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COMMITTEE OF PUBLIC ACCOUNTS debate -
Thursday, 26 May 2005

Vote 33 — Department of Health and Children.

Chapter 12.1 — Follow-up of 2001 Report Issues.
Mr. M. Scanlan (Secretary General, Department of Health and Children) called and examined.

The relevant correspondence is Nos. 3.3, 3.12 and 3.13. Witnesses should be aware that they do not enjoy absolute privilege before the committee. The attention of members and witnesses is drawn to the fact that as and from 2 August 1998, section 10 of the Committees of the Houses of the Oireachtas (Compellability, Privileges and Immunities of Witnesses) Act 1997 grants certain rights to persons identified in the course of the committee's proceedings. These rights include the right to give evidence, to produce or to send documents to the committee, to appear before the committee in person or through a representative, to make a written and oral submission, to request the committee to direct the attendance of witnesses and the production of documents and to cross-examine witnesses. These rights may be exercised for the most part only with the consent of the committee.

Persons invited before the committee are made aware of these rights and any persons identified in the course of proceedings who are not present may have to be made aware of these rights and provided with a 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 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 of 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 in Standing Order 156 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 of the objectives of such policy or policies.

Will Mr. Michael Scanlan introduce his officials?

Mr. Michael Scanlan

I am accompanied by Mr. Dermot Smyth, Mr. Dermot Magan and Ms Helen Minogue from the Department's finance unit. I am also accompanied by Mr. Colm Desmond from the unit dealing with the GMS scheme, Mr. Diarmuid Collins, Mr. John Magner and Mr. Peter Finnegan from the Health Service Executive.

Will the Department of Finance officials introduce themselves?

Mr. Joe Mooney

I am from the Department's public expenditure division.

Mr. Jim O’Farrell

I am from the Department's organisation, management and training division.

I call on Mr. Purcell to introduce Vote 33, chapter 12.1. Chapter 12.1 of the report of the Comptroller and Auditor General reads:

Follow-up of 2001 Report Issues

Recovery of Overpayments to Doctors

In my 2001 Report I drew attention to potential overpayments to General Practitioners (GPs) which came to light when the Department was implementing a Budget decision to bring all persons aged 70 years and over within the Medical Card scheme. The matter was subsequently examined in detail at the Committee of Public Accounts.

The Accounting Officer has since informed me that in advance of resolving certain outstanding issues with the Irish Medical Organisation (IMO), the GMS (Payments) Board has continued, in co-operation with Health Boards, to update the GMS register and identify expired medical card records. As of July 2004, a total of 104,236 records have been removed from the GMS register. Most would be considered by the Health Boards to be normal deletions due to death, change in eligibility status or persons moving from one board area to another.

The number of records relating to over-70s, and more than 3-months expired, was 29,165. The estimated overpayment arising from the removal of these cards from the register now amounts to €8.468 million (of which €0.769 million relates to superannuation). The overpayment amount was calculated in line with detailed guidelines drawn up by the Health Boards Executive in early-2003. The number of GPs involved was approximately 1,780 with individual overpayments ranging from €31 to €42,000. Nothing had been recovered by July 2004.

The Accounting Officer informed me that negotiations with the IMO on this matter were ongoing. Immediately after his attendance at the Committee of Public Accounts in September 2003, the IMO were informed of the Department's intention to fully recoup the overpayments identified, in line with the commitment given to the Committee. The IMO resisted recoupment of overpayments and maintained that GPs have been underpaid for certain other categories of medical card clients under 65, namely unregistered newborn babies and teenagers who become eligible for a card in their own right on reaching the age of 16.

He added that given the strong probability of a legal challenge, the Department agreed to have the alleged underpayments examined. The IMO have only recently responded to draft terms of reference for an examination of alleged underpayments and have also raised a number of other concerns. The GMS (Payments) Board and Health Boards have undertaken a preliminary examination of the issues raised by the IMO and, following acceptance of the terms of reference, the formal examination was expected to get underway shortly. He hoped to have this process completed by end September 2004.

I asked the Accounting Officer if the general contract with GPs has been amended to meet the concerns raised by the Committee of Public Accounts.

In response he informed me that the terms of the existing GMS contract reflect the agreed outcome of industrial relations negotiations between the Department of Health and Children and the IMO. There was no provision in the existing contract that would allow for the automatic deduction of an identified overpayment. However, the Department had offered to engage with the IMO in a wide-ranging review of general practice, which would address all aspects of the relationship between GPs and the public health system, including a full review of the current contract. The review would take full account of the structural changes taking place in the Health services, the Health reform agenda, the Primary Care Strategy, the flexibility terms under Sustaining Progress and other relevant issues. He added that the IMO had refused the Department's offer of a review until certain industrial relations issues are addressed. Discussions on these issues were ongoing.

Refunds under the Drugs Payments Scheme

In my 2001 Report, I also drew attention to the overpayment and underpayment of subsidy to persons availing of the then new Drugs Payment Scheme arising from the delay in making regulations to give the scheme legal effect.

In response to my request for an update regarding the payment of refunds due under the Scheme, the Accounting Officer informed me that 36,278 refund cheques in total had been issued by July 2004 amounting to €6,437,845. The average refund was €177.

He added that apart from a small number of valid claims being finalised, query cases and late claims — which would be dealt with sympathetically — the process was complete.

The administrative cost of processing the overpayment refunds was approximately €55,000.

Mr. John Purcell

Chapter 12.1 deals with outstanding matters from two issues on which I reported in my 2001 report. The first was the difficulties associated with trying to recover approximately €8.5 million from doctors who had been overpaid capitation and related payments under the GMS scheme, arising from the failure by health boards to delete invalid medical card records from the system at the appropriate time. The second issue was the state of play regarding the refund of moneys to persons affected by the delay in putting the drugs payment scheme on a proper legal footing.

The committee will recall the evidence given by Mr. Scanlan's predecessor at an earlier meeting regarding the Department's determination to pursue full recovery of the overpayments from the doctors. However, the doctors' representative body put forward the view that any such recovery would take account of what they claim to be compensating underpayments arising under the GMS scheme, resulting, for example, from the delay to the GPs' authorised lists of medical card holders, newborn babies and teenagers who would become eligible in their own right for medical cards on reaching 16 years of age. The bottom line is that no recoveries have been effected to date. The Department's Accounting Officer can update the committee on developments since.

The final outturn in the second issue shows that refunds totalling approximately €6.5 million have been made to those who submitted claims on the basis of being adversely affected by the delay in legalising the drugs payments regime. Over 36,000 people received refunds at an average value of €177. The committee will recall that the refunds were not automatic as the onus was on the individual to make a claim. This accounts for the difference between the outturn and the estimated liability which was originally put at between €17 million to €18 million for a potential 175,000 potential recipients.

Mr. Scanlan

My predecessor last reported to the committee on this matter in September 2003. At that stage, an extensive exercise had been conducted by the former health boards which had resulted in the removal of some 80,931 records from the GMS medical card register. These records related to clients aged more than 65 years of age, of which 72,945 records related to persons aged over 70 years.

Based on guidelines agreed with the former health boards for this exercise, not all records would have generated an overpayment. The bulk of them would have related to normal activity, such as removal due to death or a person moving from one board area to another. Of the remainder, a total of 28,156 records were more than three months on the register at that time and would have generated an overpayment. The estimated overpayment in September 2003 amounted to €8.294 million. This broke down into €7.54 million in respect of capitation payments and €754,000 in respect of superannuation. A further amount of overpayment would have occurred in the case of GP non-capitation allowances. However, as this proved extremely resource-intensive to calculate, it was not considered cost-effective to pursue the additional amount.

A commitment was also given to continue to update the GMS register and identify expired medical card records. An update was provided to the Comptroller and Auditor General in July 2004. At that stage, a total of 104,236 records had been removed from the GMS register. The number of records relating to over 70s and which were more than three months expired was just over 29,000, a slight increase on the earlier figure because the bulk of these records had been identified by September 2003. The estimated overpayment had also risen slightly to €8.468 million, of which €769,000 related to superannuation. The number of GPs involved was 1,780.

To date, the level of overpayments identified with some balancing of data amounts to approximately €9 million. The position regarding records is as reported in July 2004, which resulted from an extensive examination of the 104,236 records that were removed from the database in the period, from February 2002 to February 2004, that was agreed for this exercise.

In line with the commitment given to the committee in September 2003, the Department and the HSE undertook to recoup the amount of overpayment identified. However, the IMO resisted recoupment of overpayments and maintained, as the Comptroller and Auditor General pointed out, that GPs have been underpaid for certain other categories of medical card clients under 65. Given the strong probability of a legal challenge, the Department agreed to have the alleged underpayments examined. This further examination got under way in mid-2004, when terms of reference were eventually agreed with the IMO. A draft report of the alleged underpayments, carried out by the same dedicated HSE or former health board-led team, was provided to my Department in March 2005.

Potential underpayments have been examined with regard to three principal categories relating to delayed registration of infants, removal of young adults from the GMS register at age 16 and interruption of eligibility due to failure to meet a review request. The underpayment amounts to €1.8 million with regard to these three categories. In addition, a number of other categories identified by the IMO have been accepted for examination. Among these are out of hours and special-type consultation claims, which were not complete and which were not paid. The task of calculating the value of underpayments in these and other related areas is much more complex. An estimate of the value has been made and is being independently quality-assured at present. It is expected that this process will be completed within the next two to three weeks. On the basis that all of the areas of alleged underpayments are accepted by the HSE and the Department on completion of the exercise, it is expected that the amount of underpayments will increase significantly and that the net overpayment will reduce accordingly.

With regard to ongoing management of the databases, the HSE team has expressed its satisfaction that the focused work on the data cleansing has removed the expired records and duplicates. The HSE, through the schemes modernisation project, has produced a management and control document which sets out a standard national framework for managing the medical card database and ensuring data integrity and currency. Minimising the risk of duplicates being created on the system is being addressed on an ongoing basis through standard management and control procedures. However, eliminating this risk ex-ante will only be achieved when the national schemes client index is fully implemented and applicants can be uniquely identified at a national level. The national schemes modernisation and national client index projects have been progressing this agenda and some 95% of cardholders on the medical card register now have a valid PPSN assigned to them.

This is very significant progress in terms of the preparatory work that needs to be done in advance of implementing a national schemes client index, as the PPSN will be the unique identifier for the future. Proposals for moving towards a single national schemes IT system are currently under active consideration by the schemes' modernisation project team. The implementation of a national schemes IT system allied to the implementation of a schemes client index will significantly improve the performance of schemes both from a customer services perspective and from a management and control perspective.

Other enhancements are being progressed through the two projects such as a national medical card assessment guidelines document, which is currently under consideration by the Department, the introduction of a standard national medical card application form and the implementation of a national standard training programme for staff involved in administering the medical card scheme throughout the HSE. Overall, the HSE has assured the Department that management of the database and removal of records as they expire is more robust. Evidence of this is borne out by the number of eligibilities expired each month, resulting in the overall increase in cards currently being low. Regarding the drugs payments scheme refunds, the position is basically as set out by the Comptroller and Auditor General. This scheme has been brought to a conclusion.

My statement was prepared so that it would be ready for the committee but I believe my predecessor touched on the fact that overpayments to GPs are part of a wider industrial relations process. Some of my colleagues have spent the past two full days on that matter, right up to late last night. I could, therefore, offer some update on that, if the committee wishes.

Will Mr. Scanlan do so now?

Mr. Scanlan

We had the first substantial engagement with the IMO in the past two days on a range of industrial relations issues, including a variety of claims by the IMO and a variety of items which the management side — the Department and the HSE — would have been seeking. My understanding is that although there was good engagement on a range of issues, the negotiations were ultimately adjourned last night and had effectively broken down. That happened very late last night so we must consider where we go from here.

May we publish Mr. Scanlan's statement?

Mr. Scanlan

Yes.

I welcome Mr. Scanlan and wish him well in his new and onerous task in taking health off the political agenda. I also welcome his colleagues from the HSE and the Department of Finance.

I would like some general information. I do not need to tell anyone here that the hospital services and system have been under considerable pressure on a number of fronts. Does Mr. Scanlan have the overall figures for the number of patients treated in hospital and as day patients during the past 12 months or does he have the most recent figures in this regard? How would they compare with the numbers of such patients treated in the past?

Mr. Scanlan

I thank the Deputy for his welcome. I have figures for inpatient discharges, day cases and total discharges. I also have some figures for casualty attendances. The figures I have relate to 2004 and back over a number of years. If the Deputy wishes, I can provide a few headline figures and give the details later.

Total discharges in 2004 amounted to 1,040,181 million. That included day cases and inpatient discharges and represented an increase of just over 2% on the 2003 figure. In 1997, the total discharge figure was 779,539 and, therefore, from 1997 to 2004 there was a cumulative increase of 33%. It should be noted that there is quite a significant difference in terms of the increase between inpatients and day cases. With regard to the cumulative increase mentioned, 33%, the corresponding figure for day cases is an increase of 91%, while the inpatient figure is 7.4%.

The 2004 figure for casualty unit attendances is 1,240,241 million, a 2.4% increase on the 2003 figure. Going back to the 1997 figure, the cumulative increase over the entire period is 2.2% so the figures have risen and fallen somewhat in this area. They have generally been around 1.2 million.

I do not have full details for outpatient department attendance but the 2004 figure was 2.368 million, compared to a figure of 1.9 million for 1996. I am sorry the figures are not directly comparable but I just have the 1996 and 2004 statistics for outpatient departments. If one looks at inpatient, day, casualty and outpatient attendances and the totality of people who came through the hospital under those headings, the figure for 2004 was 4,615,000. The total population for 2004 was just over 4 million, so——

That brings me to my second question. There is a population of just over 4 million, a good environment, reasonably good nutrition, opportunities for housing and so many different socio-economic areas have improved. There must be no comparable figure in Europe for such an enormous percentage of the population seeking hospital treatment in a particular year. It is obvious that there has been a fantastic increase in day hospital throughput, which is welcome because people can return to their daily business quickly, etc. A great deal of effort has gone into that. Pursuing that trend for a moment, there has been a 30% increase in staffing in the health services — I shall ask some questions about that later — in a period of seven or eight years. In statistical terms, we are talking about a quarter of the population availing of hospital facilities. Is there any comparable figure anywhere else in the world?

Mr. Scanlan

I must admit the Deputy's question is good. In the period I have dealt with, I was trying to come to grips, in the first instance, with the services we provide. I do not have figures with me. We believe our figures are higher than the corresponding UK statistics. It is a valid question to ask and I believe that is the 1 million to whom the Deputy is referring, particularly if one looks at the day and inpatients. I assume it is more difficult to make comparisons if one includes casualty because that could lead to a debate over how much care is provided in hospital as opposed to primary care areas in other countries. However, as regards the Deputy's question about actual day or inpatient admissions, it should be possible to get comparable figures as a percentage of the population. I do not have those figures with me but I will seek them out.

Does Mr. Scanlan have the figures for the increases in staff over four, five, six or seven-year periods, particularly in terms of those who are in the frontline in respect of delivering services?

Mr. Scanlan

I have some figures with me. Again, I have figures that start in 1997 and run up to 2004. I have a second set of figures that shows the changes from 2002 to 2004. The Deputy is aware that the Government introduced a system of numbers control that took effect in 2002.

Let us consider the 1997 to 2004 period. The Deputy mentioned an increase of nearly 50%. It is 45% overall. If he so desires, I will give the top line figures first. The figures have gone from 67,895 to 98,723, an increase of 30,828 or 45%. They are categorised as medical, nursing, health and social care professionals, general support and other patient care and management administration. They may be looked at in different ways. I can give the Deputy the figures and I was also looking at the percentage increase for each category. One may also look at the actual increase as a percentage of total. There are different ways of looking at the figures.

In broad terms, management administration accounts for just under a quarter of the total increase of nearly 31,000. General support and other patient client care accounts for another quarter. The other half is accounted for by medical, nursing and health and social care. That is one way of looking at it. Another way is to say that medical numbers have increased by just over 40% during the period in question. Nursing has risen by 25%. There is something of a problem with the other two categories — health and social care and general support — because a group of child care workers moved from one to the other. In that sense, the figures are somewhat skewed. One is very high, at 115% and the other is very low, at 37%. Management administration is approximately 80%. Just over two thirds of management administration personnel are involved in direct patient services, which leaves approximately one third who are involved in core administration. Everyone accepts that to run an organisation of this size, a certain level of administration is a prerequisite just to pay people, etc.

The more recent figures show that the large increase in numbers was concentrated in the period 1997 to 2002. If one goes back to what I said about an increase of nearly 31,000, the increase from 2002 to 2004 was just over 3,000. Instead, therefore, of a 45% increase over the entire period, there was an increase of 3.4% in the 2002-04 period. I do not want to highlight too many figures. Depending, however, on what the Deputy is interested in and if he just takes the 3.4% as an overall average, the variances show that the increase for medical-dental is somewhat higher at 3.5%. Nursing is just under this, at2.7%, as is management administration, at 3%. Other patient and client care is above the average at 7.7%.

If I were to say to Mr. Scanlan in 1995, 1996, 1997, 1999 or 2000 that over a period of seven or eight years he would have a 45% increase in his staff, would he have been able to promise me he would not have any problems?

Mr. Scanlan

If the Deputy had promised me that in 1997, I probably would not have believed that he could deliver. There has undoubtedly been a large increase in the resources that have been provided for the health services. If financial investment is provided for the health services one has to recognise that it is a people-delivered service. That means the vast bulk — 70% — of the funding will go into staff.

Did Mr. Scanlan's Department approve all those appointments? To what extent was he aware of these appointments or were all of them necessary?

Mr. Scanlan

My understanding is that the system which the Department had for managing numbers in the former health boards varied over the period. I will have to recall the precise time when the system changed as the Department exercised an oversight role and then delegated that out to the health boards on the basis that the numbers would, in any event, have to be managed within the available financial resources. Approximately four years ago it was delegated out and then, with the introduction of Government policy on numbers, the Department has required the former health boards to report to it on the numbers. We now have the HSE and it has changed again. This is because the HSE under the legislation has the responsibility. The emphasis has changed.

As to whether all the numbers were justified, I do not believe the Department could say yea or nay to that.

Does Mr. Scanlan believe some former health boards took their responsibilities in this matter more seriously than others?

Mr. Scanlan

The short answer is that I do not know. The figures I have seen suggest that the rate of increase varies across the health boards. It varies between health boards and voluntary hospitals and it also varies between the health boards and the voluntary sector. It expands all of these areas.

I must make a couple of points. We have to recognise that extra resources have been invested in the health services. The health services, in turn, have delivered a higher level of service. I do not think it is sufficiently recognised that it is delivering much higher volumes of service. There obviously are problems and the Deputy started by suggesting it be taken off the political agenda.

I accept that completely. The figures indicate an increase of 250,000 in respect of day hospital places in a short period.

Mr. Scanlan

The employment level — in addition to our outside financial management — warrants management in its own right. It is not sufficient to grant a financial allocation and allow the numbers to be managed within that. Employment numbers bring particular rigidities into the system. Once people tend to be employed in the public service, it is hard to change that. They also bring year on year inflation as pay inflation tends to be higher than normal inflation. One must consider how the numbers are going in addition to monitoring the position regarding cash.

Perhaps there has been an over-emphasis on the management administration side. We need to stand back from these rather crude categories and take a broader look at what is involved. I do not have comparative figures on activity in hospitals across different countries but I recently saw some interesting figures on the numbers employed. These figures showed that the ratio of nurses to population is over 12 to 100,000. That is 50% higher than comparable OECD figures for other EU countries. There must be reasons that Ireland has proportionally more nurses than other countries. It may have something to do with a country's skills mix, a matter that was raised in our negotiations with the IMO.

Medical card assessments, as well as other aspects of administration which are part and parcel of the health services, must be carried out. The traditional system of managing hygiene in hospitals was done internally. In more recent years, responsibility in this area has been transferred to outside agencies. According to recent figures, as many as 50,000 patients could suffer from MRSA in one year. This is down to in-house hygiene management. Considering the pressure on the health services, we cannot afford a situation where one in 20 patients becomes ill as a result of MRSA. What action is appropriate to deal with this? In the worst of times we dealt with this in an old-fashioned way.

Mr. Scanlan

Many people have made that comment and there is much truth in it. The figure of 50,000 is way off anything I have received. There were 445 cases of MRSA reported in 2002, 477 in 2003 and there is a provisional figure of 533 for 2004. The Deputy is absolutely correct about the importance of patient safety. The idea of going into a hospital to be treated and being even more at risk——

What is being done about it now?

Mr. Scanlan

MRSA is now on a list of notifiable diseases and we have a strategy which was launched in June 2001. Funding was provided for it but I would have to ask people in the HSE to explain what is being done about it. I attended a WHO assembly meeting a few weeks ago at which I met colleagues from the UK. Some of what was being said about patient safety made one think seriously about the management thereof. Money is important and we need to keep investing in the system. However, money is not the solution. The latter lies in people using the money and working sensibly to do certain things. Some very simple practices like washing one's hands before moving from one patient to another are very important but are not happening.

Mr. Peter Finnegan

There have been developments such as the appointment of section control nurses in all hospitals and an increase in the number of microbiologists. For example, in the south east we are now about to appoint a third microbiologist. They have drawn up policies, procedures and guidelines for all the hospitals. Within that, there are specific ways of dealing with patients diagnosed with MRSA. When patients enter hospital they can be carriers of MRSA so the task is to stop them infecting other patients in the hospital.

In my constituency, we have the highest incidence of suicide in Ireland. Are there statistics relating to attempted suicide? Is there any procedure for a follow-up to attempted suicide? An attempt is often made in advance of the final determination.

Do we distinguish between disorderly behaviour, drunkenness, illicit drug taking and people who come in with genuine illnesses in order that accident and emergency departments can cope? I accept that we need more beds in some hospitals and that the service is being improved. I am not a medical person but I have strong views on these matters. I have been given figures on self-inflicted damage on weekends and they are quite frightening. There is consequently a great pressure on accident and emergency departments at these times. What extra facilities are required to cope?

Mr. Scanlan

I have some figures on attempted suicide but they are not available from all hospitals and, therefore, are not available on a county by county basis. The national parasuicide registry, which was established in 2000, publishes annual reports. Its third annual report, which was published last December, indicated there were approximately 11,200 presentations in 2003. However, those figures are not broken down on a county by county basis. From the figures available to me, which have been discussed in the House, the total number of suicides in 2003 was 444. I understand what the Deputy is saying, namely, that in some cases self-harm or parasuicide may be a signal that the individual intends to commit suicide. Equally, it has been said to me that the contrary is the case. I do not have any evidence to suggest a particular link between one and the other.

More generally, on the accident and emergency issue, Deputy Michael Smith is correct about the nature and scale of the problem. I should not provide statistics because I am still awaiting the results of a broader study that is under way. I hope the committee will bear with me if I use an indicative figure. I have heard that some 25% of attendances are in some way alcohol related. On the other hand, it is a difficult area to judge and much depends on the nature of the presentation — the HSE representatives might know more about the operational reality. If somebody presents unconscious having fallen, he or she would have to be treated. One may have a sense of what has induced that situation but it would be clear that the person needs medical attention. The short answer is that at present, probably correctly, everybody is treated in his or her own right as an individual, depending on what medical care is required.

There is a related issue, to which the Deputy referred, concerning the disruption caused within accident and emergency units and patient and staff safety. The committee will be aware of the studies carried out by the Health and Safety Authority. Further such analysis is ongoing. My concern is that if we do not find a different way of managing this issue, it might happen that any extra investment in accident and emergency would be spent on security. It is obvious that a safe, secure area is necessary for patients and staff. When one stands back from the issue, however, if there is an intention to invest in accident and emergency units, it would be hoped that the investment would be to improve medical services. The thought that investment in security would be necessary is one with which I am uncomfortable. One would want to know whether an alternative way of dealing with the issue was available.

Assuming Mr. Scanlan was serving in the Department of Health and Children in 1997 and obtained a commitment for a staff increase of 45%, Deputy Michael Smith asked him whether this would have solved the problems. I was Minister of the Department in 1997. The analysis at that time was that if adequate resources and staff were available to deliver the service, the problems in the health service would be solved. It was also recognised, however, that day-to-day problems and crisis management would remain. The health service had been run down in the late 1980s but picked up in the 1990s. The argument was that if enough resources were provided, we could solve all the problems. What has happened since has contradicted that analysis.

In 1997, the health budget was €3.4 billion. In 2005, the figure I have for current expenditure is €10.4 billion. In cash terms, in the eight years since 1997 expenditure by the Department of Health and Children has tripled, with an increase of 207% in total and of 15.1% annually. In that period, the number of staff employed in the health services — when agency staff are included in the full complement of employees — increased from approximately 67,000 to slightly over 100,000. That constitutes an increase of approximately 33,000 staff delivering services. The Celtic tiger has increased employment. Given that the total number employed is approximately 1.9 million and 100,000 are employed in the public health service, one person out of every 19 at work is working in the public health service. However, a hopeless service is being delivered.

It is no longer about money or numbers because the money and numbers have been put in place. There might be greater output from the health service, as was elucidated in the statistics provided by Deputy Michael Smith. However, while one person out of every 19 in employment works in the health service, the public perception is that there is no value for money. I fully accept that the analysis in the mid-1990s was that if we had the resources and could use them to hire extra staff, we would have a super service. It has not happened.

While I wish the Health Service Executive well, it seems that difficulties will arise. The executive is not fully up and running operationally because too many of its key positions remain unfilled. My memory may be playing tricks but I understood that, as part of the legislation, the remit of the CEOs of the traditional health boards will end in June. The HSE should be given a fair chance. Its staff, at all levels, are working very hard at present. However, Dr. Halligan, who originally took up the position, does not intend to serve as chief executive. Mr. Kevin Kelly acted as executive chairman and did a very good job but he will not stay on either as executive chairman or chairman.

As I understand it, the position of human resources director — in traditional terms, head of personnel — is still vacant despite continual advertising. I congratulate Mr. Diarmuid Collins, HSE national director of finance, on a very satisfactory recent appearance before the committee. However, I read in a newspaper four days later that he intends to move to a position in financial management at University College Cork. Another key position will, therefore, become vacant. I read in the weekend newspapers that Dr. Drumm has not fully signed on yet. I hope he will do so because I know him and am aware of his reputation. Dr. Drumm is held in high esteem and will be a great asset to the HSE. However, regardless of whatever is going on in the background, he has not fully signed on yet.

It is perhaps 18 months since legislation introduced the new HSE. The health boards and their chief executives are being stood down. This must be put in the context of the points I have made, namely, that the spend has trebled and the number of staff has increased to 100,000, meaning that one person in 19 of those in employment works in the health services. In addition, the new health authority does not have its full complement of key people. This means it will be difficult to effect the necessary changes. Perhaps Mr. Scanlan or the representatives of the HSE would like to comment on those points. I will then pose further questions.

Mr. Scanlan

I fully accept what the Chairman says about the belief in 1997 that money might solve the problem. I also accept that there has undoubtedly been significant investment in the health service. However, the manner in which that money has been spent bears examination by this committee and in the wider public domain. As members are aware, a significant proportion of the money invested in the health sector has gone towards staff payment. There are two reasons for this. First, as the Chairman observed, increasing staff numbers mean a higher wage bill. Second, as I mentioned already, once a person is employed in the health service, the rate of inflation in pay costs tends to be high.

This is an issue that must be considered because there is clearly a difficulty in regard to inflation in the health sector. I have been involved in negotiations on pay in the public service on many occasions and some of them have taken place during my time in my current role. Rather than reacting to particular disputes in a certain way, people should recognise that in every set of negotiations the Department of Health and Children and the Health Service Executive try to represent the best interests of taxpayers in terms of how funds are spent and how much is allocated for individual pay packets, additional staff numbers, direct service provision and so on. There is insufficient data in this regard but it is accepted that health inflation is higher than general inflation. New drugs that come on the market tend to be more expensive. However, they are also usually more effective and it is understandable that the health service should try to produce and deliver the most effective care. We should acknowledge that endeavour.

We must try to strike a balance. I fully accept Deputy Michael Smith's observation that health is an issue still very much on the political agenda and that there are difficulties to be overcome. However, I cannot accept the contention that we are providing a hopeless service. Perhaps one of the problems with the health service has been its failure to communicate the message of the good service that is provided. I am aware of independent surveys which point to good patient satisfaction with the service received.

These difficulties are not unique to the health service. We all know that good news does not sell in any walk of life and, therefore, one often does not hear about it. My understanding from talking to people is that patients generally rate the health service highly. I accept that there are problems in regard to access and this is sometimes reflected in the conditions in accident and emergency units. However, it is incorrect to contend that significant sums of money have been invested in the health sector without any improvement to the service provided.

It is now clear that money is not the only issue. I regularly attend discussions and presentations and the consensus among the experts is that what is required is sustained investment in health to make up for the earlier under-investment identified by members. I accept that. There is a similar situation in regard to infrastructure. Our infrastructure cannot be brought up to international standards through the allocation of significant funding for only two or three years. We saw what happened when such an approach was taken. Funding for the health service must be forthcoming at a sustained level.

Equally, however, one can only manage the system year on year if any value is to be had from the investment that is given. The money must be put in the hands of the various actors in the system and everybody must work together. Additional funding is too often seen as the solution to every problem and it usually translates into extra staff. I am conscious of my background in the Department of Finance in emphasising that I do not contend that there is no need for investment in the health service. Such investment is required but it is not merely a question of money. The health sector delivers a level of service of which the public may not be fully aware. That is our fault and it is an issue on my agenda. We must communicate what is delivered for the money that is invested.

The HSE was established on 1 January 2005 and has been in operation for almost six months. I am not sure what I said on this matter on the previous occasion but I am learning as I go along. There is a significant job to be done in terms of the transition from the old health boards to the HSE and an even greater job after that of transforming the entire system. A simple transition from 11 health boards to one national executive is not the final objective of the reform programme. I share some of the concerns of members about the pace at which this transition is taking place. I do not want to go into too much detail on this but members' points have been well made.

I wish to move on but my next question also relates to numbers and the division of responsibilities. I do not want to drag the Tánaiste into this discussion but must mention her in order to position my question. A report in The Irish Times of 16 May was headlined, “Harney to pick which hospitals will get funding”. In regard to the capital programme, will it be a function of the Department of Health and Children or the HSE to decide which hospitals receive funding?

Mr. Scanlan

This is a question to which there is a straightforward answer. There is no basis to that article. The HSE prepares its capital programme and submits it to the Tánaiste. The Department, which has an advisory role with the Tánaiste, then engages with the Department of Finance. We have done that and are close to a conclusion. This is an issue about which I need to consult the Tánaiste. It is not a question of the Department of Health and Children picking and choosing which projects go ahead.

My Department will evaluate the programme in an overall sense to determine whether there is a reasonable mix between the acute and non-acute sectors and whether we are generally satisfied with the strategy being adopted. For example, we must satisfy ourselves in regard to the revenue and staffing implications of any capital investment. I argue strongly that there is a level of evaluation and analysis in which the Department should be engaged and for which it has a responsibility in its new role. I make no apologies for that. This role is not, however, operational to the extent of choosing which projects will go ahead, as was portrayed in the article to which the Chairman referred.

The same article prompts other questions. Capital projects with a value of some €400 million have been built but not commissioned. Money was available in the capital fund for the construction of the new wing of Mullingar Hospital or the health centre in Ballymun, for example, but there was no money in the current account to staff those facilities. That has been the historic position. There is now a suggestion that the Department of Health and Children will proceed differently in the future and will only provide a building when it is sure it can commission and staff it immediately. The idea of the vacant building as a type of monument to the inefficiency of the system with no staff or output and no access for potential patients would, therefore, be a thing of the past. Is that the position?

Mr. Scanlan

I would go even further in terms of the view I have formulated since taking this job. The process by which projects are selected in the health service at the very initial stages of capital planning involves the requirement to balance need, cost and impact. I contend that this type of selection and analysis cannot be done if there is no reasonable estimate at that stage of the full cost of what is being undertaken. It is incorrect and simplistic to consider only the capital cost. I recognise that a change in this regard will take some time but I will press for a system whereby an estimation of the current and staffing costs must be provided at the project analysis and evaluation stage. One must update costs as projects proceed and go to tender because one will continue to get a better grip on such projects. I do not see much point in building facilities and then trying to ascertain whether one can afford to open and staff them. There is a legacy issue which we must address. A major chunk of it was dealt with last year. However, there are remaining legacy issues in this year's proposal and we will address them.

That is not to say that one does not proceed with certain projects simply because they have a revenue implication. When one makes a decision, one does so in the knowledge of such an implication and one makes a call whether to fund it.

Mr. Scanlan distributed figures on staffing to the committee on Tuesday night and Deputy Michael Smith took him through some of them. The Department must reduce its total numbers by approximately 1,100 staff in order to comply with the complement allocated by the Department of Finance. How will the Department develop and staff new projects along the lines suggested by Mr. Scanlan if 1,100 people are to be taken out of the system? Mr. Scanlan is saying that capital projects will be replacement projects, whereby existing staff will operate replacement facilities. The Department will not be in a position to have any new facilities because it does not have the staff. This is shown in the figures supplied. The Department is moving in the opposite direction by removing 1,100 staff.

Mr. Scanlan

That is the case only if one accepts that the existing staffing situation is static and will remain as it is. This is not easy and I do not have a simple solution. However, I do not necessarily accept that the Government's numbers policy immediately and automatically translates into a policy whereby one cannot grow the capacity for new developments. My former colleagues in the Department of Finance may have a view to express on the matter. However, the fact that one must incorporate revenue and staffing implications into a decision does not mean that a particular decision is not made. It means that one makes the decision in the full knowledge of the facts.

Depending on scale and need, we could go to the Department of Finance, or ultimately to Government, and present the choice. We could state that we have a need in terms of extra capacity and know what it will cost in terms of revenue and staffing. We would combine this with a numbers and revenue management policy and give our view and advice. I do not wish to speak for the Department of Finance but I do not regard the situation as a straitjacket which forces us into making decisions that do not make sense. It still allows Government to get better advice and make decisions.

The numbers' ceiling is a major issue and we are above the limit. There are other issues which we still must settle. We owe the Department of Finance figures and proposals in respect of the impact of the packages sanctioned this year for disability and accident and emergency services. It was known that these would have implications in terms of numbers and we have yet to get back to the Department of Finance. This demonstrates the point I am making. Government can make a call and adjust the numbers' ceiling accordingly. However, the health service has a major issue in terms of bringing the numbers down below that ceiling. There is a level of turnover within the system which, if managed properly, allows us to adjust the numbers across the system. This will, however, take time.

We need to look more seriously at the sort of figures to which I referred earlier. I am not singling out nurses but I saw the figures. Deputy Michael Smith asked about inter-country comparisons, which at least give us somewhere to start and a way to identify where we may be overstaffed. Otherwise, more and more people will be working in our health service in the future. How sustainable is that? There must be a limit.

We hope Mr. Scanlan is very successful and that matters go well. However, he should not suggest that one of the solutions is that there should be fewer nurses. He is going down a dangerous road by saying that we have too many nurses in the system on the basis of inter-country comparisons. Mr. Scanlan can clarify the matter if I misunderstand what he has said.

Mr. Scanlan

I am not making a judgment on the issue. I agree with Deputy Michael Smith in that one of our roles in the Department of Heath and Children is to start getting a much better grip on the facts and figures across the health services with regard to what we spend and deliver, how we deliver and our staff. Inter-country comparisons always have downsides and difficulties and must be carefully done. However, questions should be asked and issues explored when the evidence is produced.

The ratio of nurses is higher in Ireland than elsewhere. I am not making a judgment on that but it is reasonable to question the figure and seek an answer. There are options. There are other areas where our numbers per head of population are less than other countries. Where will that lead us? The argument about management administration perhaps does not take us to the level of analysis required to tackle the issue.

One of the problems is a lack of joined-up government. Mr. Scanlan's predecessors were faced with the quandary of having funds in the capital budget which they wished to spend and not having enough funds in their current budget to commission the facilities. They did not receive permission from the Department of Finance to exceed the numbers cap. However, they decided to build the facilities anyway because they had the money to do so. They thought that as time went by the pressures of the system would ensure that they could commission and staff the facilities with the additional numbers. This was not an ideal situation. However, Mr. Scanlan is faced with something similar. He has the capital funds and a cap on numbers. Unless the Government makes a specific decision which allows for exceptions in respect of a particular service, Mr. Scanlan will be removing 1,100 staff rather than putting in additional people. Either the Department will simply carry out replacement work from its capital budget, which is also important, or it will return capital funds to the Exchequer at the end of the year. That was the problem faced by Mr. Scanlan's predecessors and they dealt with it differently. We could philosophise about the issue for a long time.

I wish Mr. Scanlan well in his position and I hope the HSE gets up to speed as quickly as possible. It is in all of our interests, as politicians and citizens, to see it succeed quickly. Is it a concern that so many vacancies exist six months into the life of the Health Service Executive and that some people are leaving and others pondering the decision for a long period? Has Mr. Scanlan begun to wonder about that matter? Is there cause for such early disquiet about the positions on offer?

As far as the figures mentioned by the Chairman are concerned, a number of companies have come to Ireland and, using the mix and profile of employees elsewhere — either on the Continent or in England — as a basis, have decided to set up in a similar manner here. However, they have found that the Irish economy is quite different. A large number of interests came here on the assumption that they could superimpose a successful unit of their operation in Ireland. In my experience, three different companies lasted for two years and found they were simply unable to continue the service.

As a way of commenting on Mr. Scanlan's statements so far, I suggest that the problem is not the service. My colleagues from the South Eastern Health Board might find it strange to hear me state that but plenty of good news stories come out of the service being delivered. The question is not about the service one actually receives, it is about getting that service. In my experience, it is becoming more difficult to get the service or to even be considered for the treatment purchase fund.

I draw Mr. Scanlan's attention to the number of parliamentary questions. The Chairman touched on this at the previous meeting and referred Mr. Scanlon to the manner in which the Department of Social and Family Affairs operates. I appreciate that the HSE has only been in operation for six months. Even at this early stage, however, the type of information Deputies receive in reply from the Health Service Executive and the Department of Health and Children is nothing short of disgraceful. The Department passes questions on to the HSE as quickly as possible, with the least amount of information provided. This happens even though it may be a departmental issue. The Health Service Executive then provides so little information that the question was not worth asking in the first instance. This leaves one to wonder if the question was even read.

I will give an example of the issue, because Deputy Michael Smith has raised it. The witnesses should take note of this because it will arise in a different and public way shortly. Although the HSE has only been in operation for six months, I am of the view that Members of the House will no longer accept the replies they receive. If memory serves correctly, I recall that I tabled a question relating to MRSA on 1 March 2005 which has yet to be answered. Before that, I tabled another question regarding psychiatric services in Kilkenny. That question has also not been answered. I can point to a number of questions tabled concerning money, efficiency in the service and value for money. I can also highlight numerous other parliamentary questions tabled where replies have not been given or where apologies have been given for the delay in delivering the replies.

Today, I have tabled a further parliamentary question to the Tánaiste and Minister for Health and Children asking that she do something about this problem because it is unacceptable. If Deputies are unable to provide the public with information about a service which fails to deliver either the information or about the service itself, what hope has the Department of winning public opinion over to its side?

The MRSA superbug has been mentioned. I chaired a public meeting last Friday night in Kilkenny at which I had expected perhaps 20 people to turn up. I did not count them but more than 150 people gathered in the room. I was shocked and horrified by the stories told. I will not go into many details here. Deputy James Breen was present and recounted his own experience. A lady of 68 with perfectly good health caught MRSA and is now in a wheelchair. She has never been informed that she has MRSA. Another young lady of 24 also contracted MRSA, I believe in the stomach, and is now blind in one eye and her condition continues to deteriorate. A case which is constantly spoken of in Kilkenny concerns a man with plates in his back who has returned to hospital. His wife can tell of some horrific experiences with hospitals. Has the Department arrived at any costings for conducting a public information campaign? This was such a major issue in the recent British general election that, having been re-elected, the British Government immediately set about doing something about MRSA.

How much would it cost to implement a public information campaign dealing with the issue in every hospital and GP clinic throughout the country? Why are people not informed that they have MRSA? One of the major complaints to emerge from the meeting was that people have died from MRSA but the death certificate records cancer or something else as the cause. People told their own stories and I was amazed. They came to the top of the meeting room and told their stories. Other people present informed the meeting that they had provided quotations to the HSE for the provision of isolation units or wards and for the provision of alcohol based hand cleaner. Why is this information not acted upon? Does the Department not have money? It has €12 billion at its disposal. When it comes to this issue, what has been done with that money?

I have another question regarding psychiatric services. Is it a fact or just another newspaper story that the Tánaiste and Minister for Health and Children is considering the use of private funds to provide these services by way of tax relief schemes or other methods? If we are playing catch-up in the context of general health issues, we are certainly also obliged to do so with the psychiatric services. I understand that the number of suicide cases in Kilkenny is 26, a particularly high number as far as Carlow, Kilkenny and Wexford are concerned. What funding is being provided to deal with this issue and to provide what some consider to be very poor community support within the psychiatric services? One of the parliamentary questions I tabled concerned a group which attempts to support the psychiatric services in Kilkenny but which gets the cold shoulder. I am particularly interested in the suicide issue and I ask Mr. Scanlan to elaborate on it because, to say the least, the responses thus far have not been full of information.

Mr. Scanlan

Deputy McGuinness raised a point about filling the vacant senior posts within the HSE. It is a question of balance and quite a number of the posts have been filled at various levels. However, I did not disagree with the Chairman on this point earlier. I would have preferred to have seen a situation, as I am sure would the HSE as a corporate entity, in which a chief executive was in place and had been so since the beginning of the year. To that extent, I share the Chairman's concern about the issue. I hope the individual he mentioned will take up the position soon. Some posts have been filled while some key posts remain to be filled. This is a matter of fact and the longer the situation continues, the more unsatisfactory it becomes.

I agree with the Deputy's point about superimposing cultures or practices from other countries on Ireland. What I attempted to state earlier is that it is reasonable to look around at what others do. Inter-country comparisons must be undertaken very carefully. One must examine differences in systems. Very often staff are trained and categorised differently and provide an entirely different level of service. If one does not look at such evidence, I am not sure what else one will be left with. I agree that it should not be just a straitjacket but one assumes that something that works in another country will work here. We tend to come up with our own solutions which tend to work better most of the time.

Regarding the NTPF, Deputy McGuinness's more general point was that it was access, rather than the level of care received, that tended to be the problem. It is a fair point but I am not sure I follow his argument. I attended the launch of the NTPF's annual report yesterday. The numbers availing of the fund are increasing and this year additional funding has been provided — I think the figure is €64 million. The number who will be treated under it this year will be higher than last year's figure. The fund is also taking on a pilot outpatient treatment programme. I am not sure where the difficulty lies with access to the fund. When one examines the hospitals involved and the patients they are referring, waiting times appears to be decreasing. I am not saying we have resolved the problem; I am merely saying the position appears to be improving.

Regarding parliamentary questions and the service provided for Members of this House, I agree with the Deputy's point. The Chairman made the point very strongly at the last meeting of the committee and I heard it being raised by a number of his colleagues. All I can say is we are in discussions with the HSE to examine what practical steps we can take to improve the service. There is an issue with establishing an organisation such as the HSE and I ask members to bear in mind that the HSE is specifically designed to remove operational matters from the ambit of the Minister for Health and Children to enable her to perhaps begin the evaluation, analysis and joining of all the issues we have discussed in a better way than before, while trying to maintain continuing accountability to the Oireachtas. Whichever way we do it, the point has been well made that if one cannot continue to provide a level of service for Members of the Oireachtas and allow them to reflect on what is happening on the ground, we have a serious problem. I do not have a solution for members of the committee; I would be mad if I said I had.

Regarding MRSA, Deputy McGuinness mentioned the position in the United Kingdom where the Conservative Party had a particular policy on the issue. With support from us, the chief medical officer in the United Kingdom has pursued a project at WHO level around the issue of patient safety. Therefore, the issue is high on the agenda. We would also regard it as a high priority and funding has been provided. This is where we must join the discussion. Is it a question of funding or of what is done with it? Additional funding, including funding for educational initiatives, has been made available. There may be value in the Deputy's point about running a public information campaign, possibly in hospitals. Sometimes the simpler things which I am sure will not solve all of——

I would like to stop Mr. Scanlan because I wish to return to his point about MRSA and funding. How much money is available to hospitals or the HSE for an information campaign about MRSA? One can take all of the annual reports and national statistics one wants and make them sing and dance which can cloud what is happening on the ground but there is no campaign to combat MRSA in hospitals. A person can walk in and out of a hospital without washing his or her hands. He or she can do what he or she likes. Does Mr. Scanlan not realise there are insufficient wash-hand basins in wards and around hospitals, even for staff, which means MRSA cannot be dealt with? That is a fact. The HSE must be aware of the situation because it is engaging with those who are trying to sell it the appropriate infrastructure in hospitals to deal with it.

There is no evidence of an MRSA information campaign within GPs' waiting rooms. Those affected by MRSA do not even know it. The Department of Health and Children has a crisis on its hands. There is an information deficit, to which there is no response. Mr. Scanlan stated the Department had engaged with the authorities in the United Kingdom to help them. They must be in a deplorable state if they need our help because there is no evidence that anything is happening on the ground here. Those who look after MRSA patients in their own homes receive little or no support and are begging for help from an agency which has significant amounts of money to deal with issues such as this. I would like to hear from whoever is responsible about what is really happening.

I do not accept that the information Mr. Scanlan has given me reflects the situation because it is entirely different on the ground. In spite of an invitation from a local person, the HSE did not attend the meeting, despite the fact that many individuals involved in the area of health and safety attended in an informal capacity. Mr. Scanlan has a considerable problem with the Department or the HSE and I want to know what is his response.

Is it the case that legal problems will arise if it is openly stated a patient has died from MRSA? What money has the Department spent on informing those on the front line about MRSA? How much was spent on informing the GPs about it? How much has the Department spent in providing the appropriate wash-hand facilities throughout hospitals to deal with MRSA? How much is it costing it to look after MRSA patients in their own homes? Mr. Scanlan has answered none of these questions. In spite of the time he has been there, there should be sufficient information within the old health board structures and the HSE to answer them openly and honestly. I suggest the reason the parliamentary question was not answered on 1 March was the requested information was not available.

Mr. Scanlan

From the perspective of the Department, funding has been provided.

Where is it? On what is it being spent?

Mr. Scanlan

Funding has been provided in the past for the health boards and since 1 January for the HSE. From the Department's perspective, we provide the funding and advice and undertake policy analysis. I cannot run the health service from Hawkins House and if I did, I am sure I would make a mess of it. The operational delivery of services was a matter for the health boards and now for the HSE.

Deputy McGuinness asked on what the money was being spent. I am not clear on whether it is a question of funding; that was the only point I was making to the Deputy. Is it a question of a shortage of funds, funds not being spent well or people knowing about MRSA and safety precautions but deciding to ignore them? At its simplest, is it a question of not having a wash-hand basin or someone not using one? One question relates to education while the other relates to infrastructure.

Is Mr. Scanlan asking me the question?

Mr. Scanlan

I am merely saying the Department provides the funding and has done so in the past.

Can Mr. Scanlan tell me where the funding has gone?

Mr. Scanlan

I cannot tell the Deputy where it has gone.

Who can tell me?

Mr. Scanlan

I will have to talk to colleagues in the Department and the HSE to see if we can pull together an analysis of spending which would specifically examine the issue of MRSA and hygiene in general.

Would it not have been much better for Mr. Scanlan to tell me that by way of a reply to the parliamentary question on 1 March rather than sending it to the HSE which did not reply? What about the Department of Finance which looks after the public purse and gave the Department of Health and Children the money?

Mr. Scanlan cannot answer the question. I will give him my view of the health boards. He spoke about nurses. Inter-country comparisons on the issue of management should be examined alongside the nursing issue because it is management of the service that is in question. There is much scope for change and someone must have the answer. Sitting across from me are Mr. Scanlan's officials, representatives of the HSE and officials from the Department of Finance. Mr. Scanlan cannot tell me he has come before the Committee of Public Accounts and does not know some of the answers. If his finger was on the pulse or on the purse strings, he would know. I would expect any company with the number of officials involved at management level in the Department of Health and Children and the HSE to be able to give this basic answer.

Mr. Scanlan

I can only speak for the Department of Health and Children. Additional funding has been provided to tackle MRSA. Funding is also available in the system for normal hygiene management and control which forms part of this matter in terms of infrastructure and minor capital investment.

I have acknowledged there are issues about the way in which parliamentary questions are dealt with. Is the Department responsible for the operation and delivery of the health service or not? How does it ensure Members of the House receive a reasonable service? I accept these points.

Does Mr. Collins have information for the Deputy on the specific issue of funding to tackle MRSA?

Mr. Diarmuid Collins

I do not have it to hand but will get the required information on the HSE's relevant expenditure to date.

Can someone from the HSE also explain why MRSA is not identified as a cause of death in hospitals? This refers to the giving of a comprehensive reply to the parliamentary question I asked. The Tánaiste said there were higher standards of hygiene to be found in factories than in hospitals. Does Mr. Scanlan agree this is an incredible statement to make and consider it to be a reflection on the HSE, even though it is a new body, and hospital managers in general, irrespective of the MRSA issue? What will he, as a front line manager, do about the issue in regard to the money allocated and the standards of hygiene to be found in hospitals? Does he have a concern about the money allocated? Is the Department not receiving enough money to raise standards? A Spar corner shop, for example, has a plaque denoting its hygiene standards but the local hospital has no such standards.

Mr. Scanlan

I am concerned about what is occurring in the system in terms of patient safety generally and MRSA, in particular. I heard the Tánaiste's statement and understand why she made it as we both attended the WHO meeting. Without being alarmist, the figure and examples I mentioned would make one sit up and take notice. Therefore, I fully accept the point.

On whether we are receiving enough money to cope with the problem, the first reaction should not be to treat this as just a money issue, a comment I stand over. The first reaction should be to determine the amount being spent, what is being done with the money, what remains to be done and if more money is required to do so? The Deputy's point about Spar and factories touches on the issue of standards and accreditation in the health system, regardless of where a service is provided. When removing itself from involvement in operational issues, the Department should examine general quality, safety and standards issues across the health care system.

I will leave the MRSA issue as both the Department and the HSE have been exposed on the weakness of their organisations in that regard. I do not know how the Committee of Public Accounts will do its work with the Department without having a string of HSE officials also present for the questions we ask about value for money. The Department is taking the position that the HSE deals with day-to-day business matters. While I accept this and understand the Department's position concerning policy creation and so on, from a public accounts point of view, it receives the money. We will require the HSE's presence if we are to determine how it is being spent.

I want to make a point to reinforce Deputy McGuinness's comments as Members of the Oireachtas are concerned about this matter. Two years ago the Deputy and I could have gone to a health board meeting as due members or made a telephone call to get information on what was happening in our local hospitals, what was being spent on the hygiene programme and whether the MRSA crisis was manageable. There is no longer that public accountability and an alternative system has not been established. While I hope events go well for Mr. Scanlan, the Department and the new HSE, I am concerned that no one will know due to the lack of a discursive forum. I share Deputy McGuinness's view that today's meeting has been unsatisfactory. Reasonable questions are being put but no answers are being given. We must reflect on how we will interact with the Department and the HSE.

Will the officials from the Department of Finance which oversee these matters comment on the committee receiving joined-up answers? We talk about joined-up management or government. The money is available to the Department. Mr. Scanlan said he managed the big picture while the HSE delivered services. In conducting the business of the Committee of Public Accounts is there a need to have all three stakeholders involved to give an open and adequate collective response on any issues arising? The Department of Finance is allocating the money. Is it concerned about accountability and transparency and the work we do?

Mr. Mooney

The committee asking questions such as the Deputy's is not unreasonable. It is also reasonable to be able to receive information. The money invested in the health service is being spent in a myriad of different ways. Identifying precisely what is happening in one area is often difficult. We conduct our business with the Department of Health and Children through the Estimates process which tends to focus on major Government programmes, issues and priorities. When we allocate moneys, we tend to do so on a very broad level for hospitals, disability and child protection programmes and so on.

We are not familiar with the details of the amount of money spent on the issue on which Deputy McGuinness has touched. We do not consider the amount that may be spent on cardiac or renal treatment. When we award money, I expect the system to track expenditure across subheads and to be able to generate the information the Deputy requires. Much of the activity taking place is concerned with building financial and personnel information systems in the health service to which a figure in the region of €70 or €80 million will be allocated for the building of information infrastructure. This should allow the information the Deputy sought to be identified.

The Department of Health and Children and the HSE should put in place processes to provide information. If a Deputy asks a question about how much has been spent on a particular service, the information should be available within a reasonable time. It would not be satisfactory if he or she did not receive a response. While there may be instances where it is not possible to identify how much is being spent, the broad expenditure programmes should be identifiable.

Mr. Purcell

On a point of clarification, we are in a period of transition. From this year the HSE is directly accountable to the committee for the vast bulk of expenditure. The gross estimate for 2005 for the HSE is €11.5 billion while the gross estimate for the Department of Health and Children is €401 million. The vast bulk of expenditure will have to be accounted for by the HSE, as I am sure Mr. Scanlan will be relieved to hear. That is the result of political debate on where accountability should reside. From this year onwards I foresee a situation where the HSE will be brought before the committee, on which occasion perhaps the Secretary General of the Department of Health and Children might not need to be present as it is a totally separate Vote. That was the policy decision made when the new structures for the health service were established.

Mr. Scanlan

I am grateful to the Comptroller and Auditor General for clarifying that point. It was a policy decision. I was not able to provide the information sought in certain questions today. I can understand why one might think I would be pleased not to have to attend but on the substantive issue of accountability, if the Department is to be one step away from the operation, it will have to deliver something else in return. Perhaps it could focus on the tracking of spending, delivery and value for money, part of what I referred to as capital appraisal. The difficulty arises when one leaves the Oireachtas without an acceptable level of accountability. The issue of how the Department and the HSE interact with the Oireachtas and this committee needs to be examined.

Deputy Deasy is getting married tomorrow and we congratulate him. He has asked me to pose a question on his behalf. He is interested in cancer services in Waterford.

When radiotherapy services are provided in a private hospital, will arrangements be made to ensure public patients will have access to them? Will the State pay for such patients? Private hospitals are putting radiotherapy services in place which is satisfactory if one is a private patient. However, the capacity being provided is far greater than what is needed for private patients. How will public patients access these services and who will pay?

Mr. Scanlan

I touched on this issue briefly the last day. The Hollywood report looked at how radiotherapy services should be provided by the public service for public patients. It made recommendations on the need to provide services from a limited number of centres for patient safety reasons. I am aware that private facilities are being developed at particular locations. The Tánaiste has indicated that she will make a decision on this issue. I would not rule out, as a matter of principle, public patients availing of private services. Just because services are provided by a private provider one cannot say public patients will automatically avail of them. Broader issues such as the delivery of radiotherapy services and patient quality need to be examined. They were articulated in the Hollywood report. There are sensitivities about this matter in the south east, Limerick and the north west. I am conscious of this and referred to it the last time I appeared before the committee. As a policy decision will have to be taken, I do not want to comment further.

When is the revised cancer strategy due to be published? I understand it is concluded, or nearing that point.

Mr. Scanlan

I am sorry; I am afraid I do not know.

I noticed in the 2005 Estimates an allocation of only €22.5 million for cancer development funds.

Mr. Scanlan

On the revenue or capital side.

On the expenditure side. The total expenditure is pencilled in under the heading of cancer development funds, as distinct from ongoing expenditure. The development fund for new initiatives in 2005 is less than €23 million. It is estimated that the incidence of the four main cancers will increase by 40% by 2015. The provision made for cancer services is totally inadequate. Can any of the officials confirm the figures I have given? They are taken informally from the cancer registry.

Mr. Dermot Smyth

I think there is a figure for an additional spend this year. It is just over €20 million for disbursement throughout the system. The funding allocated to cancer services since 1996 or 1997 has been significant. The targets set in the cancer strategy were met three years ahead of schedule because of the level of investment. Over 90 oncologists and a significant number of nurses were appointed during the period.

I take the Chairman's point about what may happen in the future and the new cancer strategy will have to deal with those eventualities. The level of cancer funding will always present difficulties as it is the budgetary issue which exerts the greatest pressure on a hospital. The amount to be made available this year is €22 million. We have appointed many new members of staff and I presume additional funding will be considered as part of the Estimates for 2006.

The problem is that information within the system suggests the incidence of the main cancers is increasing rapidly. I am not pulling the figure of 40% by 2015 from the sky. It is also part of the well established strategy that while there will be integrated inter-disciplinary national centres in Dublin, Cork and Galway, there must also be regional centres if the strategy is to work properly. Development funds are necessary for the regional centres. Unless the level of spending is significantly increased next year, the Department will not be able to put in place the facilities in the regions to deliver the strategy and services to which it is committed. Even though we will not solve this year's problems today, Mr. Scanlan should consider next year's allocation for developing additional cancer services. The total spend is a different issue.

Does Mr. Scanlan have any profile for the roll-out of the BreastCheck programme?

Mr. Scanlan

I should apologise as Mr. Smyth has pointed out to me that the cancer strategy is to be completed later this year. I will take away the figures the Chairman has given. They are startling. I have not seen them before.

The roll-out of the BreastCheck programme began in Wexford in March 2004 and in Carlow in April this year. It is expected to be rolled out in Kilkenny in early 2006. The Tánaiste has approved the design team for the static units in Cork and Galway which are expected to be rolled out in late 2007.

Is it ahead of or behind target?

Mr. Scanlan

The target date for the national roll-out is 2007. The programme will be rolled out incrementally. The roll-out will begin in the last two regions, the south and west, in late 2007. It should be just about on target.

The private sector is installing mammograph machines in many clinics which are available to private patients but has much capacity that is not being used. Would Mr. Scanlan consider using the treatment purchase scheme to provide a service for public patients who require a mammograph until the full roll-out is complete?

Mr. Scanlan

The short answer is that I will examine that matter.

Barrington's clinic in Limerick has one and I know its capacity is large but not being fully used because it is only for use by private patients. Meanwhile people living in the region cannot access the service. There could be many achievements in a joined-up system if a little thought was put into the matter.

Mr. Scanlan

I agree. I am particularly conscious that the radiotherapy issue is sensitive but in general we should examine using capacity available in the private or public sector. I will certainly consider it.

I asked two questions in correspondence at the last meeting but did not receive a reply. I note that in the accounts approved payments in respect of certain legal settlements were less than anticipated. On the last occasion I mentioned a court case to Mr. Scanlan involving the South Eastern Health Board in which a settlement had been reached. It still has not been dealt with in a satisfactory way and I requested Mr. Scanlan to investigate it. I ask him to do so again to remove the stubbornness surrounding the case which perhaps is of a personal nature. I raised this matter through a parliamentary question but know the South Eastern Health Board was reluctant to deal with the outcome of the court case. I understand the matter is returning to court. I raise the issue because it is similar to what happens in the case of the Department of Education and Science and the OPW regarding the holding of land where one gets to the steps of the courthouse and the case is settled. This case has been settled but is heading back to the courthouse again. Why waste money in this manner when so many organisations are requesting funding?

There were savings because expenditure on IT services was lower than anticipated. Is a general information technology roll-out taking place within the Department connected to the HSE? In the past health boards had state-of-the-art information technology systems which were not linked to each other or the Department. Is it envisaged there will be a connection between the Department and the HSE and any other unit within the structure in order that information will flow and inform this committee and the Department on its spend?

In 2000 the Department of Justice, Equality and Law Reform bought a property in Myshall, County Carlow. The issue was raised here on many occasions since and now seems to fall within the remit of the Department of Health and Children. It is noted in report 33, section 4. The title to the property has still not been transferred to the Department of Health and Children or the HSE. I understand this issue runs parallel to an analysis of autism services required in the south-east region. What is happening regarding the centre of excellence to be established at that property? For Mr. Scanlan's information, the property was purchased for €1.3 million but never used. It is now lying derelict. It has probably cost the Department, the South Eastern Health Board and the Department of Justice, Equality and Law Reform approximately €600,000 in security and insurance costs. Every time I ask a question I am told it has to do with a report. While I understand the need for reports from time to time, Mr. Scanlan must be tired of examining reports which have been written but not acted upon. The report on the use of the property for autism services is still being discussed. As it is included in the accounts, I presume the Department is dealing with the matter.

Mr. Scanlan

On the court case, I apologise that no one has responded to the Deputy. I will pursue the matter and speak to him about it.

The information technology item referred to by the Deputy concerns our own spend in the Department which is relatively small. Perhaps my HSE colleagues wish to speak on this but my recollection is that Mr. Kevin Kelly confirmed to the committee at the previous meeting that the IT systems of the 11 health boards worked independently of one another, although there was some degree of co-ordination in more recent years. One of the clear policy objectives of the HSE is to ensure that co-ordination takes place nationally and that the system becomes a national one. Some proposed major projects are being examined in that context.

Mr. Collins

There were 11 health boards, each with different systems. However, we have a programme of consolidation in place to ensure that staff are using the same financial and human resource systems. The programme of IT investment within the HSE is designed to ensure that the entire HSE and all of the former health boards are using similar financial systems.

Mr. Scanlan

There is agreement among the players — the Department of Finance, the Department of Health and Children and the HSE — that there is a need to put the information systems in order and money is being invested in that. On the issue of the property at Myshall, the title has been transferred to the Department and is in the process of being transferred to the HSE. The former South-Eastern Health Board was asked to examine a possible use for it in the autism area. I have not seen the report but I will ascertain the stage at which it stands and report back to the committee.

Perhaps a representative from the HSE could inform the committee of the position?

Mr. Finnegan

The report has not been finalised but it appears that the facility will not be used by those involved with autism. We have, however, given a commitment that if the property is sold, the proceeds will go to the provision of autism services in the region.

Is the report publicly available?

Mr. Finnegan

No, not at present.

How long will it take to complete?

Mr. Finnegan

The report is expected to be completed within four weeks. That is the latest information I have received on the matter.

Has the property at Myshall been valued recently?

Mr. Finnegan

The valuation I saw was in the region of €500,000.

The Department of Justice, Equality and Law Reform bought a property for €1.3 million, spent €600,000 on insurance and security and it is valued, four years later, at €500,000. Would the Comptroller and Auditor General or the Department of Finance like to comment on that?

I ask the Department of Finance to comment first, followed by the Comptroller and Auditor General.

Mr. Mooney

I do not know the details of the case. I had never heard these details before today. Clearly, it is unsatisfactory if property is purchased and not immediately put to its intended use. Where a decision is made quickly to the effect that a property will not be used as originally intended, it is also unsatisfactory that it is not disposed of as rapidly as possible. Nobody can stand over a situation where €1.3 million is spent on a property and then it is allowed to deteriorate to a point where it is worth only €500,000, if that is what has happened.

It is not a question of if because this has happened. The amount spent was not €1.3 million but was closer to €2 million. In that context, the initial cost must be added to the €600,000 spent on the property. I was informed that, up to a certain point, it cost the Department of Justice, Equality and Law Reform X amount for insurance and security. The Department then transferred the property and insurance and security costs were transferred to another State body and then to another. One must, therefore, ask questions right along the line because no one has taken charge or responsibility. I suggest that the figure €600,000 is probably correct because it would compare with the costs of other properties owned by the Office of Public Works. The exact cost of the property was €1.3 million. When this is added to the cost of security and insurance, one concludes that €1.9 million was spent by the State on a property that is now worth approximately €500,000. That is absolutely extraordinary.

Mr. Purcell

I confirm that the property was bought in July 2000 for €1.3 million. I do not have complete figures but I can inform the Deputy that security and other costs amounted to €176,000, up to the date of the property's transfer to the Department of Health and Children, with an additional €18,000 in costs incurred by the Department up to 31 December 2002. Extra costs were undoubtedly incurred in 2003 and 2004 but I cannot provide a definitive figure at this point. One can only hope that the figure of €500,000 is only a guide price and that the property will sell for more at auction. However, that may be a forlorn hope.

Can we establish the exact costs to the State? Would the Comptroller and Auditor General undertake to determine the amount because the information we are receiving is unclear. How much has the property cost, over and above the €1.3 million that was paid for it, irrespective of which Department paid the bills? I wish to see an up to date total.

I will ask the staff at the Comptroller and Auditor General's office to carry out that task.

I wish to express my disappointment that this property will not be used. Why did the Department of Justice, Equality and Law Reform and then the Department of Health and Children accept the property? I do not understand that. I hope we can return to this issue when the Comptroller and Auditor General supplies the final figure.

There are many sites throughout the country where there is a considerable land bank around existing properties such as hospitals and so forth. The campuses of some of these hospitals will not be developed to the extent that was originally intended when the sites were purchased. One example would be St. Canice's Hospital in Kilkenny. I am aware that there are other examples. What effort is being made, in the context of the Myshall scenario, to dispose of land on those sites or to identify what parts of them can be disposed of, to the financial benefit of the State or the Department of Health and Children? Does Mr. Scanlan have a list from the former health boards of the properties now owned by the HSE and will he outline his intentions regarding such properties?

Mr. Scanlan

I may ask Mr. Collins to comment but my memory informs me that Mr. Kevin Kelly confirmed at the previous meeting that one of the tasks currently being undertaken by the HSE is an audit of the property portfolio. From the perspective of the Department, an audit is required and then decisions must be made about properties in a long-term context. While there may not be an immediate use for land, there may be a need for it in the future. If the Department rushes in and sells off property for which it does not have an immediate use, it may find itself in a scenario opposite that which obtains in respect of Myshall. In other words, it may have to buy back the property at a higher price and thus incur a loss.

However, there is a provision whereby unused capital assets can be sold and the proceeds can be, subject to the approval of the Department of Finance, reinvested in capital investment in other services. There is a real case for examining this more closely. The Tánaiste has mentioned on several occasions that she wishes to examine the possibility of leveraging the value of the land banks in a variety of ways. One obvious way is to sell them but another might be to enter into a joint partnership arrangement with a private sector developer.

Another area that should be examined is the real use to which other Departments or the HSE could put those land banks. For example, there is an organisation which works within the Alzheimer's unit at St. Canice's Hospital, which would like to use part of the hospital's lands and which applied to the South-Eastern Health Board in this regard. That would represent a real and proper use of such lands. There may be greater advantage for the Department of Education and Science to use the lands for schools seeking sites than to dispose of them on the private market. In the context of establishing a register of land assets, I ask that the proposals of other Departments be examined and that organisations, including the Alzheimer's association, be consulted on whether they would have use for lands such as those to which I referred in Kilkenny.

Mr. Collins

We are in the process of compiling a consolidated register of all agencies, properties and land banks with the intention of assessing their appropriateness for use elsewhere and in the future or for potential disposal.

I draw Mr. Scanlan's attention to a question on St. Luke's Hospital, Kilkenny, which I asked on a previous occasion. I do not raise this issue from a parish pump point of view. The hospital is often raised as an example of a success story to the detriment of the expansion of its services on campus. It has submitted requests on accident and emergency services and other matters. I would like the Department to examine these because the hospital is a success story.

It was remarked at our previous meeting that success stories of this variety are isolated and, as they are in the context of serving a region, might not be applicable to Dublin or elsewhere. This perspective should be explored further because it is not necessarily true. After hearing of this perspective, I made inquiries into the matter. St. Luke's is an example of best practice from which much may be learned. Its model could be applied elsewhere. I investigated the problems of other hospitals, particularly those in Dublin, for which many solutions may be found in St. Luke's, thereby saving money in terms of reinventing the wheel. Officials from the Department of Finance visited St. Luke's Hospital because of comments made about it. It would be worthwhile for Mr. Scanlan to do likewise. Perhaps the HSE should take note of the hospital's requests and prioritise them.

I support the Chairman in his comments on cancer services for the south east and elsewhere. Dialysis, which is also relevant, was discussed earlier in a different context. I ask that the issues of cancer, dialysis and the transport of patients from the south east be immediately investigated. The situation cannot continue. I received many complaints from patients who travel on public transport or in ambulances. These arrangements are far from satisfactory and must be expensive to organise in a manner which suits patients.

A reply was received on the question of the scanner in Kilkenny, which was purchased partly through a public subscription of either £350,000 or €350,000, with the remaining cost being met by the South-Eastern Health Board. Those figures may be slightly inaccurate. The scanner is not used on a 24-seven basis, the constant reason given for which is that the HSE is undergoing consultations with staff on its use. If negotiations in businesses and private practices took that length of time, they would close. Negotiations should have beginnings and endings, unless matters go awry. The reply does not adequately address this matter.

Do issues arise in terms of retired nurses who return to the workforce? Mr. Magner may, in his capacity as acting national director of human resources at the HSE, be able to inform me on this matter. Are the pensions of retired nurses affected if, due to pressure, they return to the workforce? Are pensions reduced relative to salaries paid to nurses of similar grades?

Mr. John Magner

Discussions have been held on the pensions abatements policy in recent months. I had discussions with Mr. Scanlan's Department on the matter yesterday. We will be putting forward a proposal to the Department of Finance to revert to the previous method of pensions and return-to-work management. We make use of a number of retired persons on an occasional basis. This suits them and the executive. They find it unacceptable that under the new arrangements mean their pensions can be reduced by virtue of returning to work for fewer than 19.5 hours. That number of hours obtained under the previous arrangement. The matter is in hand and we hope to achieve a positive result from the Department of Finance in view of the scarcity we face in terms of nursing and other paramedical skills.

Does the HSE have a timeframe for this? I hope it will not take as long as the negotiations to install the scanner. Otherwise they will all be retired afresh.

Mr. Magner

To be fair to the Department, we met the nursing policy division yesterday to discuss this issue. We have agreed on a submission to present to Mr. Scanlan and the Tánaiste. We hope this will be forwarded to the Department of Finance next week.

I may have been slightly hard on officials of the Department and the HSE. If so, it was only an expression of the level of frustration experienced by Deputies and the general public. I ask, in the context of our work, that some mechanism be found to address issues involving the Departments of Health and Children and Finance and the HSE. Otherwise our meetings will become unworkable.

I have seen that, in the case of private business, money is lost if transition is not managed. I am afraid, in the context of value for money for taxpayers, that this might transpire.

Mr. Scanlan

To reassure Deputy McGuinness on Kilkenny, I do not raise hidden operational issues to duck the issue but because he asked earlier about capital. I agree with his point that those who perform well should be rewarded rather than penalised. I have heard it said that Kilkenny is exemplary and, without intending to prejudge the HSE's examination, is being well managed in light of the physical facilities. It may be well worth a visit.

Mr. Finnegan

It may appear that the CT issue has been ongoing for some time but it does not pertain only to St. Luke's. Whatever agreement is reached may have repercussions for hospitals across the country. We cannot reach a separate agreement on a different rate of pay for call outs and other matters in respect of St. Luke's without causing an impact elsewhere. It is taking a long time because we have to be careful on this issue.

I do not want to debate the issue of patients being sent up and down the country for treatment while the HSE deliberates with staff. I am aware that hospitals throughout the country are affected but patients are also involved. It is ridiculous that patients from St. Luke's and other places are sent elsewhere despite the equipment being in place. It is unfair to patients and transporting them costs the Exchequer a lot of money in ambulance staff, nurses and others who must accompany them. The trauma caused to families in these instances must be seen to be believed. It is unacceptable that these negotiations be allowed to drag on. The matter of €9 million for GPs is similar. It is not right and I ask that the HSE makes an effort to end negotiations and ensure that the service is delivered, not only in Kilkenny but also in other affected hospitals. I do not know what analyses have been carried out on value for money in terms of the current system.

There is a perception that people are shipped many miles away to obtain a service while there are scanners available at St. Luke's and Aut Even hospitals. That is not right. It is part of the joined-up management within the Department of Health and Children. If it is the HSE's role to take an overview of it, then I suggest that is a good place to start. We shall be watching the progress in regard to that €9 million. The figure decreased from €16 million to €6 million, increased to €8 million and now stands at €9 million.

Mr. Purcell

I wish to provide a brief recap. Two major issues emanated from today's discussion — not necessarily from the Vote or the chapter in the report — namely, the 45% increase in staff, which was highlighted earlier, and what we are getting for that increase. From the health sector report, which we considered on a previous occasion, it is fairly clear that the Department lost control over staffing numbers for a particular period. The move to substitute control over staff numbers and to rely solely on budget arrangements could be seen, in hindsight, to be ill-advised. It certainly was not altogether effective. It was not the only cause of what happened. There is a broader issue there but it certainly contributed to it.

The other issue on which I very much agree with the Accounting Officer relates to the costing of proposals for capital and for service developments in the health sector. These never seem to have been matched in the past. As has been said, a particular capital project would go ahead and money would be found for it, etc., but the ongoing running costs were not always factored in at the appropriate stage. I agree with the Accounting Officer that the appropriate stage is the earliest possible point at which one can do meaningful work.

I wish to make two brief references to St. Luke's Hospital. I heard what was said at the previous meeting. I may have mentioned at some stage that we are doing some value for money work in respect of accident and emergency services. One of the objectives of that examination is to look at good practice and not just to find out if services are badly run. We had selected a representative sample of ten hospitals but St. Luke's was not on that list. Just to show I do not fall asleep, despite the long sessions here, we have included St. Luke's in the list of places we will visit in undertaking that study.

On the issue of MRSA and the broader question of hospital acquired infections, my counterpart in the UK compiled a major report three or four years ago. This bore out much of what was said here about the basic hygiene requirements that there was not a need for huge technical advances in order to cut down on the incidence of hospital acquired infections. It referred to proper washing of the hands, what one washes one's hands with, how frequently one washes one's hands and so on — what we would regard as a normal requirements even when dealing with food.

I am mindful of what people say about making comparisons between one jurisdiction and another. I would imagine in this particular instance that much of what is said in that report would still be relevant here. I know from other work I have carried out that when a certain group of hospitals in London introduced what would be regarded as a rigid and rigorous hygiene regime, the incidence of hospital acquired infections, of which MRSA is the main manifestation, fell dramatically in comparison to other hospitals in the London area. I can certainly communicate about that particular material if the Accounting Officer feels it would be useful. There may be something there. This is not new. It is new in Ireland in the sense that it has only appeared here in the past ten to 15 years but it is not new, it is a worldwide phenomenon.

Is it agreed to note Vote 33 and dispose of Chapter 12.1? Agreed.

The witnesses withdrew.

The agenda for the meeting on Thursday, 2 June 2005 includes the 2003 annual report of the Comptroller and Auditor General and Appropriation Accounts, Vote 42 — An Roinn Gnóthaí Pobail, Tuaithe agus Gaeltachta.

The committee adjourned at 2.55 p.m. until 11 a.m. on Thursday, 2 June 2005.

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