estimates. However, the Comptroller and Auditor General will not stand over them because they are not verified. A more direct approach would have been not to provide information and be upfront. We do not have a concept of the number of procedures and we cannot conclude whether there was value for money based on the procedures carried out. Perhaps the report should have been shortened because, due to inadequate information in the system, it is not possible to conclude whether there was value for money. We only know the cost.

Estimates have been provided with suitable health warnings on other occasions regarding upcoming matters that may or may not have been accurate. This is a matter relating to the past for which best estimates could be provided with a suitable warning. At least we would know whether 1,000, 50,000 or 100,000 procedures were carried out. The Chairman is none the wiser in this regard and I do not know how we can conclude the report.

Chairman

Has the Deputy questions for the principal witness?

Deputy Fleming

Yes. Is the Chairman cutting short my questioning of the Comptroller and Auditor General on the report?

Chairman

Other members are offering to ask questions. There is a time constraint.

Deputy Fleming

I refer to paragraph 2.4 on page 17 of the report, which covers how the funding was allocated. The same point is made on page 18. Paragraph 2.4 states it was "recommended that the (smaller) second phase of the funding would be awarded to service providers with the best performance record". The Comptroller and Auditor and General states on the following page that the Eastern Regional Health Authority collated information about the use of the funding. Information is in the system that could be used for the allocation of funding and it must have been checked to some extent. The Comptroller and Auditor General refers to that information but did not include the number of procedures. It would have been helpful if a range of best estimates had been included because we do not know the number.

Paragraph 2.18 on page 21 refers to the current pattern of allocating funding. It states that significant amounts of initiative funding are being directed "on a more or less permanent basis to the service providers that have consistently succeeded in reducing their reported number of long waiting patients and maintaining this record". The Comptroller and Auditor General is happy to refer to the consistent record of reducing patient numbers but, if he is happy to do so and the Department is happy to rely on that, it would have been helpful to have given the committee some of the benefit of that issue.

I refer to paragraph 2.42 on page 27, on which I would like the Comptroller and Auditor General to comment. The paragraph states that the decline in elective in-patient activity treatment arose because of the number of emergency admissions and the lack of step-down beds. However, another significant reason is that elective day admissions increased significantly during the period.

The Secretary General stated in his opening contribution that, in 1998, the number of in-patient procedures was 537,000 and out-patient day care cases was 270,000. In other words, the split was 63%-37% in favour of in-patients. However, he stated that, in 2002, the number of in-patient procedures was 556,000 while the number of day cases was 401,000. The split was 58%-42%, which is a major improvement. That is a significant reason there was a reduction in in-patient treatments and that should have been reflected in the report.

Mr. Purcell

I am in agreement with Deputy Fleming for once. Paragraph 2.42 states: "Apart from the increased treatment of patients on a planned day case rather than an inpatient basis as a result of advances in treatment the decline in the elective inpatient treatment in hospitals may be attributable to..." those two other factors. I make it clear that the primary factor is the increase in the treatment of day cases. I do not see an inconsistency.

Deputy Fleming

The Mater Hospital gets a raw deal on page 20 of the report. The Comptroller and Auditor General refers to divergence in the Dublin hospitals and states:

The Mater Hospital reported the biggest target group (over 1,600 long waiting patients) at the end of 2001 — up 4.5% from the end of 1997. Despite this, its share of the waiting list initiative fund fell from 15.5% of the total in 1998 to 9.5% of the total in 1992.

The implication is that, while the waiting list increased, the hospitals proportion of the funding was decreasing. The figures quoted by the Comptroller and Auditor General are wrong.

Mr. Purcell

These figures were put to the Department and it did not have a problem with them. There were capacity problems in some hospitals and they were unable to take their fair share of the waiting list initiative funding. The Accounting Officer mentioned that in his opening statement and that is the primary reason that happened.

Deputy Fleming

I understand, but appendix B of the Comptroller and Auditor General's report states that €1.2 million was allocated to the Mater Hospital in 1998 from a fund of €15.224 million, which is 7.9%, not 15%. A sum of €3.647 million was allocated in 2002 from a fund of €43.806 million, which is 8.3%. The arithmetic is wrong if one goes on the basis of the appendix. The paragraph does not correspond with the appendix and, because of the mistake in calculations, the Mater Hospital has been done down unintentionally by the Comptroller and Auditor General. I would not like the hospital management to feel it received reduced funding, because it had increased during the period. The report states otherwise and the wrong impression might have been created for the hospital.

Mr. Purcell

I can certainly come back to the committee on those figures and, if there is an error, I will acknowledge it but it would be impossible to do it at this moment. I will get back to Deputy Fleming.

Deputy Fleming

It is just in case it is interpreted as a reflection on the Mater Hospital.

Will the Secretary General explain the capacity problems at Tallaght Hospital because it was unable to take up waiting list initiative funding in 2002? Its waiting list at the end of 2002 comprised 1,440 people, of which 885 were in the target group. It is extraordinary that such a new hospital was not in a position to avail of the funding. These circumstances might be explained.

Mr. Lyons

The report indicates that there were fluctuating performances by individual hospitals in regard to waiting list initiative work over the period in question, including Tallaght Hospital. The Deputy will be aware that Tallaght is a new hospital which has been gearing itself up to full capacity since its establishment.

Apart from physical capacity problems in the acute hospitals, there are practical ongoing issues that compromise the ability of hospitals such as Tallaght to do waiting list initiative work to the level that perhaps they could do. For example, Tallaght had been experiencing a high number of delayed discharges. These people had finished their acute phase and were delayed in being discharged. The hospital had increased activity coming through the accident and emergency ward. The winter vomiting bug hit the hospital and it has ongoing high levels of emergency activity.

Having said that, there has been a significant improvement since the end of 2002. Over the entire period from March 2001 to September 2003, the period during which the authority related to Tallaght Hospital, there has been almost a 30% reduction in the overall numbers waiting. There has been a 61% reduction in long waiters and a 58% increase in the number of patients waiting within the Department of Health and Children target times.

Deputy Fleming

Given that Tallaght has capacity constraints and 885 people were waiting longer than the target time, has each of these people been offered the option of the national treatment purchase fund? If there are capacity constraints in the four large hospitals, it will not be possible to meet these targets in a reasonable period. While the Minister has made changes since then, I hope that, as a matter of priority, all patients in the four hospitals that exceeded the target time were offered the national treatment purchase fund option.

Mr. Lyons

A representative from the fund is here today. I understand that each of the people who were waiting were written to by the hospital.

Deputy Fleming

Were they written to recently?

Mr. Lyons

Yes.

Mr. Pat O’Byrne

Tallaght Hospital has particular problems, some of which were referred to in regard to capacity. Approximately 400 to 500 patients were identified to us when we were set up and defined as the longest waiters in Tallaght. By the end of December, most of these patients had been treated, with the exception of a few. Part of the process was that the hospital wrote to patients and offered the option of NTPFs.

Deputy Connaughton

While I have a number of questions, I do now want to go back over the ground covered. There is a public perception that there is a black hole in the health services and that all these initiatives, although good in themselves, are a let-down for many citizens. We do not have to say it at this meeting for most people to understand that this is the case.

The bottom line is that, under the 1996 accountability legislation within which the whole service planning process works for health boards, the ultimate and overriding requirement that every health board must address is to achieve a break-even situation under total allocation. That requires them to employ some flexibility, even in relation to funding that is earmarked for a specific development by the Department in the letter of determination.

There is no absolute science that one can apply to tracking an amount of money which was given at any time. It forms part of the overall pool. However, by and large, it is used for the purpose for which it is allocated.

Deputy Connaughton

With all the money that has been spent on behalf of the taxpayer, and by any standard it has been a large amount, is it not a remarkable commentary on the system that, according to page 40 of the Comptroller and Auditor General's report — I am sure Mr. Lyons will comment on this — 1,300 people or 8% of those in the Eastern Regional Health Authority area are four years or more on a waiting list? Irrespective of what one might suffer from, four years or more is a long time. Are there 1,300 on waiting lists and, if so, what is the profile of people who must wait so long? Obviously, they have seen a consultant and have a bona fide case, or so it appears to me from the people who have contacted me over a period. Can Mr. Lyons throw some light on how it is that neither the national treatment purchase fund nor the waiting list initiative have been able to assist these people?

Mr. Lyons

The Deputy's last point reflects the position of the people he refers to in that the treatment purchase fund has not picked them up either. This raises the question of their profile and their suitability for elective procedures. In any waiting list there is a range of people who would be medically unfit, may not want to have surgery or whose social circumstances may dictate that they cannot avail of it. Some people defer surgery or may even be on a waiting list in another hospital, either in the region or elsewhere in the country. There is an issue as to whether or not the 8% should be included on the waiting list at all or whether there should be an agreed methodology which would involve clinicians who have the ultimate say in whether or not a person is referred to a waiting list or should be suspended or removed from a waiting list. There need to be some suspension criteria to enable decisions like that to be taken.

The average waiting time, as indicated in the report, refers to persons waiting over 12 months and includes longer waiters, such as the 4% and 8% referred to in the Comptroller and Auditor General's report. That does not take into account the numbers who access the system very quickly, usually in the first three months of referral. When one looks at the totality of persons who access treatment and who wait for a short period of time relative to the long waiters, the average waiting time comes down quite considerably.

Dr. Tony O’Holohan

This brings up the issue of prioritisation. In that context, which was referred to in the Comptroller and Auditor General's report, there is by implication the fact that not all conditions or cases will represent the same degree of priority or should do so.

People who are waiting for long periods will wait for some of the reasons Mr. Lyons outlined but the process is a complex one based on the clinical assessment of people by individual clinicians, not just at a particular point in time but on an ongoing basis. These people come back and are reviewed on an ongoing basis at three monthly or six monthly intervals on an out-patient basis with their general practitioner who will maintain a relationship with the consultant. If deterioration takes place either at the level of symptomatology, ability or disability, that can then lead to a situation whereby the GP makes a representation, or others may make representations, to the consultant to move that person up the waiting list. That happens all the time.

Unlike other health board regions, the eastern region does not have the network of district hospitals that others have. On a population basis, in fact, it is poorly served by the number of public beds in the system. For example, the Northern Area Health Board, which is the third largest board in the country, has only 600 public beds available for a population of 500,000. There is a huge reliance on the nursing home sector. We operate within finite budgets, as we are required to do under the letter of determination of the 1996 legislation. In trying to make the finite allocation for nursing home places go as far as it can, we have shifted the emphasis from the provision of contract beds to subvention. In effect, therefore, we are putting more people through the system on the basis of subvention than we were under the contract beds system. That has increased the capacity of the nursing home system in the eastern region with virtually the same resources as we have had. In addition to the nursing home placements, we have been planning on a patient-centred basis to accommodate the needs of patients in non-institutional settings, particularly in their own homes. We have had significant consultation with patients in developing those systems.

There is a well organised data collection system in regard to hospital activity generally under the hospital in-patient inquiry. There is a computerised record of each discharge which covers much detail in regard to the particulars of each discharge. In overall figures we can reliably state, although it is a provisional figure for end 2003, that the total number of discharges was short of 1 million. There were 1 million discharges from the acute hospitals, some of which may have been the same person who was in hospital twice. That is up 4% on the figure for 2002. Over time one can see a gradual growth in the productivity of the system.

Given much of the ill-informed public commentary on the health system, it is legitimate to ask whether throughput in the Irish hospital system reflects an efficient performance. The best indicators of that are to judge it by the experience of health systems in other developed countries. Among OECD countries, for example, two of the key indicators used in regard to efficiency of throughput are the average length of time people remain in the acute hospitals and the percentage occupancy. There has already been some comment in the eastern region on that point. In regard to average length of stay, we are approximately in the middle of the table, so we are fairly average among OECD countries. In regard to percentage occupancy, we are near the top of the table which suggests that the efficiency with which existing hospital capacity is used in the Irish health system is relatively high in comparison to other OECD countries.

Deputy Dennehy

I welcome the report because any information we get or practices measured is a good addition because "if it ain't measured, it ain't done". Of the nine specialties targeted at the time, two, in particular, came through with flying colours, namely, orthopaedics and cardiac surgery. Is there any reason those were targeted? Many of the complaints and much of the publicity related to orthopaedics and cardiac difficulties. Were those specialties targeted specifically among the nine already targeted?

Mr. Kelly

For obvious reasons, cardiac surgery was given particular priority and specific funding was made available, in particular, for cardiac surgery procedures for adults and children. That would account for the leap in performance there. The additional capacity in St. James's Hospital and the extended facilities in that hospital for cardiac surgery were a factor in that also.

Mr. Kelly

Deputy Curran

I am unclear as to where the report stands. I have read it and listened carefully to the discussion. The scheme was in place for ten years and it cost €246 million, of which €172 million was spent in the latter five years. The committee has examined how much was spent, how many people were on waiting lists at different times, how long they were on the lists and the total number of procedures done in different years. However, what did the State get for the investment of €172 million? I understand the big picture and the lack of information in the Comptroller and Auditor General's report. However, there is no question the position has improved and it must be borne in mind that, while €172 million was spent on the initiative over the five years, the budgetary allocation to the Department of Health and Children increased significantly over the same period. There is a number of variables but I am struggling to tie in the sum of €172 million.

I do not want to go back over all the arguments but Mr. Lyons said he could identify the number of procedures carried out in his area under the initiative for the years 2001 and 2002. That is significant because his region used a great deal of the money in the past two years. His board received €21 million out of a total of €43 million, almost 50%, in 2002 and this was similar to 2001. If we are to make sense of the report, a breakdown of the number of procedures is required. We know where the money went hospital by hospital and region by region, but we cannot say how many procedures resulted for the various amounts expended. That is the kernel of what we are doing in terms of value for money.

I accept Mr. Kelly's comment that the position has dramatically improved. The total number of patients on waiting lists and the times they are waiting have improved significantly but the purpose of the report was to determine whether the initiative provided value for money. While figures are not available for the ten years, I was encouraged that Mr. Lyons said he could provide figures for more recent years. Expenditure in 2001 and 2002 accounts for almost 40% of total expenditure over the ten years of the scheme. It would be worth carrying out a further analysis of the scheme. I do not know if the other health boards throughout the country are as efficient. However, as Mr. Lyons's is the largest figure, I suggest that we consider the matter in more detail unless, as Mr. Kelly said, it is physically impossible. From what I have heard today, this appears to be a necessary exercise, or else the report is lacking.

We cannot go back over the ten-year period. Mr. Lyons was emphatic that he has the information for the last two years, which is 50% of the expenditure. We should look at this issue to try to determine whether we got value for money. Too often we miss the point. The total number of procedures have increased significantly but so also has the budget for the Department of Health and Children. We are trying to tie this down to its initiative. As it is a general comment, I do not know if Mr. Kelly or Mr. Lyons would like to reply to it.

Chairman

Would anyone like to reply?

Mr. Lyons

Perhaps it will help the committee and prevent us from being called back again to give the specific information. In the two-year period we carried out an additional 13,278 procedures for the investment of €49 million. The important issue is the fact that the unit cost of procedure represents very good value for money when benchmarked against comparable prices in the private sector and, more recently, the national treatment purchase fund.

Deputy Fleming

Some 10,500 patients being treated at a cost of €32 million averages out at approximately €3,000 per patient. The figure of 13,000 costing €42 million provided by the Eastern Regional Health Authority averages out at approximately €3,500 per patient. The figures are close enough, depending on the actual patients and their condition.

The meeting should have been about finding out what we are getting for our money. This is the first bit of concrete information I have received in terms of output, costs and value. It is easy to compare these figures. We have a choice with regard to the report. It contains no information regarding the numbers of procedures, their average cost or even an estimate of that. I propose that the committee write to the chief executives of the health boards to give them an opportunity to give us their best information for the last five years, accepting that it will be subject to a health warning and that there are possible anomalies. However, we are all adults and if we get the information we can decide to use it or discard it. The report gives us no information and we are not, therefore, in a position to do anything. The committee should be able to assess the information, accept or reject it or take it with a health warning. We need to do that because we have no idea what was carried out.

When I first read the report I was struck by the absence of detail regarding numbers and I submitted a parliamentary question to the Minister as to the number of procedures carried out annually in the last five years in each of the health board areas. The Minister replied that he would write to the health boards. I received those figures from the Minister this week. They correspond with those given by the Comptroller and Auditor General as the final figures for the Midland and Mid-Western Health Boards. Some information is available and we must have sight of it before we make a judgment as to whether we use it or not.

In fairness to the health boards who have spent €172 million, they must be given an opportunity to explain what they did with it. The report does not say what they actually did. We can then judge accordingly. I do not propose that we invite them to the committee. This can be done by way of correspondence. We can assemble the information and decide what to do with it.

Deputy Boyle

Is the question whether the report being submitted to the committee is a fair and accurate one or not or whether we are using the report as a basis to question whether the waiting list initiative has been effective? I thought the second question was the one the committee was meant to be asking. If it is the former, I do not have difficulty with the report. I feel it is indicative of the information that can be verifiable and of how this programme has succeeded since 1993, and particularly since 1998. I would not want any question mark put over the report itself or the Office of the Comptroller and Auditor General in putting the report together.

Deputy Connaughton

I concur with that in this regard. Given that the information we received on this report was the best available — the Secretary General concurred with this — and that the information we would have liked was not available, which is one of those problems we regularly meet in this committee, I believe the Comptroller and Auditor General's report is a fair and honest assessment of what he and his professional people found. It will mean a great deal to the taxpayers in the future because it appears, from all the stakeholders who have spoken today, that in future we will receive the type of information, analysis and assessment that is needed. If that is the case this report has been excellent.

Deputy Dennehy

Let us not take sides and start a row or get excited about the wrong thing. Deputy Boyle says this is all about verifiable figures. The Comptroller and Auditor General told us he cannot verify the figures. Any report we have ever received has been used as a tool for trying to advance matters.

It would be nice to know the price per operation. If someone puts in a permanent member of staff as a result of this funding, that effect will trickle down for years to come and the employee will help other cases along the line. Someone else might have used the money to buy five or six operations. We are not comparing like with like. It would be useful to be able to compare the Eastern Regional Health Authority figures with the national purchase scheme, for example, to see if they are in the same ballpark. All procedures should be measured. We have identified hospitals in the past which, in one case, had only one 15th the output of a different hospital in the same country. If we are to measure health expenditure and make recommendations we must know what is being done, who is doing it and whether they are all producing the same amount of work.

Deputy Fleming is only asking us to write to the eight CEOs and request the figures. We can argue afterwards about whether they are accurate or not. It would only cost us the price of eight letters. We have written to individuals and residents' associations, and so on. Are we saying we cannot write to the CEOs of the health boards? It would be useful to get some idea of the figures. I will not object if we decide to leave today's report as it is. I am sure Mr. Kelly has already taken good note of it.

Mr. Kelly

I do not want to interfere with the committee's discussion about how this might be handled. However, in an effort to make a constructive suggestion as to how much of the information available to us is less than 100% accurate, there are firm estimates of activity. I would be inclined to take recent data, particularly in the period 2001-02, as accurate. The Department would have no difficulty, with the assistance of the Comptroller and Auditor General's office or in liaison with the committee, in engaging with the health boards in trying to produce hard data regarding 2001-02.

More importantly, the suggestion has been made by Deputy Connaughton regarding 2004, where we have the opportunity to zone in on this with the single lead agency, the national treatment purchase fund, that we would make a particular point of tracking expenditure under this heading more closely. It must be accepted that part of this would have to be done on an attributable basis because a significant part of the waiting list initiative funding in 2004 will be incorporated in the base allocations of health boards. A statistical exercise will have to be done whereby we analyse hospital activity and attribute a certain proportion of it to the funding under the waiting list initiative, and then there is directly funded activity under the lead of the NTPF, which should be more trackable during 2004. I say this in an effort to be helpful.

Chairman

It would be helpful if you can forward whatever information you have for the past two years. The fact that you accept Deputy Connaughton's recommendation that we track spending, going forward, is also appreciated.

I propose that we suspend the debate on this issue and that we reflect on the evidence. We will resume in five minutes with a consideration of the accounts of the Eastern Regional Health Authority.

Sitting suspended at 2.50 p.m. and resumed at 3.05 p.m.