I will start by providing some background. The primary purpose of the National Treatment Purchase Fund is to offer an alternative to the public patients who have waited longest for elective surgery. It does this by funding surgery for public patients, primarily in private hospitals within Ireland. It has arranged treatment for more than 165,000 public patients to date. When the NTPF was established in 2002, public patients often waited two to five years for surgery. The median wait time for surgery is now 2.5 months. In the early years there was a need, in order to ensure treatments were provided more quickly, to send some patients to the UK for surgery, but with the increase in private hospital capacity, there is now no need to refer patients outside Ireland. In 2009, less then 5% of referrals were treated in hospitals in Northern Ireland.
The budget for the NTPF in 2010 is €90 million and it is proposed, subject to discussions with the Department of Health and Children, to provide 19,500 inpatient procedures, about 3,000 MRI scans and about 8,000 first-time outpatient consultations. The NTPF also has a specific role within the new fair deal scheme and has agreed prices with 439 private and voluntary nursing homes on behalf of the State.
The NTPF has two distinct core roles: working with hospitals to ensure the patients waiting longest can access treatment, and the collation and reporting of waiting lists and waiting times. The management of individual public hospital waiting lists is the responsibility of the public hospitals. It is the hospitals themselves that record patients being placed on and coming off waiting lists as they receive their treatment. In addition, there are inpatient and outpatient waiting lists. Inpatient waiting lists record those patients who have seen a consultant and been placed on a waiting list for a procedure. Hospitals report inpatient waiting lists to the NTPF through the patient treatment register. Waiting times for all procedures are updated monthly on a website and the NTPF reports extensively on waiting lists in the biannual national patient treatment register report. The NTPF has concentrated most of its efforts on shortening inpatient waiting times on the basis that these people have been waiting the longest, in line with our mandate. At the end of 2009, 18,517 patients had been waiting for treatment for more than three months, of which 14,451 were awaiting surgery. I have included in the documentation a table with the various time categories.
The NTPF operates a consultant-provided service rather than a consultant-led service. This means that public patients under the scheme are seen and treated by hospital consultants at all stages. To participate in the NTPF programme, consultants must be registered on the specialist register with the Medical Council, which is the gold standard in Ireland. When we last met this committee, concern was expressed about a perception that some consultants were able to treat their own public patients under the NTPF. I would like to update the committee on this matter. While it has always been vigilant in ensuring this did not occur, the NTPF has introduced additional checks which ensure consultants do not treat, under the scheme and in private hospitals, patients who are on their public hospital waiting list. In a small number of cases, however, this is necessary for medical reasons and is performed in the interests of the patient. In 2009 such cases amounted to 1.6% of NTPF activity. Each case is specifically pre-approved by the NTPF. The increase in private hospital capacity has also contributed in this regard.
Hospitals must receive prior approval before they can treat patients under the auspices of the NTPF. A broad range of surgical capacity is required to provide for the needs of the public patients referred under this scheme. Referrals are matched with available appropriate capacity with regard to patient age, the procedure required, other medical needs of the patient and value for money. Patient choice and geographical considerations are also accounted for where possible.
The NTPF in no way affects the ability of individual hospitals to schedule their own public patients for treatment. In fact, it steps in only when hospitals have failed to provide treatment for public patients and they have been left waiting for too long. As a matter of policy, the NTPF is allowed to source 10% of its activity from the public hospital system. This is to be used for cases for which capacity does not generally exist in the private system and only on the strict understanding that it does not interfere with core hospital activity or the level of service agreed between hospitals and the HSE. In 2009, the NTPF sourced 6% of its activity from the public hospital system.
In association with the HSE, the Department of Health and Children and the public hospitals, the NTPF has developed a national waiting list policy to enable consistent management of inpatient and day case waiting lists. The policy prescribes a minimum standard, facilitates the quicker treatment of patients on waiting lists and has established more accurate reporting of waiting list information through the patient treatment register. To monitor compliance with this policy, the NTPF regularly visits hospitals and examines waiting lists. After this review and analysis process, any necessary changes are highlighted to the hospital. The NTPF also provides a training and development program for staff on hospital sites.
The longest waiters — about whom we hear a lot nowadays — are currently classified as those patients who have been on inpatient waiting lists for more than a year. It is unacceptable to the NTPF that any patient must wait this length of time for treatment. At the end of 2009 there were 719 surgical patients in this category. However, this represents a reduction from 5,584 in December 2006 and a maximum of 7,000 when the NTPF was established in 2002. With approximately 675,000 discharges from the public hospital system annually, it is difficult to believe 700 people cannot be accommodated.
The NTPF is working with the Department of Health and the HSE to obtain treatment for these patients. However, from the NTPF's review and analysis of the longest waiters in the latter part of 2009, it is clear that many of these patients are outside the ambit of the NTPF. A total of 43% of these patients failed to respond to correspondence from the hospital or have not attended a scheduled date for admission; 27% were removed from the waiting list after having treatment or are currently unsuitable for treatment; 11% required treatment in their own hospital for medical reasons; and 5% have actually declined an NTPF offer of faster treatment. This means that 14% of the cohort examined are suitable for treatment either in hospital or by the NTPF. We are actively working with hospitals to get these patients referred.
We have always said in the NTPF that it is not number of patients waiting but the waiting time that is the most important indicator of the efficacy of the system. The average median waiting time for all procedures is now 2.5 months.
From the outset the NTPF has worked with public hospitals to maximise the benefit for public patients. The number of people waiting and the length of time they have waited for treatment continue to vary across the public hospital system with different figures for different hospitals. There are many reasons for this and the NTPF has endeavoured to work around it while at the same time not penalising the better performing hospitals. As an example, two years ago there were 4,500 patients waiting over 12 months, including 1,200 in Letterkenny Hospital alone. Members will be aware that we regularly highlighted this unacceptable situation. The NTPF applied a particularly rigorous focus to this issue, working with hospital and its staff to prioritise those longest waiting and today there are 30 patients waiting more than 12 months for surgery in that hospital. In 2009 20% of referrals were waiting over 12 months. In 2010 we will apply a special focus to those waiting more than nine months. Our intention is to make good progress in this area this year.
The provision of access to consultants at out-patient level for first-time appointments remains one of the bottlenecks in the public hospital system and in many ways is similar to the issues in elective in-patient surgery when the NTPF was established. It has been reported that 175,000 people are on out-patient waiting lists. While NTPF involvement in this area has been limited, in the years 2005 to 2009 more than 82,000 patients were contacted and offered appointments at out-patient clinics, with substantial reductions in waiting times achieved in the specialties targeted through this pilot initiative. In 2010, it is planned to offer 8,000 outpatient appointments. Experience tells us that this alone can result in the removal of up to 16,000 people from lists through a validation exercise.
Demonstrating value for money remains a key objective for the NTPF. In 2009 it has continued to work with private hospitals to maximise the volume of patients that can be treated. If particular treatment prices offered to the NTPF by a hospital are high we will source an alternative supplier. That means we do not have to accept prices as offered and also means that when and where it makes sense to do so, NTPF patients are treated by better value providers. This simple principle of "volume follows value" has an additional positive consequence because private hospitals can plan in a way that treatment prices reduce as the volume of NTPF referrals increase. This means the NTPF can, and does, negotiate volume discount deals. We have also continued to leverage the effect of increases in capacity due to newer private hospitals and clinics coming on stream.
The impact of this approach is the lowering of overall average costs. Aside from the reduction in overall average cost another test of value for NTPF is how it compares with others who purchase healthcare. Prices offered by hospitals are subjected to a number of checks including comparison against prices for similar treatments in other peer private hospitals and, when publicly available, prices paid by medical insurers. Prices are also benchmarked with public hospital average costs, namely, case-mix data. The NTPF notes that, following an analysis of NTPF processes, the Comptroller and Auditor General reported that most procedures purchased from private hospitals cost less than case-mix adjusted benchmark costs. It is worth noting that the cost of data summarised in figure 124 of that report uses treatment costs from 2008. The prices for 2009 reduced by up to 15%. While NTPF is of the view that this demonstrates value for money we obviously continue to look for ways of getting the most from the taxpayer funds made available to us.
Since 3 July 2009 the NTPF has been negotiating and agreeing prices with private and voluntary nursing home owners for the purposes of the new nursing homes support scheme, otherwise known as the fair deal scheme. The NTPF has a specific remit within this scheme. If the NTPF is of the view that prices offered by a nursing home represent value for money a pricing agreement is reached with that home and in turn we provide the HSE with the relevant pricing details. The home is then placed on a list of participating nursing homes. Agreements were reached on prices with almost all private nursing homes in the country before the commencement of the scheme on 27 October 2009. At the time of writing, 439 or 99% of private and voluntary nursing homes have agreed prices with the NTPF.
The NTPF is committed to arranging treatment for the longest waiting public patients, to ensure this is delivered to the highest clinical standards and at the best possible value to the taxpayer. Patient satisfaction levels remain very high with access to faster treatment under this scheme. There is no doubt that people want to be treated faster. While 2010 will be a challenging year, our main priority will be to keep overall waiting times as low as possible, with the current average median waiting time for all procedures now 2.5 months. We will place a special focus on those waiting more than nine months for treatment, with the goal of ensuring this cohort is treated by hospitals and by referral to the NTPF.
In total we expect to arrange treatment for more than 30,000 public patients in 2010. This will include 8,000 first-time outpatient appointments. It is at outpatient level that one of the main bottlenecks in the public health system exists and this is an area where much progress for public patients can be achieved. From a financial point of view, we will operate in 2010 with the same budget as in 2009 but we will endeavour to treat more patients and to gain maximum value for money.