COMMITTEE OF PUBLIC ACCOUNTS debate -
Thursday, 7 Feb 2008

Chapters 18 and 19: Part C Cross-Cutting Reports.

Mr. M. Scanlan (Secretary General, Department of Health and Children) and Professor B. Drumm (Chief Executive Officer, Health Service Executive) called and examined.

Chairman

I welcome everybody. We are looking at the 2006 annual report of the Comptroller and Auditor General and the Appropriation Accounts; Vote 39 - Department of Health and Children; Vote 40 - Health Service Executive; HSE financial statements 2006; chapter 10.1 - control and sanctioning of ICT expenditure; and relevant chapters from value for money report 56 of the Comptroller and Auditor General, Improving Performance - Public Service Case Studies.

Witnesses should be aware that they do not enjoy absolute privilege. As and from 2 August 1998, section 10 of the Committees of the Houses of the Oireachtas (Compellability, Privileges and Immunities of Witnesses) Act 1997 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 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 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, either by name or in such a way as to make him or her identifiable. They are also reminded that under Standing Order 158, the committee should 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.

I welcome the Secretary General of the Department of Health and Children, Mr. Scanlan, and invite him to introduce his officials.

Mr. Michael Scanlan

I am accompanied by Mr. Dermot Magan from the finance unit, Mr. Colm Keenan from the parliamentary affairs unit and Dr. John Devlin from the chief medical officer's office.

Chairman

I welcome Professor Drumm, chief executive officer of the Health Services Executive, and invite him to introduce his officials.

Professor Brendan Drumm

I am accompanied by Ms Laverne McGuinness, national director of the office for primary community and continuing care, PCCC, services; Mr. Damien McCallion, national director of ICT services, and Mr. Liam Woods, national director of finance.

Chairman

Officials from the Department of Finance officials are also present.

Mr. Tom Heffernan

I am a principal officer in the sectoral policy division and I am accompanied by my colleague, Mr. Dave Ring, principal officer.

Chairman

I invite Mr. Purcell to introduce Votes 39 and 40 and chapter 10.1.

Chapter 10.1 of the report of the Comptroller and Auditor General reads:

10.1 Control and Sanctioning of ICT Expenditure

General Arrangements

All the expenses of a Department paid from money provided by the Oireachtas are required to be sanctioned by the Minister for Finance. Public Financial Procedures provide that sanction may be either

•Specific – sanction related to a particular once off proposal or

•Delegated – general sanction to a Department or Office to deal with clearly defined cases without further recourse to the Department of Finance.

Public Financial Procedures also provide that where there is general delegated sanction in relation to a particular category of expenditure, it is the responsibility of the Department concerned to ensure that any expenditure falling within that category is properly covered by the sanction.

Upon its establishment on 1 January 2005, the HSE became subject to the requirement that it receive the sanction of the Department of Finance for all expenditure. The Minister for Finance sanctioned current expenditure by the HSE for 2006 up to a maximum amount of €11.8 billion – the amount of the Revised Estimate for 2006 – and expenditure on agreed capital projects up to a maximum of €555.5m.

ICT expenditure is subject to a particular sanctioning regime, which is set out in Circular 16/97 "New Delegation Arrangements for IT Related Expenditure (including Office Machinery)". Previous delegation arrangements in relation to IT-related expenditure were based in the main on preset spending limits set out in Administrative Budget Agreements. The intention of the Circular was to provide for a more coherent arrangement for delegation, within agreed spending limits, of IT-related expenditure, subject to appropriate controls being in place in Departments.

In order for the Department of Finance to operate the delegated sanction arrangement with a Department the following requirements must be met

•The Department must have a current ICT strategy covering the management of information, systems and applications and technical infrastructures. This should cover a period of 3-5 years. It must be updated regularly and the Department of Finance kept informed of updates.

•Formal project management and governance arrangements must be in place for all projects.

•A total figure for the Department's planned ICT expenditure in the following year must be provided by end-November (the Part I return).

•A detailed breakdown of planned current year ICT expenditure must be provided by end April each year (the Part II return). The planned figure must be within the amount agreed during the estimates/budgetary process.

•A detailed breakdown of actual previous year ICT expenditure must be provided by end April each year.

•A Succinct Impact Statement must be provided for any new ICT project and revised as appropriate during its lifetime.

•There must be adherence to guidelines on procurement and the expenditure of public moneys.

The expenditure information provided must be analysed between new projects, existing projects and non-projects. The costs associated with each must be further analysed over a number of headings such as hardware, software, telecommunications and consultancy.

In this context, "project" refers to business projects which aim to realise the objectives and business plans contained in the organisation's strategy statement. A typical example of a business project would be the improvement of Human Resource management, requiring the purchase and installation of a new personnel package.

Non-project expenditure is all ICT expenditure not associated with a specific business project and covers a wide range, including replacement of hardware and software, office machinery, telecommunications services, IT-related training, maintenance, consultancy and outsourcing. Typically, it would include the ongoing enhancement and maintenance of ICT infrastructure.

If the Department of Finance is satisfied, it will issue an Annual Delegation Certificate. Expenditure should only take place by the spending Department on the basis of an Annual Delegation Certificate or where specific sanction has been received for that expenditure.

Control and Sanctioning of ICT Expenditure in the HSE

The arrangements for securing sanction require the HSE to submit expenditure proposals to the Department of Health and Children. That Department is required to evaluate them and submit its analysis and recommendations to the Department of Finance.

In the early part of 2005 the HSE set about making the detailed ("Part II") return of its planned ICT expenditure for 2005 to the Department of Health and Children with a view to obtaining delegated sanction. In the event, discussions with the Department of Finance continued throughout the year so that sanction for project expenditure of €27.8m only issued on 16 November 2005. Sanction for non-project expenditure of €41m only issued in April 2006.

Arising out of its discussions with the Department of Health and Children and the HSE during 2005, the Department of Finance wrote to the Acting National Director of ICT of the HSE on 16 September 2005 setting out key governance and technical principles, which the HSE would be required to commit to as specific agreed goals as part of the delegation process.

The governance principles were

•One ICT Steering committee for making priority and activation decisions in relation to all major project proposals.

•One central source of decision making in relation to implementing ICT strategies, ICT plans and ICT projects who would also be the normal interface for Circular 16/97 purposes with the Department of Health and Children and with the Department of Finance (IS Director).

•Project boards for every significant project, reporting to the ICT Steering Committee and using a project management methodology chosen by the HSE and using the capital appraisal guidelines issued by the Department of Finance.

•Compliance with 16/97 delegation sanction requirements for all ICT spend, regardless of the source of funding.

•A peer review gateway process in place for all major projects.

•One central management point under the control of the IS Director for all purchases of hardware, software, telecommunications, ICT Development or advisory services in all of the HSE including hospitals, medical centres etc. under its funding control.

•No further delegation of ICT spending authority within the HSE.

•All hiring decisions in relation to ICT contractors and ICT consultants under the control of IS Director, regardless of funding sources.

•All tenders for ICT products or services to be approved and advertised by the IS Director and in compliance with a specific 16/97 sanction.

•All HSE developments to comply with central guidelines – actual or emergent.

The technical principles were designed mainly to ensure that the HSE's systems were, as far as possible, properly integrated and designed on a national basis and that shared platforms/services within the HSE, across the public service and with the private sector were maximised, as appropriate.

The Department's letter made it clear that the principles applied not alone to the HSE's own direct ICT expenditure, but also to expenditure in hospitals and other facilities under the HSE's funding control and extended both to administrative ICT systems and medical ICT systems.

Sanction of 2006 ICT Expenditure

In early 2006 the HSE commenced the process of seeking delegated sanction for 2006 ICT expenditure. It indicated in January 2006 that there were certain areas of expenditure that were traditionally outside the remit of ICT – such as telephony and communications generally, including the emergency services – but which came within the terms of the delegated sanction arrangement. It undertook to begin a process to validate and consolidate, where necessary, the 2006 planned ICT expenditure. However, on 9 June 2006, the Department of Finance withdrew delegated sanction arrangements with the HSE on the grounds that there were difficulties in verifying the actual ICT expenditure by the HSE in 2005 and in establishing the planned expenditure for 2006. The Department stated that the HSE would be required to obtain sanction for ICT expenditure in 2006 on a case-by-case basis.

The HSE made seven submissions in relation to planned expenditure for 2006. Table 1 shows a breakdown of each submission between new projects, existing projects and non-project expenditure.

Table 1 Submissions re ICT Expenditure 2006

	30.11.05	31.03.06	28.04.06	16.08.06	13.10.06	01.11.06	10.11.06
	€m	€m	€m	€m	€m	€m	€m
New Projects	31.8	18.7	18.7	63.1	112.9	32.6	25.8
Existing Projects	49.0	35.2	36.6	54.2	40.2	50.0	50.2
Non-Projects	45.1	51.9	52.0	62.7	58.4	58.4	58.4
Total	€125.9m	€105.8m	€107.3m	€180.0m	€211.5m	€141.0m	€134.4m

As the table illustrates, the level of planned expenditure under each heading fluctuated considerably over the period. In the event, the level of expenditure actually reported for the year differed from that planned in all three categories –€689,274 for new projects, €21.5m for existing projects and €63m for non-project expenditure.

On 11 December 2006, the Health Service Executive received sanction for ICT expenditure as follows: New Projects €5,525,848, Existing Projects €30,627,240 and Non Project Expenditure €58,426,044 for 2006 subject to the following general conditions

•All procurements should comply with General Procurement conditions set out in the Appendix to Circular 16/97.

•Formal and appropriate arrangements should be used for the control of business projects and the monitoring of compliance procedures.

•All projects should conform to the technical and information architectures being adopted by the HSE and the HSE should comply with the Governance and Technical Principles for ICT Developments detailed in the Department's letter of 16 September 2005.

•The HSE, when reporting actual expenditures in line with the requirements of Circular 16/97 should detail the source of all ICT expenditures in 2006.

On 21 December 2006, the Department of Finance sanctioned additional expenditure up to a maximum of €1,520,640 on ICT consultancy for PPARS. This related to production support, the delivery of a stable environment, and the automation of existing processes and it brought the total sanctioned for existing projects to €32,147,880.

Circular 16/97 Returns – 2006

As required by the provisions of Circular 16/97, the HSE made a return to the Department of Health and Children on 1 May 2007 giving a detailed breakdown of actual ICT expenditure for the year 2006. This return showed a figure for non-project expenditure in 2006 of €63,017,248 – an amount which exceeded the sanctioned amount of €58,426,044.

In the letter accompanying the return, the Head of ICT explained that there were difficulties in extracting the information required for the 16/97 returns from the consolidated reporting system, which produces the consolidated accounts, as it does not provide the level of detail required. The returns are completed by the local ICT functions and are amalgamated by the ICT Directorate for submission as a single return to the Department of Health and Children and the Department of Finance. Further difficulties arise within the various Health Areas, due to different coding and processing systems in use.

This return was examined in the course of the audit and was found to be deficient in a number of respects

•In a number of instances, significant amounts were either misclassified or were classified under one heading when seeking sanction but under a different heading when reporting the outcome.

•Some costs that did not come within the terms of the Circular were included in error and some costs were included twice.

•Some categories of expenditure were not analysed in the level of detail required by the return, as the general ledgers of some HSE Areas do not facilitate the breakdown of expenditure into the relevant categories.

In summary, it appeared that the inconsistencies of treatment of expenditure and the level of error were so significant as to greatly limit the value of the return for control purposes. This, in turn, called into question the basis of the original figures compiled for the purposes of seeking sanction.

Non-Compliance with Case-by-Case Sanctioning Requirement

Notwithstanding the requirement that ICT expenditure be sanctioned in advance on a case-by-case basis, the HSE issued requests for tenders for a number of projects without obtaining sanction. These were for

•Strategic ICT Consultancy (July 2006)

•Staff Scheduling & Time Management (October 2006)

•Asset Management System (October 2006)

The latter two requests for tender were issued without the approval of the Acting Director of ICT and were subsequently cancelled.

Requests for tenders continued to be issued in 2007 by agencies under the HSE's funding control, where sanction had not been obtained. For example, St. James's Hospital published a tender for an Emergency Department clinical information system in March 2007 and a tender for telephony services on 1 June 2007.

Unsanctioned Expenditure

The 2005 sanctions for ICT expenditure specifically excluded any developmental expenditure on the PPARS system, although as noted in my report to Dáil Éireann, Development of Human Resource Management System for the Health Service (PPARS) December 2005, significant expenditure had been incurred on the system in 2005. This expenditure remains unsanctioned.

The Accounting Officer confirmed to me in July 2007 that the figure of €63,017,248 for 2006 non-project ICT expenditure cannot be regarded as a final figure and that discussions are ongoing with the Department of Finance regarding the 2006 sanction.

Furthermore, I note that certain project expenditure charged to the 2006 Vote expenditure has not been sanctioned in accordance with the requirements of Circular 16/97viz.

•€522,000 on miscellaneous projects authorised prior to 2005 in accordance with the procedures then in force in the former health boards but where payments were not made until 2006

•€1,103,000 in relation to the FISP accounting system, of which €422,000 related to expenditure incurred in 2005 but paid for in 2006 and charged to the 2006 Vote

•€4,634,000 on costs related to PPARS which were incurred in 2005 and accrued in the 2005 financial statements but paid for and charged to the 2006 Vote.

Audit Concerns

In view of the foregoing, I was concerned that

•The HSE did not have systems, procedures and practices in place that would allow it to control its ICT spend effectively and enable it to comply properly with the requirements of the Department of Finance in relation to the sanctioning of ICT expenditure

•The variations in the sanctions sought during 2006 appeared to indicate the absence of a coherent ICT strategy and a lack of linkage to the estimates/budgetary process

•ICT governance in the HSE may not comply with the principles set out by the Department of Finance in its letter of 16 September 2005.

I asked the Accounting Officer for information on

•The action taken by the HSE to enable it to comply with the Department of Finance's sanctioning arrangements in relation to ICT

•The circumstances in which the unauthorised requests for tenders referred to earlier had issued, and the action taken to prevent a recurrence

•The action taken to develop an ICT strategy and to put in place a supporting budgetary and management reporting framework

•Progress in implementing the governance and technical principles set out in the Department's letter of 16 September 2005.

Accounting Officer’s Response

Action Taken to Comply with the Department of Finance’s Sanctioning Arrangements in relation to ICT

During 2005 the HSE began to put in place arrangements for complying with the Department of Finance sanctioning requirements. The Acting National Director of ICT assumed overall responsibility in this regard and requested the ICT Departments of the former Health Boards to make the required submissions to him. Resources were assigned in his office to collate the information and prepare it for submission to the Department of Finance. These arrangements have continued and have been strengthened since then.

With the appointment of a new Head of ICT in November 2006 one of the existing Directors of Information Systems was assigned lead responsibility on an interim basis for the ICT Directorate's Programme Office, which included responsibility for submission of sanction requests to the Department of Finance. Therefore, from the outset, responsibility was assigned within the ICT Directorate to ensure that all expenditure sanctioning requirements were met.

During 2006, the arrangements that had been put in place within the ICT Directorate the previous year continued. On any occasion that the Acting National Director of ICT became aware of potential situations where unauthorised expenditure might occur he took steps to prevent it.

In 2007, the Head of ICT issued a number of communications to the management team within the HSE clearly advising of the requirements for prior sanction for all ICT-related expenditure. This was circulated to line managers within the HSE. It was also circulated, through the National Hospitals Office, to all the major voluntary hospitals that have significant expenditure on ICT.

An ICT Expenditure Review Group with senior ICT and Finance management representation was established by the Head of ICT and the Director of Finance in 2007. It includes representatives from Corporate Finance, Shared Services and the ICT Directorate. The group is undertaking a review of 2007 ICT expenditure transactions, both revenue and capital in the former health board areas. The Group will make recommendations on the following

•Coding of ICT expenditure in the accounting system having regard to the reporting requirements of the Department of Finance in relation to non-project expenditure

•ICT budgetary process

•Procedures for processing revenue and capital ICT expenditure

•Financial reporting of both revenue and capital expenditure.

It is anticipated that the Group will produce a final report by the end of September 2007 with a view to implementing recommendations where feasible before the end of the financial year. Some recommendations have already been put in place.

The HSE has developed a report to record capital expenditure and payments by project, by HSE Area, by pillar. This report is prepared manually. All HSE Areas prepared this report for December 2006. The reports were consolidated and the ICT capital payments figure was reported in the 2006 Appropriation Account.

However, the absence of a national financial system prohibits ICT revenue payment reporting. Different areas of the HSE are operating legacy financial systems which are not configured to provide the level of detail required in order to report ICT revenue payments under the specific categories identified as non-project type transactions. On completion of the recoding exercise for 2007, information will be available on an income and expenditure (accruals) basis for all non-project expenditure under the headings set out in Circular 16/97. Considerable further manual intervention will be necessary to restate these income and expenditure figures if they are required on a Vote basis. A business case is being developed to support the development and implementation of a national financial system which will meet the HSE's Vote reporting requirements as well as fulfilling the Department of Finance requirements under Circular 16/97.

Unauthorised Requests for Tenders

Of the five requests for tenders mentioned, three were issued by the HSE and two were issued by St. James's Hospital. The three HSE tenders date from 2006 and occurred because of a genuine lack of understanding of the requirements of Circular 16/97 by the personnel concerned.

As a result of changes to the HSE senior management team in mid 2006 and the requirement for the strategic development of the ICT and Procurement Directorates, tenders were issued for corporate strategic advice on ICT and Procurement in July 2006. It was recognised by both the Chief Executive and the HSE Board that the ICT Directorate needed to be strengthened and this was one of the actions identified to achieve this.

The two other unauthorised requests for tenders - for an Asset Management System and a Staff Scheduling & Time Management System - issuedin the context of equipping/commissioning the new Cork University Maternity Hospital. The proposed Staff Scheduling & Time Management System was identified as an important requirement by the Commissioning Group for the new hospital, given the complexities around staff scheduling, where staff from a number of existing hospitals were transferring to work in the new hospital and would need to be scheduled for duty in an equitable fashion providing the correct skill mix across the units on a shift by shift basis. The Commissioning Group were concerned to have the new system in place in time for the opening of the new hospital and mistakenly thought that it would be in order to proceed with the procurement process in parallel with seeking approval for the expenditure.

The HSE ICT Directorate was not aware of the Commissioning Group's decision in this regard until after the procurement was advertised. At that point, the ICT Directorate raised the matter with hospital management and the procurement process was terminated without delay. The strict requirement to have sanction from the Department of Finance in place in advance of the commencement of the procurement process was not fully understood at hospital level at that time. This is now fully understood by all concerned arising from the action taken by the ICT Directorate at the time.

A letter was issued by the Head of ICT in 2007, through the HSE Management team, reminding all managers of their obligations with regard to ICT procurement and the serious manner in which noncompliance will be treated. In addition, the Procurement Directorate has appointed a nominated manager, who will have responsibility for all ICT procurements within the HSE. A senior member of the ICT management team has also been nominated to authorise all ICT procurements prior to publication on eTenders.

Both of the St. James's Hospital procurements were initiated without the prior knowledge or approval of the HSE. In both cases, the HSE has taken up the matter with the Hospital and requested that the procurements be put on hold until the appropriate sanctions are put in place. The HSE continues to engage with the Hospital to bring it into line with the requirements for prior sanction in advance of initiating procurements. Both the Head of ICT and the National Director, National Hospitals Office are in discussions with the Hospital on this matter.

While there have been some difficulties with the voluntary and non-statutory sector in complying fully with requirements for prior sanction, it is important to recognise that in the acute hospitals sector alone there are 17 independent voluntary and non-statutory hospitals in total. The vast majority are complying fully with the sanction requirement, despite the significant change in practice for them and the perceived removal of flexibility for the operation of their services. There are several hundred voluntary agencies funded by the HSE.

Further work is required with the voluntary sector and a new service level agreement, which is being introduced in 2008 for voluntary and non-statutory bodies, will specify the requirement for compliance with the ICT sanction process.

Developing an ICT Strategy

The question of the HSE's ICT strategy must be seen in the context of previous work done in advance of establishment of the organisation. Upon its establishment on 1 January 2005 the HSE took over the responsibilities of 17 separate organisations. During 2004 significant ICT strategy development work had been completed by the Health Boards Executive (HeBE). This was expected to provide the strategic direction for all ICT development across the former health boards and other related agencies for the period 2005- 2011. This was set in the context of the National Health Information Strategy (NHIS), which had been published by the Department of Health & Children in 2004. In addition, an ICT strategy for Primary, Community and Continuing Care (PCCC) services had been further developed with the assistance of management consultants.

All this previous ICT strategy work had been done on a whole health system basis – i.e. a national approach was taken, as opposed to any individual organisation or region. The establishment of the HSE did not change the strategic context, rather it put in place a single organisational structure, which in fact would be expected to better facilitate the delivery of the strategic agenda. The focus, therefore, since the establishment of the HSE has been more on unifying the ICT organisational structure and establishing appropriate new governance arrangements rather than on fundamental review of other ICT strategy elements.

In this context the following actions have been taken

•In November 2006, a consultancy company was appointed to provide strategic ICT consultancy to the HSE. The purpose of this consultancy is to ensure that best in class strategies and approaches are implemented throughout the HSE. The consulting company worked initially with ICT management to review and assess the current state of ICT within the HSE and also within the voluntary and non-statutory healthcare sector and they have continued to be involved in the definition of the new ICT management structure and the identification of the major development priorities.

•Since November 2006, the HSE has put in place an ICT Steering Group. The key purpose/role of this group is as follows:

"To oversee planning of, promote and prioritise HSE investment in ICT and control its implementation and deployment throughout the organisation via the ICT Directorate in a manner

which assures related projects/processes are delivered as designed within agreed budgetary and timeframe parameters and that benefits (including transformation and business improvements) identified for such projects/processes are fully realised."

The ICT Steering Group which is chaired by the National Director, National Hospitals Office is effectively a sub-committee of the senior management team with some additional external expertise. ICT management has been reporting to this group on progress and on proposals for development.

•Following on the review of the current ICT status, a proposal for the organisation and structure of ICT within the HSE has been developed. The proposed structure has been discussed with the current ICT management team and it has been agreed with the CEO and the senior management team. This new structure represents a significant part of the overall ICT strategy.

•With regard to more immediate planning requirements, members of the current ICT management team have been assigned specific responsibilities until the new structure has been established, with a view to improving the coherence of short-term plans.

•As part of the new management structure it is proposed to have a Programme Office to provide an overview of all the ICT development activity across the organisation. Steps are under way to get this Programme Office in place even while the new organisation structure is being established. The position of head of the Programme Office has been advertised and, in parallel, tenders have been sought from appropriate consulting firms to establish the Office and get it operational. In parallel with this activity, a group within the ICT directorate has been developing a project lifecycle approach to be applied to all ICT projects.

•Since autumn 2006, the HSE has adopted the Transformation Programme, a significant package of business change projects and this whole programme represents the vehicle to deliver on the HSE business strategy. In parallel, the ICT Directorate has been developing a prioritised list of major projects to support the business. In keeping with the principle that the business strategy should drive the ICT strategy, the Transformation Programme has been decisive in developing this prioritised list. The selection of priority projects has been influenced also by previous ICT strategy work, as mentioned earlier (NHIS, HeBE's ICT Strategy, PCCC ICT Strategy). The ICT strategy work carried out by the Dublin Academic Teaching Hospitals has also been influential. The process of developing the priority list of major projects is ongoing.

It is recognised that the HSE needs to develop a comprehensive longer term ICT strategy covering a 5-10 year period. Given some of the recent difficulties within ICT in the health sector, priority is being given in 2007 to improving the manner in which ICT is organised and managed while progressing some major priority projects that have stalled in recent years.

It is planned to commence development of an ICT strategy in 2007 with a view to completing it in 2008. Based on evidence from other countries, such as Denmark and England, it is vital that the strategy development process is inclusive of all stakeholders and sets a direction for a significant period of time.

Governance Principles and Technical Principles – Current Status

The Accounting Officer said that the Head of ICT had reported to the Department of Finance in June 2007 on the progress made within the HSE on the implementation of the governance and technical principles. Significant progress had been made in 2007. At this point he could confirm that, as required by the governance principles, the following were in place

• One ICT Steering committee

• One central source of decision making in relation to implementing ICT strategies, plans and projects i.e. the Head of ICT

• Project boards for every significant project using a common Project Management Methodology. A methodology implementation group, representative of voluntary hospitals in addition to the HSE, is currently being set up to develop guidelines for its usage within the health sector.

• A peer review gateway process for all major projects.

A peer review process is being put in place as each project that requires it emerges. In addition, peer review principles are being applied to projects that do not require external peer review.

• No further delegation of ICT spending authority within the HSE.

In addition, the HSE is currently in discussions with the voluntary and non-statutory bodies as to the feasibility of including their ICT non-project expenditure within the HSE 16/97 return.

• All ICT development staff and ICT operational staff under the control of the IS Director

• All hiring decisions in relation to ICT contractors and ICT consultants under the control of the IS Director, regardless of funding sources

• All HSE developments to comply with central guidelines.

The ICT Directorate is supporting any appropriate central guidelines as they emerge, e.g. Framework agreements, REACH and Data Centre project.

In relation to the remaining principles, the Accounting Officer reported as follows

• Compliance with 16/97 delegation sanction requirements.

This is in place. Known and emerging difficulties with adherence by the wider health system are being addressed. The Expenditure Review Group has been set up to identify and resolve control and reporting difficulties

• One central management point under the control of the IS Director for all purchases of hardware, software, telecommunications, ICT Development or advisory services in all of the HSE including hospitals etc. under its funding control.

Central management processes are in place for all ICT procurement contracts directly controlled by the HSE. There are issues which need to be dealt with in relation to the authority of independent and voluntary agencies, funded by the HSE, to enter into procurements without the approval of the HSE.

• All tenders for ICT products or services to be approved and advertised by the IS Director and in compliance with a specific 16/97 sanction

All tenders for ICT within the HSE now come through a nominated senior manager in the ICT Directorate. It has also been agreed with the HSE management team that this arrangement will be extended to include all voluntary organisations funded by the HSE.

As regards the technical principles put forward by the Department of Finance, the Accounting Officer said that resulting from a strategic review of its ICT infrastructure, the HSE has identified that it needs to initiate a series of major projects to unify the healthcare ICT Infrastructure. One of the earliest programmes of work that will be needed is the completion of a single technology plan that will, inter alia, plan for a single technical (including networking), information and applications architecture for the HSE. It is intended that the technical principles espoused in the letter of 16 September 2005 will be fully reflected in the technology plan and the range of implementation projects that will give effect to it.

Action Taken – Accounting Officer’s Summary

The Accounting Officer confirmed that the HSE is committed to full compliance with the requirements for control and sanction of ICT expenditure as set out in the Department of Finance Circular 16/97 and that it will continue to improve its internal systems, processes and procedures to address any weaknesses that exist in this regard.

The review of ICT undertaken in the first four months of 2007 has resulted in a number of recommendations which will improve the sanction process including

•New ICT governance arrangements have been put in place since the start of this year and these are in compliance with the principles set out by the Department of Finance letter in September 2005

•Implementation of a new organisation structure for ICT that has a strong corporate ICT division

•Introduction of a corporate ICT Programme Office that will assume responsibility for ICT performance management – including budgeting and reporting

•Working group to implement improvements in how ICT expenditure is planned, recorded and reported within the HSE to enable greater visibility of ICT expenditure.

The Accounting Officer said that it was important to set the issues and concerns raised during the audit in the overall context of the establishment and development of the HSE. Upon its establishment the HSE became immediately subject to the terms and conditions associated with Vote Accounting. The HSE had subsumed the roles of the former Health Boards, Eastern Regional Health Authority, Health Boards Executive, General Medical Services Payments Board, Health Services Employers Agency, National Disease Surveillance Centre as well as a number of other formerly independent statutory agencies. This resulted in a range of strategies, systems, processes, procedures and approaches having to be amalgamated into a single financial control and reporting system for the HSE. Reporting, in the manner required by Circular 16/97, has proved enormously challenging over the last two years in the absence of a single financial management system.

It is clear that the process within the HSE for compiling consolidated statements of planned and actual expenditure on ICT can be improved. However, it is important to state that while the HSE has experienced problems with compiling the consolidated statements he was satisfied that ICT expenditure has been appropriate and that value-for-money has been obtained.

While the audit raised some concerns about requests for tenders being issued without prior sanction of expenditure by the Department of Finance the small number of these must be seen in the overall context of the scale of the HSE's operation. Also, the majority of voluntary and non-statutory agencies, of which there are over one hundred, are complying with the revised ICT procurement rules.

A number of actions have been taken in 2007 to improve compliance on ICT tendering including

•Nominated ICT Senior manager to approve all ICT tenders in the HSE

•Nominated procurement manager responsible for coordinating all ICT tenders

•Letter to all line managers in the HSE highlighting consequences of non-compliance

•Compliance with circular 16/97 will form part of the formal service level agreement to be introduced between the HSE and voluntary / non-statutory agencies for all services in 2008.

A short-term plan/strategy for 2007/2008 has been put in place while a longer term strategy covering the next 5/10 years is developed. For 2007/2008 the priorities have been identified as

•Re-organisation of the former health board ICT structures

•Improving how ICT programmes and projects are managed through a series of actions

•Progressing critical programmes and projects, for example diagnostic imaging and laboratory management systems.

While there have been some difficulties, since the requirement for compliance with circular 16/97 was introduced two years ago, the Accounting Officer said that he was confident that the actions currently being progressed will not only improve compliance but are necessary so that the HSE has full oversight of its investment in ICT to support patient care.

Views of the Department of Finance

I also sought the views of the Accounting Officer of the Department of Finance. He indicated that sanction for ICT expenditure is still provided on a case-by-case basis and that this position will be maintained pending the establishment of new governance and accountability arrangements for ICT by the HSE. He said that, in addition to the new governance arrangements which are being put in place, it is also essential that the HSE develops an ICT Strategy which will inform its Administrative and Patient Care Systems development over the next number of years. This strategy should determine its work programme and priorities going forward, as well as allowing for improved planning and ensuring better value-for-money.

The Accounting Officer said that he was aware of the difficulties caused by lack of a proper Financial Management System and that he shared my concerns in this regard. He understood that the HSE is currently reviewing the position with a view to determining its immediate and longer-term requirements. He said that his officials would engage, as a matter of urgency, with the Department of Health and Children and the HSE on any proposals which they bring forward.

Mr. John Purcell

There is much material associated with the health sector before the committee. It might be helpful if I broke it into three parts: the accounts, the chapter from my annual report and matters arising from my follow-up of value for money issues which have been the subject of earlier reports.

I will first consider the accounts, of which there are three. These are the appropriation account of Vote 39 - Health and Children, and two accounts covering HSE activities. Vote 39 covers health expenditure other than that of the HSE, which amounted to some €363 million in 2006. The main elements of that expenditure were €83 million to health agencies, such as the Crisis Pregnancy Agency and the Food Safety Authority; some €78 million went to the National Treatment Purchase Fund and €75 million to compensation and ancillary costs to the hepatitis C victims. Nothing arose on Vote 39 which in my opinion merited public accountability.

Moving to the HSE, there are two accounts. The first is an appropriation account recording how the HSE spent the money voted by Dáil Éireann in the year. It is compiled on a cash basis and presents the expenditure by subhead, largely reflecting spending on services in the regions corresponding to the old health board areas.

The account shows a surplus of €365 million to be surrendered but the bulk of this, €340 million, was provided to meet the expected costs of the long-stay charges repayment scheme, which in the event did not arise in 2006 to a significant degree. Only €16 million was spent in the year on that particular service but the mechanism for drawing down the money was not completed until 2007. This sum was charged to a suspense account in 2006.

The other accounts are the conventional financial statements for the HSE, and these are more informative of the detail of expenditure, although not necessarily more intelligible to the layman. In this regard, members will note the accounts show a cumulative deficit of over €1 billion. This does not represent a black hole but is attributable to timing factors and a consequential difference arising from matching cash-based funding with accruals-based expenditure. There is a note to this effect on page 13 of the accounts.

The accounts show over €12 billion in current expenditure, of which €9.5 billion was funded by the Exchequer, with a further €1.2 billion coming from health contributions and the rest from the likes of income from services provided under EU regulations, patient charges and superannuation contributions. On the capital side, the HSE received its funding almost exclusively from the Exchequer and spent €263 million on its own projects, and issued €194 million in capital grants to voluntary agencies.

I will turn to chapter 10 of the 2006 report. In common with all other Departments and offices funded by way of a Vote, the HSE is required to obtain the sanction of the Department of Finance for its expenditure. This may be given by way of a general delegated sanction or a specific sanction. Within that framework there are special arrangements attaching to information and communications technology, ICT, expenditure.

Normally, the Department of Finance approves ICT expenditure in a Department at a global level by way of delegated sanction, provided it is satisfied the Department has an acceptable ICT strategy in place and that project management and governance arrangements are adequate. One of the key conditions under which delegated sanction is given is that planned expenditure for the following year must be provided in a specified format to the Department of Finance, and the details of actual expenditure be furnished soon after the year end in which it was incurred.

The HSE has struggled to meet the requirements of the Department of Finance with regard to the approval of ICT expenditure. For example, it had problems in reporting its actual expenditure on ICT, due in part to the lack of a single financial system. It is also clear the Department of Finance was not happy with the governance arrangements for ICT in the Health Service Executive and was not convinced that a strategic approach to ICT was being adopted to the development of administrative and patient-care systems across the health sector.

These factors led the Department of Finance to withdraw delegated sanction in 2006 and insist on approving ICT expenditure in advance on a case-by-case basis. Even then there were admittedly a small number of instances of requests for tender being issued without the prior approval of the Department of Finance.

One can see in the chapter where the Accounting Officer outlines what has been done to remedy this situation. I am informed further action has been taken since the date of my report which should go a long way towards meeting the requirements of the Department. I will leave it to the Accounting Officer to provide the details.

Bearing in mind the key role ICT must play in the development of the health service, it is imperative a sound and comprehensive strategy is put in place to avoid the type of fragmentation which characterised IT development in the days of the health boards. The strategy should be supported by appropriate governance and management arrangements to reduce the risk of repeating the mistakes of the past.

The last part of my introductory comments deals with the follow-up on two of my value for money reports published about ten years ago. The subject matter of the first of those was a scheme to achieve savings on GP prescribing in the GMS scheme, mainly by substituting generic drugs for more highly priced branded drugs. Those savings could be used to develop GP services.

The original report identified a number of opportunities for more cost-effective prescribing without compromising patient care. However, our follow-up shows the savings achieved under the scheme in more recent years did not meet expectations. A study carried out in 2003 reported the scheme had probably reached its limits in terms of savings. This is evident from figure 5.1 on page 50 of the follow-up report.

The scheme has been suspended for the last two years, pending the outcome of a review involving the Department, the HSE and the IMO. In a broader context, the possibility of introducing a system of generic substitution was considered as one of the options in the renegotiation of the agreement for the pricing and supply of drugs and medicines concluded last year. This will help to secure price reductions on substitutable off-patent medicines, which should result in savings in the coming year.

The second follow-up report examined developments in the emergency ambulance service since the 1977 report, which had identified scope for improving the use of resources and efficiency and effectiveness of the service, and for achieving faster response times for emergency calls. There has been some progress in these areas in the intervening years, as recorded in the chapter, although not as much as one would reasonably expect given that we are discussing a ten-year period. In particular, the implementation of a fleet management information system and a personnel rostering and overtime management system on a national scale has still to be effected. The national medical director of the national ambulance service has still to be recruited.

For the sake of completeness, I point out that the follow-up report also covers the special housing aid for the elderly and supplementary welfare allowance schemes administered by the HSE. In both cases I considered reasonable progress on the issues raised in my initial reports had been made in the intervening period.

Chairman

I invite Mr. Scanlan to make his submission.

Mr. Michael Scanlan

I am pleased to have the opportunity to meet with the committee today to discuss the 2006 Annual Report of the Comptroller and Auditor General and appropriation accounts with regard to Vote 39 - Department of Health and Children.

When I met the committee of the 29th Dáil last January and March, I referred to the challenges facing health systems worldwide in achieving and sustaining improvements in population health. I pointed out that, in addition to these common challenges, our own ongoing programme of health system reform was producing its unique demands. We continue to experience and address these challenges but, importantly, we are doing so not just in terms of immediate need but by reference to the rational organisation and most effective delivery of health services into the future.

I previously referred to the hard work and innovation which health service staff deliver for the benefit of the public on a continuous basis. Of course, it is necessary and appropriate to question things that go wrong and the progress of the wider reform process. However, it is important to keep in mind that every day life-saving, or life-enhancing, services are being delivered by those who work in the health service. In 2006, the public acute hospital services alone dealt with over 590,000 inpatient discharges, over 550,000 day cases, over 1.2 million accident and emergency attendances and over 2.7 million outpatient attendances.

Last October, the Department published a small booklet entitled Health in Ireland: Key Trends 2007. This was designed to provide a quick and handy reference guide to trends in health and health care over the past decade. The following month, the OECD published its Health at a Glance 2007, an authoritative source of comparable data on health and health systems to 2005 in OECD countries.

Among the key trends which emerge from these publications and other authoritative sources are the following. There has been a rapid increase in life expectancy since 1999, unmatched by any other EU country. Life expectancy in Ireland in 2002 exceeded the average over the 27 EU countries for the first time and is now more than a year above the average at 79.6 years. The percentage of people in Ireland reporting good or very good health is the highest in the EU. There have been significant reductions in mortality from circulatory system disease, namely, a reduction of 38% since 1997 and a reduction of 50% over the past 30 years. Between 1980 and 2003 there were approximately 6,000 fewer deaths due to better prevention and treatment.

There have been significant reductions in all major causes of death since 1997 and our rates of improvement are about double the EU average. This includes reductions in cancer mortality. For breast cancer, the five-year relative survival rate in Ireland is nearly 80% for the period 1999 to 2004 compared with 73% for the period 1994 to 1998, although it is still below the OECD average. Infant mortality rates in Ireland have fallen dramatically over recent decades. The rate in 2005 was four deaths per 1,000 live births, which is lower than the OECD average of 5.4. Our maternal mortality rates are among the lowest in the world. The mortality rate from suicide in Ireland is ten per 100,000, below the OECD average of 12.1, and it has shown welcome signs of levelling off or even reducing slightly in more recent years.

In Ireland, the share of the population aged 65 and over was 11.2% in 2005, the fourth lowest and well below the OECD average of 14.7%. Total expenditure on health in 2005 accounted for 8.8% of gross national income, which puts Ireland close to the OECD average of 9% of GDP. Between 1997 and 2006 the number of day cases in Irish hospitals more than doubled from 243,000 to more than 550,000. The use and provision of community mental health services has increased over the period 1997 to 2004, with numbers attending mental health day centres increasing by 84% and the number of places in community residences rising by 9%.

This information is robust and reliable. It shows there have been real improvements - not just major increases in funding, staffing and health services but also much improved health outcomes. The rapid increase in health care expenditure in recent years is delivering more health care for more people and there has been an unprecedented improvement in the health of Irish people. The health system cannot claim credit for all these improvements but it has been estimated that health service interventions and treatments account for close to 50% of the improvement we have seen. Other factors such as lifestyle, housing, environment, employment and education also have an impact on health outcomes.

Equally, the health system alone cannot deliver the further improvements in health to which we all aspire. Health system planning and investment are by their nature slow burners in terms of delivering significant improvements in the health of the general population. However, it is reasonable to expect that a combination of sustained high levels of funding and the implementation of meaningful system change under the ongoing reform programme will result in continuing improvement in the health status of the population.

In Ireland, as in other countries, acute hospital care tends to attract a great deal of media and public attention even though chronic conditions account for most of the cost. The international evidence is that approximately three quarters of health care spending is related to chronic diseases such as heart disease, stroke, diabetes and cancer. Patients with chronic illness and the complications of such illnesses account for some 80% of general practitioner consultations and the use of more than 60% of hospital bed days.

Almost 60% of the disease burden in Europe is accounted for by seven leading risk factors: high blood pressure, tobacco use, alcohol use, high blood cholesterol, excess weight, low fruit and vegetable intake and physical inactivity. In addition, there are strong interrelationships between physical and mental health through common determinants such as poor housing, nutrition or education or common risk factors such as tobacco and alcohol.

Our demographic profile gives us a somewhat longer lead-in time to address these problems. We are already taking steps to help our system to meet these challenges. For example, we are adopting a more co-ordinated approach to interactions between sectors to improve health outcomes; we are finalising a policy framework for chronic disease management, which will focus on the full cycle of care and on maximising self-care and minimising admissions to acute hospitals, and a number of pilot initiatives for chronic disease management are taking place; we are putting in place a national cancer control programme, fully consistent with the principles of good chronic disease management, under the leadership of Professor Tom Keane; the roll-out of primary care teams is proceeding, with a focus on the delivery of integrated and multidisciplinary services; home support and community care services for older people are being increased and improved; and steps are being taken to improve the collection and use of health information to improve the delivery of frontline services and better inform the planning of services in the future.

The Department recognises that the best way to deliver change on the necessary scale is to secure the widest possible buy-in from the many stakeholders involved. We will make every effort to pursue our goals in partnership with those concerned. The ultimate objective is a sustainable health care system that is entirely patient-centred and focused on outcomes. I thank the committee members for their attention.

Chairman

I thank Mr. Scanlan. May we publish your statement?

Mr. Michael Scanlan

Yes.

Professor Brendan Drumm

I thank the committee for the opportunity to have this meeting, which is always a useful interaction for us. As the Accounting Officer I am pleased to confirm that for 2006 the board of management of the Health Service Executive delivered health and personal social services within the allocated budget of €12.3 billion. This was a major challenge and was achieved during a period of significant change, including a requirement to amalgamate 17 separate financial control systems. It reflects our commitment to carry out all our financial duties and responsibilities in accordance with the highest standards of governance and financial management.

It is clear an integrated financial management system is essential for an organisation such as the HSE. A project team is preparing the specifications and business case for an integrated financial management system for consideration with our colleagues in the Department of Health and Children and the Department of Finance. This process will be completed shortly.

As mentioned in the report of the Comptroller and Auditor General, information and communications technology expenditure is also subject to an additional sanction under circular 16/97. Prior to the establishment of the HSE in 2005, the former health boards and agencies were not required to report against this sanction. ICT is the only expenditure category subject to an additional approval process of this type.

It probably will be helpful to explain the scale of the ICT landscape within the health care system. More than 600 clinical applications are deployed, ranging from integrated intensive care clinical systems and child care information systems to solutions that link general practitioners to hospitals. There are also approximately 200 business systems supporting, for example, the production of E111 cards, medical card applications and drug payment systems. Our key systems have about 40,000 users and many are critical in terms of quality of patient care. International evidence suggests that successful deployment of ICT is essential to improving our health care system overall.

Although the HSE inherited a range of financial and coding systems across the various agencies, we have taken a number of steps to strengthen compliance with the sanction, some of which I will outline. In 2007 we implemented a single coding system for ICT revenue expenditure. ICT capital procedures and coding systems have been updated and staff have been trained in the new arrangements. A formal financial regulation on ICT has been drafted for consideration and approval by the board of the HSE. All ICT procurements are now approved through a recently established national ICT programme office. Key service managers have been briefed on their obligations under the sanction.

In addition, a forum was established for all ICT senior managers, which included all voluntary and non-statutory agencies, to improve communication within the ICT community. The forum's initial meeting reaffirmed our requirements under the sanction.

ICT governance has also been strengthened in line with our own needs and the requirements expressed by the Department of Finance. This has been achieved through the following actions. An ICT steering group, which includes international expertise, now provides oversight of all ICT activities within the HSE. Prioritisation groups involving key service managers are in place for each key service directorate to ensure the HSE establishes clear investment priorities. A new ICT organisation structure within the HSE has been designed and it is hoped it will be rolled out in 2008, subject to Government agreement. During the latter half of 2007 the HSE started to roll out a project framework and methodology for all ICT projects to ensure consistency and quality is maintained at all times. Each major project now has a well defined project charter and clearly defined roles and responsibilities.

In addition, an overall ICT strategy is being finalised for consideration by the HSE board in 2008. This strategy has drawn on extensive international expertise from comparable health systems such as those in Canada and New Zealand.

In summary, the additional measures taken last year and this year in the area of ICT will strengthen our compliance with the requirements of the ICT sanction. For the first time in Ireland, the development of a clear national ICT strategy, in conjunction with best in class governance and organisational arrangements, will enable information and communication technology to play a greater role in supporting improvement in patient care.

I wish to comment on the Comptroller and Auditor General's value for money report No. 56. Chapter 5 of the report refers to the prescribing practices and the development of the general practitioners service. The indicative drug target savings scheme, IDTS, was introduced by the Department of Health and Children in 1993 following agreement with the Irish Medical Organisation, IMO. The purpose of the scheme was to assist general practitioners achieve cost-effective prescribing and was considered an integral part of the blueprint for general practice.

The HSE, soon after its establishment in 2005, met the Department of Health and Children to discuss the scheme. It was agreed that the scheme would be suspended from 1 January 2006 and would be subject to an independent review by the national pharmo-economic unit. The review sought to determine if there was an evidence-based rationale for continuing with the scheme in its current format. The review, completed in January 2008, concluded as follows: "Evidence to date suggests the Indicative Drug Target Savings Scheme is no longer achieving its stated objective to promote rationale cost-effective prescribing by the GPs".

The contents of the review have been agreed by the key stakeholders, namely, the Department of Health and Children, the HSE and the IMO, and the Department and the HSE are considering its findings to determine how the scheme's original objectives can now be best achieved. In this context consideration will be given to recent changes in the pharmaceutical supply chain, that is, the Irish Pharmaceutical Healthcare Association agreement with the HSE, the reduction in wholesale margin which is planned to take effect from 1 March 2008, the review of the pharmacy contract which is being initiated and the GP contract review process in progress.

I wish to comment on chapter 8, administration of supplementary welfare allowances. In June 1998, the Comptroller and Auditor General published a value for money report on the administration of the supplementary welfare allowance scheme. In 2002, given the changing nature of the scheme, the rapidly increasing levels of expenditure and the range of changes then being proposed in relation to individual aspects of the scheme, it was decided that a fundamental appraisal of the supplementary welfare allowance scheme was required. The appraisal primarily was aimed at improving customer service administration efficiency and dealing with the Comptroller and Auditor General's concerns. The appraisal was carried out as part of the periodic root and branch review of expenditure schemes agreed by each Department with the Department of Finance.

In view of the extensive terms of reference for the review, the complex nature of the scheme and its numerous component parts, each with its own individual purpose, it was decided to carry out the review in two phases. The report of phase 1 of the review was published in December 2004. The second phase of the review was published in November 2006. The findings of the review have provided both the HSE and the Department of Social and Family Affairs with sufficient information to guide the necessary policy and organisational changes necessary to improve the scheme.

The committee will be aware that the HSE administers the supplementary welfare allowance scheme, subject to the general direction and control of the Minister for Social and Family Affairs. Following the Government's decision in December 2006, this service is to transfer to the Department of Social and Family Affairs. This will provide for greater effectiveness and efficiency and will allow the Department of Social and Family Affairs to improve directly the performance of the scheme in the post-transfer period. The HSE will play an important role in assisting with the smooth transfer of the service.

I wish to comment on chapter 16, special housing aid for the elderly, and make the following general comments. The Minister for the Environment, Heritage and Local Government has signed the regulations which transfer the housing aid scheme to local authorities and which merge it with the essential repairs grant scheme. The handover date is 1 April 2008. As part of the handover a joint group between the HSE and local authorities is working to ensure best practices and knowledge gained from the scheme over the years are not lost. In particular, arrangements will be put in place to ensure primary carers in the community can link up with the administrators of the new scheme to ensure speed and responsiveness are key performance targets. Special emphasis will be placed on advertising the new scheme and making the arrangements known to older people in the community as well as their families and carers. The grant amounts are being increased and the procedures will be changed to give maximum flexibility to applicants in selecting contract options and in being involved with managing the work as they wish.

A system for ensuring continuous improvement, mainly through partnership initiatives, will be developed between the different agencies involved. This will include a review of effectiveness and a more general and broader needs analysis. This is a very important scheme for older people, in particular in assisting them to remain in their homes as long as is possible, which is a priority for this organisation. The HSE will be most anxious therefore to ensure this service has a smooth transfer to the local authorities.

I thank committee members for their attention and I will do our best to answer any questions. On the issue of the ambulance service, we have with us Mr. Frank McClintock who is an expert in that area and the committee may wish to refer to his expertise.

Chairman

I thank Professor Drumm. Is it in order to publish his statement?

Professor Brendan Drumm

Yes.

Chairman

Thank you. Before I invite some of my colleagues to ask questions I wish to make one comment on Vote 40. Under administration there are seven headings given by the Department of Health and Children. Under the Health Service Executive heading there is just a blanket heading for salaries, wages and allowances and other administration expenses of corporate HSE. It would be helpful for us all if that head could be broken down into subheads because we do not know the level of consultancy services, as they are not given, nor do we know the amount for travel and subsistence. It would be helpful if we could get the amounts under each of the headings supplied by the Department of Health and Children.

Deputy Darragh O’Brien

I welcome Mr. Scanlan and his team, Professor Drumm and his team and Mr. Heffernan from the Department of Finance. The performance of the health service and the management of the Health Service Executive is the number one issue of concern for my constituents in Dublin North and the country as a whole. With that in mind, I welcome the opportunity to put a number of questions to the Department of Health and Children and the Health Service Executive regarding the management of the health service financially and, most importantly, ensuring delivery of a service that meets the needs of the people.

The annual funding of the HSE is equivalent to 25% of the total tax revenue of the country. With that level of investment by the taxpayer, it is incumbent upon all stakeholders, the Government, the HSE and the Department of Health and Children, to find efficiencies in their operation and, most importantly, front-line services in the health service. Late 2007 saw the suspension of certain HSE activities, particularly in disability organisations, due to the HSE overspending its budget allocation, even though the Government provided year-on-year increases of approximately 9% to 10% from 2005 to 2007. That is something I, as a member of the Committee of Public Accounts, and I am sure every other Member do not want to see repeated.

Under Vote 40, administration, the estimate for salaries and wages for 2006 was €27 million but there was an outturn of €45 million, a significant overspend. Will Professor Drumm explain how it arose?

Chairman

That relates to my opening question also.

Deputy Darragh O’Brien

Should I put the rest of my questions?

Chairman

That is an important one.

Deputy Darragh O’Brien

The Chairman mentioned that there were usually seven subheadings in section A, as in Vote 39 for the Department of Health and Children. There is only one in Vote 40. I am asking specifically about the outturn. It is difficult to know whether the figures relate to salaries.

Professor Brendan Drumm

Mr. Woods might comment on that specific aspect. Regarding Deputy O'Brien's comment about the overspend in 2007, we agree with him but it was not a cutback on our service level agreement.

Deputy Darragh O’Brien

I understand that.

Professor Brendan Drumm

We delivered significantly beyond what was included in the service plan. There is the option for us this year to make sure we stick to our service plan deliverables and we will.

Deputy Darragh O’Brien

I put that question in the context of the questions asked earlier. None of us, the HSE included, wants to see a repeat of what happened in 2007 because I am talking about issues that we find arise on the ground. I understand Professor Drumm's point.

Professor Brendan Drumm

I will ask Mr. Woods to comment on the financial issue.

Mr. Liam Woods

On the Chairman's point, we can provide a breakdown of the subhead over a range of headings. If that is helpful, it will not be a problem.

Chairman

Could we have them now please?

Mr. Liam Woods

Yes. To refer to the detailed question, the main item giving rise to the variance the Deputy is referencing is the national insurance policy of the HSE, for which the figure in the subhead is €25.2 million. The other items to refer to include the HSE Employers Agency, HSEA, which is coded and for which the figure is €6.8 million. The figure for the national hospitals office, formerly known as Comhairle, is €900,000. It is also coded. The corporate cost element amounts to €11.9 million. Those figures collectively come to €45 million.

Deputy Darragh O’Brien

Mr. Woods is saying the figure for the national insurance policy for the HSE is €25 million. Could that not have been estimated for the previous year? Why was it not shown in the estimate for the year?

Mr. Liam Woods

It is just an issue of the formatting of the report and the subheads. The cost was known but 2006 was a transitional year. The Deputy will be aware that the HSE was established at the start of 2005 and our financial systems were only settling as we went from 2005 to 2006. There is an issue—

Deputy Darragh O’Brien

It was estimated.

Mr. Liam Woods

Yes. It was in the budget. In fact, we negotiated a saving on the overall price as part of what we were doing as an organisation.

Chairman

It is not clear to me. Can Mr. Woods give us an actual figure for salaries, travel and substance, incidental expenses, postal and telecommunications, office machinery, office premises expenses and consultancy services as provided by the Department of Health and Children?

Mr. Liam Woods

I can, but it is not contained within just that subhead but across all the subheads. The subheads are split on the basis of the former boards. Perhaps I should explain the reason for this. There are eight main financial systems running within the HSE, the systems which ran in the former board headquarters. To report on a Vote basis we must report at a transaction level to comply with the requirements of public accounting. The only transaction level systems are at an area level in the former boards. We are amalgamating the data in a Vote format and also an annual financial statement format. The information the Chairman is requesting is available. The annual financial statements on an accruals basis will show some of the data. The subheads - it is an objective of ours and the Departments of Health and Children and Finance to reshape them to align with the service structure of the HSE - are determined to some extent by our systems.

Deputy Darragh O’Brien

I appreciate that but we have gone through the accounts in detail and if we cannot get a handle on them, it will be difficult for the general public to do so. The Estimate for 2007 still has an administration category of A1 in which everything is lumped together. That did not change in 2005, 2006 or 2007. I understand and appreciate the constraints with regard to systems but for the sake of transparency, not just for us but also for the general public, we should know what is being spent on administration, consultancy services, travel and subsistence, etc.

Chairman

If we take one of them, consultancy services, surely that should be centralised and itemised under "administration".

Mr. Liam Woods

I have a figure for consultancy services which I can give the Chairman now but it has been abstracted from a number of systems. However, that does not detract from the notion that we can get the information. There are two issues involved. The structuring of the information on a subhead basis is system dependent but in providing it for the committee, I could draw attention to some of the notes in the annual financial statements. Page 74 onwards contains much detail on pay and expenses. The figure for consultancy services in 2006 in total was €7.96 million.

Chairman

Would Mr. Woods give us an example of the type of consultancies involved?

Mr. Liam Woods

Yes. The largest item relates to work done on a hygiene audit, for which purpose there is a figure of €400,000, to which I will come. There is another figure of approximately €200,000 which relates to a hygiene audit. There is a range of consultancies. I have a detailed list which I could provide if it would be helpful.

Chairman

Would Mr. Woods read it?

Mr. Liam Woods

The list?

Chairman

I am sure it is not too long, is it?

Mr. Liam Woods

It is. It runs over—

Chairman

Mr. Woods could give us the top ten in expenditure.

Mr. Liam Woods

Probably the largest one is with an organisation called Accenture, for which the figure in 2006 was €1.4 million.

Deputy Darragh O’Brien

Are they management consultants?

Mr. Liam Woods

Yes.

Deputy Darragh O’Brien

Andersen Consulting.

Mr. Liam Woods

That is correct. They had been providing support on what was then known as the PPARS project. They had also been doing work on developing a national shared services strategy which was about driving value in the health environment.

The next highest one is with a company called Healthcare Science Limited for a decontamination audit at a cost of €412,000. There is an ICT contract, for which the figure is €354,000. There is a contract for outpatient waiting time and HR systems, for which the figure is €362,000. There is a contract for €230,000 with a group called PA Consulting for the acute hospital inpatient bed utilisation project. There was a social research contract for €154,000 with Warren House Group. I can order and provide the full list.

Chairman

Please do so.

Deputy Darragh O’Brien

Can Mr. Woods give any indication as to when the accounts could be presented in the format we require? The Estimate for 2007 for salaries, wages, etc., stands at almost €58 million. Compare that with the figure for 2006 when the Estimate was €27 million. Therefore, the figure has increased from €27 million to €58 million. That is fine if it can be broken down and explained but if not, it is a massive increase. Why is the Estimate for 2007 €58 million? I assume we will find out in the next couple of months what the actual expenditure was. When will Mr. Woods be able to provide those details transparently?

Mr. Liam Woods

There are two levels to the response. We are doing work to try to revise the subhead formats to a basis that would be more appropriate for the organisation of the HSE and for the public and public representatives. We are trying to align it to the services. That is dependent in the long term on having a single integrated financial system. In the short term we are working to develop our existing systems. I hope during the course of 2008 we will have aggregated our system sufficiently to ensure that level of visibility. I should flag for the committee that from page 75 onward in the annual financial statements document there is detail on pay and non-pay expenditure globally. Members can see where the trends are.

Professor Brendan Drumm

The Chairman appears to be looking for a total figure for items such as travel and subsistence. Those are important figures which we can supply. We can give national figures—

Chairman

I am looking for simple information in order that this committee can make a judgment on what the HSE is doing. There is a serious lack of transparency.

Professor Brendan Drumm

We can provide them for the Chairman. You are absolutely right. Those figures are important. It should be possible to provide the committee readily with global national travel and subsistence figures and some of the other information the Chairman is seeking.

Mr. Liam Woods

Yes, we can certainly provide it. The reason I am pointing out the systems issue is that to provide it on a Vote basis is a challenge. We can provide it in expenditure terms.

Deputy Darragh O’Brien

That would be okay. It is fine if it is not on a Vote basis. We just wish to know how it is categorised. To follow on from that, is there a reason the sum went from €27 million to €57 million between 2005 and 2007 in that category? Does that still include the figure for the national insurance policy? Why has the figure increased so substantially?

Mr. Liam Woods

It does. The growth factor was primarily the national insurance policy. I will confirm this for the Deputy to be certain.

Mr. John Purcell

I do not wish to cloud the issue but it was generally recognised that the systems in the HSE when it was set up could not support the Vote structure. Everyone believed the Vote format which very much followed the old health board arrangements was a totally unsatisfactory way of producing and presenting the information. That is the reason I mentioned, in my opening comments, that there was far more detail in the annual financial statements on an income and expenditure basis. If one wants to see the figure for travel and subsistence, it is shown in note 8 as €85 million. The figure for insurance is €27 million; it was €32.6 million in the previous year. One must dig a little through the notes to get the figures but they are there. I agree with the sentiment that the format of the Vote account is close to meaningless for anybody who wishes to make sense of the figures and make comparisons.

Deputy Darragh O’Brien

Even if one spends a number of hours digging through the numbers, as I did, it is difficult to break them down nationally. I appreciate there is an annual report available also. I am glad, however, that this is being worked on and that we will have further information. Under the HSE medical card services scheme, section B.10 of the report, a sum of €1.4 billion was spent in 2006. This might be a crossover matter between the HSE and the Department of Health and Children. One of the main complaints I receive from constituents is that some general practitioners and dentists will not take on additional medical card clients. I can give the example of Swords, where only two dentists will take on medical card patients. A significant amount of Exchequer funding is being paid for this scheme but taxpayers cannot get services from their general practitioner or dentist. Will Professor Drumm or Mr. Scanlan comment on this? Given the massive investment in this area, how can we improve the service and ensure it is available to people who have a medical card? The practitioners seem to be closing their books to extra patients or clients.

Professor Brendan Drumm

I can comment on the general practitioner scheme but might need help on the dental scheme. There is a restriction on the issuing of what we call GMS billing numbers, through an agreement with the Irish Medical Organisation that long predates the HSE. It is interesting at times that we hear about the difficulty in recruiting general practitioners in certain areas such as the north city—

Deputy Darragh O’Brien

North county.

Professor Brendan Drumm

—while at the same time there is a significant difficulty in getting a GMS number on occasion for individuals who wish to start up a practice. That has been the practice historically. We are waiting to negotiate a new general practitioner contract but it certainly can lead to challenges in creating availability of services in some areas.

Deputy Darragh O’Brien

Does Mr. Scanlan wish to comment?

Mr. Michael Scanlan

I echo what Professor Drumm said. In fairness, he has raised the issue with us. It has also come to the Minister's attention. It is only a question of how and how soon we address it rather than whether we will. We will address it; it is just a question of how.

Deputy Darragh O’Brien

Obviously, we are addressing this issue directly with the IMO. We are expanding our medical card services and the number who qualify for medical cards but there is no point having them if they cannot use them or if they must travel 15 miles to visit the doctor or dentist. I do not know if negotiations are under way but if the Exchequer paid €1.4 billion in 2006 and will probably paid significantly more in 2007, it should be getting more bang for its buck. People should be able to access medical card services through general practitioners and dentists.

Mr. Michael Scanlan

I deliberately mentioned in my opening statement that our overall approach to health reform was to try to talk to people, to be reasonable and to engage everybody. As Professor Drumm said, we are about to head into - I do not think I can use the word "negotiate" any more - a new general practitioner contract. However one wishes to describe it, this would be top of both mine and Professor Drumm's agendas. While we would prefer to do it in partnership, this is a "must do" issue.

Deputy Darragh O’Brien

Absolutely.

Mr. Michael Scanlan

I prefer not to say more than that; it is a "must do" issue.

Deputy Darragh O’Brien

It is a priority.

Mr. Michael Scanlan

Yes.

Professor Brendan Drumm

There are two sides to this hugely important issue. There is the issue of patients having access to services and the issue of fully trained professionals having access to a career.

Deputy Darragh O’Brien

With regard to capital commitments in note 24, a sum of €5.8 billion was allocated for the period 2007 to post-2011. Is that money strictly for that period? What significant projects should be delivered in that timeframe? Do they include any frontline local medical centres which could take pressure off accident and emergency departments?

Mr. Liam Woods

The commitments potentially go beyond the term of the NDP. In reply to the last question, the primary care developments will primarily be funded through the use of private capital. In fact, we have advertised for expressions of interest to have parties make themselves known to provide such facilities across the country. It, therefore, would be paid for on a revenue rather than capital basis. The major components going through the capital plan include the development of community nursing units for older people's services.

Deputy Darragh O’Brien

That is fair enough. We have €5.8 billion there over a four-year period, unless I am reading it incorrectly. What specific projects are we looking at? We are talking about respite care but where and what is it basically?

Mr. Liam Woods

This is not my specialist area but the major projects that will come through will include hospitals, such as the construction of the children's hospital on the Mater site and potentially the Mater itself. I would imagine a hospital in the north-east may be on that agenda as well.

Deputy Darragh O’Brien

Perhaps Professor Drumm could comment on that significant capital investment. Surely we can have a clearer idea than possibly a hospital in the north east. We understand what is happening with the Mater but surely we have a capital works programme.

Professor Brendan Drumm

Absolutely. We have a detailed plan and the major capital demands on that will be, as Mr. Woods has just said, the new Mater development, the new children's hospice and significant coverage of community nursing units. Some of those units are already well under way, for instance, at St. Mary's in the Pheonix Park with 100 beds, Cherry Orchard with 100 beds and many others. These are now being delivered in eight to nine-month timeframes compared to the historical system of design and build contracts. We can provide the committee with the entire flow-sheet.

Deputy Darragh O’Brien

That would be useful. I know we are under pressure, Chairman, but I have just two more questions. Under the heading of risks and uncertainties, it shows a figure of €1.654 billion, including budgetary pressures in relation to pharmaceutical services and costs in 2006. Everyone is aware of that. In his statement, Professor Drumm mentioned that the HSE is seeking to make savings from dispensing drugs from pharmacies. This is a topic of regular discussion in the Houses of the Oireachtas, but I strongly disagree with the manner in which the HSE approaches this issue with the IPU. In a financial context this will end up costing us more money given the time and effort being spent. We have all received information both from the HSE and the IPU. Can we not sit down with the IPU, without preconditions, and discuss the contractual changes needed to make these savings?

Chairman

I do not think that is relevant.

Deputy Darragh O’Brien

It relates to the statement.

Chairman

All right.

Professor Brendan Drumm

I will certainly comment on that because it was a priority of mine when I came to this post that we would achieve value for money in the health services. At times it seems challenging to me that on one day we are criticised for not managing the system, such as towards the end of last year, and not deriving value in the system, yet when we move to take some serious management decisions we are asked to come up with a different approach. We could make savings of about €200 million in pharmacy expenditure. We came to an agreement with the IPHA, which represents the manufacturers, leading to significant reductions, which will continue into the future in terms of how much we pay for new drugs coming on the market - that will be a substantial saving in future - and in terms of drugs coming off patent. That will deliver real value for the taxpayer. We then looked at the wholesale agreement in place before it got to the retailer. We were legally challenged on that and it was discovered that we could not negotiate.

Deputy Darragh O’Brien

I understand.

Professor Brendan Drumm

To cut to the point, at the moment we are operating a budget that has made an allowance - and we accept that - of €80 million to €90 million savings being achieved on the wholesale agreement. If that is not implemented - and we have already slipped two months, which is about €16 million - that money has to come out of front-line services or else it has to be provided by the taxpayer, and I will be quite happy to hand it over to the pharmacies.

Deputy Darragh O’Brien

I appreciate that but this is an important issue. Earlier on, I asked questions about services that were not delivered last year. I am simply asking a question here as to why normal industrial relations and negotiation practices are not being followed in this case. I do not believe that one can negotiate with people by saying "Accept the interim contract, then we'll talk to you". I want to see savings in all sectors, as I believe the IPU and HSE do. Why can we not leave the independent review group to do its job, talk about the contractual changes that can be made, and make submissions to the independent review group that was set up by the Minister in December, without setting a false deadline of 1 March? We are walking our way into a great deal of trouble here - not just ourselves but the HSE. I am only saying this as someone who is concerned about the situation. The general public will suffer. I wonder why we cannot sit down and negotiate with the IPU on that basis.

Professor Brendan Drumm

There are two issues there and I will come back in a second to the question of whether we can negotiate. The first issue is that the IPU represents pharmacy retailers. We are quite happy to discuss the retail contract with them and we are quite happy to go to the proposed review body on the proposed new contract. We have not taken action concerning the retailers; we have taken action concerning the wholesalers.

Deputy Darragh O’Brien

With all due respect, Professor Drumm has written directly to every pharmacist over the heads of their own representative body. Is it not correct that he has asked them to accept the interim contract before sitting down to talk?

Professor Brendan Drumm

No. We need to be clear on this because there seems to be confusion all over the place.

Deputy Darragh O’Brien

I am not confused about it.

Professor Brendan Drumm

I will be very clear on it. The question is whether we manage the system. We are managing the system by dealing with each of the bodies. The wholesaler body is a separate body - it is not the IPU.

Deputy Darragh O’Brien

Yes, I understand that. I am talking about the retail pharmacies.

Professor Brendan Drumm

The taxpayer has been paying 15% for the wholesale distribution of drugs, albeit that it has come through the retailer to be paid to the wholesaler. We are saying that we will reduce that wholesaler amount to 8% and then to 7%.

Deputy Darragh O’Brien

I understand that.

Chairman

Please allow Professor Drumm to finish.

Professor Brendan Drumm

That is not a retail issue, it is a wholesale issue. If it was a retail issue it needs to be explained because it raises questions about how that money was being used.

Deputy Darragh O’Brien

The professor knows what the retail issues are.

Chairman

The Deputy should let Professor Drumm continue without commenting.

Professor Brendan Drumm

Then it begs the question as to how the taxpayer has been treated in this regard. The second issue is negotiating. It has been clear from everybody, including all legal opinions received by independent bodies and the Attorney General's opinion, that one cannot sit down and negotiate—

Deputy Darragh O’Brien

A price.

Professor Brendan Drumm

—in relation to anybody representing a conglomerate of independent contractors. One does not even have to be in the legal profession to say that.

Deputy Darragh O’Brien

No.

Professor Brendan Drumm

So we are not in a position to sit down and negotiate. We are in a position to sit down and discussthe new contract concerning the retail sector and we are quite happy to do that. What we are not happy to do, however, is enter into negotiations on a wholesale agreement with the retailers.

Deputy Darragh O’Brien

Is Professor Drumm happy to sit down and discuss - not negotiate - the matter? An independent review group is being set up. Is it not true that a deadline of 1 March has been set by the HSE?

Professor Brendan Drumm

In relation to the wholesalers.

Deputy Darragh O’Brien

In relation to the price reduction, yes, I understand that, but also to have discussions - not negotiations - with the retail sector so that they must accept the interim contract that has been sent out.

Professor Brendan Drumm

Not at all. The acceptance was to accommodate the previous concerns of the retailers that if we brought in the wholesale agreement some of their members would be discommoded because they were dependent on the GMS.

Deputy Darragh O’Brien

Many of them, yes.

Professor Brendan Drumm

We said therefore that we would create the option for them to create an interim contract so that will not happen to them. Whether they sign that is totally up to them. That was to try to help them.

Deputy Darragh O’Brien

I understand.

Chairman

The Deputy's time is up.

Deputy Darragh O’Brien

I know this is a difficult situation. Would it not be better to allow the independent review group to decide upon submissions forwarded by the HSE and the retail sector, "retaining the status quo” and let them adjudicate on it, rather than pushing forward?

Professor Brendan Drumm

As regards a retail contract, absolutely, but not concerning a wholesale agreement.

Deputy Darragh O’Brien

Yes, but the 8% reduction is there beforehand.

Professor Brendan Drumm

No, that 8% reduction is on the wholesale agreement.

Deputy Darragh O’Brien

I understand that.

Professor Brendan Drumm

If something else was happening to that money then I believe the taxpayer deserves an answer.

Chairman

We have to move on now. For the information of members, this matter will be discussed next Tuesday by the Committee on Health and Children, when we will have both the HSE and IPU before us.

Deputy Pádraic McCormack

This is a value for money report. The HSE is the biggest spender of all Departments. It seems extraordinary that consultancy and training fees were not clearly spelled out in the Vote and that members must prise that information from it. I am not at all happy with that. However, I will be happy if we get the figures on total expenditure for consultancy and training fees for the years 2005 to 2007, inclusive.

I refer to Vote 40 and the return of the €365 million, which the Comptroller and Auditor General mentioned. That is €1 million per day being sent back to the Department. It was supposed to cover the nursing home refund scheme to reimburse those illegally charged. Only €16 million was used for that purpose, so €250 million - still almost €1 million per day - was sent back to the Department.

We were assured by the Minister that the fund to reimburse those patients illegally charged would not come out of the health budget. Was it the intention to send back the €365 million to cover the reimbursement of patients in public wards who were illegally charged? The money was not spent, so it was a return to the Exchequer. Think of all the benefits which could have been accrued if the €365 million had been spent for the purpose for which it was allocated.

Chairman

I will not intervene too often, because it is unfair to questioners, but will Mr. Scanlon tell me where he got the dates? I am looking at note 30 on the Health (Repayment Scheme) Act 2006. It refers to people who were wrongly charged at any time since 1976 and the estates of people who were charged and died on or after 9 December 1988. From where did that date come? Has there been any indication of a legal challenge to that cut-off point?

Mr. Michael Scanlan

I will try to answer both questions. When Deputy McCormack said the Minister made the point that the cost of the repayments would not come out of the health budget, the point she was making was that it would not affect the level of ongoing service funding for the health services. Therefore, what was provided was a separate provision of €340 million as the estimated cost on top of the service funding for the HSE.

The corollary of that is that if it is not spent for the purpose for which it was provided, it is surrendered not to the Department, but to the Exchequer. If one follows that through into the current year, there is a provision of, I believe, €150 million in the HSE Vote for this year for the same purpose. It is still not clear to me but the current projections we have suggest that it would not be sufficient. I expect that in that circumstance, health services would not suffer as a result. I would have to talk to colleagues in the Department of Finance.

We have tried to deal with the issue of repayments as an entirely separate funding line. It was provided for a specific purpose and not for services and, in that sense, was not available to be spent on services and was correctly surrendered. The alternative would have meant that one was in some sense counting it in the funding one was providing for services. If one looks at increases in funding provided to the HSE since its establishment, the only fair way for the Deputy to look at them, as someone concerned with services, is to take out the long stay funding figures because they will only confuse matters.

The Chairman asked about the date. That date essentially relates to a policy decision that was taken in terms of the scheme and based on legal advice to the Minister about the options open to her. There is certainly no intention to change the scheme. It is open to people to take legal challenges against us and there are a number of legal cases being taken. I do not know whether some relate to that date but I would imagine they do because they cover a range of issues in terms of public and private nursing homes. There are approximately 400 legal cases at present.

Deputy Pádraic McCormack

Mr. Scanlon is right to say I am concerned about the provision of services, and I will deal with that. Under Vote 40, I wish to ask about salaries, wages and allowances. This has been explained but I am not fully clear about it. The Estimate was €37 million and the overrun was €45,134,000. How did that come about?

Chairman

It was €27 million.

Deputy Pádraic McCormack

It was almost double the Estimate provision.

Mr. Liam Woods

The cost of the national insurance policy for the HSE was €25 million. That was coded into that expenditure heading. It is the main factor giving rise to the difference. I will provide the level of detailed analysis requested, which will show about six or seven lines that make up the €45 million spend.

Deputy Pádraic McCormack

It is a pity that was not shown more clearly in the Vote.

Vote 40 refers to a maximum individual payment in one case of €160,557. I understand that refers to one individual but correct me if I am wrong. Is that an allowance on top of the individual's salary? It also refers to an overtime payment of approximately €135,000 for one person and payment in respect of on-call of €132,812. Are those payments to individuals on top of their salaries?

Mr. Liam Woods

Yes.

Deputy Pádraic McCormack

If the answer to that question is "Yes", I want to get back to my concern about services provided which Mr. Scanlon identified. In his opening statement, he stated, "I have previously referred to the hard work and innovation which health service staff deliver for the benefit of the public on a continuous basis". As a public representative who must deal with those problems on a day to day basis, my experience is the opposite to that. If one person is able to earn that kind of money, why have six beds been closed in St. Francis's nursing home Galway and six or seven beds been closed in St. Ann's nursing home in Clifden? It is due to a lack of staff.

We hear this flowery language that staff are delighted to deliver services, etc., but services are very badly delivered and I will give an example of a case which I have been dealing with since December 2005. A small farmer in Connemara minding his invalid mother at home had eight hours home help and he was just about able to manage his mother with that. One of the home helps had to quit for family reasons and I tried to get the four hours restored to him. I received a letter from the HSE on 16 December 2005 stating that there were some people in the north Connemara area who would work evenings but that it could not recruit them as there was an embargo on the recruitment of staff.

I have letters up to October 2007 indicating the length of time I was dealing with this case. The last letter I received from Alex MacLean of the HSE on 10 October 2007 stated that I should note the ceiling on the employment of home helps. That man struggled on to mind his mother, who is now in institutional care. He could no longer continue to mind her even though he tried to manage for two years without the four hours of home help. If he had received that help it would have cost the HSE €50 per week and not over €160,000 in overtime or over €132,000 for on-call services.

Incidentally, I do not know whether that person was ever called. If that man had got his four hours home help, his mother would not now be in institutional care costing the State approximately €2,000. That is the reality of the situation on the ground. Mr. Scanlan stated that he appreciates the hard work and innovation, but there is no innovation at that level in the HSE. I am sick and tired of writing, including to Professor Drumm and everybody else, about this case and getting no satisfaction whatsoever. That is the end result of the case. As a public representative who must come in here and listen to that waffle about the good health service and hear them state that they are doing everything possible, I am very concerned and annoyed about that matter.

What about the emergency unit at the Mercy University Hospital in Cork, a matter relevant to the Chairman, which was completed last year and is not yet opened? What has it cost to keep that unit for a year with no staff in it?

Three reports were commissioned on the breast radiography service at Portlaoise and there are no results from them yet. In my constituency, a report was commissioned on alleged abuse in Kilcornan, County Galway. It took the consultants, or whoever was appointed, nine years to produce the report and as soon as the report was produced, the Minister of State, Deputy Devins, commissioned another report - an inquiry into the delay in producing the first. Who does the HSE think it is fooling?

The service on the ground is deplorable and I could give several more instances. I am just giving that one because I am so passionately concerned about that poor man, who was minding his mother and having to change her. He was delighted and willing to do it, if he got a little backup help from the health service. However, he got no backup from the health service and, reluctantly, he had to put his mother into institutional care. What is happening on the ground is a scandal.

Chairman

Deputy McCormack deserves more of an answer than "Yes" to the question he asked. How could any individual claim that sort of overtime?

Professor Brendan Drumm

I am perfectly happy to deal with that.

Deputy Pádraic McCormack

I have spoken to Professor Drumm about this previously. I raised it several times.

Professor Brendan Drumm

I am perfectly happy to speak about all the issues Deputy McCormack raises and, obviously, about which he and indeed many of us feel passionate. I will take all of them but they may not be in the order in which they arose.

I must state clearly - it was in Mr. Scanlan's report but it could have been in mine - that all fair and independent measures, not independent cases but all studies done independently each year, of the health service up and down this country show percentage satisfaction rates in the high eighties and nineties by people who use the service. Those are the scientific facts and the studies are there. They are not our studies.

Chairman

Who commissioned the studies?

Professor Brendan Drumm

The studies must be commissioned as part of our quality control, but they were done with over 3,500 households by an independent authority, which combined UCD and Lansdowne Market Research.

Chairman

A study should be done, asking the people themselves.

Deputy Pádraic McCormack

I was not consulted in that study.

Professor Brendan Drumm

Let me be clear. Unlike studies by The Irish Times which ask people on the street, that study was commissioned to deal with 3,500 families - that is a huge sample - up and down the country that use the services, not people who perceive them. By any standards, that is a huge study. It is there for anybody to have and it will be repeated.

Chairman

Deputy McCormack was getting passionate. I am getting upset now at hearing this sort of stuff presented to us.

Deputy Pádraic McCormack

I am on the ground every day.

Chairman

We all are on the ground every day—

Deputy Pádraic McCormack

I am in my office every Monday morning listening to complaints about the HSE.

Chairman

——and those studies are meaningless because they are out of touch with reality. Professor Drumm, maybe you are depending too much on consultancies and studies and should get down to reality.

Professor Brendan Drumm

We have to do these studies each year and if people do not believe them, then maybe we should stop doing them and then people do not believe what is a scientific approach to studying the population.

The second issue mentioned in connection with the HSE was Kilcornan. The Kilcornan report was commissioned by the Western Health Board and went through many years when absolutely nothing happened with it. We would be perfectly happy to deal with the delays on the Kilcornan issue. In fact, it was when the HSE took over the issue that it got dealt with.

Deputy Pádraic McCormack

I only give it as an example.

Professor Brendan Drumm

It was being given to me as a scandalous performance by the HSE. It is an undertaking where the HSE went in and took on a situation which had lain for years without being addressed. It was not the HSE but an older authority that was dealing with that issue. We can give the committee the full timing to exactly each intervention and it will be perfectly clear.

The overtime Deputy McCormack raised is a huge issue. Those huge amounts of overtime the Deputy outlined are generally related to junior hospital doctors. At present, we run a system that has junior hospital doctors on call across 50 units in the country each night. Unfortunately, that demands an enormous workforce and an enormous contribution to overtime. The ironic aspect is that it is in places where the workload is least that the overtime is highest because one clearly could not be claiming that kind of overtime and doing those kind of hours in units that were hugely busy, and they are in specialties where call-in is very low.

We are delighted to deal with that issue, but it does mean a complete change in how we provide our services. Indeed, our transformation programme in areas like the north east, if it is supported, will have a very definite effect on overtime. If it is not supported, the committee may expect to see these overtime figures increase considerably in the years ahead. If we are going to keep in a small hospital three registrars and three house officers on call each night to cover services that may only admit seven or eight people between six o'clock in the evening and nine o'clock in the morning, then the committee can expect overtime to be extraordinarily high.

That is the basis of the overtime. I accept fully that it is our responsibility, but if we get the support to make the changes we can address that. I accept fully that the figures on which the Chairman focused are unacceptable, but that is the basis of them and we can give the committee an absolute listing of the payments.

I can leave to finance the question of the returned money. They have dealt with that issue.

The other big issue Deputy McCormack raised related to Cork Mercy Hospital. Every time we have gone to open new units, serious issues about their staffing have arisen. The development at Cork Mercy Hospital, which I have seen, is a superb one. The Chairman and other Members from Cork may have visited it.

Chairman

I live within a mile of it. To see it empty for 12 months is a bit much.

Professor Brendan Drumm

It is a fabulous unit and we would be delighted to open it. There is, however, a significant demand for extra staff to open this unit. At present, our accident and emergency departments across the country are staffed at a level that runs between one and two members of staff per attendance per day, which is reasonably comprehensive staffing. I suspect that the committee will find it hard to come up with that anywhere else. That is the level of staffing with which we deal. No doubt people are working extraordinarily hard in our accident and emergency departments but we have very comprehensive staffing in those units. If opening a new unit which is essentially to deal with the same workload, or a slightly increased projected workload, will result in us having to dramatically increase the workforce - to be fair, it is not just an issue in the Mercy Hospital in Cork because there is the same issue in opening the new Tullamore Hospital and the accident and emergency unit in Portlaoise - I am sorry I cannot justify that type of spending. We must have some rationale up and down the country to be able to open new infrastructure without us moving to huge levels of staffing change for the existing level of service.

Deputy Thomas P. Broughan

Is the HSE's new deal with the consultants related?

Chairman

It is Deputy McCormack's question.

Deputy Pádraic McCormack

Those explanations are fine. The Cork development is not open. St. Anne's and St. Francis's nursing homes are open and there are beds lying idle in them. I asked why that was so and did not get an answer.

I will briefly return to the matter that caused me to become emotional, namely, the poor man in Connemara to whom I referred earlier. I even went as far as tabling a parliamentary question in respect of this issue on 26 September 2007. The reply I received stated that, as a Vote holder, the HSE has responsibility to ensure the optimum delivery of services within the resources available to it. In the case to which I refer, the HSE did not deliver the necessary services.

I inquired about Portlaoise Hospital, in respect of which three consultants' reports were commissioned. These reports were expected some time ago but they have not yet been submitted. There is a review of pathology services at University College Hospital, Galway, in the wake of another misdiagnosis of breast cancer. In the case in question, a woman was wrongly given the all-clear on two occasions. This review has still not been completed. What is causing the delays in the completion of these reports and reviews?

I apologise for blaming the HSE for the report relating to Kilcornan. As far as I am concerned, there is no difference between the HSE and the old health boards because the provision of health services is and was the purpose of both. The report on Kilcornan took nine years to complete and more consultants are to be appointed to investigate what caused the delay. I do not particularly want to discuss this matter and I only raise it as an example of consultants being appointed and reports not being forthcoming. As Deputy Gilmore stated in the Dáil yesterday, five or six firms of consultants were appointed to produce reports into certain matters. Those reports were supposed to be presented some time ago but they have not yet appeared. Who is responsible for overseeing matters when they are referred to consultants?

Professor Brendan Drumm

We must make clear the frustration we all feel in respect of reports but we must also stress that the actual process relating to their compilation must be fair. Three reports were commissioned in respect of Portlaoise Hospital. The first of these was requested by the HSE and was carried out by Dr. Ann O'Doherty, a consultant radiologist. The subject of the report was the functioning of radiology breast services at the hospital. The report was completed some time ago but it is subject to judicial review on the part of several people who are alluded to in it. There is nothing we can do but undergo the process. We will have no control over the matter until there is legal acceptance of the fact that there has been adequate due process for the individuals who might consider themselves either fairly or unfairly treated by the report. There is nothing we can do about that because people's legal rights are at issue.

I apologise if there is any confusion about names, but the second report was carried out by Ms Ann Doherty, acting director of the National Hospitals Office. It was requested by the Minister, through the Department of Health and Children, and relates to how the review was established by the HSE. The report is complete and, having been subjected to legal vetting, was sent to the Department in recent days. The entire process relating to the report's compilation was completed within a two-month timeframe, which is remarkably quick.

The third report involves the board of the HSE, which was asked to study the management processes relating to Portlaoise Hospital. This matter is not within my direct control but it comes under that of the chairman of the HSE. I understand that the report is essentially complete but I suspect it will have to be legally vetted in respect of the individuals who may or may not be identified in it. However, that may not be the case because I am not privy to the report.

Deputy Pádraic McCormack

What is the position regarding pathology services at University College Hospital, Galway?

Professor Brendan Drumm

The report on that matter is the responsibility of HIQA and is, therefore, outside the remit of the HSE.

Deputy Pádraic McCormack

It is whose responsibility?

Professor Brendan Drumm

The report is the responsibility of the Health Information and Quality Authority. The latter is actually compiling a report on the HSE's services.

Mr. Michael Scanlan

I might be of assistance in respect of this matter. I spoke to the HEO of the Health Information and Quality Authority recently who hopes the report will be completed by the end of the month. However, the relevant process will again have to be undergone.

Deputy Pádraic McCormack

Responsibility for housing aid and essential repairs grants has been transferred to local authorities. This is not a matter for the HSE but I have been informed by officials of these authorities that they do not have adequate staff to allow them to deal with queries relating to these grants. There is a two-year wait in Galway for elderly people who want to have bathrooms or toilets installed on the ground floor of their homes. Local authorities state that they either do not have the staff or the money to allow them to deal with this matter. Transferring responsibility for these grants to local authorities has done nothing to resolve the difficulties for elderly people.

Chairman

Representatives from the Department of the Environment, Heritage and Local Government are due to come before the committee next week. Perhaps the Deputy might quiz them on this matter at that stage. However, I am in agreement with him in respect of what is happening. I am aware of a number of people who died while waiting for occupational therapists to carry out assessments of their applications. We will deal with that matter next week.

Deputy Seán Fleming

I welcome Professor Drumm and his colleagues. Approximately how much of the €12 billion spent in 2006 was allocated in respect of hospital services? Is it possible to provide figures in respect of the number of bed nights, bed days, outpatient day cases and accident and emergency cases? Such figures are not included in financial reports such as that presented to the Committee of Public Accounts. However, they provide us with an indication of the volume of activity relating to the HSE's work.

What percentage of the bed nights to which I refer relate to patients covered by private insurance? Figures have emerged which indicate that consultants were allowed to use approximately 20% of beds in public hospitals for private use. We have been informed that the actual figure could be 30%. Will Professor Drumm indicate the actual percentage involved? How much money did the HSE recoup from the VHI, BUPA, Quinn-healthcare and VIVAS? I estimate that, relative to the figures which have come to our attention in respect of the number of beds being used by privately insured patients, the HSE appears to be recouping quite a small percentage of the cost relating to its hospital budget.

Professor Brendan Drumm

If the Deputy wishes, we can provide up-to-date figures for 2007.

Deputy Seán Fleming

That is fine. I merely wish to obtain an indication of the current position.

Professor Brendan Drumm

The total outturn for 2006 in respect of outpatient attendances was 2.854 million.

Deputy Seán Fleming

Does that figure include accident and emergency cases?

Professor Brendan Drumm

No, the figures for accident and emergency are separate. Inpatient discharges for 2006 were 592,269. The figure for 2007 was 597,135. The outturn for day cases in 2006 was 554,000 and in 2007 it was 564,000. The national total for emergency presentations in 2006 was 1.146 million. We can provide the Deputy with a breakdown in respect of the figures.

Deputy Seán Fleming

To what does the figure of 2.854 million mentioned by Professor Drumm refer?

Professor Brendan Drumm

That is the number of patients in all categories.

Deputy Seán Fleming

Will Professor Drumm forward to the committee the number of bed nights?

Professor Brendan Drumm

We can do that.

Deputy Seán Fleming

What is the estimate for private beds?

Professor Brendan Drumm

The split is 75.6% to 24.4%. A cautionary note in this regard is that it is totally different depending on the part of the country. For example, there is no private hospital in Limerick but 50% of its population is privately insured.

Deputy Seán Fleming

What is the hospitals budget?

Mr. Liam Woods

It is approximately €4 billion. The Deputy asked about income from private insurance. Maintenance charges, as they are referenced, in 2006 were €146 million. Those are payments from VHI and other insurers.

Deputy Seán Fleming

I refer to note 4 on page 76 and the figures relating to patient income - maintenance charges, €145 million; inpatient charges, €24 million; outpatient charges, €10 million; and road traffic accidents, €4.7 million. I tabled a parliamentary question recently in which I sought the payments by private health insurance companies to the HSE on a hospital by hospital basis in 2006 and the total operating budget for each hospital. The executive replied with a detailed list and I estimate €250 million was paid by these companies in 2006, yet the annual operating budgets for the hospitals amounted to €3.8 billion. These companies are, therefore, paying approximately 7% of the operating budgets of hospitals. This is a long way from the 25% of activity in hospitals relating to private patients. I was surprised at how low the figure was and the delegation might be wondering why I am seeking more recoupment. It appears the HSE is only taking in 7% of the operating budgets of hospitals to cover 25% of its activity. Is the HSE only charging one third of what it should charge? Will Professor Drumm explain that figure? The figures in the reply I received do not tally with those in note 4. They are a long way short of €200 million, yet the reply states the income private insurance companies is €250 million.

Mr. Liam Woods

The Minister sets the amount the HSE can charge for private, semi-private or day beds. The rate for a private bed, for example, was €758 in 2006.

Deputy Seán Fleming

What was the estimated cost?

Mr. Liam Woods

It very much depends on the case. While the averages can be misleading, the average inpatient case amounted to €5,000.

Deputy Seán Fleming

Per day?

Mr. Liam Woods

No, overall. Using that analysis, one is very much dependent on how many days a patient stays on average but, on the hospital side, we might need to analyse the kind of cases coming through as private because they may not be the average. Clearly, if there is an orthopaedic implant on its own, that could be €3,500.

Deputy Seán Fleming

I understand that but I am surprised these figures are not available. Mr. Scanlan is looking a little puzzled. The charge for the private bed set by the Department of Health and Children is unconnected to the cost of the bed. Why is there not proper recovery? Will Mr. Scanlan address this?

Mr. Liam Woods

I refer to one issue relating to the difference in the numbers between the reply to the parliamentary question and the accounts. The accounts are the HSE statutory accounts but the reply to the parliamentary question covered all hospitals, including voluntary hospitals.

Deputy Seán Fleming

I asked about public hospitals.

Mr. Liam Woods

The likes of the Mater Hospital and others are included.

Deputy Seán Fleming

The Mater private or the Mater public?

Mr. Liam Woods

The Mater public.

Deputy Seán Fleming

But that should have been included. Is it not part of the HSE's accounts?

Mr. Liam Woods

No, that is the reason for the difference.

Deputy Seán Fleming

Mr. Scanlan sets the price the VHI, VIVAS Health and Quinn-healthcare pay the HSE for a night in a private bed in a hospital. That does not tally with the HSE charge. How did the Department arrive at that figure?

Mr. Michael Scanlan

The Deputy's point is the spend on our acute hospitals is approximately €4 billion, yet the income from private insurers is between €200 million and €250 million, which is a long way short of 25%. That amount covers the total activity. For example, the sum of €1.2 million for accident and emergency department attendances must be taken out of it. The Deputy is referring essentially to inpatient and day cases only. He cannot base these on the €4 billion.

With regard to the charge per bed night, the clear policy over the past three or four years is to charge what we understand to be the economic cost. If I understand what the Deputy is suggesting, we are in complete agreement with that. Those rates have increased significantly. The difficulty tends to be working out an average charge when the cost varies. It varies not only per patient but also per type of hospital and it has reached the stage where my best advice is that we are close to, if not exceeding, the economic charge in some hospitals. We need to seek expert advice and conduct a cost analysis of the economic charge. It was clear for some years that we were well below it and, on that basis, we have increased charges at a substantial rate. It is no longer as clear that we are well below the economic charge.

Deputy Seán Fleming

I will come to the HSE but I hope Mr. Scanlan will appreciate that the lead in to my question referred to separating the charges because I suspected there were a multitude of costs in addition to bed nights in a hospital. That is why I asked about day beds. I still do not know how the HSE arrived at its figure.

Mr. Liam Woods

I take the point made by the Secretary General. Under the model we use, approximately 70% of total hospital spend relates to day case and inpatient cases, which is the main throughput the Deputy is referencing. We also have costings for every diagnosis treated within the hospitals. We have costings under 660 headings for different treatments in hospitals. For example, a hip procedure costs €13,000 on average.

Deputy Seán Fleming

I presume the National Treatment Purchase Fund must be a good benchmark for the HSE.

Professor Brendan Drumm

We have the figures for our own activity.

Mr. Liam Woods

All our cases are coded on a national activity system and they are costed in that way. The Deputy's point moves on from that in terms of the public-private ratio.

Deputy Seán Fleming

It still seems low and my instinct is the HSE agrees.

Professor Brendan Drumm

We absolutely agree with the Deputy but there is a wider issue. When the country talks about private insurance, it is a strange conversation. If I have private insurance in most countries and I have a stroke, the company is responsible for my hospital stay, physiotherapist visits at home and home help. A total of 53% of the population has private insurance but only 15% of the cost of their health care is picked up by private insurance companies. The statutory system, through the taxpayer, picks up the tab for most of it. Significant complex health care, in terms of ongoing effects, is provided outside hospital and all of the cost is picked up. Let us be clear in our minds that this is not a regular private insurance market. I agree fully with the Deputy that we certainly have not——

Deputy Seán Fleming

The accounts for last year indicated that staff numbers were 101,042. On page 78 of the accounts these figures are restated on a different basis. We read that there were an extra 1,244 staff at the end of 2005 and that these figures are being compared with those for 2006. I direct this question to the Comptroller and Auditor General. Should he not have highlighted for us last year in the note to the accounts - I presume note 7 for 2005, which I do not have - that they did not represent the staff numbers at the end of the year? They have been restated to be compared with the 2006 figures, the end-of-year figures. It seems an average figure was included in the 2005 accounts. In his audit report this time the Comptroller and Auditor General has referred to the fact that he was not satisfied with the level of non-capital expenditure on information technology because of the systems in place. Could he not, therefore, have referred to the numbers in another note to the accounts? Is that within his remit? What areas did he audit in the financial statements?

Mr. John Purcell

Yes, it covers all of the notes. There are several bases on which figures can be presented. It is an accounting standard that where one changes the basis for recording figures or including them in the account and if it is inconsistent with that used in the previous year, one refers to this. However, presenting figures in one way and then another does not invalidate the way in which they were presented in 2005. It is a matter of choice for those who prepare the financial statements to present the information in the best way they see fit and, in the case of the HSE, in accordance with accounting standards laid down by the Minister for Health and Children. I would only take issue with it if I felt the accounting policy was inappropriate. I do not think it is. It is an alternative way of presenting the information.

Deputy Seán Fleming

I accept that. There is nothing wrong with it; it is just a different way of accounting. However, the Comptroller and Auditor General can understand how we can get the impression that there are 101,000 people employed in the service and the next time we can find out that there are really 102,000. The public is alarmed by the figures. There is an issue with regard to how many work in the service. How many were employed at the end of 2007?

Professor Brendan Drumm

I can tell the Deputy how many are there now. There are 111,700 today.

Deputy Seán Fleming

Therefore, the figure has increased by 9,000.

Professor Brendan Drumm

The increases year on year are related to many issues. We can only provide posts under new developments. I will have to check, but the restatement may be related to a recalculation of the figures for student nurses. I will confirm this and come back to the Deputy.

Deputy Seán Fleming

Okay.

Chairman

Professor Drumm spoke about the level of private practice. He said it was 25% on average but could vary from area to area. Does the HSE monitor, on an individual basis, the activities of each consultant? I tried to obtain information on this previously but was told it was a private contract matter between the individual and the health board. As a member of the health board, I was not able to receive that information. Is the information available? Does Professor Drumm have it and can it be made public?

Professor Brendan Drumm

I am sure it is available, but whether it can be made public, I do not know. I would like to get back to the Chairman on it. The issue of private practice has been dealt with in an upfront manner in the new contract being negotiated. On account of the details of that contract which relate to an 80:20 split between public and private practice, everybody must sign up to full disclosure of all private activity, not just on our side, but also in the private sector.

Chairman

The nearest we got to the truth at the time - approximately seven years ago - was that the level varied from 20% or less to 50% or 60% in some specialties. Other than that, we could not obtain the information. Will Mr. Scanlan address the issue?

Mr. Michael Scanlan

I am happy to address it because I understand the Chairman's frustration. We have figures. I know people will always query their accuracy, which is fair enough. However, we have figures through the casemix system with which we have examined by hospital and specialty. I understand they could also be examined by individual. On the other hand, I am advised that the data are provided on the basis that individual results will not be published. In fairness, even if one is frustrated by this, I understand it. A lot of data, not just in the health system, are provided on the basis of anonymity. I understand the reasons for this.

Chairman

We are taxpayers and Mr. Scanlan is the manager. Surely he should know what is going on in hospitals and the information should be made available to a body such as this.

Mr. Michael Scanlan

I sympathise with the Chairman and understand his frustration. I have information, but under the rules under which information is provided, I am not in a position to make it public for individual consultants. I understand the reasons for this, up to a point. That said, Professor Drumm and I spent long nights recently talking to the consultants. This issue was at the front and centre of those discussions. It did not just come down to setting an 80:20 division and hoping that would happen but to absolute transparency in measuring the figure. We are going to use the casemix system, where it applies, in the case of inpatient and day cases. In the case of all other activities, we are committed, between now and September, to putting in place quantifiable measurements for everything and retaining the right to publish the data by hospital and specialty if the limit is not complied with. I envisage much more information being put in the public domain.

Chairman

The answer Mr. Scanlan is giving me is that he cannot provide the information sought because it was provided by individual consultants. Is it not the job of managers in hospitals to monitor activities and compile their own information, rather than being dependent on individual consultants to provide information? If that was the case, the information would be readily available.

Mr. Michael Scanlan

My understanding is that while we have the information, we do not have permission to make it public under the terms under which it was provided. It was provided for a different purpose, namely, the casemix system. We were able to use it to extract the data. The point the Chairman is making, which arose in a report the Comptroller and Auditor General compiled on consultants, concerns why management information is not available at the next level of management to implement this measure, from a different source and in a different way in order that it could be made public. It is a fair question.

Chairman

I suggest that during the years Mr. Scanlan put his head in the sand and ignored what was happening.

Professor Brendan Drumm

It is important that at management level we have access to the information. I am not sure, no more than Mr. Scanlan, what the status is. If the Chairman is requesting the information, we can clarify whether it can be made available to him. I am happy to do this.

Chairman

I would like to receive it. I tried to obtain it via a question in the Dáil and as a member of the health board but was refused. I went to the Information Commissioner and was also refused. Now I seek it at a meeting of the Committee of Public Accounts. It would be nice to receive it to find out what is really happening in our hospitals.

Deputy Deirdre Clune

In his opening statement Mr. Scanlan referred to mental health services. Recently, reports from the Irish mental health coalition on implementing A Vision for Change in 2006 and 2007 indicated that less than half of the €25 million or €27 million available was spent in those years and that funding had been suspended in 2008. That information was obtained under the Freedom of Information Act. Is it true? Will someone comment on the matter?

Professor Brendan Drumm

I will ask Ms Laverne McGuinness to comment on that point.

Ms Laverne McGuinness

The implementation plan is ready for Vision for Change. Our service plan has prioritised the developments that will be put in place in mental health services in 2008. These include child and adolescent psychiatry and the development of child and adolescent psychiatry teams. Eight new child and adolescent psychiatry teams will be put in place throughout the country, four in each administrative area. In addition, 30 additional inpatient beds for child and adolescent psychiatry will be put in place in Galway, St. Vincent's in Fairview and also in Cork. Two new 20-bed units are being built for child and adolescent psychiatry and these will be available and commissioned for use in 2009, the final date, although one of them will be ready in 2008. Services for child and adolescent psychiatry are being put in place in 2008. The forensics post in the Central Mental Hospital is being put in place as well as other posts and these will be finalised in the early part of this year. The focus has been on providing the service in 2008. There was a difficulty in getting the posts filled in 2007 but they will be in place in 2008.

Deputy Deirdre Clune

The funding was not spent in 2006 and 2007.

Ms Laverne McGuinness

By the end of 2008, 72% of the funding that was available for 2007 will actually be in place. This will also include some of the other multidisciplinary teams. A piece of work is being carried out with regard to the resettlement of services. The old psychiatric services need to be facilitated back into the community and this in turn has additional revenue funding available to it. A total of 72% of the totality of the funding for 2007 services will be in place by the end of 2008.

Deputy Deirdre Clune

Is it that funding will be spent but that it is just late in being spent?

Professor Brendan Drumm

It is now all being spent, over 70% of it.

Ms McGuinness has been doing a lot of work on this. Child and adolescent psychiatry is a huge challenge. There are a number of places where it is being dealt with very successfully by different models of care. This is about more than money; this is also about beginning to sit down and discussing how that service is provided and the role, not only of psychiatrists, but also of clinical nurse specialists. In some parts of the country we are running a service with no waiting lists.

There are issues other than money that must be dealt with. A Vision for Change is a wonderful document. It was ahead of us in providing a community-based approach to services and it must now be aligned very closely with our roll-out of community services through primary care teams. This work is going on, irrespective of money but most important it is both about money and changing how we provide the service. There are some great examples of where it is being provided very successfully with the same resource as against another place where there are significant waiting lists.

Deputy Deirdre Clune

What about the money raised from the sale of land at psychiatric institutions that was not put back into the mental health services?

Professor Brendan Drumm

I have that information. Our estates are now managed very proactively. When money is freed up from those estates it is returned to the Department of Finance. I will let the Department of Finance answer on that point.

Deputy Deirdre Clune

My understanding is that the sale of land at psychiatric institutions was to be ring-fenced for mental health services.

Professor Brendan Drumm

I think that remains the plan.

Mr. Michael Scanlan

Broadly yes. To be fair to the Deputy, I need to add a caveat. First there is an accounting procedure that needs to work. As is the case with all Departments, because the HSE has a Vote, once it gets money in, that money must be returned to the Exchequer and then be re-voted by the Dáil to the HSE.

Strictly speaking the agreement we have with the Department of Finance is that lands or other assets sold are available to the health services. It would then be up to the Minister of the day to decide how to prioritise it. The current Minister has agreed to prioritise mental health services so that the money could be recycled through mental health services.

The recent report to which the Deputy refers, the Lie of the Land report, seemed to go back quite a number of years. I do not yet have the details of all the cases it examined. My understanding is there was one major piece of land disposed of. I apologise to the Deputy but I cannot remember the amount of money involved but it is in the region of tens of millions of euro. This was remitted to the Department of Finance. We have said to the Department that this is money, so to speak, which we believe should be recycled back into the health services when they are ready to spend it and make proposals for its expenditure.

Deputy Deirdre Clune

This specific sum of €10 million is with the Department of Finance now but it seems to go back many years, is that so?

Mr. Michael Scanlan

It goes back two or three years. It is relatively recent. It takes time just to dispose of land and then to get the receipts in. For accounting reasons it has to go back into the Exchequer and then be re-voted. This would require the HSE to come to the Department with a capital plan to the effect that it was ready to use the money on the following facilities and it would have to request the money to be re-voted back to it. We would then go to the Department of Finance with the proposal. The money is there.

Chairman

It was Government policy as far back as 1984 that resources raised from the sale of surplus psychiatric lands would be devoted to psychiatric services. I remember when the land was given away for almost nothing in Cork city. I was told at the time that the moneys would be going to psychiatric services but I never saw a sign of it.

On 10 August 2004, the then Minister of State, Tim O'Malley, said that despite opposition from the Department of Finance he had secured Government assurances that all proceeds from the sale of lands would be ring-fenced for funding of mental health services. This goes back a long way.

The Department of Finance might wish to comment.

Mr. Tom Heffernan

Certainly. The position with regard to the treatment of those receipts is as explained by the Secretary General. The moneys go back into the Exchequer as an extra Exchequer receipt. The Department of Finance agreed in principle to €36 million from the sales of properties related to mental health facilities being available for reinvestment in future on the basis that priority projects would be brought forward. In the wider context, outside of mental health, there is an agreement in principle, based on a Government decision, that resources from the sale of surplus properties would be made available for reinvestment in priority projects with the prior approval of the Department of Finance.

Deputy Deirdre Clune

Is the Department of Finance waiting for priority projects to be proposed?

Mr. Michael Scanlan

Before the HSE was established there was no need for the money to come back into the central Exchequer. Assets were disposed of by the health boards and the way they were used was then, as I understand it, a matter for the health boards. To answer the Deputy's question, I confirm we are waiting for a programme of expenditure on the mental health side relating to that money.

Deputy Deirdre Clune

What about the site where the Beacon hospital is to be situated in Beaumont Hospital? Is this site supposed to be for the provision of mental health services? Would that not have been a proposal for spending some of the funding that the Department of Finance is waiting to spend?

Mr. Liam Woods

It might be helpful to say that in light of the HSE there are two amounts in the Vote information. I will refer to one or two properties as it might be helpful to tease out what is happening. The main element of the €36 million referred to is the sale proceeds of surplus land at St. Loman's. There is already interaction at the capital estates level within the HSE. A project is under way, which may have already commenced, to build a new mental health facility on the site. This development is contingent on the resource within the €36 million coming back for that purpose. This is under discussion.

The 2006 figures show the largest figure as €19 million from sale of lands at Cherry Orchard. I am not sure if it is mental health——

Deputy Deirdre Clune

It is local authority housing.

Chairman

Deputy Clune referred to Beaumont Hospital. That unit was promised 20 years ago. It was announced in 2005 and was put to tender in 2005. It received planning permission on 30 January 2004. Late last year we were informed that Beacon will be going onto that site.

Why were the psychiatric services just cast aside again? How much money was expended on architects, engineers, professional advisors in preparing the plan for the badly-needed acute psychiatric unit at Beaumont which has now either been abandoned or aborted? At the same time there are 20 patients in St. Ita's in Portrane in an open ward, crammed together in Dickensian conditions and only 3 ft. between each bed. What is the rationale behind this madness?

Professor Brendan Drumm

I understand there is a psychiatric unit in Beaumont and maybe we can get the details of where that is. Deputy Clune was concerned that the site had been given up. All I can tell the committee is that we have been very clear about sites that would be transferred, that they would not interfere with the absolute ideal development of the hospital even going forward many years. Beaumont is a voluntary organisation and does its own work in that relationship. We would certainly challenge any plans that came that we felt would interfere with the overall developments. I do not think it would interfere with the development. I will need to come back to the committee with the specifics of the psychiatric unit and whether what the Chairman is saying is accurate and whether we can give any clarity. Regarding St. Ita's maybe we can provide some of that clarity.

Chairman

Would the HSE not know the facts about such a considerable development in Beaumont?

Professor Brendan Drumm

We will check that very quickly for the Chairman, but I certainly do not know the facts of it off the top of my head.

Ms Laverne McGuinness

There was a question about St. Ita's, but in terms of the overall investment in capital infrastructure for psychiatric services, over the past seven years €145 million has been invested in infrastructure for psychiatric services. The €36 million concerned the sale of St. Loman's. There are definitive plans available to utilise that money in respect of St. Loman's when that funding comes to the HSE. There are also plans for St. Ita's. That is the piece that I said in relation to A Vision for Change. There are six priority areas that have been identified as part of the HSE's service plan which is what we commit to in 2008. One part of that is the decampment or the moving from old institutionalised settings like St. Ita's into more community-based facilities. Some of that has been done already. A lot of the patients in St. Ita's have been moved to community-based facilities around the vicinity. That obviously is dependent on the release of the funding from the sale of the site for St. Ita's. There is a proposal that will be ready for all of those lands. There are large land banks as well in Monaghan and throughout the rest of the country that will be available for reinvestment in the mental health services, which is the piece to which the Chairman referred earlier.

Chairman

In case the wrong impression is given, there are still 23 patients in St. Ita's.

Ms Laverne McGuinness

There are.

Chairman

The plan was just blown out of the water. There is a private hospital going into Beaumont now, is that not correct?

Ms Laverne McGuinness

Moving the patients from St. Ita's where they currently are is dependent on acquiring additional accommodation that is more user friendly, which is dependent on the release of funds from the sale of the lands.

Professor Brendan Drumm

We would not move patients from St. Ita's into an acute facility on a Beaumont site. I do not think that would be appropriate. We will find out about the acute facility for the committee.

The other cautionary note on this is that we may have significantly overestimated what can be released from these lands because there has been a propensity to rezone HSE lands as community or environmental from commercial use. It went out in the newspapers that we had sold lands under market value. It is absolutely untrue. We have sold land that was zoned only for community use because that is the way it was zoned. However, depending on the zoning and the changes in zoning by the local authorities, which may see our land as different from, shall I say, a commercial owner's land, the money that is freed up for mental health services will become challenging. Equally it may go into other hands. For instance Grangegorman was the jewel in money terms - perhaps rightly so. However, it is not coming to the mental health services but a significant amount of it will move to education. Because of its location that was probably something that had to be done in terms of DIT coming together. We should not lose sight of the fact that it is not as simple as it might seem in terms of freeing up this money.

Deputy Deirdre Clune

As Mr. Scanlan stated earlier there is a considerable amount there. Perhaps the HSE might look at the report, to which we referred at the beginning and come back to the committee with information on it. We have seen media reports of asset stripping. There is considerable information there. We do not have it all here today.

Chairman

I know what I am talking about. For example in Cork there was a land bank of 24 acres sold for £49,000 at the time. A one-acre site a short period later was sold for £50,000. The land was sold off without consultation with professionals. No outline development plan was carried out in conjunction with the local authorities. It was just sold off as agricultural land. It was a disgraceful waste of assets. I wonder how often it is happening. I am not comfortable with the HSE's statement that it is happy it is getting the maximum from it.

Professor Brendan Drumm

I accept it is a huge issue. This is a hugely valuable public and indeed health service resource. Maybe I will leave it with the committee that I would be perfectly happy for all of the transactions since the HSE was established to be considered. I will bring Brian Gilroy, who is our head of estates. There will not be that many of the big ones to which the Chairman referred. I think clarity on that issue would be very helpful for the committee because I can see how it could be a worry. There are significant challenges there in terms of informing the system including the local authorities that if this money goes in a different direction it is being lost to health services potentially. It might be a very useful engagement if at some stage we had the opportunity to go through that with the committee.

Deputy Deirdre Clune

There have been media reports that the national office for suicide prevention does not have sufficient funding this year.

Ms Laverne McGuinness

On the national office for suicide prevention, additional funding was not received in 2008 for mental health services, but the national office for suicide prevention and that programme, which should have been in place in 2007, will continue and that is part of the 72% of all services that will be delivered in 2008.

Deputy Deirdre Clune

Will it have sufficient funding?

Ms Laverne McGuinness

It will not have sufficient funding, but it will maximise the funding it has available. There was not additional funding received as part of our Vote in 2008 for mental health services.

Deputy Deirdre Clune

From what I read in the media, it will be able to carry out less than half of the services required of it.

Ms Laverne McGuinness

Part of it will be looking to see how we can maximise and create efficiencies in order to achieve the best we can with the funding that is available.

Deputy Deirdre Clune

Given the rate of suicide it is extremely important that funding would not be lost to that area.

Mr. Michael Scanlan

I agree.

Deputy Deirdre Clune

We have a strong advertising campaign at the moment. Services on the ground are extremely important in this area. While the figures can be bandied about, more people die by suicide than on our roads.

Mr. Michael Scanlan

I agree with the Deputy. To the extent that we can we have provided extra funding and we will do all we can to support the delivery of the service. I happened to be at a North-South meeting. I know they do a lot of good work on joint North-South all-island advertising and everything. We will support it.

Deputy Róisín Shortall

Further to the point made earlier on the details of consultant activity in hospitals, I ask Mr. Scanlan to provide us with details of the new contracts that have been agreed. Information on the terms of the contract coming into the media has been very sparse. We would appreciate if the HSE could provide us with the full details of the terms.

I want to raise the issue of prescribing practices and chapter 5 of the Comptroller's report. The indicative drug target scheme was intended to encourage GPs to prescribe generic drugs instead of expensive branded drugs. Tied into that was the incentive scheme for investing in GP practices. I would like Professor Drumm to provide us with detailed totals for the cost of operating that scheme since its inception and also the cost of providing the grant scheme to GPs.

We all agree that reducing the cost of prescription drugs is a worthy objective. I do not want to get into the issue of the IPU, which will be addressed next week at another committee. It appears to many of us that the HSE has taken a very arbitrary approach to pharmacists in this regard. What is the HSE doing to reduce the cost of drugs apart from targeting pharmacists? For example what consultation has it had with the main stakeholders, the GPs, pharmacists and patients regarding prescribing practices? What can be done to reduce patient expenditure in that regard?

What is the HSE doing to tackle the problem of the over-prescribing of drugs? Many pharmacists and patients have reported that large amounts of drugs are being returned to pharmacists without having been used. What is the HSE's view of the incentive schemes operated by drug companies to encourage GPs to use their products? What is the HSE's view of the ethics of such an approach? What can be done to tackle the problem?

Professor Brendan Drumm

I will come up with the costs for the indicative drug targeting scheme in a second. I will comment on the efforts being made under the new contract to reduce drug costs. The Deputy rightly pointed out that large amounts of medication are prescribed but not used. People sometimes have cupboards full of unused drugs. The system currently in operation, whereby a profit is made per item prescribed, does nothing to control the over-prescription of medicines. The more drugs go out across the counter, the more income comes in. If we introduce a new system whereby there is a cost per prescribed item, and we meet that cost, pharmacists will work with us. They will be prepared to tell patients that they have a reasonable supply of a certain drug, and to ask them whether they have been using it. If pharmacists learn that the drug has not been used, they will not need to hand out another box of the same substance but they will get paid nonetheless.

Deputy Róisín Shortall

I am talking about the over-prescribing of medicines by GPs.

Professor Brendan Drumm

If pharmacists get paid in any event, the return or non-use of medication will be greatly reduced. It will also help the supply of medicines which are already available in adequate numbers. In terms of the role of GPs, we are working with Professor Colm Bradley, who is professor of general practice in Cork, on an overall educational programme as part of our whole approach to health service-acquired infections. The programme aims to alter prescribing habits among GPs throughout the country. The programme will be informed by the very good health atlas project, which is examining the health of the population in each electoral area. We are now able to begin to map the extent to which various classes of drugs are being prescribed in various parts of the country. The mapping project will continue to inform the GP education programme. There is a major focus on altering prescribing patterns. It is not only a matter of cost. If we are to deal with the issue of health service-acquired infections, it is incredibly important that we tackle the over-prescribing of antibiotics. The educational programme, which is based in Cork, is up and running. It will have a significant impact nationally. I should not express a view on the GP incentive scheme. I get into enough trouble with my colleagues as it is.

Deputy Róisín Shortall

Professor Drumm should express his view of the ethics of the scheme.

Professor Brendan Drumm

The view is that we have to be—

Deputy Róisín Shortall

To what extent is the scheme counteracting what the HSE is trying to achieve?

Professor Brendan Drumm

—extraordinarily careful when there is interaction between the pharmaceutical industry and the providers of health care. This challenge has been taken up in other parts of the world. It involves the Medical Council as well as the HSE. It is a question of the ethics of those relationships. This issue needs to be constantly addressed. I accept fully what Deputy Shortall is saying.

Deputy Róisín Shortall

Are there guidelines in this area?

Professor Brendan Drumm

There are Medical Council guidelines on things like GPs' commercial relationships. I think the Medical Practitioners Bill 2007 alludes to this matter. There are no specific guidelines on the amount of personal travel doctors should accept from pharmaceutical companies. I am not aware that any such guidelines have been issued.

Deputy Róisín Shortall

This is an important issue. Like all public servants, the Members of the Oireachtas are subject to strict ethical guidelines. It is time to do something about what GPs are doing. They have ethical responsibilities, as have the pharmaceutical companies. We should make recommendations in that regard.

Professor Brendan Drumm

The issue raised by the Deputy is pretty obvious. Employees of the HSE, including consultants, are bound by governance rules that are applied quite strictly to those who work within the organisation. The question of whether such rules should apply to other medical professionals has often been raised. General practitioners are obviously independent of the HSE. Perhaps we should take that suggestion on board after this meeting. I cannot say, in all honesty, that this problem has been dealt with in any formal way at the level highlighted by Deputy Shortall. I accept that we should probably address this issue.

Deputy Róisín Shortall

It is not as if there are no victims of this practice if the HSE is trying to achieve savings in the prescribing of drugs while other interests are incentivising the prescribing of expensive drugs.

Professor Brendan Drumm

Yes. It undermines us completely.

Chairman

Perhaps Mr. Scanlan can clarify the matter.

Mr. Michael Scanlan

I understand that the Medical Council is engaged in a review and revision of its ethical guidelines. Deputy Shortall has raised this matter at an appropriate time. The Department of Health and Children has submitted views and comments to the Medical Council's review. It is not for me to say what should happen. If the committee has a view on the matter, this would be a good time to express it at that forum.

Deputy Róisín Shortall

Many of us have come to the view that self-regulation is no longer acceptable. The HSE and the Department need to play a role in this regard.

Mr. Liam Woods

Yes.

Deputy Róisín Shortall

The Department should take the initiative in the interests of value for money, in particular, as well as ethical standards within the medical profession.

I would like to move on to the figures provided for the analysis of pay costs. There is no reference to the payment of bonuses. Is there a total figure for bonuses paid? How many employees of the HSE were in receipt of bonuses?

Mr. Liam Woods

I can give the Deputy that figure if she gives me a moment to go through my file.

Deputy Róisín Shortall

I will move on to another issue, if that is all right. I wish to ask Professor Drumm about the enormous difficulties the HSE seems to have with the recruitment and retention of staff. Such problems, which have been evident for a long time, were also encountered by the health boards. There seems to be a huge mismatch between the staffing needs of the health services in general and the provision of training places in universities. For as long as I can remember, there has been a serious lack of supply of therapists across the board. What action is the HSE taking on that?

I am particularly concerned about the fact that community services seem to be the poor relation of the health service. There is a great sense of urgency about hospital services which are the subject of a huge amount of publicity. Those of us who work as public representatives are conscious of the equally huge gaps in community services. The large number of vacancies in the occupational therapy sector, for example, has a significant knock-on effect at community level. Elderly people are unable to get out of hospital and go home when they want to do so. Basic things like hand rails are not being provided because there are no occupational therapists to do assessments. I am concerned that such crazy logjams continue to exist.

The child health screening services in my constituency are far worse then they were 20 years ago. The services cannot be improved until the many vacancies for public health nurses and medical officers are filled. We have a certain number of posts in theory, but when one asks how many of them are filled one discovers that large numbers of positions have been vacant for a long period. There is no community service, in effect. I am particularly concerned about child health screening services and occupational therapy services. What is the HSE doing to deal with this problem? It seems to have been going on for the past 15 years, at least.

Professor Brendan Drumm

I am still trying to get the figures for the drug target savings scheme for the Deputy. I know I have them somewhere. We will try to get them. The scheme was discontinued at the end of 2005, in the early days of the HSE. The payments would have been made before 2005.

Deputy Róisín Shortall

I would like figures for the savings and the expenditure on grants to GPs.

Professor Brendan Drumm

I think those figures might be in the report. I think that is where we read them. We will provide them.

In terms of recruitment of staff the Deputy is right that there have been huge challenges. However, from a manpower perspective there has been an enormous increase in actual output. I suspect we will face the opposite problem very quickly. For instance, in terms of graduation arising from extra pharmacy intake, the opening of new schools in Cork and at the College of Surgeons will lead to a very large output. I think the first class will graduate in Cork either this year or next and I understand the first class has graduated in the College of Surgeons.

In terms of nursing, graduate output will be huge. In terms of medical schools, the number of Irish graduates - that has just started this year and some of the programmes are four years - will have more than doubled four and five years from now. I suspect the challenge will be similar to what it is in the UK at the moment. The UK did this four or five years ahead of us and is now experiencing significant unemployment among these groups of people. This year, there are three junior doctors for every one post being advertised. One very quickly tips over because the universities take on full classes when only a small number of graduates is required per year because retirements are obviously relatively slow. The challenge will move to the opposite end of the spectrum very soon, apart from in podiatry which seems to be the area in which we are most challenged. However, there is a move to open a school in podiatry.

Deputy Róisín Shortall

Whose responsibility is it to ensure a proper match between supply and demand in medical personnel?

Professor Brendan Drumm

A number of studies have been done on this.

Mr. Michael Scanlan

In fairness, the question was related to the therapy grades. The Deputy is correct that there was a problem. At that level, it is largely the Department's responsibility to interact with the Department of Education and Science. However, and I think this is the point Professor Drumm is making, speech and language therapist training places have increased from 25 to 105, occupational therapy training places have increased from 29 to 120 and physiotherapy training places have increased from 64 to 152. We are producing enough therapists.

Personally, I was getting justifiable complaints about service deficits, as the Deputy described the issue. People say, "You are now starting to produce people. I have a son or daughter about to graduate who will not be able to get employment in the health service, yet you say there is a service deficit". There was an issue, like many things in the health service, which was IR and work practice related. We have been tackling this issue. In fairness to the therapy professions it was all to do with the level of the posts we were trying to fill. We were trying to fill senior posts that required so many years' postgraduate experience. At the same time, we had many very good but only recently graduated therapists looking for work. That all came down to a view that there should be certain levels of reporting relationships. We are producing enough therapists now. The challenge is to get them into the system to deliver the services.

Deputy Róisín Shortall

One must ask why this is only happening now. What has been going on for the past 15 years?

Mr. Michael Scanlan

I am just saying the numbers have gone up.

Deputy Róisín Shortall

Does Professor Drumm have a figure for the number of current vacancies?

Professor Brendan Drumm

I can get the Deputy a figure on the number of vacancies in therapy grades.

Deputy Róisín Shortall

I refer to community services generally.

Professor Brendan Drumm

We can get the Deputy that information. We constantly have vacancies and we can probably give the Deputy an idea of how long the posts have been vacant. However, I point out the difficulty in getting consistency in terms of what a wholetime equivalent, WTE, actually produces for the community. Starting next week, we will work to a new programme we call "healthstat", which will deal with very accurate performance measures across our system of hospitals. In three to four months we will have it for the community services and we will actually know - the Chairman raised this issue earlier - how many outpatients attend a clinic and the number of new patients versus old patients. We will also deal with how many patients are seen per individual therapist, new and old, or by any worker in the system. This will at least bring some equity to the system in terms of how it actually performs. We will now have to take account of absences as well, which will then have to be dealt with to ensure there is equity. I can get the figures on absences relatively easily.

Deputy Róisín Shortall

While global figures are fine in terms of health planning, what is the professor's response to those who live, for instance, in the Finglas area where virtually no health screening - in terms of developmental tests for children - is taking place due to the level of vacancies for public health nurses and medical officers?

Ms Laverne McGuinness

We can give specific figures to the Deputy.

Deputy Róisín Shortall

I have sought figures on many occasions over many years. There does not appear to be any response from the HSE in terms of identifying particular blackspots where there is an unacceptable level of public health care and ensuring steps are taken to fill the vacant posts. It is not enough to state we cannot recruit medical officers or nurses at community level. The fact is that generations of children are being neglected and there does not appear to be any sense of urgency on the part of the HSE to tackle these blackspots. The HSE knows where it is difficult to recruit staff, perhaps because it is not a very attractive proposition due to security or similar issues. There does not appear to be any proactive work being done in this area.

Professor Brendan Drumm

It has been extremely difficult in certain areas, specifically certain areas of the cities, to retain staff, whatever about recruiting them. As I stated, and Mr. Scanlan has alluded to this issue, with supply and demand changing, one will see significant changes in this area. The Deputy is asking whether we may need to bring a focus to very specific areas in terms of retention. I do not think we have necessarily done that and it is maybe the challenge. However, it will be much easier if there are more people to apply for the jobs and there will be many more.

I have one of the figures the Deputy sought. It was in the Comptroller and Auditor General's report. Of those general practitioners who drew down on the fund for practice development purposes, 1,778 drew down €105.2 million from the time of its inception to 2005.

Deputy Róisín Shortall

Is there a corresponding figure for the savings achieved in drugs prescribing?

Professor Brendan Drumm

Again, I will have to seek that figure. I suspect it is significantly less than the figure I gave because one of the concerns the Comptroller and Auditor General raised was that we were making funds available in lieu of future savings.

Deputy Róisín Shortall

The whole idea of the scheme was to makes savings on one side and invest these in GP practice development. Is that not correct?

Professor Brendan Drumm

I stress that the HSE has discontinued the scheme.

Deputy Róisín Shortall

That may well be the case but we are asking questions about what happened over recent years. If €105 million in theoretical savings was paid out to GPs—

Professor Brendan Drumm

Up to 2005.

Deputy Róisín Shortall

—can Professor Drumm inform us where the actual savings were made during that period?

Professor Brendan Drumm

We can get the figure up to 2005. As I said, this has not been an issue since 2005.

Deputy Róisín Shortall

I appreciate that. Is a figure available on bonuses?

Mr. Liam Woods

On the performance related scheme, 111 posts are eligible for the scheme. I have two sheets of figures and have roughly calculated a total of about €1 million. The average payment per person would be around €10,000 gross.

Deputy Róisín Shortall

May I ask a final question?

Chairman

Before the Deputy does so, the Comptroller and Auditor General may wish to comment.

Mr. John Purcell

Earlier, when I maligned the appropriation account for the HSE, saying it was meaningless, I meant the way in which expenditure was categorised. The information the Deputy required is in the notes. Performance related pay in 2006 was €1,239,274.

Deputy Róisín Shortall

The issue of patients transferring from psychiatric hospitals and other big institutions to community care was raised. I will ask a specific question because it was raised with me by families of patients in the psychiatric hospital in Castlepollard who have been waiting for a long time to move to community houses. Three community houses were bought by the health board in 1998 and refurbished. Ten years later, they remain idle and need to be refurbished again. I and the families of the people waiting to go into these community services cannot understand how this could happen. I have tabled two parliamentary questions and written to the Health Service Executive three times on this issue. Is anybody in a position to explain the reason this has occurred?

Ms Laverne McGuinness

I do not have specific details but I undertake to get them and provide the Deputy with an answer within a week.

Deputy Róisín Shortall

It is not acceptable that three houses have been lying idle for ten years.

Professor Brendan Drumm

The issue came up at a regional forum. I cannot tell the Deputy the details because it was not very clear-cut. We will obtain the answer. The local people—

Deputy Róisín Shortall

I would like Professor Drumm to come back to me on that. I have been attempting, by various means, to obtain replies.

Professor Brendan Drumm

I believe it was Castlepollard. It arose at the regional health forum. I will revert to the Deputy on the matter and find out whether there is a reason for the problem.

Deputy Róisín Shortall

I thank Professor Drumm.

Chairman

The Ombudsman for Children, Emily Logan, stated some weeks ago that adult psychiatric wards had been used for the treatment of children on approximately 200 occasions between December 2006 and December 2007. This is fairly horrific. Bearing in mind what occurred in Beaumont and elsewhere, what is being done about the matter?

Professor Brendan Drumm

This issue is being addressed, no more so than in Cork and Dublin.

Ms Laverne McGuinness

Two issues arise, one of which relates to the use of adult beds for children availing of psychiatric services. There is an adequate supply of beds for children and adolescents availing of psychiatric services at present, particularly those between the ages of 16 and 18 years, because there are new beds coming on stream in 2008. Six of these, in St. Vincent's Hospital, will be open in March. In total there will be 30 new inpatient facilities for children and adolescents in 2008 and they are to be located at St. Vincent's, St. Anne's in Galway, and in Cork. Warrenstown Inpatient Unit in Castleknock is a five-day facility but will be extended to a seven-day facility. Therefore, by the end of this year there will be 30 additional inpatient beds for child and adolescent psychiatry. Two new 20-bed units, in Cork and Galway, will be opened by March 2009. In the interim, pending the development of these services, we must have access to beds and we have arrangements with the consultants to provide the service in adult units until such time as the new beds come on stream.

Deputy Brendan Kenneally

I, too, welcome the representatives. Questions were asked about staff numbers and the difficulties that arise in this regard. I do not know how many are employed in administration and management in the HSE. The executive removed many responsibilities from the Department of Health and Children and it would therefore seem clear that there must have been a reduction in the number of staff in the Department. I do not refer to frontline staff but to administrative and managerial staff. What was the extent of the reduction?

I tabled a parliamentary question last week and it, as with many others, was referred to the HSE for reply. It concerned Cashel hospital where there are no patients although there is a director of nursing, two assistant directors of nursing and at least five staff nurses. Those staff could have been transferred to other hospitals. I am awaiting a reply on this matter from the HSE but Professor Drumm may be able to answer today. The information I have been given seems extraordinary.

Is there still a recruitment embargo and what is the position in this regard?

Mr. Michael Scanlan

I will give the number for the core Department. We would also have numbers for the General Register Office, which is now under the remit of the Department of Social and Family Affairs, in addition to the Adoption Board, the Office of the Ombudsman for Children and two appeals offices. In the rest of the Department, including the Office of the Minister for Children, which is the responsibility of the Department since the HSE was established, the number serving at the end of December was 487. The approved number of posts is somewhat higher and we therefore have some vacancies at present. I have only one comparable figure to hand. In December 2002, which is not quite when the HSE was established, there were approximately 645 staff serving.

An issue arises regarding the amount of work transferred from the Department and how much it should be doing. Some questions raised today query why the Department was not doing certain tasks in the past. We have lost some posts pertaining to purely operational matters. We used to collect health service employment figures but no longer do so, and this led to the transfer of some posts to the HSE. However, there are jobs that the Department needs to do and which it has not done in the past. These include measuring what is occurring in the system, considering policy in a more evidence-based way and conducting research. We have an agreement with the Department of Finance this year to conduct a review of our staffing figures. I say this advisedly in that an agreement with the Department of Finance on staffing usually means one thing. I am happy to accept that the Department would take a hard-nosed look at our staffing figures and ask whether we are over-staffed. Equally, it is right and proper that we determine the job people want us to do and the staff required to do it.

Professor Brendan Drumm

On the question on Cashel, I will have to obtain the specific figures. I presume there is activity in the hospital. Surgical activity, as Deputy Kenneally knows, was moved to Clonmel. If there is somebody doing nothing, it is clearly a great challenge. However, one of the greatest challenges facing the health service is the lack of alignment between workload and people. Nowhere is this more obvious than in Deputy Brendan Kenneally's back yard, where there is an accident and emergency department that deals with 62,000 or 63,000 people with – dare I say it – significantly fewer staff than other such departments dealing with 40,000. One can list many reasons for this but one that stands out is the superb organisational and management structure in the department. This is evident when one visits it.

The challenge is not unique to Cashel hospital, as will be highlighted. We already have received the pilot data and will have data from across the country on the number employed per unit of activity, be it in a consultant-led clinic or social work department. Our figures will be anonymous for the first year so as to be fair. One will have access to one's own data but one will not know from where the comparative data are derived. We plan to put the information on the Internet over the coming year so the public will see where the challenges lie. I agree fully with the Deputy that there has not been full accountability in respect of alignment between staffing levels and activity throughout the system.

I am looking for the activity levels pertaining to the hospital in Cashel but do not seem to have them to hand.

Deputy Brendan Kenneally

There is no activity.

Professor Brendan Drumm

Even on the medical side?

Deputy Brendan Kenneally

Yes.

Professor Brendan Drumm

If that is the case, we will have to examine the underlying industrial relations issues. We certainly come across industrial relations issues that lead to such circumstances.

Chairman

There are no industrial relations issues related to this case. Mallow General Hospital received a new CAT scanner in 2006 and it is unused but five or six patients per day must be transported by ambulance from Mallow General Hospital to Cork University Hospital. It hinges on an embargo on the recruitment of two radiographers. They were interviewed and told they were successful but the embargo prevented them from taking up their positions. The ambulance must travel up and down the Cork-Mallow road five or six times per day although there is an idle CAT scanner in Mallow General Hospital worth €1.5 million. This has nothing to do with industrial relations but with mismanagement.

Professor Brendan Drumm

The precise issue is that Mallow General Hospital has exceeded its employment quota. As the Chairman said, we held a successful competition for the radiographer posts. Given that we must be accountable for our budget, every health facility in the country must work within its employment quota. On the basis of the answer I have given to Deputy Keanneally, it will be obvious when we consider the figures that there is much room for flexibility in the application of the employment quotas. We must have accountability for employment numbers.

Chairman

How can Professor Drumm explain the lunacy of supplying a CAT scanner which cost €1.5 million of taxpayers' money? The HSE identified a need for two radiographers, went through the interview process but did not appoint them. The ambulance is going up and down the Cork road five or six times a day. That is mismanagement.

Professor Brendan Drumm

It is for us to manage locally our employment numbers within that hospital to ensure that the service begins. We cannot send the message across the system that we can continue to employ people. That service needs to be provided within Mallow. The unit is there and we will continue to manage it into place but it must be done within our employment schemes.

Chairman

The hospital was penalised this year. It is not in my backyard so I am not being parochial. That was one of the hospitals identified for penalties because management did not make adequate returns. The frontline staff were penalised.

Professor Brendan Drumm

I do not know. The suggestion that returns were inadequate is a constant—

Chairman

It is for the HSE to investigate the situation on both counts.

Professor Brendan Drumm

We certainly can do that. We try to run a system based on incentivising performance which means that some win and some lose. Many explanations are put forward by those who are penalised giving reasons for not applying the penalties.

Chairman

I have before me correspondence between local management, senior medical personnel and the Department of Health and Children and the HSE outlining the areas where they believed they were seriously aggrieved. Any reasonable person reading it would see that it is another example of resources being allocated for capital projects until the HSE suddenly realises it has a problem and cannot utilise those projects.

The Mercy University Hospital is a classic case. A multimillion euro building has been lying idle for over a year and suddenly the HSE realises it has an industrial relations problem. Surely it should have dealt with that problem before the building was supplied or during the building of it? It is a scandal that droves of people are kept in poor conditions facing an ultra-modern building. This is the kind of problem for which we receive half-baked explanations while people suffer. Professor Drumm can see the level of frustration among people this morning because we are not getting value for money and the public is not getting the service it deserves.

Professor Brendan Drumm

Mallow General Hospital has 76 beds and 251 staff and we should be able to manage a CAT scanner there.

Chairman

Yes.

Professor Brendan Drumm

The Mercy University Hospital has 230 beds and over 1,000 staff. In comparison with other units that is a reasonably healthy staffing level. I can either move the money for the Mercy hospital from somewhere else in the country which is not as well staffed, or ask people to be more compliant about opening new units which would serve the public and the people who work in them positively. I have cited examples of this, such as Tullamore.

It is not simply a case of everyone saying they have new units. The Chairman makes a sensible point when he says perhaps we need absolute sign off on these developments.

Chairman

I declare my interest, in case anybody says later that I am self pleading - a relation of mine is in the Mercy hospital.

Professor Brendan Drumm

The Mercy hospital provides a great service as do many other units but we must get flexibility. The Chairman's point applies to many new units other than the Mercy hospital. Saying we will not open until we have more staff has worked well in the past. We learn by experience.

Deputy Brendan Kenneally

Geriatric service subventions are becoming more costly. Mr. Scanlon outlined why patients live longer, partly because of better medical care. This puts more pressure on geriatric hospitals and nursing homes which are not meeting the demand. In my constituency in Waterford I heard recently that the HSE provides subventions for only two nursing homes. The others have fallen out of the system for different reasons.

A man told me last week that the hospital is telling him to take his bedridden mother home but there is nobody to look after her. He was told it would take a couple of weeks to find out about a subvention and he will probably not receive the full cost of a nursing home, and there may not be a bed for her. This is becoming a major issue. What plans is the HSE putting in place to deal with these problems?

Why does the long-stay patient repayment scheme not cover people who were in community houses?

Ms Laverne McGuinness

New legislation will be passed on the subvention issue in the next few months. It will be equitable for anyone seeking a nursing home bed, whether enhanced or lower subvention. The threshold will apply throughout the system.

Deputy Brendan Kenneally

Is that the legislation covering people's houses?

Ms Laverne McGuinness

Yes.

Deputy Brendan Kenneally

What happens in the interim?

Ms Laverne McGuinness

The old arrangements apply.

Deputy Brendan Kenneally

They do not work.

Ms Laverne McGuinness

One can still apply for subvention and the level has increased substantially in recent years. Home care packages and home help hours are other options. A total of 53 million home help hours were delivered in 2007 and 11,500 older people were able to stay in their homes as a result of home care packages in 2007. The same will apply for 2008.

To keep an older person at home requires occupational therapy, physiotherapy, speech and language therapy. A total of 290 of those posts will be put in place in the next couple of weeks to allow more people to stay at home, which is the preferred option.

A total of 860 public fast-track beds will be put in place this year for community nursing units throughout the country. Over the past three years 2,200 private nursing home beds have been put into the system. In addition, in the absence of the legislation coming on stream as was intended on 1 January, the Minister put into place 200 additional privately funded nursing home beds to alleviate any pressure.

Deputy Brendan Kenneally

That sounds lovely but it is not the reality. We are all frustrated in this area. We meet it every day and the HSE is not taking it seriously enough. In response to my example, Ms McGuinness suggests a home care package for a bedridden woman who lives alone. If she was ambulant I would accept that point but the home care package may not even be available for her. The home care package may not be in place or it is not sufficient. The effort to get it improved can take too long. If one goes to the office in Waterford, it will make a decision and advise the applicant to come back for a top-up. If it informs the applicant to appeal the decision, it has to go to Clonmel, County Tipperary, which can take a long time. The scheme's bureaucracy is unreal and it is not working on the ground.

What about long-stay patients and the repayment scheme for people in community houses?

Mr. Michael Scanlan

My understanding is that the Deputy is referring to community houses and that these will be called the voluntary contributions—

Deputy Brendan Kenneally

No, I am referring to individuals who were previously in mental institutions and now HSE staff are looking after them in community houses.

Mr. Michael Scanlan

The description I have heard is that people were paying a voluntary contribution for places like that.

Deputy Brendan Kenneally

No, that is not what I was referring to.

Mr. Michael Scanlan

I will have to check the matter then. All I know is that the legislation applies to making charges illegally for inpatient services in our hospitals.

Deputy Brendan Kenneally

So, inpatient does not cover those who have been moved out of a hospital into the community.

Ms Laverne McGuinness

It applies to older persons living in nursing homes.

Deputy Brendan Kenneally

Those living in the community, even though they are still under the care of the HSE, are not covered.

Ms Laverne McGuinness

It was not part of the scheme as intended by the Ministers.

Deputy Brendan Kenneally

It has been proposed for some time to transfer the supplementary welfare allowance scheme to the Department of Social and Family Affairs. When will this happen?

When it does, will community welfare officers transfer from the HSE to the Department? I assume it will be a staff-neutral issue with no staffing implications because the same volumes of work will be done.

Is such a transfer the right approach? Community welfare officers working within the health system have a raft of information available to them about many of their clients. This access could be lost if they come under the remit of another Department.

It is also proposed to transfer the old housing aid for the elderly scheme, funded by the Department of the Environment, Heritage and Local Government and administered by the local authorities, which was a marvellous system. As the amounts of money being sought were small, say €4,000, it meant a community welfare officer could examine the house and easily approve the grant payment. Will there be too much bureaucracy in the new scheme? There is a case for keeping the smaller scheme in place. Will staff transfer with that?

Ms Laverne McGuinness

The transfer of the supplementary welfare allowance is at an advanced stage. The scheme will transfer to the Department of Social and Family Affairs by the end of 2008. An independent officer has been appointed to ensure a smooth transition.

Both the Departments of Social and Family Affairs and Health and Children and the HSE are involved in ensuring the smooth transition. It will be staff-neutral. An exercise has been carried out to identify all the community welfare officers who do community welfare work and those who do other elements of the work such as assessments for medical cards. The latter component will remain with the HSE.

Supplementary welfare allowance is an assistance-type scheme. The value of transferring it to the Department of Social and Family Affairs is that applicants will only have to be assessed once, as in the case of unemployment assistance.

We have a good working relationship with the Department in regard to shared information. We have much of the information anyway but we will be able to keep up the links with them. The process is ongoing conjointly and will be on a staff-neutral basis. The transfer of undertakings and so forth come under that. Legislative arrangements are being worked out at this point.

Deputy Brendan Kenneally

Is the HSE in consultation with the community welfare officers?

Ms Laverne McGuinness

Yes, that is being done jointly between the Department of Social and Family Affairs—

Deputy Brendan Kenneally

I have been informed by some officers that their level of input is almost non-existent.

Ms Laverne McGuinness

The Government decision was made to transfer this service after a full review and a value for money initiative. It is also what is best for the client, so that he or she will not have to interface with several different Departments.

The trade unions have interacted with the Department of Social and Family Affairs and the HSE with the community welfare officers.

Professor Brendan Drumm

The important issue is how these services and other local authority services interact. In County Donegal much work has been done with the county manager on reviewing all community provided services, not just health, to speak to one another and act through one front door.

Questions arise as to where these people are housed. As we get our primary and continuing community care centres built in the communities, perhaps this is an area from which they should operate. There is a need to tie a knot and bring many other community services into close association with the health services.

Deputy John Curran

Last September the HSE discovered it had overspent its budget. It subsequently introduced an embargo on recruitment and overstaffing to correct the overspend. This was eight months into the year. What financial procedures, monitoring and reporting are now in place?

It seems to have taken a long time either to discover it was spending ahead of target or to take the necessary corrective action. The complaint public representatives heard was that the embargo affected front-line services. Whether that is true is not the issue. However, with good financial accountability and reporting, could the overspend not have been picked up earlier and the corrective action less severe?

Mr. Liam Woods

There is a monthly monitoring of expenditure within the HSE against budget. There is a central control process which meets on a monthly basis once the data is available. This also happens at a local level.

We also monitor our Vote expenditure on a daily, weekly and monthly basis. I do not want the impression to be given that it was only in September that the HSE became aware that it had a financial problem.

Deputy John Curran

Are you saying the HSE decided to act only in September?

Mr. Liam Woods

No. The issue was clear some time before that. There were several issues in services that were driving it. I will explain the actions taken.

First, with schemes, such as the drugs payment scheme and other community schemes, significant and increasing deficits emerged as the year proceeded. By the end of the year, they were €170 million over budget, a significant factor.

Alongside this, services in our hospitals were growing significantly into the latter half of the year. We were 3% over the budget in hospital services by year-end, some €75 million. Day-cases were over by 6%. Our older persons services were increasing above the provided levels.

Measures were in place from much earlier in the year to manage within the overall finance resource while trying to deliver the optimum service level. That is always the challenge in a health services environment. Several factors moved against us on that.

The continuing growth and deficits on the bad debt schemes was not of assistance. We did maintain high levels of services in hospitals beyond our contracted level. There is a process to identify the deficits. Sets of actions were identified earlier in the year than September. The pause in putting people on the payroll was an escalation of the measures already in place.

There were also measures in place which were designed to maintain services and contain costs.

Deputy John Curran

When were the first of those measures put in place?

Mr. Liam Woods

At the start of the year. The service plan is adopted at the beginning of the year in terms of the Minister's approval, and from then plans are made at the hospital and LHO level - for the 53 hospitals and 32 LHOs - which amalgamate into the two main service pillars of the HSE. Those plans are in place by the end of January in any year, and the measures would effectively entail management of the budget against a plan - from the commencement of the year.

Deputy John Curran

I take it the recruitment ban has expired, as we are in a new financial year.

Mr. Liam Woods

As at the end of December 2007 the recruitment embargo, as it became known, was removed. There was a derogation process within the recruitment embargo process. It was effectively a pause in putting people on the payroll, not an embargo on recruitment, as such. There is a slight difference between the two. Quite a significant number of posts were approved and put into service in the latter part of 2007, to ensure services were sustained.

Deputy John Curran

I will just state the accounts, rather than going over issues raised. This account is quite complex and detailed. When one refers to billions, sometimes hundreds of thousands and millions appear to be quite small in the overall scheme of things. One item I looked at is from the revenue income and expenditure account, the non-pay issues. There are office and administration expense of €555 million. On page 18, explanatory note 8 breaks down that €555 million. One figure stands out in particular, under office and administration expenses, because oftentimes the public perception is that the HSE is top heavy with administrators. The figure of €85 million for travel and subsistence under this heading seems outrageous. It is an enormous figure.

Mr. Liam Woods

We are doing a very specific piece of work in 2008 to manage that expense heading, with a view to reducing it. We have set a target for ourselves of 10%. Perhaps I should comment on the background to it. Most of that figure, about €67 million, is in the broad community services. A very large proportion of it refers to areas such as public health nursing, where in-built in the role is a significant travel element because there is a movement to clients. Most of the balance relates to aspects of hospital services. The corporate component of it rather than the service element, from the analysis we have done, is just under €3 million. However, the Deputy is correct in that it is a very large cost. Most of it is related to delivering front line services and travelling to locations. We have done some work to integrate the information on existing payroll systems to manage that very tightly for 2008 as part of our value for money programme.

Professor Brendan Drumm

Deputy Curran might like to know there is an issue as regards whether that model of care that is costing so much is the right one or whether many of those clients would be happy to undergo care more centrally. These are among the issues we now have to address because we accept, precisely, that the figure is high.

Deputy John Curran

Private industry would strive to maintain existing levels of service by introducing efficiencies and at a reduced rate year on year, not an increasing rate. It is through addressing issues like that we need to find those efficiencies so that existing levels of service do not have to cost significantly more year on year.

Professor Brendan Drumm

It is a major target area for the HSE. We believe the Deputy is correct in saying there should be room for significant gains.

Deputy John Curran

Several people have spoken about a variety of properties, from houses left empty for years, to facilities built and perhaps still vacant and so forth. Professor Drumm suggests it would be worth bringing a property manager along, next time. I agree, but perhaps Professor Drumm might broaden this issue somewhat. I notice that office expense, rent and rates, comes to €155 million. Can the HSE provide the committee with an asset breakdown of the properties either in its ownership directly or rented and the level of occupancy as applicable? We know that some properties are not occupied, as was mentioned here today. Perhaps prior to that scheduled meeting the committee might have a full property asset register, with notes as to the levels of use and occupancy. I mean not only those properties owned by the HSE but those in which it has a lease or obligation. Again, we are looking for efficiencies in the service and ways to avoid waste. Individual examples were given today and this initiative would afford the committee an opportunity to clarify the situation.

Professor Brendan Drumm

I want to stress that is not about the HSE and pharmacies or single issues. Estates agency is a major issue for the HSE and we have brought a great deal of emphasis to bear on it. Our estates agency is developing a national database of our entire property assets. We could bring that forward. The Deputy is right in indicating that we might, perhaps, rationalise some of the rentals portfolio. In Wexford town we have five poorly functioning units because of the building infrastructure in one location, which are all carrying costs. We are focusing on this area at the moment. It would generate a very important discussion if we could put all that information before the committee and I am happy to do that.

Chairman

As regards the duration of the leases, some of them are for 25 years, which is unjustifiable.

Professor Brendan Drumm

Leases have been signed which we find quite challenging to explain as well, and so getting the information out will be interesting.

Chairman

Will the HSE also give us a report on the biggest derelict site in the country, Our Lady's Hospital, Cork, which I can guarantee will be burned to the ground if it is not secured properly? It is a major property asset.

Before I interfere too much, I want to ask about the economic and social disadvantage fund €22 million of which went unspent. This was money from the dormant accounts. Professor Drumm said no applications were made to that account. I find it incredible, again, that €22 million was available for economic and social disadvantage and there was no draw on it.

Mr. Liam Woods

I have a note on that which I shall run through. That fund is managed for the HSE by Pobal and it is based on an application process. I am aware that some of that resource has been drawn down in the following year. The issue there related to the split out of moneys from dormant accounts for their intended purposes, some of which are health orientated. Then the application process is run through Pobal. I have a slightly more detailed note here.

Chairman

I should like to have it because I know of projects throughout the country that are crying out for money to deal with social disadvantage. They are awaiting decisions and not getting them and I find €22 million there unused.

Deputy John Curran

In relation to previous questions Professor Drumm mentioned the levels of staffing in various hospitals in comparison to others. He talked about accident and emergency units and so forth and indicated quite clearly that there were enormous discrepancies in matching up workloads - and he analysed that. Specifically, he gave examples. Will the HSE publish the figures?

Professor Brendan Drumm

From looking at the data from international systems, if we just throw these figures out straightaway, people will find them intimidating. To be fair, it is because one starts from zero, letting people work a different way and suddenly different figures are produced. The experience in the British national health service, NHS, and possibly other systems, is that the data should be given to people to identify their own data, with the rest of the data being anonymous for a period of 12 months. In recent days we have discussed whether this data should appear on an Intranet or on the Internet. To be honest, I do not see why it should not be put on the Internet, but it would be anonymous and identifiable only to the individual institutions in terms of their own data. After 12 months this is information that should be in the public arena because it is highly funded by the taxpayer. As Mr. Woods can confirm, when one talks about funds in the health service, one is essentially talking about WTES, people. This is a 70% labour intensive business. The answer to the Deputy is that I hope so, going forward.

Deputy Thomas P. Broughan

I welcome everyone to the committee. As regards the control and sanctioning of ICT expenditure, the Accounting Officer told the Comptroller and Auditor General that a whole series of measures had been put in place in relation to the ICT steering group, the programme manager and transformation programme. However, we read in the newspapers the other day that the Irish Blood Transfusion Board has had to write off €750,000 of taxpayers' money because of the failure of the Progesa system. I am not sure who is ultimately responsible for this, but it seems astonishing that a year later, we are still finding out that there are major problems with computer systems. I was not on the last Public Accounts Committee and we are coming on to it after the PPARS disaster and other problems in ICT and telephony, but has anything improved at all? I notice that the Comptroller and Auditor General drew attention to the five tenders on ICT, St. James's Hospital and so on. We have just written off another €750,000 on computers.

Professor Brendan Drumm

The IBTS issue is not a HSE problem, but maybe we should ask the Department officials. When I was appointed to the HSE, we stopped the PPARS project. It was a project we inherited, but we stopped it. Mr. McCallion will comment on the Deputy's overall concern for control of ICT.

Mr. Damien McCallion

A number of steps have been taken. The governance issue relating to PPARS was important, and we have now put one steering group in to prioritise all projects that come before us. At any one time we could have up to 200 projects running, from endoscopy projects, patient management systems, digital imaging systems and finance systems. Professor Drumm alluded earlier to the scale of the landscape in health care ICT. One of the key things for us has been to rebuild confidence and to ensure that clinical and front line staff are engaged in it. The benefit from IT is not the bit of software or hardware technology, but what we can do with it to effect change. Professor Drumm spoke about the performance statistics that make those available. We are focusing on the applications for the clinical side.

A significant number of lessons have been learned out of what was a difficult period for health care ICT. These lessons have been applied. Research is available from Trinity College and other universities that state that IT projects are notoriously difficult and the more we try to tackle the underlying process change and the benefits we are trying to get out of it, the greater the risk that we could take in the scale. It is often easier—

Deputy Thomas P. Broughan

With 111,000 staff, the HSE is by far the biggest enterprise in the State. Are there many different control centres where salaries are paid and employees' conditions facilitated? Or are we getting to a more centralised system?

Mr. Damien McCallion

I will take that in a broader context. That applies to all health care and there are variations. Many of those variations were inherited through a collection of agencies and interpretation of agreements over the years. There is now one single support centre through which the technology of the payroll is managed and there are moves afoot through our shared services programme to consolidate the payroll. When something is distributed across health care, there will always be an element that will apply to the local health office in Belmullet and to St. Vincent's Hospital. It is a bigger challenge in a clinical setting where practices can vary. That is where the test will come for us when trying to use the technology to bring about changes and improvements in frontline care. It is a gradual process and I do not think there is a silver bullet.

Changes in the HR piece have been made and some of that has been centralised. That is partly contingent in most cases on systems. Looking at private sector examples, such as the Microsoft shared services centre in Dublin, there is quite a significant process involved in moving to that model. A single system is an integral part of it.

Deputy Thomas P. Broughan

Is Mr. McCallion therefore saying that we will not come back to this in subsequent years? The Comptroller and Auditor General has been involved with the IBTS problem, which will presumably be in the report for 2007-08. The Department used to be known as Angola by a former Minister, given the things that happened there and the land mines that were waiting for the chief executive and the Secretary General. As far as Mr. McCallion knows, there are no more computer land mines or expense land mines there for people to step on.

Mr. Damien McCallion

No. The report contains the actions we put in place to meet the obligations under the sanction, which was a new arrangement for the health service. We have a significant challenge in Ireland to modernise the health care system to use technology. The strategy we are putting in place is highlighting the benefits that have appeared in countries like Canada and New Zealand.

The challenges are difficult. The Deputy called them land mines, which can crop up from time to time. We are looking at better managing those projects and making sure that the structures and the processes put in place around those projects allow us to do that.

Deputy Thomas P. Broughan

I would like to ask the—

Chairman

May I interrupt the Deputy? Perhaps Mr. Heffernan and Mr. Ring from the Department of Finance might address some of the issues the Deputy has raised, especially regarding sanctions and the guidelines in place.

Mr. Dave Ring

I will answer that. In recent years, the Department of Finance has worked carefully with the HSE, through the Department of Health and Children, on several sanctioning issues. Part of the sanctioning process involves ensuring that projects and products are fit for purpose and technically feasible and the price is about right, etc. An IT strategy has been in development in the HSE in recent years. Governance principles have been put in place.

Deputy Thomas P. Broughan

I know all that. I have read that. Was the Department of Finance aware that the Irish Blood Transfusion Service was about to embark on the architecture associated with the Progesa system?

Mr. Dave Ring

The Irish Blood Transfusion Service does not come under the remit of the Department of Finance.

Deputy Thomas P. Broughan

No. I understand. I have read the governance documents. Under whose remit does the service come?

Mr. Dave Ring

It comes under the remit of the Department of Health and Children.

Deputy Thomas P. Broughan

Was Mr. Scanlan of that Department aware that the Irish Blood Transfusion Service was embarking on the Progesa system? Did the Department ensure the guidelines were adhered to?

Mr. Michael Scanlan

While the Irish Blood Transfusion Service is funded through the Department, it is not subject to the arrangements under circular 16/1997, the application of which to the HSE is being discussed by Deputy Broughan. I know very little about the Progesa project. I understand the Progesa system that has been in place for some years is working well, but it seems that problems have arisen with the move to a higher level or variant of the system. As the Deputy said, the Comptroller and Auditor General is looking for information from the Irish Blood Transfusion Service.

Deputy Thomas P. Broughan

Why is the Irish Blood Transfusion Service exempt from the circular? Why would it apply to the HSE but not to another body under the remit of the Department of Health and Children?

Mr. Michael Scanlan

The Deputy can ask the officials from the Department of Finance that question. As I understand it, the point the Comptroller and Auditor General made in his report was that the circular applies to money spent directly from a Vote of a Department or agency. When the HSE got its own Vote for the first time, it became subject to the circular. A range of bodies across the public service - not just in the health sector - are not subject to the circular. That is my understanding of it anyway.

Deputy Thomas P. Broughan

Can I ask the—

Chairman

Perhaps the Deputy will allow the Comptroller and Auditor General to speak at this point.

Mr. John Purcell

There was a leak about this issue - the use of the Progesa system in the Irish Blood Transfusion Service - from somewhere last week. This matter had been of concern to the Office of the Comptroller and Auditor General for some time. We arranged meetings and engaged in correspondence with the service on this subject in the context of our annual audit of the service's accounts. When we issued an official audit query to the head of the service, we asked questions about matters we felt should be the subject of accountability. I do not want to pre-empt what we will ultimately publish. I do not think we have received a reply to date to the official query, which will form the basis of the public report that will be made. I intend to provide that my report on this matter, which is to be published in the first half of this year, will form part of a general report on matters arising from my office's audits of semi-State bodies. That is just the one item which will be raised in the report in respect of the Irish Blood Transfusion Service. I am conscious that my office produced a special report on the service three or four years ago. That report highlighted the inadequacy of the service's financial controls at the time. It also outlined the cost overrun in the development of the original Progesa system. I felt that to go back with a special report on this matter would be perhaps to overdo it and put the boot in. I have no doubt the full story will see the light of day in the general report we will certainly produce in the first half of this year.

Chairman

We shall await that report. Mr. Ring may continue.

Deputy Thomas P. Broughan

I would like to move on as I am conscious of the time.

Chairman

Perhaps other members would like to hear Mr. Ring's final comments.

Mr. Dave Ring

I will summarise three areas. First, the principles and the framework for sanction are in place. Second, we have a peer review process in place whereby we examine projects at various stages and do not just wait until the end to see what is happening. Third, we have interfaced this with the delegated sanction. In addition, information is no longer coming through in an ad hoc fashion and the central decision-making process, the governance, the technical principles and an IT strategy are all in place. These are all fundamental to having good IT systems. It is important continuous project management and monitoring is effective throughout the process to ensure matters do not get out of hand and there are no runaway projects, and this is also in place. We are closely monitoring this through the Department of Health and Children and with the HSE.

Chairman

Thank you.

Deputy Thomas P. Broughan

I do not share some of the overall views of my colleagues with regard to the HSE. Looking back at the health board era and the grotesque failures in Irish health care delivery, in general terms I support a national health system. My difficulty with the chief executive is that he is not elected and it is not possible to have regular democratic control. Perhaps the Comptroller and Auditor General could give this matter some attention. Do we even need the Department of Health and Children? Why should we spend €50 million—

Deputy Seán Fleming

On a point of order, that is very much a policy issue and has nothing to do with the HSE.

Chairman

I was just about to say that. I have been flexible but it is a policy issue.

Deputy Seán Fleming

It is not this man's responsibility to deal with that.

Deputy Thomas P. Broughan

The chief executive knows this because we write to him fairly continuously. The Minister will not answer on policy issues whereas Professor Drumm generally gets back to us, even when the issues affect policy.

I want to address a basic point. We know of the rolling out of BreastCheck, which I hope is in line to be delivered to the entire country. There is a feeling that delivery of prostate examination services should also be rolled out. Does the HSE see it as part of its role to implement an annual health check for every member of the population? Is it thinking in terms of such a preventative approach to health delivery? BreastCheck is in place for an important and dangerous disease. I commend the HSE for rolling it out in so far as it has been rolled out. This issue was on my mind because we are conscious of how we perform in comparison with other jurisdictions - the Secretary General referred to this. Should a health check be an ambition of the HSE in the future?

Mr. Michael Scanlan

Despite what the Deputy said with regard to policy, the Department of Health and Children still exists and has an important role to play.

I will comment on the issue of a personal health check and will then ask Dr. Devlin to comment, as he may be more expert than I. There is reference in the programme for Government to a personal health check. We have a programme of screening, which includes BreastCheck, to which the Deputy referred, and the cervical screening programme is due to be rolled out this year. We also have processes in place to evaluate the medical effectiveness of particular screening, which is undertaken not by lay administrators but by expert clinicians. This is the basis on which we operate. It is the same with regard to immunisation programmes, for which we have a national immunisation advisory committee. We try to set up processes which allow the experts to consider not just the costs but the medical case.

Deputy Thomas P. Broughan

Has the Department given consideration to a general check-up for everybody?

Mr. Michael Scanlan

As I noted in my opening statement, we have been examining that issue in the context of an approach to managing chronic diseases which is far more proactive than just waiting for somebody to present to a GP a surgery or an acute hospital where there is not the care or initial diagnosis they need - this may be the point the Deputy is trying to address. The problem with simply suggesting we will have an annual check-up for everybody is that, as I understand it, from a medical point of view it is doubtful how effective this would be in picking up patients' conditions. While some, including myself, go along for our annual or biannual MOT because we think it is a good thing to do, the medical effectiveness of such a programme is not certain, nor is its cost.

We are trying to find, particularly with regard to the chronic disease management programme, whether some programme could be developed for specific conditions, for example, diabetes, which we have discussed, or chronic obstructive pulmonary disease, COPD. While it is an issue, it is one on which we must be careful. We should not rush to assume we can run some sort of screening programme that will be medically effective let alone cost effective.

I brought Dr. Devlin to the meeting to address the issue of chronic disease. Perhaps he might add to what I have said.

Dr. John Devlin

There are well-established international criteria that we use to evaluate screening programmes and whether they deliver not just value for money but ultimately benefits for the population. We also need to be careful that any tests or programmes we are thinking of applying do not do harm or damage people, which is a major consideration. These are the yardsticks we use when we consider various screening issues such as cancer screening - the Deputy referred to breast and cervical screening and other issues such as colorectal cancer screening have been considered. Unfortunately, for other conditions such as prostate cancer, the jury is still out and we need to be very careful that the benefits are there. This is why we have a process in place that rigorously assesses the benefits of these programmes.

The Deputy raised the issue of a personal health check, which is a little more complicated. We are examining this in the context of trying to prevent many chronic conditions - the Secretary General referred to heart disease, diabetes and so on. There may be different ways of detecting these conditions earlier, preventing many more of them, particularly in the primary care setting, and getting people out of hospitals. This is the way many countries now view these services. On a point to which the Secretary General alluded in his opening statement, we will very shortly publish a chronic disease policy framework—

Deputy Thomas P. Broughan

The Secretary General gave statistics to show how well we were doing in recent years vis-à-vis other OECD countries. However, I could draw completely different inferences from the OECD statistics. For example, we are below average with regard to the number of physicians per capita, particularly compared to the Scandinavian and north European democracies. The same holds for the number of beds, although I know the HSE chief executive has ideas in that regard. In many delivery areas in health, our performance is pretty appalling, not to mention that we have only just set up the Health Information and Quality Authority, HIQA.

The Secretary General talks of robust statistics. He does not have robust statistics and never had them. Mortality rates in certain areas certainly in low income and deprived areas are not known. It was possible for the health system in the UK to say, for example, that Manchester is the worst place to live in England and north-east London is the best place to live. We could never say that because we simply do not have the information. For the Secretary General to give the committee this rosy picture does not reflect the reality. My colleagues have given us reports of service delivery in different parts of the country which echo this and I could do the same for north Dublin. The Secretary General picked the statistics he wanted rather than telling us the full, true picture of Irish health in the early part of 2008.

Mr. Michael Scanlan

My view is that too often we have measured the apparent success of the health service by how much we put into it, how many millions we invest and how many thousands or hundreds of thousands of staff we employ. We need to move away from that. To be honest, that was seen as success in the Department. If we got X million—

Deputy Thomas P. Broughan

We never saw it like that.

Mr. Michael Scanlan

We need to move to at least measuring what we produce.

Chairman

Mr. Scanlan is making an assumption. Our job is not to laud the amount of money allocated but to ascertain how effectively it is being spent.

Mr. Michael Scanlan

I agree. The Chairman is correct. We need to move away from that and consider what is produced for that money. I would have thought the committee would generally be of the same mind. There are two ways of looking at this. There is the question of what is produced in terms of day-to-day output, the number of additional home care packages and home help hours and so on. There have been improvements in this regard, although I accept they may not be sufficient. After that, one can look at the ultimate result of all this expenditure. I make no apologies for talking more about the results of the spending rather than the spending itself.

As I said, we have been doing much better. I consider that I owe it to the people working in the system to present as positive a picture as possible of the health service. Nevertheless, as I mentioned in my statement, I would be the first to accept that we must do much better still. Setting aside the issue of the number of physicians or beds, we are below the OECD average in terms of life expectancy and mortality rates. I fully accept that in many areas we must do far better.

Deputy Thomas P. Broughan

I apologise that I had to attend another meeting for a short while. My question is for Professor Drumm. The usual hackneyed clichés have been used and I am still unclear about the proportion of staff on the administrative side. Have we clarified how many of the 111,000 staff are engaged in administrative duties? How many pensioners does the HSE support? I note the figure of €9 million in this regard. Does this represent payment for services carried out by retired staff or payments to retired staff who previously undertook those services?

I could offer examples of the difficulties patients experience with the delivery of services. Orthodontic services for children are one such example, with scandalously long public waiting lists, particularly in the eastern region. It is appalling. The problem was inherited by Professor Drumm but it persists. There is concern that there will be liabilities arising from our failure to deliver an orthodontic service to teenagers in the greater Dublin region. What proportion of funding is being spent on pen pushers, reporters and so on and how much on front-line staff engaged in the delivery of services such as orthodontics?

Professor Brendan Drumm

In regard to resources available within the health service generally, one important measure that has never been taken in Ireland is to age adjust the data. Some 80% of our money goes towards the treatment of those aged over 65 years and most of this relates to those aged over 75, yet we compare with OECD data for countries where the load in respect of the elderly population is twice as great as ours. The data are incomparable. Otherwise, we will be bust in 20 or 30 years because we should be providing the current levels of service for far less. If we age adjust the figures for the number of doctors in the State, it turns out they are far higher than in the United Kingdom, for instance. However, Deputy Broughan is correct that northern Europe operates a completely different and very attractive model.

The Deputy asked how the overall staffing level was broken down between administrators and front-line staff. We have just completed a survey of our administrative grade and it comes in at about 17.6% of total staff. We have benchmarked this figure against that in different parts of the United Kingdom, where it is some 1% higher. There are approximately 3,500 people with backroom functions, which include human resources, payroll and other support functions. We must challenge the notion that it is the proportion of the overall health service staff who are administrators, at 17.6%, which is at the root of all the difficulties in every aspect of health service delivery. There has been a huge increase in the number of front-line staff in the health service in the last ten years across all grades. We are only beginning to measure the output from this. It is easy for the system to fall down if there is no accountability.

The delivery of orthodontic services is a major challenge and has been subject to a significant amount of work in the last year or so, on which my colleague, Ms McGuinness, will comment.

Ms Laverne McGuinness

The problems with the children's orthodontic service present a major challenge. The waiting lists have persisted for many years and were exacerbated by the high level of non-attendance at appointments. A different screening process is now in place that makes it easier to identify and prioritise those most in need and to manage the waiting list accordingly. Some children have severely impacted teeth, for example, but those with only minor problems were previously ahead of them on the waiting list.

Deputy Thomas P. Broughan

Does Ms McGuinness accept that this is a delicate issue? For teenagers, boys and girls, having one's teeth in what one considers to be reasonable shape is critical to one's well-being when it comes to meeting members of the opposite sex and so on. It seems we allowed this situation to get completely out of control, putting many children through great suffering. Many have had to wait until they are 19 or 20 years of age to receive treatment, when it may be too late.

Ms Laverne McGuinness

Yes, it is a sensitive issue. Like all services, it must be a question of prioritising according to the greatest clinical need. That is why the entire process has been changed in order that those children who have severely impacted teeth and so on will be dealt with first. Others will also be treated but they will have to wait longer under this new priority system. I accept, however, that even minor problems can seem critical to those concerned.

Chairman

Is training part of the problem? Are there difficulties in terms of the HSE's relationship with the Irish Dental Association and the question of manpower policy? What progress has been made in this regard? Unless we make progress, the problem will persist indefinitely.

Deputy Thomas P. Broughan

Dr. Ted McNamara from Limerick made some serious charges against the various health boards at an earlier time in regard to the training of orthodontists and specialist consultant dentists. It seems to the lay observer that he had a point.

Professor Brendan Drumm

This is a highly contentious issue. Excellent work has been done in reclassifying the categories of clinical need and drawing the line between what is cosmetic and what represents genuine need. The work went as far as demonstrating that a layperson could look at the pictures and understand why a particular person needed to be on the list.

The issues relating to training are being addressed. We have compiled a comprehensive but easy to read summary report that we could present to the committee. It is not extensive but provides easily accessible information on all aspects of this issue. There are some significant professional differences among those providing the service but they are being dealt with, as outlined comprehensively in the report.

Deputy Tommy P. Broughan

People are on the waiting list for six or seven years.

Professor Brendan Drumm

We will be able to improve those waiting times once we attain absolute clarity and accountability for the first time ever.

Deputy Tommy P. Broughan

When Deputy Noonan was Minister for Health and Children in the last Fine Gael-Labour Party Government, he brought forward a new protocol in this area. However, it seems to be have been entirely abandoned in the last 11 years.

Professor Brendan Drumm

The situation will be greatly improved by the absolute accountability that will ensue from the external validation of the workloads and the prioritisation thereof.

Chairman

We are beginning the second circuit of questions. I remind members that we have been here for four hours.

Deputy Pádraic McCormack

I will be brief.

Chairman

I am not demanding that. I merely point out that we will have an opportunity to meet delegates from the HSE and the Department of Health and Children again within a matter of months because we will not finish our business today. There are several outstanding issues in regard to some of the Votes. I ask members to bear this in mind and to limit their contributions to two minutes each.

Deputy Pádraic McCormack

The Comptroller and Auditor General gave a figure of €1,239,274 for bonuses to senior staff. What period does this cover?

Mr. John Purcell

It is for 2006.

Deputy Pádraic McCormack

During the two-year term of the embargo on the recruitment of staff, how many administrative staff were appointed and what was the cost?

Mr. Liam Woods

The pause on putting staff on the payroll lasted four months. As far as I am aware, no administrative staff were recruited in that time.

Deputy Pádraic McCormack

I refer to the period from December 2005 to the end of 2007. Does Mr. Woods suggest that no administrative staff were appointed during that period?

Mr. Liam Woods

No, I am not saying that. I am narrowing the timescale on the recruitment embargo. Unless I have misunderstood the Deputy, the recruitment embargo to which he referred is the measure that was taken from September 2007 until the end of the year.

Deputy Pádraic McCormack

No, there was an embargo on the recruitment of staff in 2005. Earlier I referred to a letter I received outlining how a person could not get four hours of home help because of an embargo on the recruitment of staff. The letter in question is dated 16 December 2005. An embargo existed on the ground on the recruitment of staff for four hours of home help, which would have cost €50 per week.

What administrative staff were appointed from December 2005 until the end of December 2007?

Mr. Liam Woods

I am not aware of the HSE placing an embargo on staff before September 2007.

Deputy Pádraic McCormack

I am merely quoting from a letter. It was from Mary Coyne, the deputy home help organiser of the western health executive. It pertains to a representation I made on behalf of a person who sought four hours home help.

Chairman

The Deputy should not mention the names of people who are not present.

Deputy Pádraic McCormack

I wanted to ensure the authenticity of the letter. It stated that although some people could work in the evening, due to an embargo on the recruitment of staff and because the unit was at its full complement, no one could be appointed. A recruitment embargo was in place in December 2005 in County Galway at least. My question pertains to the period from 2005 to 2007. In other words, how many administrative staff were appointed throughout 2006 and 2007?

Mr. Liam Woods

I do not have the detailed information on how many administrative staff were appointed.

Professor Brendan Drumm

I suspect that approximately 7,000 or 8,000 staff in total were appointed over that period.

Mr. Liam Woods

We could come back to the Deputy regarding the administrative staff.

Deputy Pádraic McCormack

The figures provided by the Comptroller and Auditor General and the Secretary General, show that 111 people were rewarded with bonuses. I reckon that to mean that for the year in question, 111 people each received an approximate average of €11,164 in bonuses.

Do those concerned, some of whom are present, not feel guilty in accepting bonuses when the poor man in Connemara was unable to get four hours of help for his mother?

Chairman

That is unfair.

Deputy Pádraic McCormack

It is not unfair for me to ask that question. That is merely an average figure.

Professor Brendan Drumm

If we can get the information, we will try to deal with the specifics of that case again.

Deputy Pádraic McCormack

I gave Professor Drumm's office this information more than two years ago when I raised the matter with him personally.

Deputy Thomas P. Broughan

On Deputy McCormack's point regarding performance bonuses—

Chairman

No, I am sticking with Deputy McCormack and after he has finished I will turn to Deputy Séan Fleming.

Deputy Thomas P. Broughan

Very well.

Deputy Pádraic McCormack

I want to put this matter on the record because I am obliged to explain to my constituent how people received €1,239,274 in bonuses when he was unable to get four hours to keep his mother in his own home. The loss of elderly people from a community is far greater than the loss of the €50 per week it would cost to keep them there. Their experience can be useful to the community and to their grandchildren. A total of 98% of elderly people wish to spend their final years in their own homes and communities.

Chairman

I asked the Deputy not to personalise this issue.

Deputy Pádraic McCormack

When the figure of €1.239 million was being arrived at, who decided who would receive bonuses? How is the figure arrived at?

Mr. Liam Woods

I will make a couple of points. On the Deputy's previous question on the general management of administration grades, between 2005 and 2006 there was a growth of 263 management administration posts.

Professor Brendan Drumm

That includes secretaries and—

Deputy Pádraic McCormack

The figure pertains to management posts.

Mr. Liam Woods

The definition used, management administration, constitutes quite a broad category.

Deputy Pádraic McCormack

What of lower administration posts?

Mr. Liam Woods

The figure includes all management administration posts.

Deputy Pádraic McCormack

The figure pertains to a two-year period.

Mr. Liam Woods

This is against a backdrop where the total number of staff grew between those two years by approximately 4,500.

Deputy Pádraic McCormack

What is Mr. Woods's response to the other question?

Mr. Liam Woods

On the second point, the performance-related assessment scheme applies to certain grades within the public sector. Within the HSE, my understanding is that substantially, it applies to those who are at national director or assistant national director level.

Deputy Pádraic McCormack

Is the bonus based on service or is it simply granted across the board? Is it based on productivity?

Chairman

What are the parameters for the bonus scheme?

Mr. Liam Woods

Performance targets are set over a range of criteria and the assessment is made against them. A defined scheme exists and I can provide its text to the committee.

Deputy Pádraic McCormack

Who monitors it? Is it self-monitored?

Mr. Liam Woods

At that time, unless I am mistaken, it was a central committee within the Department of Finance. While this is somewhat beyond my remit, I believe that was the mechanism.

Mr. Michael Scanlan

If it helps, my understanding on how the scheme operates within the HSE broadly concurs with what Mr. Woods has outlined. If the Deputy wishes, I also can talk about the Department. At the start of the year, a set of objectives are set for people who are covered by the scheme. While an assessment is conducted by their immediate superior at years' end, it is signed off by the board's remuneration sub-committee and ultimately, by the board itself. The final formal decisions are made at board level within the HSE. Is that fair comment?

Deputy Pádraic McCormack

I rest my case

Chairman

The Deputy should listen to Professor Drumm's response.

Professor Brendan Drumm

A remuneration committee of the board is responsible for the directors of the HSE and me. A highly detailed action planning process has been in place over the last two years. One of the directors produces a very detailed plan of one's performance targets during the year under many different headings. Ultimately, it is taken forward to a senior committee of the board. There are definite measures of what people must achieve and there were marked differences in the payments that were made under that scheme. Throughout the organisation, a total of 111 people were covered. However, the board sub-committee does not deal with those below the level of director.

Deputy Seán Fleming

How many applied for, and how many were refused, a bonus? Did everyone receive a bonus?

Professor Brendan Drumm

Did the Deputy ask how many refused it?

Deputy Seán Fleming

How many people were refused or were not granted such a bonus? Is it a question of simply putting down one's name to get it?

Professor Brendan Drumm

No, it is granted on a scale.

Deputy Seán Fleming

Did some people apply for a bonus only to have their superiors reply that as they did not measure up this year, they would not receive one? Did that happen?

Professor Brendan Drumm

Yes.

Deputy Seán Fleming

How many people were not approved for a bonus?

Professor Brendan Drumm

I dealt with bonuses at the top level of the organisation and all I can say is that this happened.

Deputy Seán Fleming

I am pleased to hear it because such bonuses should not be automatic.

I have some brief questions to ask of different people. I will direct my first question to the Secretary General. I refer to subhead G1 on his Vote, which pertains to payments in respect of disablement caused by thalidomide. Last year, the small sum of €287,000 was paid. As a layman, I encounter people who are universally acknowledged to be victims of thalidomide but who never applied. They may have been at home and did not know how or to whom to apply. Such people do not appear to have any avenues open to them to facilitate having their cases adjudicated on. Who is responsible for this? I believe many genuine cases were unable to apply due to the passage of time or family circumstances and such people now appear to be shut out. Can new people who were original thalidomide victims avail of the scheme in question?

Mr. Michael Scanlan

This is not an issue with which I am greatly familiar. I will check for the Deputy. My notes state that as one would expect, such individuals were obliged to go through a process that was recommended by the Irish Thalidomide Medical Board at the time. Does the Deputy suggest that some cases may have been missed?

Deputy Seán Fleming

Is the scheme closed?

Mr. Michael Scanlan

I am not aware of it. I will check and revert to the Deputy.

Deputy Seán Fleming

Is the scheme closed or does a mechanism exist whereby valid thalidomide victims who did not apply in time can be included?

Mr. Michael Scanlan

I will find out.

Deputy Seán Fleming

I will address my second question to Professor Drumm. I refer to the length of time it can take to issue death certificates. I am aware of examples of elderly people who died in hospital for whom the county coroner is unable to issue a death certificate because that officer has been informed a pathology report or post mortem report is not ready. I know of cases who died last April in which the families still have not received a death certificate. I belabour the county coroner who claims this is the fault of the HSE. When an elderly person dies in hospital, what is the delay? What prevents your staff from producing whatever report is required of them, which in turn prevents the issuance of a death certificate for ten months?

Professor Brendan Drumm

Based on my personal, rather than HSE administrative experience, I can tell the Deputy that some post-mortem reports are extraordinarily slow to complete in terms of getting pathologists to sign off on them. The demands placed on pathologists in terms of accuracy are great and a considerable amount of testing is sent off. Ten months seems exceptionally long.

Deputy Seán Fleming

I have asked parliamentary questions about the case. Will Professor Drumm give us a note on the topic rather than delaying matters?

Professor Brendan Drumm

Once the information is available to the pathologist, there is no reason it should not be provided. I do not know if there is a statistic we would collect but we will check in respect of completion and timing.

Deputy Seán Fleming

Perhaps Professor Drumm might send a note to the committee. The subject of my next question has not been mentioned yet. There has been a considerable amount of discussion today and we have spent more time talking about staff and salaries than about patients, which should be our focus in the first instance. How many children are in foster care and what is the cost involved? It is an increasingly significant issue. I suspect the HSE has the figures. They do not jump out at me in the report.

Professor Brendan Drumm

It is a performance measure for us so we should have the information.

Deputy Seán Fleming

What are the costs because there is a considerable amount of it out there? How many of the payments are to families as opposed to agencies? I know there are agencies that provide emergency services at weekends where a family is not available, things go wrong and children need to be taken out of their homes. This issue has not been addressed.

Professor Brendan Drumm

We can give the committee details about that because one of our performance measures in the community is the number of children in foster care as opposed to institutional care. Perhaps Ms McGuinness might speak about this.

Ms Laverne McGuinness

Approximately 3,206 children are in foster care and approximately 1,500 children are in foster care with relatives. Obviously, there are other arrangements. There are children in special high support care arrangements. We put a different scheme in place in 2007 because, very often, potential foster parents want to take children who do not have very high, complex needs.

Deputy Seán Fleming

That is understandable.

Ms Laverne McGuinness

This means there are children who must stay in residential centres. We have put a pilot programme in place whereby we encourage some potential foster parents to take children who have additional needs, such as children who are difficult to manage or who have been come from fairly complex families and have been affected by that. Some of those have been very successful.

We always carry out a number of campaigns to bring more foster carers into play on an ongoing basis. We always encourage relatives to become involved because we know that children fare better in foster placements and with their relatives.

Deputy Seán Fleming

I think Ms McGuinness said that there are 3,000 children in foster care with families.

Ms Laverne McGuinness

Approximately 4,500 children are in care.

Deputy Seán Fleming

That is a significant number of children.

Ms Laverne McGuinness

Absolutely.

Professor Brendan Drumm

That is in care. There are 3,200 in foster care.

Deputy Seán Fleming

In general, there are many children out of their homes in foster care. Obviously, they are all traumatic and difficult situations. I would welcome if the HSE can send us an information note to give us a picture. Last year there was legislation on that topic dealing with rights in foster care and hospitals and children going for operations and so on. The associations regularly ask us about these issues.

All Members of the Oireachtas would have received correspondence recently about a child who was placed in an adult psychiatric care facility. Ms McGuinness said that new facilities are coming on stream.

Chairman

We dealt with that issue when Deputy Fleming was absent.

Deputy Seán Fleming

My question, which was not dealt with, was whether the staffing arrangements are in place for the new facilities. Are we looking at painted new facilities with a security man to look after them?

Ms Laverne McGuinness

The first facility that will come on stream with regard to those inpatient beds is St. Vincent's Psychiatric Hospital in Fairview. That is an agency and we will fund it so it will put its staffing arrangements in place. The staffing profiles are drawn up so the recruitment process is ready. We will look with the human resources people to fast track those placements so that staff will be ready to go into place as soon as the units are open.

Deputy Seán Fleming

In the accounts on page 79, under note 8, are revenue grants of €3.18 billion to outside agencies - the other major voluntary hospitals, by and large - and capital grants to voluntary organisations of €194 million. Probably 30% of the HSE's budget goes to these organisations. What service agreements are in place? I really want to put this question to the Department of Finance. Grants of €194 million were given to voluntary agencies last year. What happens if the money is not spent where it is supposed to be spent? Every Deputy will appreciate where I am coming from. If an organisation gets a national lottery grant, it has to go through various hoops. For example, it must go to the Chief State Solicitor's Office if it wishes to prove title to a field where it wishes to build a dressing room. What arrangements does the State have in place in respect of coming back if these facilities are not used or are no longer used? Does a repayment mechanism exist?

This issue arose previously where grants were issued. It was a major topic here a year or two ago and involved the Department of Agriculture, Fisheries and Food. The State grants for capital purposes were not properly secured at the time they were issued. It is an issue for the Department of Finance as well as for the HSE.

Professor Brendan Drumm

Perhaps it would help if I took it on first, to be fair to the Department of Finance. By the time I arrived here the Comptroller and Auditor General had produced an extremely useful report on some of our interactions with a significant section of voluntary agencies. We all found the report to be extremely useful because it opened up that question.

We have moved in a reasonably expeditious fashion to develop much more formal service level agreements. To be fair, it is more of a health service issue than a finance issue and the responsibility was left with the health services. It would be reasonable to say that the arrangements were, as the Comptroller and Auditor General would have identified, relatively loose.

We now have formal service level agreements. We will not be able to roll them out across the thousands of agencies we fund but, as Deputy Fleming noted, a considerable amount of the money falls into a relatively small number. We are moving forward both within the community and voluntary hospital sector to get much more clarity about what is returned. We find ourselves in the ridiculous situation where in the HSE's corporate division in Dr. Steeven's Hospital, we seem to be responsible for a patient on a trolley in an accident and emergency department in a voluntary hospital that gets pretty massive funding yet if something fairly constructive happens in that hospital, there is often no mention of the Department of Health and Children and the HSE. There is an accountability issue there that needs to be dealt with. We are coming to that point very quickly.

Deputy Seán Fleming

I will let it go but we will revisit this issue.

Professor Brendan Drumm

There is another issue.

Mr. Liam Woods

We have a role in protecting the interests of the State in capital investment, which is part of where the Deputy was coming from. We have a duty to take a lien on investments in voluntary bodies. The standardisation service level agreement covers the grants appended to the accounts.

Deputy Seán Fleming

Page 89 of the HSE's annual report and financial statements shows that the HSE paid out €13 million under the health repayment scheme in 2006. That scheme is now closed for application. What is the final cost? I will roll all my questions into one so the delegation will know where I am coming from on this.

How many of the payments have gone to the families of deceased people compared to patients in hospitals and their families? I understand the HSE is paying 0.5% of the interest on the money? I understand that €50 million has gone into it but I could be wrong. A considerable amount of money is going to the patients whose accounts are being managed by the HSE. I understand there is a cost involved in that. That links into the interest earned on patients. There is a contingent liability note in the HSE's accounts on a similar topic about managing patients' fees.

On the issue of publication of the list of payments, I am told there will be a register of payments published in respect of deceased patients. Does Professor Drumm understand what I am talking about? Some people are concerned about the publication of lists of payments.

Professor Brendan Drumm

I am not aware of a list of names being published.

Deputy Seán Fleming

It is publishable. It is like a person's will. It is part of their estate if they are dead. The representatives from the Department of Health and Children should be able to answer that because the Department drew up the scheme.

Mr. Michael Scanlan

I will do what I can. To go back to an earlier question from the Deputy, one of my colleagues has confirmed what the Deputy said about thalidomide. Five cases have been submitted and we have put arrangements in place to have them reviewed by an independent group of experts so it is not completely closed off. The Deputy is right. It looks like some people are coming through even now.

I have some figures in respect of long-stay charges. They are not broken down to the level of detail about which the Deputy is speaking. I have figures suggesting that, by the third week of the month in question, the total number of claims was approximately 36,700. Payments had issued to 7,200 claimants to a value of €142 million, offers had been made to 9,700 claimants to a value of €183 million, while 6,800 claims had fallen outside the scope of the scheme. In addition to these three sub-groups, there are another 13,000 claims awaiting processing. Individual privacy has been a concern, but I must confirm whether information is publishable in the case of deceased persons.

Deputy Seán Fleming

Mr. Scanlan appears to have a good information note. Will he send it to the committee?

Mr. Michael Scanlan

I can give the committee a note.

Chairman

Before I call Deputy O'Brien, I have a question on capital services in subheads C1 and C3. The 2006 Estimates provided for a figure of €559 million, but the outturn was €444 million. The underspend in the previous year was approximately €45 million. When Professor Drumm wrote to the Tánaiste, Deputy Cowen, last September in respect of capital projects, he stated money assigned for such projects was being diverted to meet day-to-day costs and that he wanted to protect his standing and the HSE's reputation for financial probity. What were his concerns in respect of money for capital projects being diverted?

Professor Brendan Drumm

Unlike in the previous year, we did not move capital money last year to subsidise hospitals which ran into significant difficulties that year and the previous year. A considerable difference between the two years is that, while we used all of our capital moneys last year, we transferred moneys from the capital side to the revenue side in the previous year. Not moving moneys is the right thing to do. It presents the challenge of living within budget to the system. As we did last year, we will expend our capital moneys fully. The national system must deal with the challenge.

Chairman

Does Professor Drumm believe some substantial capital projects were delayed intentionally to subsidise revenue accounts?

Professor Brendan Drumm

If halfway or three quarters of the way through the year one's revenue budget looks like it will overshoot in respect of hospitals, etc., as occurred in 2006, the easy decision is to do exactly as the Chairman stated.

Chairman

Did Professor Drumm state such was justified on the basis of new developments being delayed in their first year to generate the savings necessary to make up the shortfall and that the record shows the practice was used for many years?

Professor Brendan Drumm

That is a separate issue. New development money which has been substantial but is not as substantial this year will be dealt with differently. Historically, it has been assumed that new development money will not be spent in the first year and can be used to bail out the system. We are delighted with the change this year because, while it brings challenges, it also brings accountability. This year new development money cannot be expended except on new development. Returning to the question on mental health—

Chairman

We are discussing the figures for previous years.

Professor Brendan Drumm

Yes, we delayed new developments on the basis that the budget had to be balanced at the end of the year. In such a situation we try to pick up the cost of new developments in the following year. That is fine while there are many new developments because one can put off those planned for next year until the following year and so on, but one hits a wall quickly in years such as this when there is not as much new development money available. Discipline has been imposed on us and I am happy to take up the challenge. The outcome will be simple. In previous years when a budget was given to an authority in our sector - on 1 April - everyone's incitement, if there was a budget overrun, was to rely on the moneys used in delaying developments across the system. To be fair to local managers, they could be considered negligent in their duties if, due to the sense that money would become available from other sources and be given to those who allowed budget overruns, they did not challenge their budgets. The difference this year is that money was categorised at the beginning of the year and there is clarity that new development and capital moneys will not be used as in previous years. Each manager from County Donegal to County Cork knows what his or her budget is and that he or she will not gain by not managing it and may be blamed by locals.

Chairman

Professor Drumm stated a sum of €342 million in last year's budget was diverted.

Professor Brendan Drumm

No, we diverted approximately €80 million.

Chairman

For long-term patients and staff maternity leave payments.

Professor Brendan Drumm

It was money not used under the long-term repayments scheme. We diverted approximately €80 million. I can give the Chairman the exact figure, approximately €85 million or €86 million, which relates to 2006.

Deputy Darragh O’Brien

This meeting has been useful and I hope that, instead of opening a can of worms, our sentiments will be understood by Professor Drumm. I wish him and the Irish Pharmaceutical Union well in their meetings with the Joint Committee on Health and Children next week.

Regarding contingent liability, it is mentioned in the report that the repayment of nursing home fees may materially affect the accounts. This may be a question for Mr. Scanlan. Are we satisfied that the liability is €360 million and not more or less?

Ms Laverne McGuinness

When the long-term repayment scheme was funded, it was believed there would be more applicants than was the case. Some of the applications received were unacceptable. Despite making every effort, including local road shows, to advise people of the scheme, more money was provided than used. The delay is due to the fact that cases going through the courts to seek probate have not yet resolved. As there is a cut-off date for the scheme, no additional applications will be accepted. Existing applications are being processed.

Deputy Darragh O’Brien

The ceiling is €360 million, substantially lower than the figure of billions reported when the story broke.

Ms Laverne McGuinness

It gives an indication. Some of those entitled to claim under the scheme in respect of their parents did not want to avail of it because they believed the service provided in the nursing home was good and sufficient.

Deputy Darragh O’Brien

Under the heading of miscellaneous in the report, have the 2,563 claims outstanding against the HSE in 2006 been reassessed? While I understand our guests cannot go into detail, what is the potential liability? Are there any large claims pending against the HSE?

Mr. Liam Woods

In one of the contingent liability notes we have flagged that most of the potential claims will be covered by insurance. We have also mentioned the risk that, if one goes back far enough, there would not be sufficient cover for a claim. There has been no significant development on this.

Professor Brendan Drumm

Deputy Kenneally has left but I should respond to his question on staff in Cashel. In 1996 all staff working in the surgical unit in Cashel hospital received a letter of comfort indicating that they would continue to have a job in Cashel after the transfer of services to Clonmel. A number of staff chose to remain in Cashel in line with this agreement. They have now become PCCC staff and are working in PCCC services in areas such as disability, mental health and care of the elderly. There are further plans to continue to expand these services and the use of the staff in Cashel. It is based on a 1996 agreement in a letter of comfort.

Chairman

The Department of Health and Children is listed under the overall spend on training and development in the Civil Service. Figures for the Health Service Executive are not provided in the table. What money is spent on training? I noted a newspaper headline referring to the HSE and a €100 million training splurge.

Professor Brendan Drumm

We could give the Chairman an education and training figure but the accuracy is in question because of how money is disbursed locally. Included in this figure are major sums disbursed to universities for nursing education and other major postgraduate programmes. The figure is €105 million in 2006, listed on page 80 of the annual report.

Chairman

Is it the Health Service Executive annual accounts?

Professor Brendan Drumm

Yes. Much of this money is block grants to universities for nursing training. Perhaps the Chairman is asking if money for local training is sanctioned lower down in the organisation. It is also a question on which we want to get a better handle. The figure may not encompass all that.

Chairman

It seems to be a high figure.

Professor Brendan Drumm

It includes significant grants for general practitioners.

Chairman

Will the Health Service Executive give the committee a breakdown on the figure? We have touched on many areas over the past four and a half hours. I will not delay the meeting any further but I wish to be slightly parochial. Professor Drumm referred to the Mercy Hospital in Cork and the ongoing problem of the unused building. At a previous Oireachtas meeting, Professor Drumm referred to an ongoing dispute between the HSE and local management and said that arbitration was going to be used to deal with the issue.

Professor Brendan Drumm

The note I have today is that the Health Service Executive is in active negotiation with the management of the Mercy Hospital regarding the provision of these additional staff, including 15 nursing staff to run the new accident and emergency unit. That will amount to 33 nursing staff for 70 to 80 attendances. Discussions are ongoing and both sides have agreed to an evaluation of the nursing staff requirement for the new facility, which will advance the issue. The final report of this review is awaited. I can try to ascertain a timeframe.

Chairman

Nothing has changed since November.

Professor Brendan Drumm

I will try to find out a specific date.

Chairman

It would be appreciated. I thank the witnesses for the time and responses received. Is it agreed that the committee dispose of chapter 10.1, control and sanctioning of ICT expenditure?

Deputy Seán Fleming

I propose we hold it over. I do not wish to be awkward.

Chairman

We propose only to dispose of the chapter. We will hold over on the Votes.

Deputy Seán Fleming

That is fine.

Chairman

The committee will revisit the Votes, chapters 39 and 40, and the accounts of the Health Service Executive between Easter and the summer recess. Is that agreed?

Deputy Seán Fleming

Many matters have been left with the Health Service Executive for reply later. I presume someone will go through the report and revert to the committee.

Professor Brendan Drumm

We have been very consistent with the committee and we will try to do so.

Chairman

Although I am not being nasty I hope there will be better replies than we receive to parliamentary questions.

Professor Brendan Drumm

The challenge on parliamentary questions is twofold: the rate of reply and the numbers replied to. We place a major emphasis on this. Quality is a challenge and Mr. Ray Mitchell will be pleased to take comments from members. We are focused on trying to improve it but we are dependent on input from people through the system. There is sometimes great variance in quality.

Chairman

What I cannot understand is that one could get a reasonable response to a written question within three days under the old system with so many health boards. These days it can take three months and the content and quality of the reply shows contempt for the role we have as representatives of the public.

Professor Brendan Drumm

We now answer 75% of the questions within a 20-day period. Some questions are very complex and much data must be collected. One will never arrive at 100% answered within that time. If members receive a reply that shows a lack of regard for the system, it is important that this be flagged to us. It is the job of Mr. Ray Mitchell to take this on board. It would help us in terms of going back and saying it is unacceptable.

The witnesses withdrew.

Chairman

We must agree the agenda for Thursday, 14 February 2008 as follows: the 2006 Annual Report of the Comptroller and Auditor General and Appropriation Accounts: Vote 25 - Department of the Environment, Heritage and Local Government; chapter 6.1, contract termination costs, environment fund 2006 and local government fund 2006, and relevant chapters from the value for money report 56 of the Comptroller and Auditor General, Improving Performance - Public Service Case Studies: chapter 4, management of inland fisheries; chapter 15, Met Éireann; chapter 16, special housing aid for the elderly; and chapters 18 and 19, part C - cross-cutting reports.

Deputy Seán Fleming

Is the local government fund the motor tax accounts?

Mr. John Purcell

Yes, funds from the motor tax receipts form part of the revenue of the local government fund.

Chairman

I omitted to invite Mr. Purcell to respond to any of the issues raised.

Mr. John Purcell

I could do so but we are here very late. A question was asked about pensions. The cost of pensions was €320 million in the year as recorded in the account. This is the cost of pensions paid out and does not conform to the value of the pensions earned by the employees. If one takes that as approximately 15% of the €4.4 billion pay bill, the figure would be double the amount given. The Minister for Health and Children, in her wisdom, has decided that financial reporting standard 17 should not apply to the Health Service Executive. I am sure it will in due course when this is examined on a service-wide basis.

Other issues touch on matters of concern to the committee. I indicated before Christmas that we are examining how the HSE budget was monitored during 2007. Professor Drumm mentions some of the measures that had to be employed to meet the budget. Correspondence has been exchanged at a senior level between the Department and the HSE to the effect that the situation can no longer continue in 2008, as confirmed today. We may examine this to see if we can add value by taking a perspective on why this occurred.

Deputy Darragh O’Brien

Is Mr. Purcell stating the figure for pensions represents payments to annuitants and does not include the funding of existing pensions for people who will retire, which is not shown anywhere?

Mr. John Purcell

That is exactly what I am saying.

Deputy Darragh O’Brien

The pension payments made on behalf of the 111,000 people working in the Health Service Executive, which I assume is in a defined benefit scheme and therefore sizeable, is not shown.

Mr. John Purcell

No deduction is made because it is a non-contributory scheme.

Deputy Darragh O’Brien

There is still a substantial cost.

Mr. John Purcell

I apologise; it is a contributory scheme.

Deputy Seán Fleming

Superannuation.

Mr. John Purcell

There is no payment into a fund on behalf of the employer. This is a major cost. I mentioned in my audit report that it does not conform. I did not want to qualify my report because it is a decision of the Minister. However, I mention that the cost of employing these staff is under-reported in this sense. It is no different from all other civil servants in an unfunded scheme. We are working on this issue across the public service to see whether we can bring clarity to the type of liabilities we will face. I know the matter of accrued liabilities is very close to Deputy Fleming's heart.

The value for money report we carried out on the management of the previous medical contract with consultants addressed some of the issues raised today. At that stage, we had a contract which was not managed because we had no way of ensuring the conditions of the contract were complied with. I presume the Chairman will take this matter up at the next meeting on health. Other issues exist but it is late in the day and they can be raised again.

Chairman

I thank Mr. Purcell and others who attended the meeting. The committee has seen a large turnover of membership since the previous committee. We learn a great deal from each group which comes to the committee. I hope we will have an effective relationship during the coming years.

The committee adjourned at 2.40 p.m. until 10 a.m. on Thursday, 14 February 2008.