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Thursday, 27 Oct 2005

Chapter 14.1 — National Treatment Purchase Fund.

Mr. M. Scanlan, (Secretary General, Department of Health and Children), Mr. P. O'Byrne (Chief Executive, National Treatment Purchase Fund), and Professor B. Drumm (Chief Executive Officer, Health Service Executive), called and examined.

No relevant correspondence has been received.

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 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; the right to produce or send documents to the committee; the right to appear before the committee, either in person or through a representative; the right to make a written and oral submission; the right to request the committee to direct the attendance of witnesses and the production of documents, and the right to cross-examine witnesses. For the most part, these rights may be exercised only with the consent of the committee. Persons invited to appear before the committee are made aware of these rights and any persons identified in the course of the proceedings who are not present may have to be made aware of them and provided with the transcript of the relevant part of the committee's proceedings if the committee considers it appropriate in the interests of justice.

Notwithstanding this provision in the legislation, I remind members of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable. Members are also reminded of the provisions of Standing Order 156 that the committee shall 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.

We will deal with the chapter on the National Treatment Purchase Fund first and I will open the Vote at approximately 12.30 p.m. The chapter will remain open. I ask Mr. Scanlan, Secretary General of the Department of Health and Children, to introduce his officials.

Mr. Michael Scanlan

I am accompanied by Ms Helen Minogue from my finance unit. Does the Chairman want me to do all the introductions?

Mr. O'Byrne can introduce his officials.

Mr. Pat O’Byrne

I am accompanied by Ms Anna Lloyd, director of patient care, and Mr. Dave Allen, director of finance.

Professor Brendan Drumm

I am accompanied by Mr. Aidan Browne, national director, primary, community and continuing care, and Mr. Pat McLoughlin, national director, National Hospitals Office of the HSE.

I ask the representatives of the Department of Finance to introduce themselves.

Mr. Joe Mooney

I am accompanied by my colleague Mr. Dave Ring.

I ask Mr. Purcell to introduce Chapter 14.1.

Chapter 14.1 of the report of the Comptroller and Auditor General reads:

14.1 National Treatment Purchase Fund


The Waiting List Initiative (WLI) was introduced in 1993 as a short-term initiative to tackle the problem of significant numbers of public patients waiting excessively long periods for elective (i.e. non-emergency) hospital procedures. However, the initiative continued until 2003 by which time it had been funded on an annual basis to a total cost of €290 million. My Value for Money study on the Waiting List Initiative published in November 2003 pointed to the scope for co-ordinating waiting list funding more effectively, and to the fact that up to half of WLI funding was generating activity indistinguishable from activity funded through the normal budgetary processes applicable in the publicly funded health sector.

The National Treatment Purchase Fund (NTPF) was announced by the Minister for Health and Children in April 2002, as a key initiative of the Health Strategy, to treat patients who have been longest on hospital in-patient waiting lists. Funding for the initiative was provided in a distinct Subhead of the Vote for the Office of the Minister for Health and Children, from 2002 onwards. The amounts provided were, €5m (2002), €30m (2003), €44m (2004) and €64m (2005) and these were administered through the Department of Health and Children (the Department) and by the NTPF on an administrative basis until 1 May 2004 when the Minister for Health and Children, in exercise of the powers conferred on him by the Health (Corporate Bodies) Act, 1961, formally established the NTPF as a statutory Health Body.

The remit given to the Fund was to focus on those patients waiting longest for hospital procedures and to purchase treatment for them primarily in the private hospital system in Ireland, Northern Ireland and Britain. It may also make use of any capacity within public hospitals to arrange treatment for patients.

The 2001 Health Strategy set a target that by end of 2004 no public patient would wait longer than three months for treatment. The Strategy visualised the development of a national waiting time database by the proposed National Hospitals Agency. This database would help channel patients awaiting treatment to an appropriate hospital with sufficient capacity. The management and classification of waiting lists was to be reorganised in several important ways and used in the operation of the NTPF.

Waiting lists would

·be categorized by waiting times, broken down to sub-specialty/procedure level

·include the referring GP's name

·be available to GPs

·show consultants' names as an aid to decisions by GPs regarding referrals

·allow GPs to notify significant changes in the medical status of patients and to propose that the priority of a patient awaiting treatment be reviewed.

NTPF Operations

The NTPF arranges treatment for patients waiting longest for treatment. Hospitals have been informed that any NTPF work undertaken in public hospitals must be over and above core funded activity and should not displace the normal duties of these hospitals. While it is the Fund's policy to endeavour to ensure that consultants do not predominantly treat patients from their own public hospital waiting lists, there are exceptions in relation to the treatment of children and for instance, in certain cases for reasons of procedural or patient complexity.

Reference Prices

The Department has in place a programme to collect, categorise and interpret data related to the types of cases treated in the Public Hospital system. This programme — Casemix — categorises each hospital caseload and allows the comparison of activity and costs between different hospitals. One of the benefits of Casemix measurement is the extent to which it provides a common language for service planning, management and development that is meaningful to both clinicians and managers. Currently 37 hospitals participate in the Casemix programme.

NTPF state that Casemix is one tool used as a benchmark by the NTPF in price negotiation when appropriate to the treatments being procured. However, NTPF state that Casemix is not all-inclusive in the context of price negotiation with hospitals, as it does not comprehend the full service provided to NTPF patients in all cases, such as

·routine pre and post operative visits,

·tests required for specific procedures,

·capital costs and depreciation considerations which arise for private hospitals in some instances.

While the Casemix model has not been designed as a pricing benchmark, the Department has stated that it welcomes greater use of the data for monitoring and evaluation purposes and considers that it is best used to raise questions for discussion.


Patients can be referred to the NTPF by their GP, hospitals or Consultant, or they can contact the NTPF directly. NTPF has funded the treatment of 23,379 patients up to end of 2004 — 1,920 in 2002, 7,832 in 2003 and 13,627 in 2004. Of the 13,627 patients treated in 2004, 12,762 were referred by public hospitals and 865 came through the lo-call line. Currently, the threshold for eligibility for NTPF treatment is three months waiting on an In-Patient or Day Case Waiting List. Patient permission is required before the NTPF organise treatment arrangements.

If it is necessary to arrange treatment in Britain or Northern Ireland, the NTPF will organise and pay for travel and accommodation for the patient and an accompanying person.

Audit Objectives

The examination sought to ascertain

·how the NTPF determined the price paid for procedures purchased

·the relevance of Casemix costs to NTPF activity

·the proportion of procedures purchased within and without the public health sector

·the contribution made by the NTPF to achieving the objective set out in the 2001 Health Strategy to reduce the numbers of persons waiting for treatment for an unacceptable length of time.

Treatments for the 13,627 patients funded in 2004 fall into 456 procedure groupings. The unaudited financial information recorded in the NTPF Annual Report for 2004 shows expenditure of €40,560,258 on direct patient care expenses in the year.

For the purposes of my examination the top eight procedures by volume were selected for detailed examination. Expenditure on these in 2004 was approximately €15.5 million or 38% of direct patient care expenditure (excluding ancillary costs). These 8 procedures accounted for 3,809 procedures paid for by the NTPF in 2004 or 28% of all treatments funded by the NTPF in that year.

Audit Findings

Price Negotiation

The price paid by the NTPF for treatments purchased from public and private hospitals is agreed by negotiation. The negotiation process culminates in a service agreement between hospitals and the NTPF whereby hospitals agree to provide the NTPF with agreed services. NTPF vets participating consultants or suitability. Only approved consultants are placed on a panel and are permitted to perform procedures or the NTPF.

NTPF stated that for the purposes of price-setting, NTPF uses the tools available to it as guides and benchmarks in seeking competitive prices. These are built into the NTPF comprehensive pricing database and include

·the Casemix system costs

·estimated insurers' prices

·consultant costs based on the insurers' Schedule of Fees

·prices proposed by peer hospitals.

The price negotiation process is a detailed exercise that is influenced by a number of benchmarks, prevailing prices, capacity requirements, complexity requirements and geographic considerations.

NTPF Negotiated Prices for FundedProcedures

I obtained details of the prices negotiated by NTPF for procedures with both private (Ireland and UK) and public sector hospitals. As well as using its other benchmarks in the negotiation of 2004 prices, NTPF had regard to the Department's Casemix Peer Group Report which classifies treatments carried out on patients into high level Diagnostic Related Groups (DRG). The precise treatments actually provided under the negotiated agreements cannot be ascertained until the patients are discharged from the treating hospitals.

Table 42 shows the percentage by which the highest negotiated prices exceeded the lowest prices for the 8 most common procedures arranged by the NTPF in 2004. The most costly procedure negotiated was €15,895 while the least costly amounted to €378. The Department has pointed out that prices agreed by the hospitals may vary according to the cost base of individual hospitals and the nature and age of patients being treated.

I have acceded to a request by the Accounting Officer of the Department not to disclose the prices paid for procedures by the NTPF on the basis that the publication of commercially sensitive information would affect NTPF's negotiating position and as a result its capacity to deliver a value for money service.

Table 42 Comparison of prices achieved by NTPF across the eight most common procedures


% Highest exceeded Lowest


Inpatient 87%Day Case 76%

Varicose Veins (one leg)

Inpatient 61%Day Case 44%

Total Hip Replacement (excluding revisions)

Inpatient 72%

Skin Lesions

Inpatient 126%Day Case 217%

Coronary Angiogram

Inpatient 0%Day Case 20%

Total Knee Replacement (excluding revisions)

Inpatient 71%

Grommets (< 17 years)

Inpatient 54%

Laparascopic Cholecysectomy

Day Case 206%Inpatient 215%

Casemix Cost Comparison

In order to evaluate whether the NTPF has procured treatments at the most economically advantageous cost relative to that recorded in the Casemix programme it would be necessary to consider — at national or hospital level — how the price paid compared with the corresponding Casemix cost. This type of comparison has not yet been undertaken by the NTPF. An example of the variation that can occur is illustrated by the procedure labelled in Table 42 as Coronary Angiogram. An analysis of a sample of the discharge details for patients treated under this heading by the NTPF, carried out on its behalf by the ERSI, classified the patients into two discrete DRGs. The Casemix costs for these DRGs varied by some 84%.

It is worth noting that the average NTPF negotiated price for Coronary Angiogram was under half the Casemix cost of the lower of the two DRGs identified. In contrast, the average negotiated price for Grommets was more than twice the national average cost recorded in the Casemix 2005 model for the most likely corresponding DRG.

While acknowledging that Casemix was not designed as a benchmark for price-setting, these variations point to the necessity from a value for money perspective to ensure that the full potential of Casemix is exploited as an evaluation tool. This would help in any assessment of the relative cost effectiveness of NTPF funding of treatment as against other funding arrangements e.g. the allocation of the same funds directly to publicly funded hospitals whose patients have been treated by the NTPF.

Accounting Officer's Response

Regarding apparent variations between the Casemix and NTPF data in relation to costs for particular procedures, the Department of Health and Children has advised that great care should be taken concerning the interpretation of the two sets of data. Casemix operates by classifying hospital patient data into over 600 Diagnosis Related Groups (DRGs). DRGs are the classification of patients into discrete groups which have similar attributes and resource intensity. The Casemix Peer Group Report generates a national aggregated, average cost per case by DRG and excludes capital and depreciation costs. The Department has therefore advised that Casemix provides the costs of treating patients with similar conditions rather than the cost of individual procedures or patients. Furthermore, information on diagnosis was not collected by the NTPF for referred patients. This is an essential variable required for Casemix classification and may affect conclusions drawn regarding prices negotiated by the NTPF and the Casemix costs.

He pointed out that the cost for Grommets in its Casemix model for 2004, based on 2002 costs, was radically reduced following the revision of the Casemix system for the 2005 model. The casemix tool available to the NTPF in 2004 was the 2002 cost data, i.e. 2004 casemix Peer Group Review. Using the 2004 casemix price for grommets would result in the NTPF price amounting to 62% of casemix costs. The Department has acknowledged this apparent anomaly and is actively reviewing it.

Hospital Referral Pattern Analysis

In 2002 the NTPF published a Patient Information Booklet and this was revised and reissued in 2004. Both booklets suggest that it is more likely that a patient will be treated in a private rather than a public hospital

· The NTPF will then proceed and arrange treatment for you in most cases in a private hospital

· In a small number of cases, you may receive treatment within a public hospital in Ireland.

My examination considered the extent to which NTPF procedures were carried out in private or public hospitals and the extent to which a patient was treated in the same hospital from which s/he was referred albeit via the NTPF. The results of this part of my examination are set out in Table 43.

Table 43 Referral Patterns of Hospitals utilising NTPF Services


Public toPrivateReferrals

Public toPublicReferrals

Public toPublic%

SameHospital Referrals









Varicose Veins (one leg)







Total Hip Replacement (excluding Revisions)







Skin Lesions (Simple)







Coronary Angiogram







Total Knee Replacement (excluding Revisions)







Grommets (less than 17 years)







Laparascopic Cholecysectomy














Of the 3,809 cases examined 1,674 or 44% were carried out in a public hospital. This is consistent with NTPF statistics for all treatments procured by it in 2004. Referrals to public hospitals for treatment ranged from 14% for varicose veins to 86% for Grommets.

An examination of referral patterns for the eight procedures sampled revealed that 36% of procedures (out of a total of 3,809) were carried out in the same public hospital from which the referral had been made. Same hospital referrals over the eight procedures ranged from 12% for varicose vein procedures to 74% for procedures to remove skin lesions.

It was also established that the documentation maintained by the NTPF did not systematically record information relating to the referring consultant and the consultant carrying out the surgical procedure to enable the NTPF to guard against the risk of excessive self-referral. However, the NTPF maintains that the referring and treating consultants are known to it. The NTPF informed me that its new patient management system, implemented in July 2005 incorporates processes to obtain this information in every case and thus strengthen the information base from which the NTPF can operate its monitoring activities.

Given the extent of same hospital referral of waiting list patients as outlined in Table 43, I asked the Accounting Officer to explain how it is possible for each of these hospitals to have a waiting list problem for the procedures in question and, at the same time, a capacity to undertake a substantial number of additional treatments requested by the NTPF.

Accounting Officer's Response

The Accounting Officer informed me that the predecessor of the NTPF Board had agreed that, for 2004, the use of public capacity could account for 30% of total NTPF activity, once public core service planned activity was not compromised. The Department has recently advised NTPF that use by the Fund of public facilities should be limited to 10% of its total referrals for treatment.

He pointed out that there were several reasons why it was imperative to use public capacity for shortening waiting times for surgery. It is acknowledged that minimal paediatrics capacity (in terms of both volume and expertise) exists in the private sector. In order to offer the benefits of NTPF to children there may be no other option but to utilise spare public capacity.

Other situations that compelled the use of public or "in-house" capacity were cases where for reasons of clinical or patient complexity it was clearly best practice to have certain patients treated by their own Consultant in the hospital where they were on the waiting list. Not to have used this facility would have effectively barred this cohort of patients from accessing the NTPF scheme. The NTPF considers that these activities should be excluded from the computation of the referral patterns in Table 43. This would have the effect of disregarding all public hospital to public hospital referrals for Total Hip Replacement, Total Knee Replacement and Grommets.

The Accounting Officer added that according to the Health Strategy, the NTPF might make use of spare capacity in public hospitals and pointed out that elective activity in hospitals does not take place 24 hours per day and 7 days a week. Therefore using theatres and beds outside of normal working hours is one way of creating extra elective capacity. Allowing public hospitals to undertake work under the NTPF initiative also incentivises hospitals to perform extra work and to treat more patients over and above core funded activity.

Same hospital referrals are necessary where the level of expertise provided is not readily available in other hospitals. This expertise is required for complex surgery, in the case of elderly patients and where children are involved. This activity is carried out often by staff working overtime, who come in at weekends or who extend theatre time on occasions.

Waiting Lists

The Department last published quarterly waiting list data to 31 December 2003. Waiting list data for 2003 is summarised in Table 44.

Table 44 Public In-patient Waiting List 2003 Target Specialties Summaries

3 to 6 Months

6 to 12 Months

12 to 24 Months

24 Montha Plus


Number of Adults Waiting for Target Specialties

March 2003






June 2003






September 2003






December 2003






Number of Children Waiting for Target Specialties

March 2003






June 2003






September 2003






December 2003






While no waiting list figures have been published in respect of 2004, the numbers of patients awaiting treatment at the end of 2004 will undoubtedly have improved and stabilised relative to what might have been expected as a result of

·The 23,000 treatments purchased by the NTPF

·The residual impact of the final tranche of WLI funding of €44 million in 2003

·Other initiatives implemented by Ministers since 2001.

In May 2004, the Minister announced the transfer of responsibility for the collation and publication of surgical waiting list data to the National Treatment Purchase Fund (NTPF). At the same time the NTPF indicated that in excess of 4,000 patients could be removed from the Department's reported figure and that it was expected that additional removals would result from further validation of the data by the NTPF. In October 2004, the NTPF conducted an analysis of waiting list data from hospitals, which indicated that

·Data focuses on volumes, not length of time patients are waiting

·Statistics had not been validated and were not reconcilable from one period to the next

·Data did not capture changes in patients' status, i.e. treated, temporary unavailability, no longer in need of treatment

·Data were not treated in a consistent manner and could be up to 6 months out of date.

As I was concerned that access to reliable and independently verified data on patients awaiting treatment is essential to be able to assess the impact of the NTPF initiative on the treatment backlog, I sought the Accounting Officer's observations.

Accounting Officer's Response

In his response, the Accounting Officer pointed out that over the period of the Waiting List Initiative, the Department had sought to improve waiting lists reporting by Health Boards and Voluntary Hospitals. The 2001 Health Strategy specifically acknowledged the need to further improve the management of waiting lists and as a result responsibility for waiting lists was transferred to the NTPF.

He confirmed that as a result of NTPF analysis of waiting list data, NTPF decided in December 2004 not to publish waiting list figures, but instead opted to develop a National Patient Treatment Register which would focus on the waiting times of individual patients rather than statistically based waiting lists. It was announced in May 2005 that it was intended that the register would be implemented on a phased basis in 2005. Funding of €1 million has been provided from within the NTPF's allocation for this in 2005.

Waiting list data for this register will be supplied to the NTPF by individual hospitals. The Register will contain patient specific details (including name and contact details for the first time) as forwarded by hospitals. Patients waiting for treatment the longest can now be identified and will be contacted by the NTPF with an offer of treatment. It is intended that the register will

·Track the progress achieved in reducing waiting times

·Be accessible to patients and General Practitioners

·Show patient status

·Provide the healthcare system with an accessible and accurate tool for waiting list data, and a tool that reconciles changes in patient status

·Inform patients and GPs about prospective waiting times and referral choices

·Assist in reducing waiting times to achieve the Health Strategy commitment that all patients on inpatient and day cases waiting lists will be treated within three months.

NTPF point out that the register will be a national on-line system and will capture current patient status. Hospitals will continue to be responsible for validating and changing patient status on the system. NTPF will operate an audit process of the system.

Mr. John Purcell

Chapter 14.1 records the results of an examination by me of the operation of the National Treatment Purchase Fund. The fund was set up in April 2002 under the aegis of the Department of Health and Children and was put on a statutory footing with effect from 1 May 2004 as a health corporate body. From an accountability point of view this effectively means that from that date separate accounts need to be prepared for audit and the CEO becomes accountable to this committee for transactions after that date. Prior to that, the Secretary General of the Department was the Accounting Officer because the expenditure was included in its Vote. Although my office received draft accounts for the NTPF on 25 August 2005, I have not yet certified the account for the eight-month period in 2004, as a number of issues remain to be resolved before I will be in a position to do so.

Getting back to the subject matter of the chapter, we set out to try to establish how the NTPF was delivering on its mandate to treat patients who have been longest on hospital inpatient waiting lists and to see if this was being done in a cost-effective manner. Up to the end of 2004, the NTPF had funded the treatment of 23,379 patients from a financial allocation of approximately €79 million in just over two years. Therefore, it certainly has achieved a volume of procedures that has gone some way towards addressing the problem of the long wait endured by those requiring elective surgery. At the time of our examination it was not possible to measure the impact of the NTPF on the numbers on the waiting lists but the availability of more reliable figures coupled with the full roll-out next year of the national patient treatment register, which is being developed by the NTPF, should help in this regard.

We examined the top eight procedures by volume for 2004, which represented 28% of all treatments paid for by the NTPF in that year. We performed a detailed analysis on these cases from three angles — the extent of variation between prices paid for what appeared to be the same procedure; how the price paid compared with the putative cost as calculated under the Department's casemix system; and the hospital referral pattern for the funded treatments. There was some considerable variation for prices paid for the same procedures, in some cases up to three times the lowest figure negotiated, which suggests there may be room for achieving better value for money even when taking the different patient profiles into account.

The Department uses the casemix system to allocate part of the State funding to the acute hospitals. In this system there were indications the NTPF was getting good value on procedures such as angiograms but perhaps was not as successful on grommets for example. It is hard to be conclusive on this score because of the difficulty in reconciling casemix costs with the costs of the NTPF procured procedures under present arrangements. What contributes primarily to the difficulty is that information on diagnosis was not being collected by the NTPF for referred patients. There were also some problems about the coding of procedures. Therefore, there is probably scope for more work to be carried out in this area to better inform assessments of the relative effectiveness of NTPF funding of treatments as against other funding arrangements, for example the allocation of the same funds directly to public hospitals to achieve the same purpose.

I believe this kind of assessment needs to be performed in light our findings that 44% of NTPF-funded procedures were carried out in public hospitals with 36% being carried out in the same public hospital from which the referral had been made. These findings were very much at odds with the popular perception that the demand was invariably being met by private hospitals both at home and abroad. Of course, there will be cases where medical and practical considerations will dictate that treatment should be in a particular public hospital. However, the extent of recourse to public hospitals and especially same hospital referrals was surprising. The findings would appear to suggest that more could be done in a conventional sense to maximise utilisation of elective surgery capacity in our public hospitals.

I will give the committee an update on what is happening on the accounting side in respect of the establishment of the Health Service Executive and the consequent abolition of the health boards. The 2004 accounts of all the health boards and related agencies were cleared for audit certification almost a month ago. Signed accounts have been sent to the Office of the Comptroller and Auditor General in recent days. I expect, if there are no hitches, to be able to certify the accounts formally without further delay. The staff of my office have been working closely with the HSE's audit committee throughout the year to overcome the difficulties associated with such a fundamental changeover. I hope this co-operation will bear fruit in terms of the timely submission and audit of the HSE's 2005 accounts.

I invite the Secretary General of the Department of Health and Children, Mr. Michael Scanlan, to make an opening statement.

Mr. Scanlan

I have decided not to make an opening statement because I think it would be more appropriate for the chief executive officer of the National Treatment Purchase Fund, Mr. Pat O'Byrne, to do so.

It was indicated to me that Mr. Scanlan preferred to proceed in that manner. The Committee of Public Accounts is charged with dealing with Accounting Officers, however, and Mr. Scanlan was the relevant Accounting Officer in this instance for four months. I would like him to make some opening remarks before handing over to Mr. O'Byrne, who is not an Accounting Officer.

Mr. Scanlan

Absolutely. I have no problem with that. I merely decided early yesterday morning to allow Mr. O'Byrne to make the substantive statement, in the interests of making the best use of the committee's time.

I welcome Chapter 14.1 of the report of the Comptroller and Auditor General, which relates to the National Treatment Purchase Fund. When I last came before the Committee of Public Accounts, we discussed the fund tangentially. It is obvious that the fund was established on foot of a Government policy decision. I have previously told the committee that price contestability, if I can put it like that, is a good idea in principle as it applies to the management of the health system because it helps to keep the system on its toes. I consider the National Treatment Purchase Fund to be useful in that regard. The Comptroller and Auditor General has mentioned the fund's focus on those who have been waiting for the longest periods. Previously, medical need tended to drive how people on waiting lists were dealt with and correctly so. Therefore, the National Treatment Purchase Fund has a useful role.

As I have already said, I welcome the Comptroller and Auditor General's report on the National Treatment Purchase Fund. I will allow Mr. O'Byrne to explain the decisions which have been taken by the board of the fund on foot of the report. I can give some details of the decisions if the committee prefers.

As Secretary General of the Department of Health and Children, I am the Accounting Officer who is in charge of this Vote. The Department has taken some new initiatives in conjunction with Professor Drumm and the HSE to try to manage expenditure in a more efficient manner. We are trying to put in place a better structure for the management of the expenditure review initiative. I presume that the committee is familiar with the overall initiative across the public service. We have agreed to establish an overall steering committee, chaired by the Department and including representatives of the HSE and the new Health Information and Quality Authority. The steering committee will oversee a series of examinations of expenditure across the board. It seems that this report and the Comptroller and Auditor General's other value for money reports should be referred to the steering committee to ascertain the follow-up action, if any, that is required. The value of the reports will be lost if they are just put on the shelf. While I welcome what the board of the National Treatment Purchase Fund has decided to do, I think it would also be appropriate to refer the reports to the steering committee so that it can consider what else needs to be done.

Mr. O’Byrne

The National Treatment Purchase Fund notes the report of the Comptroller and Auditor General. The fund is pleased at the detailed and thorough examination of the rigorous processes and negotiation procedures it undertakes to achieve the best possible value for money and competitive pricing on behalf of the State. The fund has expanded rapidly since its inception in 2002. It has treated over 35,000 patients effectively, competitively and to high clinical standards. It operates within a small budget of less than 0.5% of the entire health budget. It performs an effective value for money role within the public health system. Its work has reduced waiting times for surgery for thousands of patients throughout the country. In most cases, patients waiting more than three months for a surgical procedure can be facilitated by the fund.

The National Treatment Purchase Fund's primary objective is to reduce the amount of time patients spend waiting for surgery. It handles this task by purchasing treatments, primarily from private hospitals. As specified in the health strategy, the fund can also purchase treatments from public hospitals. It operates under strict criteria in that regard. Therefore, its activities do not affect core activities in the public hospitals system. Over 35,000 patients had received operations under the fund by the end of September 2005. Some of the fund's challenges include matching supply and demand, catering for patient choice, sourcing capacity for complex cases and geographic considerations. The fund is charged with treating as many patients as possible, focusing on those who have been on waiting lists for the longest periods. When the fund was established, it typically dealt with patients who had been on waiting lists for an average of three to four years. For example, it facilitated a patient who had been on a waiting list for eight years. Patients can contact the fund if they have been on a surgical waiting list for three months. The fund can contact patients under the patient treatment register. The role of the fund is to reduce the waiting times of people who are waiting for operations as quickly as possible by facilitating patient treatment that is safe and of a high standard.

I would like to make some observations about some of the issues raised in the Comptroller and Auditor General's report, such as price negotiation. One of the National Treatment Purchase Fund's core aims is to secure value for money. Its prices are influenced by factors such as prevailing insurance prices, capacity availability, complexity requirements and geographic considerations. The fund uses casemix costs, estimated insurers' prices, consultant costs based on the insurers' schedule of fees and the prices proposed by peer hospitals as reference points when it is compiling its prices. Variations in prices occur because the cost base of individual hospitals differs, due to the nature and age of patients being treated. A patient who needs surgery to have a gall bladder or prostate gland removed but who is otherwise fit and healthy requires a certain type of care, whereas a patient who needs such surgery but who has a history of other illnesses, such as heart disease or breathing problems, will require a more intensive and more costly form of treatment.

Casemix, which is a tool used as a benchmark by the National Treatment Purchase Fund in price negotiation, is a method of quantifying hospital workload by describing the complexity and resource intensity of the services provided. Casemix is not an all-inclusive price in the context of the fund's price negotiation with hospitals, as it does not comprehend aspects of the full service provided for the fund's patients, such as routine pre-operative and post-operative consultations, tests required for specific procedures and certain capital and depreciation costs. The National Treatment Purchase Fund, however, negotiates an overall inclusive price with hospitals to include the factors I have mentioned and all consultant fees. Following the publication of the Comptroller and Auditor General's report, the fund conducted a further price analysis of the top 15 procedures performed in 2004. Details of the analysis are contained in the fund's submission to the committee. The analysis, which deals with a range of minus 20% to plus 20% of the fund's average prices, shows that 11% of hospitals are above that price range and 13% of hospitals are below it. Therefore, 76% of hospitals are within the range.

I would like to speak about casemix and the cost comparison. The Comptroller and Auditor General's report refers to the use of casemix as a tool for price comparison with the prices paid by the National Treatment Purchase Fund. Casemix operates by classifying hospital patient data into over 600 diagnostic related groups, or DRGs. DRGs are used to classify patients in discrete groups which have similar attributes and resource intensity. The Department of Health and Children provides a national aggregated average cost per case by DRG and excludes capital and depreciation costs. As casemix provides the costs of treating patients with similar conditions, not the cost of a particular procedure, the question arises as to the effectiveness of the comparison. The report of the Comptroller and Auditor General refers to the variances which can occur. To aid the process the national treatment purchase fund has asked the Economic and Social Research Institute to assist it in a casemix category validation and the institute has agreed to do so.

On the question of hospital referral pattern analysis, the National Treatment Purchase Fund was established following the recommendations contained in the health strategy of 2001. The remit of the fund is to purchase treatment from private hospitals in Ireland and international providers. It may also make use of any spare capacity in public hospitals. Our objective was to remove as many patients as possible, many of whom had been waiting for surgery for years, from waiting lists. There were many compelling reasons at the time for utilising public hospital facilities, including the transition from the old waiting list initiative to a position in which the Department of Health and Children has recently advised the NTPF that use by the fund of public facilities should be limited to 10% of its total referrals for treatment.

In ensuring public hospitals accommodate the National Treatment Purchase Fund without impacting on normal activity, the following factors are relevant: not all public hospitals are on accident and emergency call and hip and knee replacement operations have been undertaken for the NTPF in some of these hospitals; elective activity in public hospitals is, by and large, performed on week days, that is, Monday to Friday, and the NTPF has used opportunities to utilise facilities on Saturdays, with day case cataract operations being one such example.

It is also the case that there is minimal paediatrics capacity within the private sector. To offer children the benefit of the national treatment purchase fund, a desirable objective, no alternative was available other than to use public facilities. This was achieved, for example in the case of grommets, by using otherwise unused capacity on Saturdays. Some other circumstances compelled the use of public in-house capacity in cases where, for reasons of clinical or patient complexity, it was clearly best clinical practice to have certain patients treated by their own consultant in the hospital in which they were on the waiting list. Not to have taken these opportunities would have left patients, both adults and children, untreated.

While the foregoing are examples of what the national treatment purchase fund encounters, in certain cases there are good and compelling reasons for using some public hospital capacity. These range from necessity, clinical considerations, the best interests of patients and practical reasons. In addition, allowing public hospitals to participate in the NTPF initiative gives them the incentive to perform better and treat more patients. As stated in the report of the Comptroller and Auditor General, the NTPF has installed a new patient management system from July which will provide more information on referral processes. This will enable the fund to significantly improve the tracking of patients and the consultants treating them.

Public hospitals are funded on the basis of an agreed level of activity against a set budget. The agreed level of activity is set out in the annual service plan. Accordingly, hospitals are charged with reaching targets as set out in the service plans. NTPF activity is over and above core funded activity. The agreement between public hospitals and the NTPF is that operations performed in-house will not displace normal activity. To ensure this the NTPF knows which patients are being treated — we have their names and addresses — by whom they are being treated, the conditions for which they are being treated in hospital and how much each operation costs.

In May 2004 the National Treatment Purchase Fund was given responsibility for the collection and collation of national waiting list data. On reviewing the historical system for collecting data, the NTPF found variations in the recording, definitions and reporting of patient data. The old system was based on the collection of statistics by specialty which was not linked to individual patient names or details. It was impossible, therefore, to determine the accuracy of the information or the status of the patients on the list. The NTPF has moved away from the old system to create a new national waiting list system known as the patient treatment register, a national system which will have information based on named patients.

The development of the patient treatment register has been achieved in close collaboration with hospitals and required significant technical and operational development. It is being phased in nationally, with phase one now complete and live. This phase comprised the six major Dublin hospitals and St. John's Hospital, Limerick. Under the prior waiting list system, these hospitals accounted for approximately 40% of the total number of patients waiting nationally. Data on the new national system, the patient treatment register, will be published biannually and provide, for the first time, validated national and hospital information on patients waiting for inpatient and day case treatments.

The new register provides, for the first time, an accessible website link for patients which illustrates that for 17 of the 20 most common surgical procedures patients are waiting an average of two to four months for their operation; a general practitioner website link on waiting times for all procedures in individual hospitals to assist the referral process; a separate link for each hospital with detailed information on procedures and patient status; a patient treatment register card and personalised advice letter to be sent directly to patients to allow them to opt for treatment under the national treatment purchase fund; and a complete and accurate picture of hospital waiting lists. The new system provides for accountability and transparency in the management of waiting lists and reducing waiting times. It will also indicate which patients have been added to and removed from waiting lists.

The National Treatment Purchase Fund will continue to meet objectives which have been set out for us by the Government and Oireachtas. We will continue to reduce the length of time public patients will need to wait for treatments that can have a significant and positive impact on the quality of their lives. The NTPF will seek to do this in the most economically advantageous manner possible and on a basis that continually puts patients first. We will exercise continued vigilance to ensure the NTPF operates its service in a way that addresses patients' needs while continuing to secure value for money for the services we provide.

Mr. Scanlan, may we publish the statement made by Mr. O'Byrne?

Mr. Scanlan


I will be succinct, given the short time allocated for this chapter.

A total of 23,379 patients had procedures carried out under the National Treatment Purchase Fund up to the end of 2004. In a survey conducted by the Comptroller and Auditor and General of 3,809 procedures, 44% of cases involved patients who were moved from a public hospital to another public hospital while 36% — 1,364 patients — were treated under the auspices of the fund in the same public hospital. Is it not daft that patients in a public hospital must be routed through an outside body, the NTPF, to have procedures carried out in the hospitals in which they are patients?

Mr. Scanlan

I do not accept that it is daft. It is a fair point for the Comptroller and Auditor General to examine in his report the numbers treated in the same hospital and in the public hospital system generally. Arguments can be made as to why that should happen. The Deputy has heard some of them.

First, there is a transitional issue. Mr. O'Byrne referred to that. From my knowledge of the NTPF, when it was being set up there was some difficulty in securing co-operation from the system. The use of public hospitals was part of the response to that. Apart from that, as I said, even if the NTPF was targeted at those who were waiting longest for treatment, it was also targeted at a different group to the one targeted by public hospitals. In my view it was the correct approach to target those most in medical need. That is the criterion that is supposed to drive it. As Mr. O'Byrne said, if there is spare capacity at weekends, I do not necessarily see anything wrong with buying that spare capacity in this way. What the Comptroller and Auditor General said is that one should look at how one uses one's capacity in the public hospital. I do not necessarily see anything wrong with allowing money to follow a patient for procedures.

The implication is that there was spare capacity within the public hospital service for years and that thousands of patients were suffering on long waiting lists for many years when they could have been treated much earlier. If the NTPF could find spare capacity, why was it not found previously?

Mr. Scanlan

I accept there was spare capacity but extra funding is required to realise that spare capacity on Saturdays or Sundays. One must bring in staff at weekends. It is a question of what funding is available and how it is used. When the funding became available it was decided to use it in this way as part of a Government initiative. It does not necessarily follow that just because the funding became available at a certain point in time and was used this way somehow the spare capacity could have been used in the past without that extra funding.

Therefore, it was a question of funding all along.

Mr. Scanlan

If one wants to bring in staff at weekends and open theatres, it will require extra funding. It is a question of getting the best possible use out of the available funding. More funding is not the only answer but it will provide better services.

The Tánaiste said in an article some months back that more than 30,000 public patients had been treated privately already under the National Treatment Purchase Fund. That is incorrect. Does Mr. Scanlan have an overall figure for the percentage of public patients treated publicly out of the total numbers treated up to the end of 2004?

Mr. Scanlan

I do not know the exact reference to the Tánaiste's statement. I take the Deputy's point that patients were treated through the NTPF but up to the end of the period covered by the report of the Comptroller and Auditor General, a high proportion of these patients were treated in public hospitals. I only have the same figures that appear in the report of the Comptroller and Auditor General. I do not have a further breakdown. I just have a global figure of the numbers treated. I do not know if Mr. O'Byrne has a more up-to-date figure.

It was stated that the purpose of the National Treatment Purchase Fund was to buy procedures in private hospitals but that did not happen in at least 50% of cases.

Mr. Scanlan

My understanding is that this was the focus of it. However, it was said that if some capacity could be used in the public system, that would be done. It was never intended that it would be confined solely to the private system.

I will move on rapidly. On page 135 of the chapter detailing a comparison of costs, if we take the example of hip replacements where the highest was 72% above the lowest, does Mr. Scanlan have any information on whether procedures carried out in private hospitals were more expensive than those in public hospitals? Has a comparison been done by the National Treatment Purchase Fund or the Department in that regard?

Mr. Scanlan

The Department has not done it and I do not know if the NTPF has done it.

I will put the question to Mr. O'Byrne.

Mr. O’Byrne

The comparison we have to date is that, generally speaking, there are ups and downs in both systems. The public system is not always cheaper or not always dearer.

It must stand to reason that in for-profit hospitals, for example, it would cost the public purse more than public hospitals.

Mr. O’Byrne

Different hospitals have different cost bases. One of the cost bases in the public system, for instance, that is not in the private system is the area of education and training.

We do not have a comparison. Is it the case that since the National Treatment Purchase Fund was set up we do not have a comparison of the cost of treatment in private hospitals as opposed to public hospitals?

Mr. O’Byrne

The best answer I can give at this time is that some costs in the public system are cheaper but some are dearer.

It would be a very useful for such an exercise to be done. It should be fundamental to carry out such an analysis. On the face of it, there should be a difference in costs if a hospital must turn a profit for its speculators and investors. The same is not true of the public service. I must move on to the last question so that other Deputies can contribute.

The traditional method of waiting lists was abandoned. Can Mr. O'Byrne tell the committee what impact the National Treatment Purchase Fund had between 2002 and the end of 2004 in numbers and can he indicate the numbers?

Mr. O’Byrne

As I said in my opening statement, the system that was previously in place was unreliable because it concentrated too much on numbers. Since the inception of the NTPF, we have tried to associate names with numbers. More importantly, numbers are not the issue; it is the length of time patients must wait for operations. When we started off we typically dealt with people who were on lists for two, three or four years. What we see now is that half the public hospitals we deal with refer patients for surgery who have been on a waiting list for more than three months and the other half refer patients for surgery who have been on a waiting list for more than six months. There has been a substantial improvement in waiting times.

There is no contradiction in having lists of numbers allied to the length of time people wait, which would give us the real picture. Mr. O'Byrne said that we will have a complete and accurate picture when the system is put in place. Will that tell us how many patients are waiting and for how long?

Mr. O’Byrne

The answer to that simply is "Yes", but I want to associate the numbers with named patients and specific conditions. If the Deputy looks at the first phase of our patient treatment register, which was published in September, it gives those specific details in regard to the hospitals involved in the first phase.

When will we have it for the whole system?

Mr. O’Byrne

I hope to have it all in place by the end of next year. We have said we will publish figures biannually from now on.

We very much welcome the fact that the waiting time for surgery has been dramatically reduced and that significant numbers of patients are being admitted to hospital and treated successfully. It is a different story from what it was just a short time ago.

Mr. O'Byrne's report states that approximately half the patients are treated in Dublin, with the other half treated throughout the country, and that 37 hospitals are involved altogether. Does he have figures on bed occupancy for all the hospitals? What kind of spare capacity existed in the system, irrespective of the reasons therefor, such as a lack of funding or staff? Surely the success of the national treatment purchase fund has allowed us to learn some lessons such that we can create more flexibility and have higher bed occupancy in the hospitals that obviously must have had a lower rate than we would have expected? What are these lessons? It will always be difficult to meet the needs of all patients and this will always represent a major drain on the Exchequer. What figures suggest that we can reach out on a more sustained basis than was possible in the past?

Mr. O’Byrne

Let me address the first part of the question. We have not carried out the type of analysis in question in detail. There are supply and demand issues to be considered. We do not have enough consultants in some specialties to go around and shop around. When I go into the marketplace, be it associated with public or private hospitals, I cannot just dictate as easily as was suggested that NTPF patients be treated at the lowest price. I wish I could but it is not that easy.

There is need for more imagination in the use of facilities. I have pointed out one possible example, alluding to the fact that there are facilities in the public system that are not used on Saturdays. Better use could be made of those. In time, one will see much more flexibility in the treatment of day cases. Certain people will want to get back to their families or businesses and will therefore opt for day-case-type surgery on a weekend in order that they can be back in harness on the following Monday morning. In order to maximise the benefit for patients, the best approach is to pool the capacity in both the public and private systems so as to treat as many patients as possible.

Certain statistics I first saw perhaps a couple of years ago indicated that there were some hospitals with a bed occupancy rate as low as 56%. Is that true? Do we have any figures on bed occupancy across the country?

Mr. Scanlan

I have some but I am not sure if they provide a breakdown in the detail the Deputy requires. His point on flexibility is well made. When I said that the report should be referred to the steering group about which I was talking, I was conscious that my colleagues in the HSE and the National Hospitals Office would be part of that process. One can take such a report and ask whether it represents the right way to continue to operate, not just from a departmental or NTPF point of view but also from that of the public system providers. One can ask if there is a better way to proceed.

To pick up on an earlier point, Deputy Joe Higgins's question on the price difference is fair. It is right to ask these questions and not to prejudge the answers thereto. All things being equal, given that the public sector does not have a need to make a profit, it should, therefore, be able to outbid the private sector if it is as efficient and flexible and has the right cost base. This is the challenge for the public system. What I said about cost contestability is important in this regard. It prompts us to consider how we are using our resources.

I have a table that shows the average length of stay in a series of hospitals. Percentage occupancy rates vary and include figures of 60%, 93%, 54% and 50%.

I know the rates vary but it is a question of whether the rates are as low as I suggest in some hospitals. Is the rate of bed occupancy between 50% and 60% in some hospitals?

Mr. Scanlan


We know there are hospitals in which the rate is dangerously high. It is a question of the flexibility we want to create in light of the experience we have had of this system. Surely bed occupancy of such a low level raises questions, given that other hospitals are stretched to the limit to try to meet the patient care demands.

Mr. Scanlan

The Deputy is asking whether the bed occupancy rate is between 50% and 60% in some hospitals. This is correct in respect of a few hospitals. In other hospitals, the rate is much higher. Mr. McLoughlin might be able to tell the members more about this.

Mr. Pat McLoughlin

The hospitals in which the occupancy level is between 50% and 60% are mainly involved in elective surgery. Such surgery is generally not carried out on Saturdays or Sundays and this is the reason for the lower occupancy. Rather than looking at waiting lists and the surgical side, a hospital manager must maintain a balance between medical admissions and surgical admissions. While one could carry out much more activity in elective hospitals on Saturdays and Sundays, one could not do this to the same extent in busy accident and emergency hospitals because one has to protect the beds for the medical cases that will inevitably be admitted on Mondays and Tuesdays. More work could certainly be done in hospitals that are primarily elective but a balance must be maintained.

We are saying that some hospitals cannot deal with the waiting lists or the accident and emergency admissions because they do not have downstream facilities. Does Mr. McLoughlin's point not indicate that there is actually under-utilisation of downstream facilities?

Mr. McLoughlin

We have capacity that could be used for more elective work but the hospitals with this capacity would not be suitable for accident and emergency work. They are primarily ear, nose and throat specialty hospitals. One could not have those types of hospitals on call and one would have to install a completely different infrastructure if they were to have accident and emergency units.

The benefit of the elective hospitals is that they protect the beds for elective work. That accident and emergency cases are not being admitted to those hospitals, including Kilcree and Cappagh and, to a certain extent, the Eye and Ear Hospital, means one can plan the elective workload for the whole week. If these hospitals had a much higher occupancy level, a premium would have to be paid for consultants, nurses, anaesthetists and junior staff throughout the seven-day period, as the Attorney General stated. This would certainly be prohibitive in the context of the existing contracts for the various staff grades.

I will address my question to the chief executive of the National Treatment Purchase Fund or perhaps Professor Drumm. A number of witnesses mentioned the waiting list threshold that exits before someone is treated using the National Treatment Purchase Fund. Mr O'Byrne said the length of time for patients on waiting lists is the main issue. General practitioners in Waterford are telling me they cannot even get their patients on the waiting list to begin with. They say the issue is that the consultants at Waterford Regional Hospital cannot cope with the numbers. Many public patients are effectively shut out of the process from the beginning. The general practitioners tell me that there is not a similar problem in, for example, Cork and Kilkenny. Some cases get onto the list there but that is not suitable for all public patients, particularly those who need to be close to their homes. Many simply do not have the means.

One doctor in Dungarvan recently referred to this as the "boomerang effect". He had two public patients within a couple of days who had serious bowel problems needing surgery but letters came straight back from the consultants at Waterford Regional Hospital informing him the waiting lists were too long and the patients in question would have to go elsewhere.

The Comptroller and Auditor General states the threshold for NTPF treatment is three months on an in-patient or day case waiting list. The GPs in Waterford say that for some patients that does not even apply. They tell me this is not a new phenomenon but has been going on for years.

Professor Drumm

We can both respond to those questions. The Deputy is correct to say that access to the waiting list is misleading, if it is read in the context of everybody who needs a procedure wanting it performed within three months of having the complaint. The big bottleneck in the system is getting access to a consultant appointment, which varies significantly across the country. It is indefensible that GPs, who are highly skilled, must wait a long time for a patient whom they judge to be in need of it to get a consultant appointment. This also increases pressure on the acute bed capacity because in an environment where people are sensitive to medico-legal issues a GP is under pressure to send a patient directly to hospital when an out-patient appointment might have reassured him or her and the patient that it was alright to deal with the problem electively.

The only way to deal with that is to increase significantly the number of consultants in our system which is highly dependent on junior hospital doctors. It is unacceptable that when GPs get a patient into an outpatient clinic they receive a letter from a relatively junior doctor with much less experience than him or her.

The Deputy has raised one of the major challenges facing us, namely, to get consultants providing service at the outpatient level in a timely manner. That involves not only throwing more money at the system but examining how the money is applied at a junior versus a senior level. It would be useful to follow up on that by asking Mr. O'Byrne to comment on an approach being taken by the NTPF to try to deal with that problem.

Mr. O’Byrne

One of the problems we have encountered is that as we make inroads into the inpatient waiting list it highlights the problems at outpatient level, some of which the Deputy identified this morning. I do not know the exact figures for the Waterford area but to date in the former South-Eastern Health Board area we have treated approximately 3,500 people as inpatients. This year we piloted several outpatient initiatives, one of which was conducted in the south east where we received good co-operation.

To indicate some of the changes I have fairly recent figures from the former South-Eastern Health Board areas. In the ear, nose and throat, ENT, inpatients unit in June 2003, a total of 219 patients were waiting for surgery. Recently, that figure stood at 28, as a result of the outpatient initiative. Some of the patients went from west Waterford to Cork, others from east Waterford to other places. The ENT outpatient list in June 2003 was 5,727 but at the moment it is approximately 1,600. The waiting time for an outpatient appointment has gone from four years to 15 months. While I do not condone a 15 month wait there has been some progress.

We ran another outpatient pilot in the ophthalmology unit where the waiting time to see a consultant has fallen from 12 months to six months. However, work remains to be done.

I appreciate the comments of Mr. O'Byrne and Professor Drumm but while I do not say there is a false debate here, there is another issue to be addressed which the witnesses have acknowledged.

Would someone, perhaps Mr. Scanlan, study the situation in Waterford Regional Hospital with regard to consultants? I am told this is not a new phenomenon, that it is an ongoing problem and public patients are being badly disadvantaged. I would appreciate if someone could study this.

Mr. O'Byrne gave us a regional table showing the number of patients from each region but as that is not compared with the average waiting time numbers in each region it is difficult to make a direct comparison. On a brief perusal this does not seem consistent with population in these areas — there seems to be wide variation. For example, almost half the numbers are in the old eastern health board region, which I presume includes Kildare, Wicklow, Dublin and parts of Meath, whereas the former southern region seems to be under-represented. Is that linked to the length of waiting lists in the regions?

On page 135 we see a trebling of the figure between the lowest and the highest prices for some procedures although paying higher fees does not seem to have delivered better results. The best result seems to be in the coronary-angiogram category which is the lowest of all price differentials of the procedures shown in the table. Is there an explanation for that?

Will Mr. O'Byrne make information available about how much each hospital, whether public or private, receives, even breaking it down to what each consultant surgeon receives from the NTPF, to make direct comparisons for public accountability? He spoke about the use of public hospitals on Saturdays when the surgical facilities may not otherwise be in use. Would there not be a knock-on effect in regard to additional staff costs for people working on a Saturday who would not ordinarily do so? This would have implications for overtime pay and people being taken from other aspects of hospital services, which seems incompatible with Mr. O'Byrne's contention that the NTPF does not have a direct effect on the provision of these services otherwise.

Mr. O’Byrne

For each hospital or former health board area we publish time zones within which patients are referred, for example, whether it is over three months or six months or whatever.

That is my question: is the correlation of the numbers treated linked to the waiting lists? We cannot see that from the table Mr. O'Byrne provided.

Mr. O’Byrne

Not in all cases. The price variation depends on how one looks at it, for instance, last year we treated 1,633 cataracts which is highest on the list. The price variation for in-patient treatment is reported as 87%. That reflects high and low prices but only five of those patients came in at the highest price. It probably works both ways.

We could consider publishing what each hospital receives from the NTPF. I do not know what each consultant is paid or what staff are paid for working on Saturdays. Whether I should know is another matter. I do not negotiate with consultants directly, nor do I want to. I want to get the lowest price possible in an all-inclusive price that takes this into account. That is how we have done our business to date. We talk about an all-inclusive price that includes consultants' fees and various staff costs. If I can negotiate on one price with a particular hospital, it is a better way of doing business than talking to the various individuals.

The purpose of the fund is to be an add-on to existing health services. If Mr. O'Byrne does not know that information, he does not know to what extent existing services are being replaced. Is anyone taking account of this?

Mr. O’Byrne

Hospitals are funded on the basis of a certain level of activity against a budget which is measurable. Any treatment carried out through the national treatment purchase fund in these hospitals is over and above core-funded activity. This, as well as the whole process, is measurable. Returning to the price issue, we know what we pay in respect of each individual and what each procedure costs. I do not believe I have to get into what consultants are paid within this.

Thank you, Mr. O'Byrne. I am now opening Vote 33 and I ask Professor Drumm to make an opening statement.

Professor Drumm

As this is my first occasion at the Committee of Public Accounts as chief executive of the Health Service Executive, I will outline what I believe is of relevance to the committee as to where the executive is progressing.

Our task is to deliver a comprehensive range of high quality health and personal social services to people. It is a significant responsibility and one that we take extremely seriously. To deliver quality health services, we must at all times put the interests and needs of patients ahead of all other considerations. I appreciate that Members are constantly subject to natural constituency demands and often come under significant pressure from the community to support local services that may appear perfectly logical and reasonable. However, they may not be sustainable from a clinical perspective or may not reflect international best practice. By making quality health care our number one priority, I hope we can provide practical support and justification for the difficult political decisions that may need to be made from time to time.

At the Health Service Executive, we must ensure all our resources are working at their optimum and completely focused on serving the needs of patients. This will require all of us to challenge the practices of the past and engage with our colleagues and the community to find better, more patient-centred ways of doing things. This will be a significant task but we will start by simplifying the way patients access our services and the way services are delivered.

One problem faced in the past was that there was a complex method of access, meaning that patients had to navigate their way through the system before arriving at the provision of care. Simplification will bring greater focus, clarity and accountability. It will also enable staff to feel the system is working with them, not against them. We must recognise, celebrate, and reward efficiency and high performance and not inefficiency. There was a tendency in the past to send money to areas where the system proved to be dysfunctional. We have been poor at putting money into highly efficient support systems as they do not create a clamour for more investment in terms of their impact on their communities or at political level.

Team-working will be critical to creating a service that puts the needs of patients ahead of all other considerations. I will invite clinicians and other professional staff to become part of multidisciplinary clinical and administrative teams, working in both hospitals and the community. I am aware that some of these services already exist. However, I want to broaden this to the health system at large. This is the only way to deliver the services the community is seeking within the finite resources available.

Within the community, we will seek to shift people away from thinking that if they do not attend a hospital, they will not get the best care. There is a remarkable focus on the importance of hospitals in the provision of health care. Changing this thinking will require a greater emphasis on developing our primary and community care systems which must become more integrated and based on specific geographical areas. Everyone wants to be in hospital for the minimum time possible. Achieving this will be a major focus for us. It can only be achieved by significant investment in our community services.

The formation of the Health Service Executive's unified structure, incorporating 17 different health boards and agencies, provided a unique opportunity to create a truly relevant and equitable health service. We are looking closely at how we can put patient care at the core of the Health Service Executive, fully integrate our service delivery channels and enable patients, clinicians and other health professionals to become directly involved in planning and implementing effective health strategies. One complaint over the years is that those involved at the coalface of providing clinical care to patients have felt distant from the central decision-making process. While work to change this is ongoing, we will be in a position during the coming months to announce more details which will make the management of the executive more responsive to messages coming from those providing clinical care. More importantly, it will allow patients to become actively involved in the development of health care strategy.

As the Accounting Officer for the Health Service Executive, I am acutely aware of my personal responsibility for the regularity and propriety of the transactions in the accounts, the control of the assets held by the executive, the economy and efficiency in the use of the executive's resources and for the systems, practices and procedures used to evaluate the effectiveness of its operations. Two key initiatives are being progressed as part of the Health Service Executive financial governance strategy. The Health Service Executive audit committee and the head of internal audit have been appointed.

The Health Service Executive audit committee operates as a sub-committee of the board, independent in the exercise of its role and meets regularly with officials from the Comptroller and Auditor General's office. The board has appointed three members to the audit committee, Professor Niamh Brennan, Mr. P. J. Fitzpatrick, both board members, and Mr. Adrian Watters, a consultant with Fund Government Solutions. Mr. Watters works in the private sector and his appointment will bring in an extra element of independence to the audit committee.

The committee's primary objective is to provide assurance on the adequacy of control within the Health Service Executive's systems and activities. Its role is to comment on the mechanisms put in place by management to ensure systems and activities achieve their objectives; follow up on the implementation of agreed actions; and bring any deficiencies to the notice of the operating management and, ultimately, the audit committee. A key focus of the committee will be the promotion and auditing of value for money management through the health system.

The head of the internal audit has recently been appointed. The issue of improving control systems within the health service is an area of specific importance and priority for me. This function will augment the current audit functions in each of the Health Service Executive areas. For example it will ensure financial activities operate in a safe manner and financial risk is minimised. It will also allow for independent examination and reporting of whether funds and resources are used in accordance with the law and HSE policies and procedures.

The HSE's head of internal audit is a member of the HSE management team and he operates independently and objectively within the organisation subject to the general direction of the audit committee. To safeguard the independence of the audit function, the head of internal audit reports directly to the chairperson of the audit committee. For administrative purposes he reports to me as the chief executive.

Another area of accountability which we have been working on in recent months will be of particular interest to the committee. The management of parliamentary affairs is a key performance indicator and a priority within the HSE service plan for 2005. The parliamentary affairs division which manages the interface between the HSE and the Oireachtas is now established and reports directly to my office. Its key objectives are to accord appropriate priority to requests for information from Members of the Oireachtas and to ensure timely and quality replies are issued to Oireachtas Members. A central task of the parliamentary affairs division will be to initiate and develop channels of communication with Oireachtas Members to inform them about HSE activities and plans at national, regional and local levels. Using facilities such as a dedicated telephone and/or e-mail service, the division will also ensure Oireachtas Members can access timely and accurate information on health issues.

Work is ongoing with the Department of Health and Children on developing the function of the parliamentary affairs division and finalising these new arrangements. The division is compiling a list of contact details of all local health office managers and hospital network managers recently appointed. The list will be circulated to Oireachtas Members who can then make direct contact at local level with these individuals or centrally through the parliamentary affairs division allied to my office.

Our objective is to ensure that replies to parliamentary questions will be given within 20 working days of the reply being issued in the Dáil, and where this cannot be done, we will issue an interim reply. Between April and June 2005, 1,046 parliamentary questions were referred to the HSE for reply. Replies have been issued for approximately 75% of these questions and work on issuing replies to the remaining questions is ongoing.

Since the start of the current Dáil session four weeks ago, 484 parliamentary questions have been referred to the HSE and 65 replies have been issued, while 22 questions were withdrawn as information was supplied by the HSE before the answer date. The remainder are being addressed.

I thank the committee for the opportunity to present this opening statement.

Thank you. May we publish that statement?

Professor Drumm


Professor Drumm stated:

I appreciate that Members of the Oireachtas are constantly subject to natural constituency demands and often come under significant pressure from the community to support local services that may appear perfectly logical and reasonable. However, they may not be sustainable from a clinical perspective or may not reflect international best practice.

That is a very condescending attitude towards public representatives and community concerns. Regarding the recent tragic death of Mr. Walsh in Monaghan, the community wisdom was much more correct than what Professor Drumm says is international best practice, and that is also the view of many of those dealing at the coalface of care in the north-east region.

Professor Drumm

This is a very relevant issue. The Deputy may take it that I accept responsibility for the provision of care to everyone in the country for the future. I do not believe it is condescending to suggest that the political system in a democratic country will always be pressurised — rightly so — in terms of local issues. I presume that is the way the system rightly operates. There is equally a responsibility on me as chief executive officer of the HSE to ensure that the quality of care provided meets best international practice.

If the Deputy is saying that he accepts that the information with which he is provided from local people, for instance with regard to the recent tragedy in Monaghan, is quite correct and suggests that everything which is going on is in line with best international practice, the Deputy is quite entitled to accept that. Equally, I have the responsibility to ensure that what happened to this unfortunate individual does not occur again. In making that decision I will be informed by a much wider constituency than the input of local people and local physicians and wider than the national input, in fact, because I want to reach what is international best practice.

We must be careful to ensure that we take account of the particular rural characteristics of much of our State. I do not know if we can have a common international best practice that might be best practice in major cities of dense population but cannot be simply transposed into far-flung rural areas where the population is not so dense. Does Professor Drumm think that this should be a major factor in how the resources are provided?

Professor Drumm

In a country of this size, that is a minimal factor. The distances involved in the provision of care in this country when moving from one centre to another are tiny compared with what is practised in other countries. I grew up in the most rural part of this country. Much greater distances are already in operation in Ireland for the provision of care for patients than exist in the north east. The notion of distance as a factor cannot therefore have a major impact on a situation where we are challenged by five acute care units on call for a population of more than 350,000 in what is a relatively small geographical area. I am challenged by that and I leave it open to anyone to come forward with any reasonable opinion which will defend that.

We are also moving now to a European working time directive situation which will demand a manning level for that system which will be very difficult for the taxpayer to fund. In all these situations there is a need for medical practitioners, as for any professionals, to employ their skills to a degree which allows them to maintain those skills. It is very difficult to see how this can be achieved in the population bases of which we are talking.

Clearly this is a debate which will continue but we must move on to other issues.

The understanding of many of us is that our health service needed approximately 3,000 more hospital beds. A week or so ago, Professor Drumm dropped what I considered a bombshell when he indicated that no new beds are needed. If he was quoted correctly, he said we would have to be careful about what he called a black hole of extra beds. I would like him to explain what he meant because for ordinary people or the hundreds of unfortunate people languishing on hospital trolleys, the black hole of extra beds would be far more comfortable and safe for them. Those beds are urgently needed.

Does it not stand to reason that in respect of a population which has increased considerably since beds were removed from the system, we need extra beds in the public hospital system? If the professor's position was reported correctly, is there not a major contradiction between his views and those of the Tánaiste, who recently launched, with great enthusiasm, a project for 1,000 private beds on the grounds of public hospitals? The Tánaiste seems to be saying that we need extra beds, although the total is far from the thousands that the Government previously promised. Is there not a major contradiction in granting massive tax breaks to investors — or speculators, as I would call them — to build for-profit hospitals on the grounds of public ones and yet saying that we have enough beds in those public hospitals, although everyone knows that we do not?

Professor Drumm

The Deputy's final comment was that everyone knows that we do not have enough beds. That is what everyone seems to have put out to date. I have come to this within recent months to lead what is a relatively new organisation. As I said in my opening statement, I can see where, historically, the system has been driven by the need for hospital beds.

One has two choices regarding the provision of such care. One can either bring people into hospital and provide it there or one can provide it for them in their communities and at home. One cannot invest the kind of money required on both sides of the equation. If one decides to invest in the hospital system — I accept that the Tánaiste and Government have decided to do that — it is a very significant chunk of money. I will come back to the need for beds.

I ask whether there is not an alternative way of looking at this. That alternative is clearly to build up community services in order that one can begin to move people out of hospital more quickly and remove those who have been placed there inappropriately in the absence of long-stay beds. The Tánaiste, Government, Opposition and everyone else should be willing to engage in that discussion at a time when the health service is undergoing substantial change.

Regarding the need for beds, as I have stated previously, we have more acute beds than the NHS in Britain. Some 11% of our population are over 65, as opposed to 17% in the UK. We must consider how we use our beds and it is only fair to the committee as Oireachtas Members, and specifically to the Tánaiste and the Government, that I examine providing a service in the manner that is most cost efficient and, from the patient's perspective, the most acceptable.

The development of community services will allow us to remove from our current hospital system in Dublin alone between 400 and 500 elderly individuals who, through no fault of their own, have been inappropriately placed in those beds. It is much more sensible for everyone in this country, specifically the taxpayer, for us to focus on how those people are placed in what for them is a much more appropriate long-term care facility than continue to keep them in acute beds which then become some of the extra beds available, if one can call them that. Their existence can explain why we need so many beds in our system.

I believe that to be a much broader way of approaching this than simply throwing beds at the problem, so to speak. That also puts demands on hospitals to begin to use beds as efficiently as possible. Our use of beds is not as good as in other countries in the developed world. That is not a direct criticism of people in the hospitals, since they are faced with a system that has not been developed at a community level to allow them to move people through and out of hospital in a timely manner. If we can set up that system, our average length of stay in hospital can come down to that achieved by international best practice. The way to deal with that may not be to have more beds. I will engage with the Tánaiste and the Government, since it is ultimately their decision, to try to use some of that funding to build up community services so that people are not in hospital.

The Deputy is correct that this country will need some more new beds as the population ages in the same way as the British and German populations. That is an absolute given. However, saying that we need it now may take some funding away from our community services, and I hope to engage more with the Oireachtas and the Government on that.

The Deputy also raised private hospitals and public beds. That is not an issue for me. I would have to ask Mr. Scanlan to answer on the tax incentives, since he is much better informed than I.

I remind members that there is a vote in the Chamber. I will pair with Deputy Smith, the next questioner, and we will work through the vote. However, members who wish to vote can make their own decision.

I will stay with Professor Drumm for the moment for the sake of continuity, but I would like to return to Mr. Scanlan on that issue.

It seems to me that right now we have a major conflict of views. The professor is the new supremo of the Health Service Executive and the Tánaiste is the Minister for Health and Children. They have very divergent views on the issue of extra beds. How will that be resolved and what policy is being implemented now — the professor's or the Tánaiste's?

Professor Drumm

When it comes to policy, it is ultimately the Tánaiste and the Oireachtas who will determine it. There has been a focus on developing new beds, and investment has already gone into that. However, as I move forward, I am in discussions with the Tánaiste, which I will continue, about trying to bring more emphasis to our community services. I have found the Tánaiste to be very focused on care of the elderly, for instance, and very open to engaging in that debate.

Money is being spent on extra beds which are being developed. To say that we should definitely invest in 3,000 beds is not necessarily the right way unless we have built up our community services to a level where we can say that they allow our acute hospitals to operate at maximum efficiency. Ultimately, I am responsible to the democratically elected Government.

What I am terrified of is that the Tánaiste would be more than delighted to acquiesce to the professor's views in that regard. How will the problem of the people suffering on trolleys be resolved? As the professor knows, it is of major national concern — rightly so — since for individuals and their families it is a source of great distress. Can the professor, as the chief of the Health Service Executive, offer a time to us when that will be a thing of the past?

Professor Drumm

I am on record as having said that the only way one will sort out the trolley problems in accident and emergency departments is to provide excellent primary and community services. There are significant difficulties at an industrial relations level concerning how our system operates in establishing 24-hour, seven-day working within a community structure. I suspect that Deputy Joe Higgins and others would agree with me that, ideally, people should be treated in their home environment rather than in hospitals. However, as he said regarding the use of hospitals, our current system is very much focused on five-day working at a community level. I want to focus on seven-day working at that level, thus allowing a great many people who must be hospitalised because of the time restrictions on community operations to be treated in the community.

I have said that it would take two years, owing to the negotiations involved, to make a major impact, but I believe that it can happen over that time. There will not be one big occurrence in two years' time. For instance, we will focus on getting acute intervention teams operating much more quickly than that in order that a patient who must now be admitted to hospital because there is no one available to administer injections over the weekend will be able to return home from an accident and emergency department or a general practitioner's surgery in the sure knowledge that community care services will be able to respond. A patient, who currently has to be admitted to hospital as there is no one able to give injections at home, would be able to go home in the knowledge that our community care services will be in a position to respond 24 hours a day, seven days a week.

I agree, but if that is to be realised, it needs an immediate and measurable input of resources.

Many of us would have concerns with this major departure in giving over public hospital lands to speculators to construct private hospitals in order to seek a return on investment. In other words, they will profit out of people's illness. Has any analysis been done within the Department on the impact this can have on health care generally?

Mr. Scanlan

The initiative launched by the Tánaiste is also a key part of the overall debate on investment and on whether it should be in acute beds or in the community. As Professor Drumm pointed out, that is ultimately a matter for the Government and for the Oireachtas. The one thing on which we are all in agreement is the sheer complexity of the health service. There are different pieces that must be managed in some way, shape or form. It may also need to be managed over different time lines so that when we look at bed needs, the loss of beds in Irish hospitals is no different from other European countries. We have a younger population than elsewhere, but there will certainly be a need for more beds in the future. A study was done which looked at a range of extra beds, but the range depended on what use was made of the beds available and how primary community services were developed. These things all interact with one another. It is a question of managing a given amount of money in one year and looking forward at the same time. It is not a question of needing beds today or next year. With beds, there is a long lead-in time and if a hospital needs them, it should start planning now. It is important to set the whole thing in that context.

The initiative launched by the Tánaiste referred to 1,000 extra beds, but it had a timeframe to it. It was not just for this year or next year, but it went up to 2011. It was not about giving public land to speculators. It was essentially trying to set up a framework that dealt with the whole series of pieces to this jigsaw. From a public patient point of view, it is worth putting them together and trying to get the best value for the public patients. This was driven by a need to improve the service for the public patient. The last time I was here we spoke about using the asset base of the health system. We have not been very good at that. Professor Drumm and I both believe that there is a need to do that in some way. The land is publicly owned and I take the Deputy's point that it should not just be given away. However, the initiative stated that we have assets and that we have a tax policy that creates incentives for investors. We have various needs and plans in the public system for investment and where a gap in investment appears, we should try to use the tax policy and the asset base to remedy that situation. It must all be done with the ultimate objective of providing more beds for public patients.

We can use the assets to construct long-term nursing homes that the professor claims are needed and have these homes in the public service. I accept that this is a policy decision and I am not able to ask Mr. Scanlan about that, but it should be noted that it is a huge departure in the health services to give so much prominence to profit seekers entering the business of care for profit.

The Comptroller and Auditor General will be doing a value for money audit on the PPARS technology system in the health service. The Vote shows €60 million being assigned for information systems while in 2004 it went to €67 million. Should alarm bells not have been ringing when that happened? Was there major consternation in the Department which was successfully kept under wraps until it came into the public domain? Was there an internal audit system working previously? Why did it not pick up these major overruns and open-ended contracts?

Parliamentary question response time is a source of great concern to many elected Members. I appreciate that some people in the health service feel they are being bothered by politicians and there is a point to that. Politicians whose parties do not give the health service sufficient resources are plaguing the same service for waiting lists to be reduced and there is a justifiable contradiction in that. We represent people who have many problems and need assistance with what they perceive to be a bureaucracy. A four week delay in coming back with an answer is a long time. However, I was astounded at the figure given by Professor Drumm that of 1,046 parliamentary questions submitted last June, 261 are still not answered four months later. That seems quite a long time.

Deputy Deasy had a problem about people not being able to get on consultants' lists. Is it not time that this bastion of privilege in Irish society was blown open? It needs to be opened to talented working class youth who can come into the service, be trained at public expense and then go into the service in the required numbers. They can provide, for a reasonable salary, the service that is badly needed by those who cannot now even get on lists. Is there not a huge issue to be examined here?

Professor Drumm

I presume the Deputy is talking about medical school access.

Professor Drumm

Regarding the PPARS, the Comptroller and Auditor General is very close to issuing a report on the whole timescale. It may be frustrating, but I feel the report will bring remarkable clarity to where alarm bells did and did not ring in the system. From what I know, it will be a very comprehensive review and it would be unfair of me to comment in advance. The change from 11 health authorities to one and the introduction of an audit system at one level will bring clarity to the situation. That will turn out be a significant issue.

We are very sensitive to and aware of the fact that in these early days of the HSE our responses to parliamentary questions have not been at the level at which we would want them to be. However, nobody should take the view that we take parliamentary questions as being a negative issue. In fact, my personal view is that inputs such as that of the Comptroller and Auditor General or parliamentary questions are a tremendous resource in terms of driving forward change in the system. I am not being patronising; I believe the questions have a usefulness at that level.

The response rate varies. We would hope to respond much sooner than within 20 days, although we are using 20 days as an average period. If we get a straightforward question in regard to a single event, it can be responded to in far less than 20 days. There are, however, totally acceptable but complex questions that relate to the system as a whole that take much more time to respond to. For example, we received a question recently on the number of working groups that operate within the HSE and the costs associated with these groups. It is a perfectly relevant question but difficult to answer within 20 days. I hope we will respond to questions in under 20 days and I believe that the problems we have experienced in the past year will be less of an issue due to the robustness of what will now be an office attached to the office of the chief executive officer. We would hope to have a much better response rate from such an office. To sum up, we are focused on this issue and accept the response time must improve.

The issue of medical school places is a major one. I am on record, as are others, as having said that we must greatly expand the number of doctors and other specialists produced by the system. We must focus on using the full resources available to, where possible, bring in Irish students who will remain within our system. Everybody agrees that it makes sense to do this. With regard to the background of the individuals who come in, there is no international evidence to suggest that interviewing candidates or using aptitude tests changes the output in terms of the type of doctor produced or their responsiveness to the public at large. I fully agree with the committee that we need to produce more doctors and that we need them to operate in the public service in this country.

The points system is not the most appropriate criterion by which to achieve that.

On another issue, an unfair perception exists that medical students from abroad are keeping Irish-born students out of medical schools. Mr. Drumm should correct that perception because it is a source of distress to some people from abroad who have contacted me. In fact, they are being used as a cash cow by the State in order to fund a part of the medical training of others.

Professor Drumm

That is absolutely true. These people pay extraordinarily high fees which fund the medical school system to a large degree. Everybody agrees that this problem must be dealt with. We cannot blame those who are paying huge sums of money that support the system.

We need to be careful with regard to the points system. I am not an educationalist but I have been involved in medical education for a long period. Given my experience of other countries, I suggest that the points system, when compared to an interview system, at least has the advantage of being totally equitable in terms of who gets in. When a move is made to other systems, there is a real danger that the privileged will benefit more than they do under a points system. The degree of coaching of the privileged to allow them to cross the hurdles presented by other systems of assessment is a major issue. I would be quite worried that a move from the points system would not be a move to a more equitable system across the social classes. We need to consider this issue to find how best it can be dealt with.

Mr. Scanlan

To respond to the Deputy, the Tánaiste and the Minister for Education and Science are both considering the Fottrell report on medical education, with which the committee is familiar, and another report on postgraduate training. My understanding is that they hope to bring proposals to Government shortly.

I welcome Professor Drumm and his colleagues. I welcome most of what is contained in his report, although, as I come from the mid-west, I might quibble with one or two lines in it. In particular, I welcome the wider consultative way in which Professor Drumm wants matters to proceed into the future.

The resources dedicated to health nationally in the past seven or eight years have by and large represented a phenomenal increase. There has been trebling or quadrupling of the financial resources available, a 30% to 40% increase in staff numbers and, to be fair, a significant improvement in procedures throughout the country. In excess of 1 million — perhaps up to 1.2 million — patients enter our hospitals every year for either day or inpatient treatment. Almost 250,000 are treated in day hospital facilities, which is an extraordinarily welcome and, in many ways, new phenomenon.

In terms of developing community services to a greater degree and the more consultative nature of the work with which the HSE intends to proceed, has Professor Drumm noticed that the percentage of our population needing hospital treatment under existing circumstances is in excess of 25%? Professor Drumm referred to international best practice. In what other European country does close to one quarter of the population need treatment? What level of resources should be dedicated to preventative care, as distinct from curative care, which will always be essential? To focus on preventative care is a much better and healthier approach. However, we have consistently wanted to go down the other road, with little commitment to keeping members of the community healthy at home. Why are we out of step in this regard?

Professor Drumm

The Deputy is correct that there is a high number of contacts with the hospital service compared with the number in other countries. I return to the point that this is an under-performance and perhaps an under-investment on the community services side. The Deputy has raised an important topic for Ireland and other countries going forward, namely, the increase rather than decrease of the need for access to medical services at a certain level. There are now good data from the United Kingdom and the Netherlands suggesting that between 30% and 40% of the individuals who present in secondary care clinics — in other words, hospital clinics — have a functional or stress-related disorder. Be it an irritable bowel, non-cardiac chest pain, back pain or a tension headache, the conditions often come from the same source.

As a health service, we have been extremely poor at dealing with stress-related conditions. When a medical system is legally oriented and has become somewhat defensive, this leads to a need to contact the hospital services to carry out investigations before an approach can be taken. Other countries have been more proactive in the provision of a much broader range of counselling services at community level.

Why have we encountered a sudden increase in workload? It is probably due to a number of factors, such as a breakdown in community supports, diminishing interactions within communities, whereby people have become increasingly isolated, and issues like church supports within the community. This will become a bigger issue for us. I return to the point that consequently, we must begin to focus on moving from a system based on hospital contacts to one based within the community.

There is an example of this in Virginia, County Cavan, and Mr. Aidan Browne, who is present, was instrumental in its establishment. One can walk into a centre with a beautiful central area in which people can meet in a social environment. The male and female long-stay wards for that community are located off to one side. The public health nurse and community psychiatry mental health service are off to another side and the local general practice service is situated off another side of the atrium. As the community is in contact with various aspects of its health service in one location, it can be much more responsive.

Unfortunately, in our society there is a perception that if there is not a hospital, the service is not adequate. In reality, the services for the vast majority of people who live in Virginia are far superior to those supplied in practically any other town. We must establish this kind of service if we are to begin to cut down on the enormous numbers of people accessing our hospital system remarked upon by the Deputy. We must accept the fact that this will increase. Our counselling services must be greatly improved to deal with problems which are not directly organically medical, but rather are stress related.

My second question relates to accident and emergency services. The people I meet who have had access to a hospital and have undergone an operation or had treatment will almost invariably state they received a good service and that everything was as good as could be expected. Simultaneously, we have the constant throbbing nature of overloading on the accident and emergency services. In what way do the plans for the future try to separate those patients who are seriously ill from those who, sometime this evening, will inflict the damage on themselves in one way or another? Such people will become competitors for extremely dedicated services and will pile in against those who genuinely need treatment and along the way, may even frustrate staff and nurses as they try to carry out their jobs. How are we planning to separate for once and for all the distinction between those in need and those — I will leave out the word that comes straight to mind?

Professor Drumm

It is a significant challenge. The Deputy is correct in that most people who have been critically ill and within the system appear to speak highly of it. The frustration arises for people who are trying to get into the system for elective work. At the accident and emergency level, we must deploy a system whereby we can triage much more effectively those who are ill and immediately in need, as against those who access our systems for other reasons.

The Deputy is probably alluding to the fact that we have significant contacts in our accident and emergency services which are related to alcohol. However, there are other inappropriate contacts in the accident and emergency services whereby people simply must have a relatively elective problem dealt with there, on the basis of not having access to a primary care service in an out-of-hours setting.

This is not such a big issue in rural Ireland, possibly because one might be able to take a half hour off work the next day to bring one's child or oneself to see one's GP before returning to work. However, for the population of Dublin, this often means taking a full day off work and, therefore, people are almost forced to access the accident and emergency services. Consequently, we will become much more actively involved in developing primary care structures that will be responsive in an out-of-hours setting to the needs of those patients who access accident and emergency services because they cannot get or are not in a position to access a service during the day at a primary care level.

The other issue which the Deputy raised is that of alcohol. It is a major challenge for our acute services. The response from within the accident and emergency services will often be that one does not know whether people have not fallen and suffered a significant brain injury, causing them to be drowsy. Unfortunately, in an environment which is quite litigious from the perspective of medical practitioners, everyone will lean towards the view that everything needs to be done for such a patient, even with knowledge suggesting that to do so is not directly necessary. It is a major challenge and as a matter of policy is one on which I cannot make a decision. It is also an issue that relates to the wider problems associated with the abuse of alcohol. All I can do is agree with the Deputy that it is a tremendous strain on our system.

At one stage in my political career as Minister for the Environment, I became notorious for increasing the penalties for drink driving and reducing the permitted blood alcohol levels. I recall receiving some letters at the time from neurosurgeons and people who were obliged to deal with the consequences of road accidents. Apart from fatal accidents, one has thousands of people who are maimed and require spinal, leg or brain treatment. What can be done, or how can the HSE help in terms of having people who are directly involved in dealing with these accidents speak on the radio or television to explain the consequences of what happens? Apart from the strain on the services, they could explain the actual impact on the individuals who are in wheelchairs or who require constant nursing care for the rest of their lives or whatever. We are simply not getting the results, although many initiatives have been tried. I would like to hear more from the people in hospitals who actually try to deal on a day to day basis with the results of these tragic, traumatic and in many cases avoidable accidents.

Professor Drumm

The Deputy is correct, we should become much more proactive. We will take that on board. The suggestion that we should engage with bodies such as the Department of the Environment, Heritage and Local Government so that those who deal with such victims when they come into hospitals would give explanations is worth considering. The Deputy also suggested getting those people who have suffered so gravely to explain what happened.

I had not thought of the corollary of the Deputy's point, which we should also take on board, which is to use the available communications systems to inform people of the effect that alcohol abuse in non-critical situations has on our accident and emergency services and to raise public awareness of it. Based on the Deputy's suggestion, we could probably use the public to begin to bring about a realisation that the accident and emergency services are also used inappropriately as a result of alcohol abuse. We should take those two suggestions on board.

In deference to the time, I will leave out my arguments relating to the mid-west.

What moneys have been allocated for the implementation of the Hanly report in the 2004 Vote and where in the Vote do they appear?

Mr. Scanlan

I do not believe they appear specifically in the Vote under any particular label. They will appear in the grants made to the health boards and within the health board accounts and as part of the money that was then allocated to the acute hospital sector.

However, there is money in the Vote.

Mr. Scanlan

There is money in the Vote to deliver an acute hospital service. There is also the Hanly report and the question of how to implement it. I am not saying there is enough money in the Vote to implement the entire Hanly report.

That is not what I am asking. I am asking whether moneys have been allocated for the implementation of the Hanly report.

Mr. Scanlan

It depends on what we mean by the Hanly report.

Could Mr. Scanlan answer the question?

Mr. Scanlan

I will answer the question. It appears that much of the public attention directed towards the Hanly report has been focused on the location or configuration of hospital services whereas my understanding is that the Hanly report was driven by the European working time directive, the need to reduce junior doctors' working hours and the corresponding need to bring in more consultants to deliver a consultant-provided a service. This is all tied in with training and the location of hospital services. It was not simply a question of which hospital services should be delivered and where.

There have been ongoing discussions with junior doctors under the auspices of the Labour Relations Commission. I suppose the primary focus of the Hanly report was to reduce junior doctors' hours. I am not in a position to introduce particular working arrangements for junior doctors let alone put all the other pieces of this together.

We will put specific questions to Mr. Scanlan if general questions do not allow him to give precise answers. How much money is contained in the 2004 Vote? If Mr. Scanlan wishes to address the 2005 Estimate, we will not object because it is nearly November. How much money is in there for the appointment of new consultants to fulfil the commitment set out in the Hanly report?

Mr. Scanlan

I do not have the figure with me today.

Is there money in there for the appointment of additional consultants to give a consultant-delivered service in line with the blueprint laid out in the Hanly report?

Mr. Scanlan

I understand the figures in the 2004 and 2005 Estimates would be driven by policy or service developments rather than a stated need for additional consultants because of the Hanly report.

What moneys are included in either the 2004 or 2005 Estimates to develop services in south Dublin and the mid-west, which were the pilot areas for the consultant-delivered services in accordance with the Hanly report?

Mr. Scanlan

I do not know the answer to that question.

Is there any money in the 2004 and 2005 Estimates for this purpose?

Mr. Scanlan

I do not know; I must find the answer to this question.

Is the blueprint laid out in the Hanly report still the policy for the health services?

Mr. Scanlan

The short answer is "yes".

Is Professor Drumm implementing the provisions of the Hanly report?

Professor Drumm

The areas looked at by the Hanly report should almost be broadened. It will take seven junior doctors on each consultant-led team to provide a 24-hour service as a result of the European working time directive. It is, therefore, imperative for us to study how we provide services. People appear to focus on areas like the mid-west and north east but it is also very important for the Dublin region where certain acute services are threatened by the imposition of the directive. The provision of paediatric surgical services across three sites in my area cannot easily be justified if seven people are needed on each rota because of the level of expertise that must be maintained. I am not aware of any specific funding for the Health Service Executive that is related to the implementation of the Hanly report. This is not to say this funding does not exist; I am simply not aware of it.

I have stated at several public fora that my total focus will be on assessing each part of the service on the basis of the quality of care that can be provided. If this is regarded as implementing the Hanly report, so be it. It is the job of every part of the service to show that it is providing the best possible care. This benchmark must be international.

We agree with these objectives but from our perspective and that of the Oireachtas there is great uncertainty as to the policy. Nobody is prepared to answer the question anymore. What is overall health policy and what is underpinning it at the moment? The Tánaiste and Minister for Health and Children stated that the Government agreed that the Hanly report is the blueprint for the health services, yet neither Mr. Scanlan nor Professor Drumm appear to be committed to it.

Mr. Scanlan

It is not a question of being committed to the report. I think the Chairman asked me whether there was specific additional money in 2004 and 2005 to implement the provisions of the Hanly report.

Is this how commitment is measured when one is talking about Government?

Mr. Scanlan

I am asking whether this is how commitment is measured because I have debated this issue before. One of the problems with the health service has been this constant focus on the incremental funding that goes in year after year, which completely ignores what is being done with the considerable core funding base that is present. I was not trying to stay at a general level when I gave an initial answer to the Chairman's question. I told the committee what the key principles that underpin the Hanly report are. It is driven by the European working time directive and driven in turn by the kind of issues Professor Drumm spoke about. He spoke about how this service can be provided safely and cost-effectively.

The Hanly report examined the cost of hiring additional consultants and the savings that would accrue from reducing the number of junior doctors. This does not necessarily mean that one needs additional money. It depends on the outcome of current industrial relations negotiations. We touched on the configuration of hospitals with the recent sad case of Patrick Joseph Walsh. I accept the matter gets far more difficult in a political sense but from my perspective as someone who advises the Tánaiste and Minister for Health and Children on policy, all I can do is give the best advice I can regarding the safest way to provide services. I do not pretend that I know these answers but I take advice, put it to the Tánaiste and tell her what the safest and best way of providing services is.

I agree with Professor Drumm that whether the Hanly report label or another label is used, we are in sense deluding ourselves. Many of these key, core messages have been around the health system for many years and there has been a series of different reports which effectively said the same thing. I understand that this agenda, whether we call it the Hanly report or another name, is the agenda for the health service.

None of the members of the committee are deluding themselves. We have a very good understanding of the issues. When the Hanly report was published, a commitment was made to the employment of a significant number of additional consultants. No suggestion was made that the suppression of junior doctor posts would pay for these consultant posts. Everybody knew that a very large additional expenditure was implied in a consultant-driven service. Is the Hanly report the blueprint for delivering health services or has it been shelved. It is a simple question that deserves a simple answer.

Mr. Scanlan

I agree that the Hanly report never stated that the suppression of junior doctor posts would pay for the increase in consultant posts but it did state there would be a reduction in the number of junior doctor posts. This is part of an industrial relations process. The Hanly report spoke about doing more than simply putting additional consultants into hospitals. It stated that they should be introduced in such a way that they would work differently, which is part of the set of issues we now face in talks with consultants. It is not simply a case of publishing the Hanly report and putting some money into the system such that the report's recommendations will be implemented. There are other levers that must be pushed to achieve this.

Could Professor Drumm be more precise than Mr. Scanlan?

Professor Drumm

The principles outlined in the Hanly report are staring us in the face. If the report had never been produced, we would still face the problem brought about by changes in the European working time directive and the demands for critical workloads based on quality. We must examine how we reconfigure the service to achieve this. A considerable portion of material in the Hanly report is aimed at bringing this about but it can only happen in a context where people and Members of the Oireachtas are willing to accept this change. It necessitates some negotiations with the different bodies involved but it is ultimately a Government decision. At a secondary level, the issues involved in the Hanly report are still present and nobody has come forward with an alternative view as to how structures should be staffed on an ongoing basis that does not fall very close to what the Hanly report has requested.

I thank Professor Drumm. There is much disappointment about the slow roll-out of national breast screening. The agency concerned seems to be autonomous under the law but does it report directly to the Department or the Health Service Executive?

Mr. Scanlan

It reports to the Department.

The United Kingdom, with its population of 60 million, rolled out a breast screening programme during the 1980s in just over four years. This matter seems to be taking forever and all we are getting are more promises. It is called a national screening programme but it only screens approximately half of the women in the most-at-risk categories.

Mr. Scanlan

The Chairman may have a point in respect of the pace at which events occur. The programme started in 2003 and, as I said previously, I believe it will meet its target of starting to roll out across the country in 2007, which is a four year period. The Chairman has mentioned how this was done in the same period in the UK but on a much bigger scale. It is the same timeframe we are working to. It is happening but perhaps too slowly.

Much concern has been expressed, particularly by the Irish Cancer Society, that patients from around the country undergoing cancer services, such as radiotherapy in St. Luke's Hospital, are not being provided with ambulance transport and that it must be renegotiated every time they attend. There does not seem to be an automatic ambulance service to St. Luke's Hospital in this respect.

Professor Drumm

I will ask Mr. McLoughlin, who deals with this particular area of service, to address that issue.

Mr. McLoughlin

We inherited the transport system operated in each health board area. We have analysed this issue and the different transport provisions for patients, such as access to minibus or taxi services for renal dialysis patients, across all of the former health board areas. We have completed this analysis and are currently examining the possibility and cost of having dedicated transport services for radiotherapy patients for 2006 but no decision has yet been made.

Until recently, the hospitals operated on the basis of ten network areas. Now, it seems that they will operate on the basis of four hospital regions. Could Professor Drumm address this matter and reflect on the concerns of certain areas that their local acute hospitals might be diminished in status if there is to be a key central hospital in each of the four regions?

Professor Drumm

I am delighted to do that as there is some confusion about what is proposed. The structures of the HSE, as I found them, related to four areas covering community care provision and ten hospital networks. If one were to attempt to link these services and hope they operate as a unit in each region, where patients are moved from a hospital to the community and back again if necessary as seamlessly as possible, it would be impossible to achieve unless they all operated within the same structure. Therefore, a proposal was made upon examining our structures to change them to four regions.

The interpretation, and very definite opinions have been expressed to me from a number of parts of the country, was that this meant we were establishing major health centres in four areas. These are purely administrative regions and have no impact on the provision of care or its planning. For example, the people of County Wexford would have been concerned that all of their patients would be sent to Cork instead of Dublin, which will not happen. Equally, there would have been concerns in the mid-west that services would suddenly go to Galway.

This initiative has nothing to do with the movement of patients. Rather, it is about our ability to provide administrative control across a large population. These services could be administered centrally, as the Department did historically. I wish to dispel any view that these new structures will have any impact in terms of how we will plan our day to day clinical services.

I welcome Professor Drumm and wish him well in his new position. I will address the issue of parliamentary questions and the new system that has been established. I welcome this system and we discussed it during our last meeting with the HSE and the Department. When one examines the parliamentary questions submitted for written answer, one is given a clear signal that much of what is happening within our constituencies or the HSE's local offices gives rise to queries on behalf of clients and a certain dissatisfaction with the level of quality communication, not only with Members of Parliament but with customers of the executive's services. If they were satisfied, they would not end up in our clinics, which must be accepted by the executive.

I take issue with the quality of replies because, at the end of letters of response from the HSE, further questions are sometimes asked and the original question asked is not dealt with and left hanging. The situation is similar here when queries are put to the officials of the Department of Finance, Department of Health and Children or the HSE. They should be answered openly and adequately, which is the least we as Oireachtas Members should get from the service.

I put a number of questions to Mr. Scanlan when last he attended the committee. This morning, I noticed that a letter of response to one of those questions was delivered by hand. I consider this to be extremely inefficient and Mr. Scanlan's response in the correspondence simply repeated the information I gave at the meeting in question, which was not the meeting in September. This is not good enough.

Other issues were raised at that meeting, such as the level of pay given to retired nurses who returned to the service. I was told that a recommendation had been made by Mr. John Magner to the Department of Finance and that I would receive further information, but I did not receive it. I have received responses to a number of other queries relating to retired nurses returning to the service who have complained about the level of pay they receive due to the pensions they are also receiving. What is the position in respect of this matter? If our delegates do not have the answer with them, could they let us know?

The principal representatives from the HSE and the former South Eastern Health Board are present. I want a comprehensive response on the court case, although I do not want the details discussed here. I do not want taxpayers' money wasted on a further court case because a decision has already been given by the court in question but aspects of it have not been fulfilled by the HSE. It is a blatant waste of money that, having resolved the matter in the court, further issues involved have not been dealt with in a way that puts the case to bed once and for all. I urge Professor Drumm to take an interest in cases such as this so they do not begin to reappear and cost the State money.

Another question raised at that last meeting that no one answered concerned the spending of €20 million on a MRSA public awareness campaign. I still have not received a response. At the time Mr. Scanlan stated he was not aware how the money was spent. The officials from the Department of Finance had questions on this. If I gave someone €20 million from my business, I would want to know exactly how it was spent and if value for money was achieved. The question remains unanswered. To restore confidence in the HSE and the Department, I expect greater efficiency of response and the requisite detail to allay public concerns.

Concerns include expenditure and the issue of MRSA. Based on the latest audit, how much money will it take to deal with the issue of MRSA in our hospitals? How many isolation units are there? Is there further need for points where the public and frontline staff can wash their hands? What questions arise regarding contracts on offer to the private sector, given the Tánaiste's comment that some factories have a higher standard of hygiene than our hospital service? In every corner shop a hygiene certificate is pinned on the wall indicating achievement of a certain standard of hygiene. In our hospitals there is no such standard of hygiene. I invite Professor Drumm and Mr. Scanlan to respond on the issue of MRSA and the exposure of the State arising from claims now being taken.

Has anyone from the Department of Health and Children or the HSE contacted the organisation representing families of MRSA victims to resolve the issue they raise? Professor Drumm referred to the desire of families to care for elderly and sick people in their homes. Families with MRSA are pushed from pillar to post. I know one case where the nursing home would not take the elderly person back. He was sent back to Waterford Regional Hospital where he was not accepted and there was no provision for the care of the person in the home. Another person from Dublin has spent 18 months in hospital with MRSA. There is denial on this point. Can the committee get a response from the Department and the HSE on MRSA? The HSE is appearing before the Oireachtas Joint Committee on Health and Children on 9 November when we will hear harrowing cases of families' experience of the hospital superbug with little or no response from the HSE and the Department.

Mr. Scanlan

I will answer the questions in the order they were posed. I am sorry the Deputy received the reply about the court case this morning. I was conscious of that when I sent it out yesterday evening. From my investigations I have given the best response I can. We cannot discuss it here.

We do not need to debate the case here but the letter, delivered to me by hand this morning, repeats the information I gave originally. It states it is a matter between the HSE and the client. I encourage the HSE to respond and to deal with the case with the help of Mr. McLoughlin.

Mr. Scanlan

I refer to what I can do from the point of view of the Department. Regarding nurses, Mr. Magner spoke about a proposal. We are still in discussion with the Department of Finance but we hope to have a final decision and publish a circular in a few weeks. This will address the lack of incentive for people to return to the system, as raised by the Deputy.

I invite Mr. Mooney to comment.

Mr. Joe Mooney

I cannot comment because I am from the public expenditure division and that aspect would be dealt with by our pay and pensions division. I am not aware of the particular case but I remember Deputy McGuinness raising the matter.

I accept what Mr. Scanlan says. I do not accept officials appearing before the committee and not having dealt with issues raised in past meetings. It is inefficient that this issue has not been dealt with given the demand for nurses and the problems experienced in attracting retired nurses to return. It is not acceptable that this can continue and that the Department of Finance can issue the same answer. Can we expect a response within a week that defines the position adequately? Mr. Magner stated there was a resolution on his suggestion to the Department of Finance. In case the matter is not completely resolved, can the response indicate if this is delayed because of the Department of Finance or the HSE?

Mr. Mooney

It is clear from what Mr. Scanlan has said that the matter is being pursued directly by his Department with officials responsible for pay matters. I understand the frustration of the Deputy but the matter has not been forgotten. From what Mr. Scanlan states it appears to be nearing finalisation in discussions between the two Departments.

Mr. Scanlan

There is frustration at the pace of change. I appeared before an Oireachtas committee in May and I hope things have changed since then. Maybe things are not changing quickly enough. I expect a resolution from the Department of Finance shortly. The Deputy is correct in that we have a particular problem this year because of the change in the nursing graduate system. We need a solution this year. As soon as we have a response from the Department of Finance, I will send it to the committee. I hope it will be what I suggested on the previous day.

Perhaps Professor Drumm or Mr. McLoughlin will speak on MRSA. The previous day I was asked by the Deputy if we know what money is being spent on MRSA. The same question applies across the board. The previous day I stated that the establishment of the HSE provides an opportunity but does not provide an overnight answer to all these issues. Professor Drumm holds the same view. One of the major problems is that we cannot track what happens when money enters the system. I believe I saw a response from the HSE after the previous meeting.

It was a response to the secretariat. It has been circulated.

Mr. Scanlan

Money is spent and is not necessarily spent on the items for which it was intended. We need greater clarity on this issue because it is only when we know where money is being spent that we can begin to ask questions on value for money.

Professor Drumm

I invite Mr. McLoughlin to speak on MRSA.

Mr. McLoughlin

We will appear before the Oireachtas committee to address this matter. Since the establishment of the HSE and the National Hospitals Office, we have been proactive on hospital hygiene and infection control. One month after the establishment of the office we set up a group to examine hygiene. We established there were no national infection control and cleaning standards. A group has been working on the development of national standards. Approximately 700 staff have come together to attempt to improve standards of hygiene. We commissioned an external consultancy to carry out an unannounced hygiene audit on every acute hospital in July and August. We will publish the data on this next week.

We are developing a skills training programme for all staff involved in hygiene. We have issued hand hygiene guidelines. By the end of the year we will have national standards, and a national audit and a publicity campaign on hygiene will have taken place. We will carry out two further hygiene audits next year. We will have baseline data for the first time. We are determined to make hygiene a major performance issue across the entire hospital system.

The unannounced audits during the summer months were well announced.

Mr. McLoughlin

We announced that it would happen in July.

Mr. McLoughlin has no idea of the activity that went on in hospitals before the auditors arrive.

Mr. McLoughlin

I am delighted such activity occurred because we would expect an improvement on whatever baseline was established.

Mr. McLoughlin would find it slipped back after the audit was complete.

Mr. McLoughlin

We will see. We announced that it would happen during July and August. We were advised that one hospital had known. We were satisfied it could not have known but to protect the authenticity of the audit, we sent the audit team in again, unannounced to anyone in the hospital. We take this extremely seriously and we are determined to make it a performance issue in every acute hospital.

There is no correlation between contract cleaning and infection control rates or hygiene rates. It is a mixed picture. We will publish the results next week. Every hospital's performance across an entire range of issues will be published. We will ensure that is improved upon next year when we will carry out further unannounced objective audits.

What about the question of care for those with MRSA and the provision of isolation units?

Mr. McLoughlin

Isolation units are part of the overall infrastructure which we require. Hygiene, overcrowding and the available facilities within hospitals are issues in hospital acquired infection. SARI is carrying out an audit on the range of facilities available in hospitals. We will address that more comprehensively at the scheduled meeting of the Oireachtas committee. I do not have the details with me.

A group was to report on the transport needs of those who must travel for radiotherapy services and cancer care from the south east and other areas. That group was disbanded. It sat for some time and surely it must have made some report. In the past a number of members of this committee raised the issue of the cost of transport and the inconvenience to the patient. The necessary improvements have not yet been made. I will focus on the south-east. Where in the general Vote is an amount of money allocated specifically for the improvements necessary within the south east for radiotherapy treatment or dialysis? Mr. McLoughlin might answer the question put at the last meeting on the scanning facilities at St. Luke's, which are only available from 9 a.m. to 5 p.m., Monday to Friday. Negotiations have been ongoing for the past few years on making that service available 24 hours a day seven days a week. Have those negotiations come to an end? Has that problem been resolved?

Mr. McLoughlin

I will return to the Deputy with the specific details. It was of concern to us that out of hours restrictions on the use of the CT scan were in place. They were in place because of the demands being made and the cost of the out of hours service. Since the establishment of the HSE, the group that examined radiotherapy services has referred the matter back to us. As I mentioned to the Chairman, we have an analysis of the various ranges of transport provided and we are examining the possibility of having a scheme in place for 2006. The question that arises is the extent to which one would provide a dedicated transport service on a disease basis. I would require professional advice on that.

People involved in radiotherapy consider that each individual should have a dedicated taxi service. There is a transport infrastructure, including minibuses and taxis, throughout the country. It will cost additional resources. Undoubtedly people use their own private transport to travel to facilities. Many patients do not want to avail of the dedicated service because it brings patients from the south east to a range of hospitals and they must wait for pick-up at a certain time of the day. Their radiotherapy treatment may be completed in a short period of time. We must balance patient need with the overall cost of the transport service to be provided.

That is fair enough but Mr. McLoughlin must acknowledge that people using their own private transport do so because the patient is so ill that they cannot avail of the type of service on offer. That is true of radiotherapy as much as it is true of CT scanning in St. Luke's, Kilkenny. One young person had to be transported overnight in the back seat of a car to avail of the service in Dublin. That car drove past the service in Kilkenny city. It is not acceptable. The issue of constituents making unrealistic demands was mentioned earlier, but in that case it would have been correct to have carried out the scan in Kilkenny. It is essential that some form of transport be put in place in a realistic way. Not all of the demands can be met but as a matter of urgency it must be specified to those concerned what changes will be made and whether that cost is in the budget for 2005 or 2006.

Mr. McLoughlin

We are examining the cost of providing a dedicated transport service. We must balance that with the emergency call service. I take issue with the comment that patients only come to the radiotherapy service because of a lack of a transport service. Many patients prefer to arrive in their own transport, accompanied by a carer or partner, rather than go on their own on a transport service. We must respect patient choice. It will not be easy for us to determine exactly what the use of a dedicated transport service would be for radiotherapy but we are examining that issue. We hope to make progress on that for the 2006 Estimates.

I thank Mr. McLoughlin for that. Many vulnerable people sought that commitment and they will be pleased with what he stated.

As this has been a long meeting, I will be succinct. I will address my questions to Professor Drumm. The rationale behind the establishment of the Health Service Executive was to replace 11 health boards with a single agency and to achieve synergies. I know it has been in existence only briefly. What synergies have been achieved in that time and when will full synergy be effected? Will that be measured in terms of the ratio between administration and direct service delivery? Are fewer people employed in the new system? Is it envisaged that fewer people again will work within the system? What degree of redeployment has taken place and how much does that redeployment cost?

Professor Drumm

The Deputy's question is asked by many people within the system. We are still in the throes of bringing together those 11 services. It is one of the major challenges we face, if not the major challenge, at administrative level. During the next month we will be in a position to publish our plans for the central management structure, including the participation of patients, physicians and nurses. That will allow clarity on how functions such as finance, HR and IT will operate.

The immediate challenge is to amalgamate the people who worked in these areas across 11 health boards into a centralised reporting structure. We are planning a powerful shared services area in which many of the services formerly provided across different areas will come through one directorate, resulting in a significant reduction in backroom administrative support. Outside the voluntary hospital system, the Health Service Executive employs approximately 70,000 people, 12,000 of whom have administrative roles. Of the latter, 8,500 to 9,000 are involved in frontline services, such as secretarial or reception work in clinics and hospitals.

We hope that a significant number of the remaining 3,500 can be reapplied by means of this new structure. That has to take place within the next six to 12 months and possibly sooner because there are pressures from unions to address the frustration experienced by people who worked in the health board offices and to give them clarity in terms of their careers. Within four to six weeks, we will be in a position to move rapidly in that direction by outlining clear guidelines on where people may go.

The deal made with IMPACT to the effect that people will be guaranteed continued status in terms of seniority and geographic location has been a significant influence on this issue. A lot of wisdom will be required, if not to the degree of Solomon, to allow people perform relevant functions in the system while continuing to work at their levels. That challenge must be taken up on the basis of providing alternatives for people in order that they can move from health board head office systems. One such alternative will involve opportunities for senior administrators to engage with frontline hospital services in order to address shortages in administrative support that have required many clinicians and paramedics to spend time carrying out administrative functions for which they are not trained. Talented administrators will now be freed up to carry out this work.

It will be a major task to bring these 11 areas together and Deputies may ask whether there will ever be an answer. There has to be because we are coming under enormous pressure, including demands by unions, to resolve this issue.

How many have been redeployed today and at what cost?

Professor Drumm

I cannot tell the Deputy the numbers redeployed or the costs involved. If the figure can be determined, I will revert to the Deputy on it. The cost of redeployment based on the IMPACT deal will be relatively low because we will not be moving people per se. I suspect that the numbers redeployed in terms of taking up new positions is quite low at present.

The health service has been bedevilled by the matching of pre-planning with capital investment and current expenditure. It was hoped that the HSE would be a vehicle to prevent this in the future, although it may not yet be in existence long enough to do so.

A considerable investment was been made in my constituency for new accident and emergency facilities at Cork University Hospital. Despite the fact that facility was opened three or four months ago, the hospital has already had to initiate emergency procedures because of a mismatch between people looking for accident and emergency services and the ability of the hospital to cope with them. What is intended with regard to advance planning of capital expenditure and matching it with current expenditure?

Professor Drumm

Others may wish to comment on this. The Deputy raised a critical issue for us. We cannot continue to progress capital planning if it is not closely allied to revenue. First, it is not an appropriate way to get services up and running. Second, services may not be opened in a situation where a new capital investment has been identified as a way of squeezing the HSE because it was not made clear when the investment was sought that the organisation concerned would be required to produce revenue. From our perspective, we need to clarify that we have sufficient money to make the system work and the message needs to be transmitted that new capital development cannot be used to wring unplanned revenue money from the system.

Mr. McLoughlin

In the case referred to by Deputy Boyle, a surge in activity in the accident and emergency department resulted in overcrowding.

It is designated as a major emergency centre.

Mr. McLoughlin

Such events can occur even in planned areas. Movement among patients can give rise to surges in accident and emergency activity. Generally, hospital systems are able to cater for these events when they are not under pressure. The highest number of patients awaiting admission into accident and emergency departments throughout the country was lower than the number of patients waiting in hospitals for facilities in the community.

Despite being designated in the event of a major fire, train accident or chemical spill into Cork harbour, the facility could not deal with a natural surge one month after its opening.

Mr. McLoughlin

I do not agree that it could not deal with major accidents. A decision would have been made, in such an event, to stop elective services. Significant increases can occur in terms of accident and emergency activity at certain times. Much can be dealt with on a see and treat basis, following which patients return home. Admission may be required in other instances. The development has brought a significant increase in space and capacity to Cork University Hospital and I am satisfied that it can cater for the demands made of it.

The Secretary General may speak to the issue of matching capital and revenue. No capital project will be approved without clarity in terms of revenue costs. Decisions on what is required to open facilities are often for management to make. While managers must make judgments in terms of revenue costs of opening facilities, they may also have to negotiate with trades unions on issues such as roster changes, extended days and additional staff. It is true that facilities around the country have remained closed because of difficulties in reaching agreement with staff associations. If a Nightingale ward in an acute hospital is being transformed into single rooms and four-bed wards, requests will be made for additional staff on the basis that it is less easy to provide treatment under the new arrangement.

In terms of staffing levels, there are no accepted norms. The HSE is investigating the issue of staffing levels across the system with a view to making better use of manpower and matching activity with rosters. We have noticed in accident and emergency departments that there is a difference between the rosters and the times patients come in for services. That applies to both medical and nursing services and is an issue we must address in 2006.

Mr. Scanlan

I debated this area at some length the last time I was here. We have a transition problem this year and perhaps will have one next year with the capital programme. We need to know the revenue implications and that the Department of Finance will support me. Neither the HSE nor the Government can sign up to a capital programme without knowing the revenue implications. It is necessary to know the full revenue costs beforehand, not only to avoid building a facility without knowing when or how it would be opened but in order to decide whether to build a certain project in the first place. I would go further than Mr. McLoughlin on the question of local negotiations. Professor Drumm said we should talk to local union representatives and put in a bid based on co-operation and agreed rostering in order to score higher than other bids. People should be rewarded for such initiatives.

In the aftermath of the Ferns report what is the Department of Health and Children doing to examine the service provided in the relevant health board region and nationally? What lessons will be taken on board by the HSE?

Professor Drumm

I will ask Mr. Aidan Browne from our primary, community and continuing care area, which deals with those issues in the community, to comment.

Mr. Aidan Browne

We are satisfied that the Ferns report appropriately assigned responsibility to where it rested and there was certainly evidence of inadequate response from the services on the ground. Some of those issues resulted from people's understanding of the legal situation and doubts about their capacity to follow through. There is an acceptance that across the country the response in the former health board areas was variable. In the case of Ferns, however, staff may actually have acted ultra vires, going beyond what they were legally mandated to do in the interest of clients.

We will work closely with the Department of Health and Children in the near future. The report makes specific recommendations about joint working with the Garda Síochána and the church authorities and we will actively move forward on those in addition to current activity in Ferns.

Has the HSE or the Department conducted an audit of land held by the former health boards that would be surplus to requirement and is that audit complete? What are the intentions for that land? We have been told a piece of land at Myshall in County Carlow is now only worth €500,000, having had €1 million spent on it. Will that be kept for the services of those with autism?

Can recommendations be made to remove some of the bureaucracy involved in DPG schemes and housing aid for the elderly and to release some of the occupational therapists and medical officers there to do other things? I believe that both schemes are over-bureaucratic and costly. If funds were to be released more quickly it would help those staff to care for those who are sick in their own homes. There is no national standard for the delivery of home help hours. Some adjustments were recently made in the south east which have caused some concern for those involved and should be revisited.

We have not discussed the psychiatric services or the community supports that are available to those with psychiatric problems. Within the south east, particularly Carlow-Kilkenny and Wexford, there is a high number of suicide cases. We can talk about alcohol and the growing use of drugs like heroin in urban centres but there is no synergy between the treatment patients receive from the psychiatric services and the support they require when they return to their own homes and communities. We must explore that situation and its link to the high level of suicides, particularly among young people.

Is it possible to direct funds from the general Vote to the support of those services, notwithstanding the transition from the old system of asylums and mental hospitals to community care facilities like the new unit at St. Luke's in my own city of Kilkenny? There is growing public concern about care for those with psychiatric illness in the community and the linkage with suicide. What are we doing about that?

I ask delegates to answer the questions appropriate to their own particular area.

Mr. Scanlan

I will answer the question on land. We have agreed that as part of the expenditure review there will be an audit. It has not been carried out yet but there will be one. It needs to look at the extent to which land is surplus and how it would be used. It is a job to be done.

Professor Drumm

I confirm to Deputy McGuinness that we are focused on establishing an active estate directorate within the HSE because the Government will not be able to fund directly from taxation much of what needs to be done on the primary care strategy and the critical development of community services. There are problems with title to much of the land and that will become a major task. I hope local community suggestions for the land bank in local areas will drive, from the ground up, the policy on how services will operate at a community level. I will ask Mr. Browne to answer on care for the elderly in Carlow.

Mr. Browne

Myshall is still under consideration. We intend to make the most appropriate use of the resource. Most of the discussion today has centred around hospitals, which is interesting. Primary care seems to come at the tail end, yet it is at the core of the future delivery of health services. The psychiatric and home help services have suffered from the separation of services into tiers and funding via streams that did not reflect the needs of total populations. I wish to see the development of a primary care service that includes psychiatric services as part of its core business. In that scenario people would be followed up on, because traditionally when people go into psychiatric care the service is expected to deliver the totality of care, even though it is not sufficiently resourced to do that.

The development of the primary care strategy and the direction of more funds to that strategy on the basis of the whole population will help us to address a number of those issues. As the Deputy is aware, we have established a national suicide prevention office within the HSE on foot of the suicide strategy. The objective of the office is to give priority to addressing the issues that arise in all local communities as a result of the numbers of suicides currently evident. Significant work is under way on the matter.

I agree with the Deputy's remarks on housing aid for the elderly being overly bureaucratic. It is a scheme that has been administered in different parts of the country in different ways. The opportunity has often existed not to co-operate with Government authorities that share the obligations in this area, such as the Department of the Environment, Heritage and Local Government. The reduction of bureaucracy in this area is high on our agenda. The question of whether the reports of area medical officers are required to obtain the grants is an issue that must be addressed, and the bureaucratic obstacles to supporting people living at home must be removed.

With regard to the disabled person's grant, help for the elderly at home is essential. The issue should be addressed in a proper constructive way. The normal bureaucracy across the country should be removed. Despite this issue not receiving full attention during the course of this morning's meeting, it does not mean the matter is not a priority in the minds of the committee members. Community care is also a priority. There has been a lack in funding community care in the context of psychiatric services, and this is a serious issue. I hope to revisit the matter more comprehensively the next time the witness is before the committee.

There are a number of sheltered housing schemes around the country, principally in cities such as Dublin, Cork and Limerick. The facilities were put in place mainly through funding from the Department of the Environment, Heritage and Local Government, with a 75% grant that has now been increased to 90%. Capital funding is therefore not an issue. However, the facilities were run by nuns who are now themselves in need of care. No new vocations are coming in, and the daily funding of these facilities is essentially coming from the pensions of elderly nuns. The nuns are hiring caring staff, but the number of nuns in the position is decreasing on an annual basis.

Replacement funds should be provided for these facilities, as the manner in which they are being run cannot continue. These are excellent centres of sheltered accommodation for the elderly, which carry out great work. The centres are exactly in line with the policy as outlined previously by Professor Drumm. I have asked the Department of the Environment, Heritage and Local Government to undertake action on the matter, but it has stated that it is principally a function of the Health Service Executive. I do not require an answer on this issue today but the problem should be investigated. The issue will not improve as it stands.

Mr. Purcell

I have some brief comments with regard to the National Treatment Purchase Fund. The initiation of the fund addressed one of the criticisms I expressed in the value for money report on the waiting list initiative. The fund provided a focus that was previously absent but which was intended with the waiting list initiative and dissipated over the years. The NTPF has been good in this respect. If a problem area exists, a logical response is to set up a body to address the problem.

Examination of the fund raised questions about the broader context in which the health services here are delivered. The statements of experts today have supported these questions. Hospitals are not places which run five days a week on a 9 a.m. to 5 p.m. basis. People do not get sick only during this period, and they are at least as likely to get sick at weekends. The health service must be designed around this. The idea of the NTPF getting work done on Saturdays is fine on its own, but perhaps this is the manner in which hospitals should be run and funded accordingly in the first instance.

Since the NTPF has been set up it has done good work and delivered services, etc. However, one cannot argue that it must deliver at any cost, and I am not suggesting that it does so. One must consider, however, if it provides value for money. The NTPF received €64 million this year, and appropriate performance indicators for it must be brought in. This could be done with the relevant Department. There are objective criteria against which the NTPF can be judged, and perhaps this can be noted in the annual report, which also communicates achievements.

Clear advantages have come about from the advent of the HSE, a unified health authority with local administration. From an audit point of view, taking the audits of the health boards and related agencies since 1994 and examining the year-on-year position, one can see problems in some health boards that have been sorted out in other health boards. There was a lack of connectivity and consistency across the health boards. I will not go into particular issues such as nursing home subventions, but these were accidents waiting to happen. If somebody was treated in a particular manner in Galway, for example, somebody in Cork should expect, and would have the right, to be dealt with in a similar manner. If he or she was not, there would be a cast-iron case which could be brought before the Ombudsman. We need not go into that.

It is clear that problems do not disappear on their own, and they have not been eliminated with the advent of the HSE either. Problems must be addressed. I indicated at the outset that I was about to certify all the accounts of the health boards and related agencies for 2004, but there is a legacy of problems which are addressed in management letters issued to the HSE. These relate to particular areas covered by the former health boards, and they must be dealt with. Reference was made earlier to assets such as lands, and in certain cases there is still a lack of a comprehensive register of fixed assets, including land. It is gratifying to hear that the matter has been taken on board, although I recognise that it will take time to deal with.

The capital programme and the manner in which it was delivered was also mentioned. I will not go back on old ground but in the general report on the audit of the health sector last year, which we discussed, there was mention of approximately €100 million worth of unauthorised capital expenditure. I have stated before that the building of a structure, without delivering the people to work in it, is not a health service.

The PPARS issue has been discussed in private session, but the committee is aware that I am carrying out a value for money report on that system. I expect the report to be completed in December, but this is dependent on ongoing co-operation with the HSE and the Department of Health and Children where necessary. I have had a good experience in recent times on the matter, but it is not all in my own hands but in so far as I can commit to that it will be on the table in December.

I thank Mr. Purcell. We may now dispose of Chapter 14.1, the National Treatment Purchase Fund. Is that agreed? Agreed. We are not closing the Vote today, we are not noting it. I ask members to clear their diaries for Thursday, 15 December 2005. We will reschedule the Vote and schedule the value for money report on hospital waste. If Mr. Purcell's deadlines are met, there will be a discussion on the PPARs report on that date also. This has been a fruitful meeting and I thank the delegation for being so forthcoming.

The witnesses withdrew.

The agenda agreed for the meeting on Thursday, 3 November 2005, is as follows: meeting with a delegation from the Committee on National Finance from the Senate of Canada. For the benefit of our friends in the media that will be in public session.

The committee adjourned at 2.55 p.m. until 11 a.m. on Thursday, 3 November 2005.