I commend the Comptroller and Auditor General for the preparation of both reports. The report on disability services by non-profit organisations will widely inform us on more than disability services because of our major involvement with the voluntary sector in other areas. The reports are fair and balanced and will serve as a very useful resource and guide for the HSE's substantial change agenda for the delivery of disability services and the development by the HSE of a robust strategy for improving waste management in hospitals.
The Comptroller and Auditor General's report on value for money examination of waste management in hospitals was the first national audit of health care waste within the health service. It was based on a survey carried out for the year 2002 and published in March 2005. This report is a timely reminder of the costs associated with the handling and disposal of waste and together with other public initiatives, such as the Race against Waste campaign, has helped to raise awareness about the importance of waste management in hospitals.
In 2002 the total quantity of waste produced by publicly-funded hospitals was estimated at 27,500 tonnes, which included 5,300 tonnes of risk waste. In 2005 these figures increased to 30,500 tonnes, which included 6,500 tonnes of risk waste. This increase in waste production reflects the increased activity in the hospitals, especially in terms of day cases, which causes a lot of risk waste. It also should be noted that all waste produced in the hospitals is now weighed prior to disposal. This was not the case in 2002.
In 2002 the cost of risk waste treatment and disposal was €870 per tonne. The present cost is €1,050 per tonne, which was agreed under an all-Ireland contract, although the Comptroller and Auditor General has estimated a higher figure. The average cost of non-risk waste disposal is approximately €270 per tonne. This cost includes contractor lift costs, compactor-bin rental, landfill costs and Government landfill tax.
Since the publication of the report, the HSE has addressed the good practice notes included in the report and is taking action. We are cutting down on the amount of waste produced. The HSE has adopted a procurement policy that encourages and persuades suppliers to investigate and introduce environmentally-friendly processes and products. It also requires suppliers to remove excess packaging before delivery or to take back packaging material after delivery. Visitors are encouraged not to leave waste behind on hospital wards and food waste reduction initiatives are being introduced in hospitals.
Since the publication of the report all hospitals have increased the amount of waste that is recycled and currently about 25% of non-risk waste is recycled. Recycling initiatives have taken place throughout the country including cooking oil, cardboard, metal, paper, glass, electronic waste and confidential paper. The composting of food waste is now being undertaken in most areas. This will result in a significant environmental benefit and cost saving, as composting results in a reduction of 25% to 30% of landfill waste disposal. All staff employed on wards and in clinical areas receive training on the segregation and handling of waste. They are also made aware of recycling programmes that operate in the hospital site.
As a result of the restructuring of the HSE opportunities will arise to obtain more advantageous pricing due to increased economies of scale. The cost of containing health care risk waste is monitored and variances from expected norms are examined.
Owing to the higher cost of excluded risk waste, which requires incineration, all hospitals are endeavouring to ensure only excluded risk waste is disposed of in the appropriate containers. Although there has been an increase in the quantities of excluded risk waste produced, this is due in part to the reclassification by the EPA of clinical by-products as excluded risk waste.
Funding has been made available in 2006 as a result of the national hygiene audit for the upgrading and securing of existing facilities in most acute hospitals. New hospital facilities include secure waste marshalling facilities as part of the development.
We are ensuring hospital staff are aware of the latest in good practice. All staff employed on wards and in clinical areas received training on the segregation and handling of waste. They are also made aware of recycling programmes that operate in the hospital site. We have also introduced the following initiatives: the introduction of environmental committees and green teams in a number of hospitals; waste awareness days and race against waste seminars have been carried out in various locations; staff induction training; development of a health care-specific waste training programme; designation of waste officers in acute hospitals; co-operation with local authority awareness officers; a national poster campaign on segregation and packaging of health care risk and non-risk waste; appointment of environmental services officers in three regions; national hygiene audits completed in 2005 and repeated in 2006, which had a substantial waste management component; and the acute hospitals cleaning manual, which is at final draft stage, contains a section on colour coding as this is currently not standardised across the system.
Waste management policies were in existence in the former health boards prior to the establishment of the HSE. A draft HSE waste management policy has now been prepared. Hospital-specific plans are being reviewed in accordance with this new policy and will also include key performance indicators working from the 2005 database.
Waste management, both at departmental level and hospital-wide, was included in the acute hospitals hygiene audit that was carried out in 2005. Since the publication of the results in November 2005, hospitals have given renewed focus to this area in preparation for the repeat audit which took place during February to April this year. A number of hospitals have reviewed staff responsibilities and designated a person with responsibility for waste management. Systems have been put into place to ensure documentation relating to the generation and final disposal of waste can be tracked. Hospitals have undertaken an audit of the waste contractor from the site to final disposal. The report of the second audit is not yet finalised but there are preliminary indications that the position on waste management in hospitals has improved in the past year.
The National Hospitals Office is also working closely with the Irish Health Services Accreditation Board, which has included waste management in draft hygiene services standards. Hospitals' compliance with the standards will be the subject of inspection and review. In addition, monitoring of key waste data is being undertaken at present in the larger hospitals. The designation of waste officers to all acute hospitals will facilitate the full implementation of monitoring key performance measures.
Risk managers, waste officers, health and safety officers and occupational health departments record and respond to waste related incidents, such as sharps injuries, exposure to risk waste etc. This has resulted in an increase in waste related incident awareness and a reduction in the number of injuries. The effective management of hospital waste is essential for the health and safety of patients, staff and the general public. The safe storage, transportation, treatment and disposal of hospital waste are important in ensuring that environment standards are met. It is the policy of the HSE to ensure that the production of waste is minimised and that the waste produced is segregated and removed in the most appropriate and cost effective manner. This report has been a major advantage as regards bringing focus fully to this issue within our organisation.
I will now deal with report No. 52 on the provision of disability services by non-profit organisations. The Comptroller and Auditor General's report on the value for money examination of the provision of disability services by non-profit organisations has proven to be an important exercise in highlighting public accountability requirements within HSE contracted service arrangements. The report deals with critical issues regarding arrangements between the voluntary statutory sectors and acknowledges the complexity of existing and historical relationships and the challenges now arising. In the context of the new restructuring of the health services, the HSE acknowledges the need for greater focus and engagement as regards regulations, evaluation and accountability and the need for further refinement of formal contractual arrangements and service agreements.
The current framework governing the voluntary statutory relationship has its roots in the 19th century and in the development of voluntary sector provision of welfare, education and health services. During the 1960s and early 1970s, an increasing number of agencies began to receive grant aid towards their costs and the health boards disbursed funds to the voluntary and community organisations principally through grants under section 65 of the Health Act 1953. These grants were aimed at supporting organisations that provided services to meet health and social needs that were ancillary and complementary to the health boards' services.
In the 1990s a working group was set up to look at arrangements for the transfer of direct funding of voluntary intellectual disability services to the health boards. The group submitted its report, Enhancing the Partnership in 1997. The report clearly articulated that the relationship between the voluntary sector and the health boards was one of partners in service provision. The key elements of the framework agreed included mental handicap services consultative committees, mental handicap services development committees and service agreements.
The roll-out of this process began in the late 1990s and was the first step towards formal service agreements with the voluntary agencies within the health services. Section 26 of the Health Act 1970 facilitated this contractual type of approach where an agency would provide services to eligible persons. Initially this process was intended to facilitate the 14 agencies directly funded by the Department but was extended to all 52 member agencies of the Federation of Voluntary Bodies under a new agreement, Widening the Partnership in 2000. This framework, however, has been one of developing a relationship of partnership in the delivery and planning of services in a rapidly changing social, health and legislative environment. The process of working out the details of contractual arrangements has been a developmental one and has required consultation over a protracted period.
As regards the wider context of funding for voluntary-community bodies, a White Paper was published in October 2001 that clearly sets out a framework for the State support of voluntary activity and for the development of the State-voluntary body relationship.
Sections 38 and 39 of the Health Act 2004 now form the basis for future HSE funding to the community-voluntary sector. The 2004 Act distinguishes between situations where the HSE is engaging service providers — section 38 — as opposed to supporting the general activities of agencies or groups — section 39. These new statutory provisions will facilitate the HSE to develop both policy and operational guidelines in its dealings with the entire voluntary and community sector.
Implementing the findings of the Comptroller and Auditor General's report is clearly extremely important. The establishment of the HSE as a unitary authority provides an opportunity to review and enhance the relationship with the non-statutory sector.
In this context the HSE has already taken the following actions: the individual cases highlighted by the Comptroller and Auditor General's report have been reviewed; a working group to standardise nationally the governance and policy approach and supporting processes for all funding for the non-statutory sector, including the voluntary-community sector, has been established and this we need to spread to cover our directions with voluntary hospitals; the HSE's obligations re service agreements and EU procurement law have been reviewed; a voluntary services unit is being established to support the overall funding process with the non-statutory sector; a review of the current disabilities database to enhance needs assessments and service frameworks for the future has commenced; discussions with the Department re the draft NDA standards of care have commenced; and the preliminary work required to initiate a review of Enhancing the Partnership has commenced with the disability bodies.
A new governance framework for the non-statutory sector is now necessary. The internal HSE working group is finalising a national policy, guidelines and procedures document for funding non-statutory agencies which include a policy context for funding, including working principles, as follows: clarity as regards the legal framework set out in the Health Act 2004 on the commissioning of services and the provision of grant aid; an overall governance framework regarding the engagement of external services providers; and the provision of funding to grant-aided bodies will be clarified.
A standard application process sets out qualifying criteria and standard templates for service agreements and grant aid will be established. A decision-making process sets out organisation requirements in each local health office area, the organisational and governance requirements of agencies, the decision criteria for managers and decision templates for signing off by managers. There will be standard national templates for service agreements and grant aid, including grants from the national lottery. The service agreement template includes provisions specifying the terms on which the services will be provided, templates to ensure the nature, extent and volume of services to be provided and importantly, requirements as regards monitoring progress of agreements.
The monitoring and evaluation policy will set out clearly: the documentation requirements — standard reports; the requirements and standards for review meetings to include financial reports, HR reports, activity performance indicators review; review of agreed outcomes; anticipated pressure points; compliance with standards, where applicable; and corporate governance. A review meeting template sheet must be signed by the manager responsible.
This documentation sets out different mechanisms and criteria to differentiate in instances where the State is purchasing services as opposed to where it is supporting voluntary bodies by way of grants.
As regards reviewing the partnership framework, discussions have been held with the key umbrella groups in the disability sector, that is, the Federation of Voluntary Bodies, the Not for Profit Business Association and the Disability Federation of Ireland. There is agreement to review the partnership framework. A cross-agency working group will be established to progress a new framework. This will require commitment from the HSE, the Department of Health and Children and the voluntary sector.
The Comptroller and Auditor General's report recommended the establishment of a voluntary activity unit in the HSE to effectively plan and manage the relationship with this sector for the future. To assist the HSE management in meeting its governance requirements, I intend to set up a national unit to support the HSE in meeting its obligations. The overall aim of the unit will be to oversee the effective governance of the relationships and engagement with the community and voluntary sector and the increasing emergence of private sector providers. The role of the unit will be as follows: to develop frameworks and policies of engagement with the various sectors; to liaise with other State sectors with a view to developing more integrated approaches; to provide guidance on standard practices and procedures; to develop standard financial allocation models and standard cost bands to ensure the efficient and effective use of funding; to collate and analyse statistical data, including the maintenance of a national register; to develop a training framework for HSE staff working with the community voluntary sector; and to support the voluntary-community agencies.
In summary, clearly the HSE's legal obligations under the Health Act 2004, the public procurement law and the issues raised in this report require an increased emphasis on the relationship with the community-voluntary sector within a context of greater regulation, evaluation and accountability and the need for further development of formal contractual arrangements and process. These obligations must be seen against a background to date of a partnership approach with the community-voluntary sector at all levels, from the small community based organisation to the large voluntary providers.
The HSE has attached priority importance to the issues raised in the Comptroller and Auditor General's report and the related implications of EU legislation.
The concentration to date has been on clarifying the HSE's responsibility and developing policies and procedures that are consistent with accountability requirements. The HSE is beginning an active engagement with all major voluntary service providers to ensure that its obligations are being met.
