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COMMITTEE OF PUBLIC ACCOUNTS debate -
Thursday, 28 Jan 2010

Chapter 36 — National Treatment Purchase Fund.

Mr. Michael Scanlan (Secretary General, Department of Health and Children) and Mr. Pat O’Byrne (Chief Executive Officer, National Treatment Purchase Fund) called and examined.

I welcome everybody to the meeting. We will consider the 2008 annual report of the Comptroller and Auditor General and 2008 appropriation accounts: Vote 39 — Health and Children; Vote 41 — the Office of the Minister for Children; and chapter 36 — National Treatment Purchase Fund.

I draw everyone's attention to the fact that while members of the committee enjoy absolute privilege, the same privilege does not apply to witnesses appearing before the committee which cannot guarantee any level of privilege to witnesses appearing before it. 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 of the provisions within Standing Order 158 that the committee shall refrain from inquiring into the merits of a policy or policies of the Government or a Minister of the Government or the merits of the objectives of such policy or policies.

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

Mr. Michael Scanlan

I am accompanied by Mr. Fergal Lynch, assistant secretary, acute hospitals, blood policy and cancer policy; Mr. Jim Breslin, assistant secretary, finance and external ICT, information, performance evaluation, research and EU; and Ms Moira O'Mara, principal officer, child care directorate, Office of the Minister for Children and Youth Affairs.

I welcome Mr. Pat O'Byrne, chief executive officer, National Treatment Purchase Fund, and I invite him to introduce his colleagues.

Mr. Pat O’Byrne

I am accompanied by Mr. Dave Allen, financial director; Ms Anna Lloyd, director of patient care; and Ms Liz Lottering, national patient treatment register manager.

Mr. Tom Heffernan from the sectoral policy division of the Department of Finance is also present.

Mr. Tom Heffernan

I am accompanied by my colleague, Mr. Dermot Keane, who has responsibility for administrative budgets.

The witnesses are all welcome. I ask Mr. John Buckley to introduce Votes 39 and 41 and chapter 36. The full text of chapter 36 can be found in the annual report of the Comptroller and Auditor General or on the website of the Comptroller and Auditor General at www.audgen.gov.ie.

Mr. John Buckley

The outturn in the Vote for Health and Children was €498 million and most of its expenditure lines came in as budgeted. Exceptions arose in the case of inquiries, which cost less than half the projected €47 million, and clinical negligence costs, which at €42 million exceeded the amount projected by 70%.

Clinical negligence claims have been settled by the State Claims Agency on behalf of the Department since the establishment of the clinical indemnity scheme in 2002. The objective of this was to rationalise the existing medical indemnity arrangements by transferring to the State full responsibility for indemnification and management of all claims against hospitals and practitioners covered by the scheme. The State Claims Agency estimated a contingent liability of approximately €566 million existed under the heading by the end of June 2009.

The bulk of expenditure on the Vote of the Office of the Minister for Children and Youth Affairs was on advances of €480 million to the Department of Social and Family Affairs to meet early child care payments and of €153 million to Pobal, which administers the national child care investment programme on behalf of the Department.

The National Treatment Purchase Fund was established in 2002 and has two main purposes: to prepare reliable lists of persons waiting for treatment in public hospitals and to purchase treatments for those patients waiting the longest. Chapter 36 of my annual report examines how it carries out these two functions. From a pricing perspective, the audit found that the cost of treatments purchased from private hospitals was on average below adjusted case-mix costs. Case-mix costs are standard costs for procedures in Irish public hospitals.

In the case of treatments purchased from public hospitals, the prices were significantly below adjusted case-mix costs but that comparison would have to take account of the fact that hospital consultant fees are already paid from the public purse. Post-contract uplifts only occurred where an extra stay in hospital was required or where the procedure was not directly comparable to a specific case-mix category.

In regard to waiting list information, the National Treatment Purchase Fund, NTPF, collects information on patients waiting in most public hospitals, collates this information and publishes it in the patient treatment register, PTR, which is a register of all patients waiting more than three months. It also carries out validation audits in hospitals to ensure that the register is accurate. In reviewing the validation arrangements, the audit focused on those waiting the longest.

The report concluded that, based on the results of NTPF validation exercises, only a small number of recorded long-waiters were actually available for treatment. Between 8% and 17% of long-waiting patients on the PTR were found to be in a position to avail of treatment. These findings make it difficult to see how the NTPF can discharge its function of ensuring that patients waiting longest receive treatment. As well as impacting on the capacity of the NTPF to manage the treatment process, waiting list data deficiencies on the scale noted cannot but affect the scheduling of treatment by individual hospitals themselves.

The findings from the validation of long-waiting patients suggests a risk that the listings for shorter periods may also be inaccurate. Two particular trends were apparent in the course of validation; the numbers declining NTPF treatment were increasing and there was a significant recent increase in patients reported by the public hospitals as only suitable for treatment in those particular hospitals where they are listed. These two matters should be probed in depth by future surveys.

The structure of the recorded waiting lists suggests the problem may be amenable to targeting. A review of over 13,000 cases awaiting surgical procedures on the patient treatment register in April 2009 showed that much of the waiting list is accounted for by a small number of hospitals. Some 66% of all patients on the PTR emanate from 11 hospitals and of those, three hospitals account for half of all adult patients waiting in the over 12 months category.

Our conclusion was that the accuracy of the waiting lists needs to be improved and proactive waiting list management is a requirement. From the perspective of daily management of treatment, it would be worthwhile considering whether and to what extent any increase in public hospital capacity arising from new working arrangements agreed with consultants is capable of impacting on waiting lists, and what steps are being taken to configure services optimally. It should also be considered whether there is a need to broker exchanges between public hospitals, approximately half of which have no long-waiting patients, with a view to matching overall capacity with demand.

The Accounting Officer and CEO will be in a position to update the committee on any further matters.

Will Mr. Scanlan give his opening statement?

Mr. Michael Scanlan

I am pleased to meet with the committee today to discuss the 2008 appropriation accounts and the annual report of the Comptroller and Auditor General in regard to Vote 39, Vote 41 and chapter 36 dealing with the National Treatment Purchase Fund.

The gross outturn for Vote 39 in 2008 was €501 million. Of this, some €315 million was allocated in revenue funding to more than 20 agencies such as the National Treatment Purchase Fund, the Crisis Pregnancy Agency, the Office of the Ombudsman for Children, the National Cancer Screening Service, the Mental Health Commission, the Health Information and Quality Authority, HIQA, and the Health Research Board. The allocation also included over €138 million for compensation payments for people affected by hepatitis C, statutory and non-statutory inquires and legal fees, and payments to the State Claims Agency. The Department's administrative budget was €40 million.

The gross outturn for Vote 41 was €645 million in 2008. This included €480 million for the early child care payment, €153 million for the national child care investment programme and €11 million for a number of other programmes. In 2010, reflecting various Government policy decisions in the intervening period, the gross allocation is €360 million, including €170 million for the new early childhood care and education preschool year scheme, €105 million for the NCIP, €47 million for youth activities, and €39 million for other programmes.

Almost 175,000 patients have used the National Treatment Purchase Fund since its establishment in 2002. In 2008, the NTPF arranged treatment or diagnostic appointments for over 36,000 people. Since 2002, average waiting times for treatment have reduced to between two and five months, down from two to five years. The median waiting time for a procedure is now two and a half months. For 19 of the 20 most common adult surgical operations, and ten of the most common children's procedures, patients receive their treatment within two to five months. There has been a fall in the number of people per head of population waiting for surgical procedures between 2002 and 2008.

The NTPF, working with the HSE, has been giving particular attention to the issue of people waiting for more than 12 months for treatment. As a result, in 2008 the total number of persons waiting over 12 months was reduced by 64% to 1,576. By December 2009, the number of people waiting more than 12 months was further reduced to just over 700.

The NTPF, the HSE and the Department are examining how these figures can be improved. A key element of this work is the management of waiting lists. The NTPF's on-line patient treatment register provides an up-to-date picture of the waiting lists for 44 acute public hospitals nationally. In December 2009, the NTPF launched new guidelines for the management of inpatient and day case waiting lists. These guidelines have been endorsed by the Department and the HSE and are intended to achieve consistency in the way public hospitals manage their waiting lists.

The principal objective of the Department is the improvement of the health and well-being of the people of Ireland. Two recently published reports – OECD Health at a Glance 2009 and Health in Ireland: Key Trends 2009 — show that Ireland has achieved significant health gains for its population over recent years.

The 2009 OECD report provides updated information on key indicators such as life expectancy and infant mortality. Life expectancy in Ireland stands at 79.7 years in 2007, above the OECD average of 79 years. A key contributory factor is the significant reduction in major causes of death such as diseases of the circulatory system – down by 26% from 13,380 in 1999 to 9,883 in 2008. Infant mortality rates in Ireland have fallen dramatically over the last few decades. The rate is 3.1 deaths per 1,000 in 2007, lower than the OECD average of 3.9. Lifestyle issues such as alcohol and tobacco consumption, as well as obesity, continue to pose challenges. However, Ireland ranks high in terms of the percentage of the population reporting to be in good health, with 84% of Irish people rating their health to be good or very good-excellent compared to the OECD average of 69%.

The five-year relative survival rates in Ireland for breast, cervical and colorectal cancers for the period 2002-2007 show improvement over the period 1997-2002, although they have yet to reach the OECD average. The national cancer control programme has made considerable progress in the symptomatic breast services but also in other areas, including lung and prostate cancers. BreastCheck, the national breast screening programme, has been rolled out to all areas of the country and more than 100,000 mammograms were performed by the programme in 2009. In 2008 CervicalCheck, the national cervical screening programme, was introduced and since then more than 250,000 women have been screened.

The report, Health in Ireland: Key Trends 2009, also covers population and health status as well as trends in service provision. For example, since 1999 there has been an increase of 148% in day cases in public acute hospitals. The number of patients in psychiatric hospitals has fallen by 31% over the ten-year period, reflecting the policy of more appropriate community-based models of care. Immunisation rates have been increasing since 2002 and are now approaching the 95% rate envisaged in the immunisation guidelines for Ireland 2008.

Policies to improve health status and social well-being require proactive interdepartmental and interagency co-ordination and co-operation in order to deliver integrated public services. The OECD review of the Irish public service acknowledged that Ireland has made inroads in developing an integrated approach through the establishment of the office of the Minister of State with responsibility for children and youth affairs, the office for older people and the office for disability and mental health. The OECD also highlighted the need to shift the focus from inputs – such as funding, staff, etc. – and to focus more on outputs, outcomes and results.

Similar to other health systems around the world, we face the challenge of maintaining and improving our health services within a much tighter expenditure framework. This will require an increased and more forensic focus on how costs can be controlled but also, more importantly, on how services can be provided in ways which will achieve better outcomes for the level of resources available.

I thank the committee for its attention.

I thank Mr. Scanlan. May we publish his report?

Mr. Michael Scanlan

Yes.

We will now have the opening statement from Mr. O'Byrne.

Mr. Pat O’Byrne

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.

I thank Mr. O'Byrne. May we publish this statement?

Mr. Pat O’Byrne

Yes.

There is another matter before I ask Deputy McCormack to speak. On 5 November when Professor Drumm spoke to the committee he volunteered, without our prompting, to provide details of the private practice of consultants. To date we have not received that information. We expected to have information on the breakdown of public and private practice on a consultant by consultant basis but we do not have it. In the context of today's discussion, it would have been interesting to have seen the level to which private practice has exceeded the limit placed on it. I shall refer later to what Mr. Scanlan said with regard to May of last year.

The National Treatment Purchase Fund accounts for just over 3% of surgical procedures in our hospitals. That means that if our hospitals were 3% more efficient we might not need this fund. This is not the fault of Mr. O'Byrne and his colleagues. However, in a way, the activities of the NTPF are dealing with a symptom while the Department and the HSE should be addressing the root cause of the problem. In addition, because Professor Drumm had volunteered to give the committee that information — although we do not have it — we had a communication from the Irish Hospital Consultants Association regarding the performance of its members in public hospitals. It stated that some members have been prevented from conducting further surgical procedures by the cap placed on hospital budgets. We have written to the IHCA requesting that it make a written submission to the committee, setting out the situation as its members see it.

There is spare capacity within the system that has not been used. Instead the money is being channelled to the NTPF to private hospitals. As Chairman, that is how I see the context of this discussion with the NTPF.

I have a question for Mr. Scanlan regarding his opening statement. He said that €315 million of Revenue funding was allocated to more than 20 agencies, of which he named only a few. The committee has received annual reports from many agencies in recent times and I have made a count of those agencies under Mr. Scanlan's jurisdiction. Perhaps one or two of them come under the Health Service Executive. However, instead of 20 agencies I counted 24. I will put the names on the record. They are the Board for the Employment of Blind People——

Mr. Michael Scanlan

That has been abolished. It no longer exists.

——the Crisis Pregnancy Agency——-

Mr. Michael Scanlan

I mentioned that.

——the Drug Treatment Centre Board——

Mr. Michael Scanlan

That is funded by the HSE.

——the Food Safety Authority of Ireland, the Health Insurance Authority, the Health Research Board, the Health Service National Partnerships Forum——

Mr. Michael Scanlan

The HSE.

——the interim Health Information and Quality Authority——-

Mr. Michael Scanlan

It is now HIQA. It was interim.

——the Irish Blood Transfusion Service, the Irish Health Services Accreditation Board——

Mr. Michael Scanlan

It is now part of HIQA.

——the Irish Medicines Board, the Mental Health Commission, the National Breast Screening Board——

Mr. Michael Scanlan

It is now the National Cancer Screening Service.

——the National Cancer Registry, the National Council for the Professional Development of Nursing and Midwifery, the National Disability Authority——

Mr. Michael Scanlan

It comes under the remit of the Department of Justice, Equality and Law Reform.

——-the National Paediatric Hospital Development Board——-

Mr. Michael Scanlan

It comes under the HSE.

——the National Treatment Purchase Fund, the Office of the Director of Tobacco Control, the Ombudsman for Children, the Pre-Hospital Emergency Care Council, the repayments scheme for 2006——

Mr. Michael Scanlan

I do not count it as an agency, but it is included.

——the Residential Institutions Redress Board——

Mr. Michael Scanlan

That is run by the Department of Education and Science.

——and the Women's Health Council. The McCarthy report recommended that some of these agencies should be merged.

Mr. Michael Scanlan

Yes.

What progress is being made on that? Have the delegation addressed the more than 20 boards which are in existence?

Mr. Michael Scanlan

A programme for rationalising some of the agencies was announced in a recent budget. Since then, some agencies have been rationalised, some are about to be and we need legislation to rationalise others. The Postgraduate Medical and Dental Board and the Crisis Pregnancy Agency are being rationalised into the HSE. The National Council on Ageing and Older People and the Women's Health Council are being subsumed into the Department, the Drug Treatment Centre Board into the HSE and the National Cancer Screening Service is due to be subsumed into the HSE this year.

The Pre-Hospital Emergency Care Council, the National Social Work Qualification Board, which was not on the list, and the Opticians Board are all to be merged into the Health and Social Care Professionals Council. We need legislation for that, which we expect to be finalised this year. The functions of the Children's Act Advisory Board are to be subsumed into the office of the Minister of State with responsibility for children and youth affairs. That requires legislation, which has been published. The National Cancer Registry is to move into the HSE but we need legislation, which will be addressed in the Health Information Bill which is currently being drafted. We also need legislation to merge the National Council for the Professional Development of Nursing and Midwifery and assign its responsibilities to An Bord Altranais and the HSE, which will be provided for in the nurses Bill.

We have a substantial programme of rationalisation. If the committee wishes I could write to it, outlining our understanding of the current list of agencies and the ones which are scheduled to be merged.

In my trawl of the agencies I missed a few which were not on my list.

Mr. Michael Scanlan

Absolutely.

Mr. Scanlon can see where we are coming from.

Mr. Michael Scanlan

Yes, I can.

It is incredible that a Department would have responsibility for so many diverse bodies. As the McCarthy report stated, some of them should be merged. We would welcome a report on that.

Mr. Michael Scanlan

I will be happy to do that.

I thank Mr. Scanlan and Mr. O'Byrne for their comprehensive reports, which contain a lot of figures and percentages. Some of the questions I will ask may necessitate a repetition of some of the figures because I could not take them all down during the presentation. Has there been much change in the past three months in the management of hospital waiting lists? Is the current system the most effective, from the point of view of hospitals?

Mr. Pat O’Byrne

Over the past three months, there has not been much change in the way lists are managed. In order to try to ensure lists are managed better we have had waiting list policies since 2007. We updated those in association with the public hospital system and the HSE, and they were also endorsed by the Department of Health and Children. They were published in December and set out how waiting lists should be managed in a standardised and consistent way. It will take some time for all the recommendations in the policies to filter through all the hospitals, but if those policies were adopted the management of waiting lists in hospitals would be strengthened in a major way.

I take it the delegation is working on an improved system of efficiency in that regard.

Mr. Pat O’Byrne

Yes, in the management of waiting lists. The new policy was published in December and sets out in great detail how, in agreement with the public hospital system because it was part of drawing up the policy, waiting lists will be managed in the future.

From what Mr. O'Byrne has said the numbers of cases requiring treatment in hospitals increased significantly in May 2009. Is that still the case? Why is it happening? What is the total number of people on waiting lists at the end of 2009? I understand the delegation provided the figure.

Mr. Pat O’Byrne

Yes.

What happened in May which resulted in a significant increase?

Mr. Pat O’Byrne

I am trying to understand the question.

I am trying to compare the figures for May 2009 with those for December to establish the trend.

Mr. Pat O’Byrne

On the trend in waiting list figures, in May 2009 the total number of surgical and medical patients over three months comprised some 17,500 people.

What about December 2009?

Mr. Pat O’Byrne

For December 2009 the figure was approximately 18,500. On the numbers over 12 months——

That was going to be my next question, so Mr. O'Byrne can answer it.

Mr. Pat O’Byrne

In May 2009, there were 1,167 patients who were waiting for surgery for more than 12 months.

The Department requested the setting of targets so that no one would be waiting longer than 12 months at the end of September 2009, a target which has not been achieved.

Mr. Pat O’Byrne

The Department said there should be nobody waiting more than 12 months at the end of the year.

That was the target.

Mr. Pat O’Byrne

That is correct. At the end of December, there are——

Mr. Pat O’Byrne

There were 1,167 in May 2009.

Mr. Pat O’Byrne

Yes.

What about December 2009?

Mr. Pat O’Byrne

In December 2009 the figure was 719.

There are still 719 on the waiting list at the end of December, despite the fact that the target was to have no one on a waiting list by that time.

Mr. Pat O’Byrne

As I have said, I gave a breakdown of the categories of patients. As far as the NTPF was concerned approximately half of the patients concerned were waiting for an administrative follow-up in the hospital system. Some quarter of those patients were cases which were notified to the NTPF as cases which could only be done in-house. Some 5% of those patients declined NTPF treatment.

The number waiting in Crumlin Hospital was 840 in April 2009. What are the current figures?

Mr. Pat O’Byrne

I will find the information for the Deputy. Crumlin hospital remains a problem area in terms of the NTPF. Bluntly speaking, we are not happy with the way Crumlin hospital is implementing waiting list management policies and the focus it has on its longest waiters.

Do evaluation audits affect that?

Mr. Pat O’Byrne

Yes. We are also not happy with the level of engagement that Crumlin hospital has with the NTPF because it is patchy to say the least.

Going back to the question, when we did a review and analysis of Crumlin hospital in mid-2009, we were able to take 150 patients off its longest waiters waiting list, that is, 150 of those who were supposedly on the list for over 12 months. That points to weaknesses in the implementation of the waiting list management policies. Later in the year, if we look at what happened with the scoliosis issue, when the hospital system, at the behest of the HSE, started working together and tackling the problem, solutions were put in place for the scoliosis patients that were not there earlier in the year. I would like to see more engagement with the NTPF from Crumlin hospital.

What does it mean that people were taken off the list?

Mr. Pat O’Byrne

They were validated off the waiting list.

What does that mean?

Mr. Pat O’Byrne

They were patients who were being followed up by the hospital or had been treated in some cases.

Ms Liz Lottering

The vast majority of them had been treated in Crumlin hospital. There were also patients who were clinically unsuitable at that time to have their treatment. There were others who had not attended for numerous scheduled admissions who had to be followed up through their GPs to see if their treatment was still required.

I thought that meant they had been offered treatment or had been treated.

Mr. Pat O’Byrne

There was no need to offer them treatment.

What are the current numbers on the waiting lists for Crumlin hospital?

Mr. Pat O’Byrne

At the moment there are 406 patients waiting three to six months, 498 patients waiting between six and 12 months and 71 waiting for more than 12 months.

Approximately 1,000 then.

Mr. Pat O’Byrne

Yes.

That increased since April, when there were 840 on the waiting list.

Mr. Pat O’Byrne

Yes. As I was saying when talking about engagement with the NTPF, if I give the committee the example of Letterkenny General Hospital where, two years ago, there were 1,200 patients waiting over 12 months for surgery, when Letterkenny engaged with the NTPF, the figure fell to 30. That is the type of engagement I would like to see with Crumlin hospital and a few other hospitals.

Is the validation process showing up inaccuracies?

Mr. Pat O’Byrne

Yes.

Mr. Pat O’Byrne

In the case of Crumlin hospital, because it is not applying the management of waiting lists.

Is the NTPF aware of that?

Mr. Pat O’Byrne

Yes, because this came to light as a result of our review and analysis. Part of our remit is to validate waiting lists. As a result of the patient treatment registers, we go out to every hospital twice a year to review and analyse their waiting lists in association with the hospitals so that if things like that are discovered, we can highlight them and deal with them.

The NTPF has stated that five hospitals do not adhere to the guidelines. What happens to those hospitals that do not adhere to those guidelines? Which hospitals are they?

Mr. Michael Scanlan

This goes back to the point the Chairman made at the start, that this is an entire system; one cannot just look at the NTPF. This is where the Chairman was coming from. In terms of placing a focus on the location of the difficulties, one must then go back into the health system.

I will say where I am coming from. On 29 May 2008, Mr. Scanlan attended here to discuss private and public medicine and new contracts. At that meeting, Mr. Scanlan said that under the new contract there was new clarity, as the Comptroller and Auditor General said, although it was not quite as simple as 80:20. Mr. Scanlan said that the key issue on which he and Professor Drumm insisted was a system of measurement and absolute transparency. That was in May 2008, and it is now almost February 2010 but we still do not have transparency and absolute measurement.

Mr. Michael Scanlan

Can I come back to that? I was joining up two different things.

The Deputy asked me what we do when hospitals are not co-operating. The Department has taken that up with the HSE, the Minister has taken it up with the Chairman of the HSE and we have had tripartite discussions where we made the point that there are, and always have been, a limited number of hospitals that account for this. We pointed that out to the HSE and said that the focus must be placed on getting those hospitals running proper waiting lists.

I accept for clinical reasons that some patients who are waiting for long periods may not be suitable to get services elsewhere. If that is the case, we said to the HSE, and the numbers are relatively small, the hospital should focus on them. We asked the HSE to do precisely what is being suggested, with a disincentive, for people who do not address their waiting list issues.

In fairness to the system, it shows that through a combination of better data, it is not that more people are undergoing more procedures, although that is part of it, it is that the data are not good. That was one of the key points in the Comptroller and Auditor General's report: how can a system be organised if the data are poor? Through a combination of better data, efficiency in the public hospitals and the NTPF, the numbers waiting longest have come down over the past five years to a significant degree.

Where are the five hospitals that are not adhering to the guidelines?

When saying the numbers have come down appreciably, they have come down because, if we look at the numbers on outpatient waiting lists, and Mr. O'Byrne referred to this, they have gone through the roof. The numbers are being massaged by keeping people on external waiting lists. There were cases in the report of the Comptroller and Auditor General where hospitals have stopped referring people to outpatient waiting lists. We discussed that with Professor Drumm and he said it could not be correct, that Cork University Hospital, for example, does not even put people on outpatient waiting lists. If those lists have gone through the roof, it is easy to project figures for a decline in the need for inpatient treatment. The figures are being massaged.

Mr. Michael Scanlan

The Chairman is right regarding outpatients but that does not mean the waiting lists for inpatients are being massaged.

A false picture was created.

Mr. Michael Scanlan

Yes, in one way but not in terms of the reduction in the numbers waiting for treatment who have got past outpatients. There has been a clear trend of a reduction in the numbers waiting for treatment. I agree with the Chairman that it does not give a full picture in terms of the patients. GPs have made the point that patients need some investigation and possible treatment right through to the end. The Chairman made that point on the last occasion. In fairness to the CEO, that is a point he has taken up and the Minister has also taken it up. It is not acceptable that a hospital would not even put people on an outpatient waiting list. My view and that of Professor Drumm's is that we need to have much more of a focus on the outpatient side. Given the work the NTPF has done and the work that has been done already by the HSE, I would almost guarantee that when this is done, the data will not be robust in that there are people on the list who, for one reason or another, should not be on it. All the evidence suggests that some patients being seen in outpatients, as we speak, should be not seen there as there is no need for them to be there. Professor Drumm has said this on a few occasions and I have heard Professor Keane say it. One will find, as is right and proper, that the numbers waiting for treatment inevitably will grow. In that respect, the Chairman's core point is correct. That is what will surface and we need to face that if we are to be fair in this respect.

What is causing hospitals to classify more patients as being only suitable for treatment in their local hospitals? Is there an incentive in the system to retain numbers on waiting lists?

Mr. Pat O’Byrne

I do not believe there is any such incentive but hospitals have particular specialties and patients that require specialty treatment should be only treated in the respective hospital. Irrespective of that, I always ask the question that if a hospital can treat thousands of patients who have been on a waiting list for less than 12 months, why can they not treat a handful of patients who have been more than 12 months on the waiting list? There is no doubt, medically speaking, that there are patients who can only be suitably treated in particular hospitals. That is a fact.

On a separate question, how does the cost per procedure carried out by the NTPF compare with the cost of a patient being treated privately? Can Mr. O'Byrne compare the costs of treatment in terms of patients treated privately under the health insurance scheme? Have any discussions taken place with the health insurance companies regarding costs?

Mr. Pat O’Byrne

There have been no discussions between the NTPF and the private insurers on costs.

Would it not be desirable that such discussions would take place?

Mr. Pat O’Byrne

There may be pros and cons to doing that. We would have to bear in mind the price sensitivity issue in such consideration.

What does Mr. O'Byrne mean by that?

Mr. Pat O’Byrne

The NTPF has always closely guarded the prices paid for individual procedures. If that information was generally known, for example, to private hospitals, it would limit our ability to negotiate to secure better prices. We have to go to the marketplace and negotiate separately.

With whom does Mr. O'Byrne negotiate?

Mr. Pat O’Byrne

We negotiate separately with all the private hospitals. If one private hospital becomes aware that the price paid to it for a procedure is less than that paid to another private hospital, the competitive advantage will be lost. It is incumbent on us to try to secure the best prices we can and to drive down prices.

There is a competitive advantage there.

Mr. Pat O’Byrne

We have noted recently that as the level of funding provided to the NTPF has increased, we have been able to lever that out in our discussions with private hospitals and use it to our advantage.

There is no check on the cost of procedures in discussions between the NTPF and the health insurance companies.

Mr. Pat O’Byrne

We do not check that with the private insurers. We check the public hospital case-mix costs and we compare the costs, where they are known, of private procedures.

Does Mr. O'Byrne not consider it is time that some discussions took place with the private insurance companies?

Mr. Pat O’Byrne

It would be good if we could do that on the basis that we would not have to divulge our prices. We would lose some of our competitiveness if we did that.

I wish to get further clarification on an issue on which the Chairman touched. How many patients were treated under the NTPF who had the same consultant when on the public list?

Mr. Pat O’Byrne

The number of patients treated in the private system by the same consultant on whose list they were in the public system is 1.6%.

To what does that percentage equate in figures?

Mr. Pat O’Byrne

That amounts to 475 cases in 2009.

If Mr. X is on a public list and, on health grounds, cannot wait to be treated from the list and is treated under the NTPF by the same consultant he had on the public list, is it not extraordinary that happened in 475 cases in 2009?

Mr. Pat O’Byrne

No, it is not.

Mr. Pat O’Byrne

I will tell the Deputy why it is not.

Then I am very innocent about this.

Mr. Pat O’Byrne

We have to deal with the realities. My medical advisers tell me that there are cases where a patient should not be treated by a consultant other than the consultant whose list he or she is on at present. That is in the best interests of the patient. That is the medical advice. This could be as a result of there being so few consultants in a particular specialty in this country that this has to be done. We have tried to confine those cases to as small a number as we can. Where we dealt with, say, 28,000 cases last year, I do not think that 475 is an unrealistic figure in this respect because that is in the best interests of the patient. We have put many more checks and balances in the system. Consultants do not control this; the NTPF controls it.

I am all for everything that is in the best interests of the patient but how can a consultant have time to treat a patient privately but not have time to treat that patient publicly?

Mr. Pat O’Byrne

My understanding is that consultants are only contracted to provide a normal week's work in the public hospital system. As I understand it, they can do what they like outside of that provision, in the same way the Deputy can do other things on leaving the Dáil this evening, as can I and everybody else on leaving work.

I would not have time to do that.

Mr. Pat O’Byrne

That is my understanding of it.

I will be going to a meeting in Maam.

Mr. Pat O’Byrne

That is how it happens. My understanding is that consultants do this work in a private hospital outside of their time in a public hospital. That is how it is done.

What did Mr. O'Byrne say was his understanding of this?

Mr. Pat O’Byrne

This is done outside a consultant's public hospital time and in a private hospital. Consultants are contracted to a public hospital for a certain number of hours a week and outside of that provision, they can do what they like.

We published a report in November 2008 in which we identified 3,800 patients who were treated under the NTPF by a consultant who had the patient on his or her public waiting list. The incidence of that has decreased from 3,800 to 475.

Mr. Pat O’Byrne

Those cases are only allowed with the expressed permission of the NTPF.

What is the cause of the significant reduction?

Mr. Pat O’Byrne

There has been an increase in capacity in private hospitals in recent years. Our options have increased. New consultants have been appointed in maxillofacial surgery, rheumatology, neurosurgery and cardiac surgery. Therefore, the pool of consultants available has increased. We have also put in place additional checks and balances.

Or one could say that the system was so loose in the past that it was not until we examined the position regarding transferring of patients from public to private that the practice was tightened up.

Mr. Pat O’Byrne

I would say it was loose.

Perhaps we did the State some service.

I, too, welcome Mr. O'Byrne, Mr. Scanlan and all of their colleagues to the meeting. It is clear, based on the Comptroller and Auditor General's report and on the evidence so far, that the management of waiting lists in the public hospital system is a mess. There has been a clear failure by hospital management in their responsibilities to patients to maintain accurate waiting lists in the hospital system and in many respects, Mr. O'Byrne is having to deal with the legacy of that through the NTPF.

Based on what I have studied, the inaccurate lists are certainly clogging up the system in the public hospital network and the amount of time and resources spent in the public hospital system administering grossly inaccurate waiting lists would be very significant indeed. What highlights that for me is figure 120 on page 352 of the annual report of the Comptroller and Auditor General which profiles the validation checks the NTPF did at various times — November 2007, May 2008, November 2008 and May 2009. Based on these sample checks, in November 2007, 46% of the cases checked on the PTR list were "not open to the NTPF due to failure of the hospital administration to follow up patients and keep records updated". The corresponding figure was 37% at the next check, 46% at the following one and then 37% again. On average, over 40% of people on the waiting lists in the public hospital system, based on these checks, should not have been there.

Based on the validation work Mr. O'Byrne did, what were the main reasons? What is that code for saying? In individual cases, what does "failure of the hospital administration to follow up patients and keep records updated" mean?

Mr. Pat O’Byrne

Perhaps I could just qualify it in the first place. To be fair to the public hospital system, I would not go as far as to say the waiting lists are in a mess. What this table refers to is a particular cohort of patients with those findings, and they relate to the longest waiters.

What it means is that there are problems at hospital level when, for instance, people get an offer of treatment. They may not respond, the hospital may be slow in getting back to them, and some patients may be treated and not taken off waiting lists. There are many problems like that in the system. However, as I said, these waiting list guidelines, if you like, are the pathway for dealing with and managing waiting lists going forward, and certainly we would like to see all hospitals implement those guidelines.

In some of those cases that were checked, would the reason have been that the patient had passed away and the hospital had not updated its records?

Mr. Pat O’Byrne

It is possible. I would think that such would be the case in only a very small number of cases, but it is possible.

It is very likely, based on the evidence that has been presented. Given the number of people involved, approximately 40% of people on a long-term list, let us say over 12 months, on verification had to be taken off that list. It is something that should be checked out.

Mr. Pat O’Byrne

That is a fair point and I agree with Deputy McGrath on that. Again, I would stress that most of the validation problems are in a small number of hospitals and even in the case of those 12 months on waiting lists, only four or five hospitals account for over half their number at present.

The Chairman hit on what is probably the key point, that is, the number of people on the outpatient waiting lists. An examination of the figures on the PTR at the end of December 2009 certainly does not present the full picture, as Mr. Scanlan stated.

My experience as a public representative is that people find it difficult to get into the system but once they do, they are dealt with quite well. However, there are, as Mr. O'Byrne said in his opening statement, reports of 175,000 people on the outpatient waiting list. Do we know the actual figure? Is that recorded on the PTR list or is the NTPF receiving only inpatient waiting list data from the hospitals electronically?

Mr. Pat O’Byrne

The only information we compile on waiting lists is information relating to the inpatient waiting lists and we do not compile outpatient waiting lists. I am not surprised by that figure of 175,000 or whatever it is. That kind of figure has been around for quite a while.

It is 175,000.

Mr. Pat O’Byrne

It is 175,000 overall in the country. Our involvement in outpatient initiatives has been minimal over recent years because our mandate primarily was to deal with inpatients. Since 2005, however, we have called 82,000 patients. Of those, 53% went forward for treatment, 36% were removed from waiting lists, which goes back to the point Deputy McGrath was making, and 11% opted to stay on a waiting list, although this was 4% in 2009. I accept that the outpatient waiting lists are a problem. They are a bottleneck in the public hospital system at present.

Perhaps Mr. Scanlan would like to come in on that.

Mr. Michael Scanlan

It might help set it in context and reinforce the point made earlier. It is worth looking at the total number of outpatient attendances in public hospitals last year, which was nearly 3.4 million. Most of those were returns. I am sure Deputy McGrath is correct that the figure of 175,000 understates it. It is still, in one way, a relatively small amount of the throughput. If one looks at the fact, as I stated earlier, that approximately 2.5 million of those outpatients' attendances were returns and that some — I cannot tell the committee any more than that — are unnecessary, there is this issue that we need to tackle the outpatient waiting list and look at how we use our capacity.

To reiterate what I said, the Minister has taken it up with the chairman of the HSE. In fairness, the chief executive was also saying this and saying the key issue is waiting time and getting to grips with that, which is a point this committee has made before. There is a big difference if there are numbers waiting but for relatively short periods as opposed to the length of time it takes to access the service. That is where we need to focus.

It is fair to assume there must be a high level of inaccuracy in the outpatient waiting lists in the public hospital system and perhaps it is time for a national audit of hospital waiting lists in the public sector. That is something that should be looked at.

Returning to Mr. O'Byrne on the issue of outpatient appointments, in 2008, the NTPF facilitated more than 12,000 outpatient appointments. From where did he draw that data if he is not responsible for managing the outpatient waiting lists?

Mr. Pat O’Byrne

Because the NTPF's involvement with outpatients is on a small scale, the way we normally operate is we talk to all the hospitals and invite proposals from them on areas where they would have longest waiters at outpatient level. We might agree a certain number with one hospital or another. We might do 400 or 500 outpatients in a particular speciality. That is all I do. I do not look at the total list. I look at it on the basis of hospitals being able to agree with us a certain number of patients who can be seen and dealt with in a specific time, but my involvement with outpatients is at the small end of the scale.

So they are specific referrals by individual hospitals to the NTPF for outpatient appointments. Does Mr. O'Byrne draw them from any list as such?

Mr. Pat O’Byrne

No. We draw them from the outpatient list of the hospital, but the hospital itself manages the list and it starts from those who are longest on waiting lists.

Does Mr. O'Byrne have access to the outpatient lists?

Mr. Pat O’Byrne

I do not have access to the outpatient waiting list.

Then how does Mr. O'Byrne choose the cases that will be given an appointment through the NTPF?

Mr. Pat O’Byrne

The hospital chooses them on the basis of those waiting longest. One starts with those waiting longest first and works back.

So the NTPF has no role to play in respect of the validation of outpatient waiting lists relating to the public hospital system.

Mr. Pat O’Byrne

No.

The Comptroller and Auditor General, in his 2008 report, made a number of recommendations in respect of improvements that could be made in respect of outpatient waiting lists. He stated that consideration should be given to calculating average actual waiting time for those patients seen in outpatient departments. He also stated that the practice of closing outpatient appointment books in order to bring waiting times under control should be prohibited. What action has been taken in respect of these recommendations? The Comptroller and Auditor General's comments in this regard tie in with the suggestion that the figures are being massaged.

Mr. Michael Scanlan

The CEO stated that this practice is unacceptable and that he would make that clear to everyone involved. The Minister has informed the HSE that it is not acceptable to refuse to take someone on to an outpatient waiting list in order to massage the figures.

We have been involved in discussions with the HSE with regard to measuring waiting times. I have been coming before this committee as a witness for almost five years. I am a big fan of using data to change the way in which people behave. The difficulty is that one must be pragmatic. We have a health system which needs to improve, right across the board, the way it collects and uses data and how it uses ICT. There is a limited amount one can do. If I was obliged to make a choice, I would probably state that we would be better off investing some of our effort into primary care. I know why I need the data and it is not that I do not want it. The fact is, however, that one must make choices. We may perhaps be obliged to proceed one step at a time.

I will be straight with the Chairman and state that we are still in discussions with the HSE. I would love someone to arrive at a way to collect the data that would not be overly resource-intensive. If it is too resource-intensive, then it is being collected at the expense of something else.

With respect, there is clear evidence that a third waiting list exists. We now have inpatient and outpatient lists. In addition, there is a list of those — whose numbers we cannot quantify — who are awaiting inclusion on the outpatient list. We have raised this issue on many previous occasions. If we are wasting our time in that regard, our guests should indicate that this is the case. Has any attempt been made to quantify the number of people on the third list to which I refer or is it too inconvenient to do this?

Mr. Michael Scanlan

The committee is not wasting its time. I do not have figures in respect of the list to which the Chairman refers. The way to quantify something that is, for want of a better expression, below the surface is to say that the practice of not putting people on the outpatient waiting list should cease. The hidden figures would then be revealed by means of an increase in the numbers on the latter list. All the evidence suggests that the outpatient waiting list actually overstates the position in respect of the true number of people awaiting treatment. The NTPF experience and that of others shows that this is the case. It will be necessary to do both in order to obtain a realistic figure. As already stated, I would love to see the data.

Someone inquired whether there is an incentive for hospitals not to update their waiting lists. It is difficult to know. The reality may be that it does not affect how the patient is dealt with my individual clinicians.

With respect, it does affect how patients are dealt with.

If one is waiting to be examined prior to obtaining an appointment for a hip operation, one will not appear on any list until that appointment is forthcoming.

Mr. Michael Scanlan

I apologise, I did not explain the position clearly. Let us consider the position with regard to the inpatient list in the context of circumstances where someone has passed away or where a person no longer requires treatment. From the point of view of an individual clinician, that part of it does not matter because he or she treats as many patients as possible in whatever clinical priority he correctly accords to particular cases. It matters to us, however, because we need to know how many people are really waiting.

The evidence seems to suggest that this is not the case. Last November, Professor Drumm expressed surprise when I suggested to him that a third waiting list was in existence and that people were receiving letters informing them that they were being allocated places on a consultant general waiting list. He indicated that he never knew such a list existed and that he would communicate further with us in respect of it. The effect of all of this is that people who are in severe pain cannot gain places on even the outpatient waiting list and are being encouraged to seek private treatment, which can cost as much as €13,000. That is a matter of concern to us.

Members are visited in their clinics each week by people who state that they are awaiting notification that they will be placed on waiting lists for hip operations. Some of them state that they have been waiting up to two years, that their doctors wrote letters inquiring about the position and that no progress has been made. It is clear, therefore, that there is a third waiting list which is separate to the two which have been long established.

Mr. Michael Scanlan

In the event that I caused any confusion in the context of what I said with regard to the inpatient list, I fully agree with that. I also agree that we do not have the data but that we should have it. I also agree that the practice to which members are referring should be stopped.

Have the hospitals been asked to provide information in respect of the third waiting list?

Mr. Michael Scanlan

We have asked the HSE to follow up on that matter. I am not sure, by definition, whether they will have that information. I do not know if they keep records in respect of people they have refused to place on waiting lists. I am being straight and honest in that regard.

It is not only members who have commented on this matter. The Comptroller and Auditor General did so in his report.

So we currently do not have any profile in respect of the outpatient waiting list and we do not know whether the 175,000 people on it have been waiting six months, 12 months, two years or whatever.

Mr. Michael Scanlan

It is managed at individual hospital and sometimes individual department level.

It is a matter for the committee to make a recommendation but I suggest that a national audit should be carried out in respect of waiting lists relating to the public hospital system. If the error rate of at least 40% — on validation — of lists of patients who, for one reason or another, were not available for treatment is replicated in the context of the outpatient waiting list, then it is obvious the system is being clogged up as a result of the administration that is necessary in respect of these grossly inaccurate lists. Priority must be given to dealing with this matter.

The NTPF should have a greater role to play in the context of validating outpatient waiting lists. Does a legislative issue arise with regard to transferring validation powers relating to those lists to the NTPF? Would the NTPF be in a position to play such an enhanced role or is provision not made in this regard in the legislation?

Mr. Michael Scanlan

I would have to check the position. I do not see any obvious reason for the introduction of primary legislation.

The NTPF has done excellent work in the context of improving the position vis-à-vis hospital inpatient waiting lists. If a similar exercise could be carried out in respect of the outpatient waiting lists, the hospital system would be all the better for it.

While overall waiting lists are coming down, it is clear that children are faring far worse than adults in the context of the length of time they are obliged to wait for treatment. The HSE's internal performance audit indicates that over 1,800 children have been awaiting procedures for more than six months. Some 700 of these are awaiting serious surgical procedures — including cardiac, orthopaedic and other procedures. As regards Our Lady's Children's Hospital, Crumlin, 1,061 children have been waiting more than six months for surgery. It was stated earlier that the NTPF is not satisfied with the level of engagement with Crumlin. We are all aware of the cases that made the headlines in recent months in respect of children with scoliosis, etc., who are in urgent need of surgery. If there was a better level of engagement, could the NTPF play a greater roll in removing children from the waiting lists and assisting them to access surgery more quickly?

Mr. Pat O’Byrne

The simple answer is "Yes". There are 230 children in Crumlin at present who have been awaiting surgery for more than 12 months and there are a further 188 such children in Temple Street. Most of the cases relating to Temple Street involve day procedures. In addition, quite a number of the 230 children in Crumlin to whom I refer are also awaiting day procedures. There are many children who have been on waiting lists for 12 months for circumcisions or for procedures to remove lesions. We are not stating that we could solve all of the difficulties involved immediately. However, there are cases which could be dealt with much quicker.

Is Mr. O'Byrne stating that between Crumlin and Temple Street alone over 400 children have been awaiting serious procedures for over 12 months? The NTPF could help to get surgery for those children quickly if there was better co-operation and engagement with the hospitals. That is effectively what Mr. O'Byrne is saying.

Mr. Pat O’Byrne

Yes.

That admission is a scandal and is an indictment of the hospital management at both Crumlin and Temple Street hospitals. If the facility is there to gain access to surgery and treatment for children on a waiting list for more than 12 months and it is not being availed of then we should be hauling those hospital managers in before the committee to answer questions because that is outrageous. It is a scandal if it is the case that help is there but it is not being availed of. What reason has Mr. O'Byrne received from hospital management for that lack of engagement? Why is management reluctant to fully co-operate? Surely the first priority is to get treatment for the people and children who are on the waiting list? Why would they not avail of the NTPF service with open arms?

Mr. Pat O’Byrne

There has been inconsistent engagement with the NTPF in a number of cases. I do not say I have all the answers. I will not speak on behalf of particular hospitals, but what I am saying is that if some of the children were referred to us we could deal with them.

Based on the data available to Mr. O'Byrne, how many children across the system currently wait for more than 12 months?

Mr. Pat O’Byrne

I might have misled the committee earlier; overall 230 children are waiting more than 12 months for surgery. A total of 188 of those are in Temple Street and Crumlin hospitals.

Even if it comes down to one child that could by helped by the work of the NTPF, then it is a scandal and an outrage. We need answers to those questions as to why there is not full co-operation between those hospitals and the NTPF to get access to surgery for those children.

In most of those cases, how quickly would the NTPF be able to arrange a surgical appointment if that is the appropriate intervention in those cases? Would it be a case of weeks or months?

Mr. Pat O’Byrne

A number of those waiting require day case procedures. One is talking about a small number of weeks to deal with such cases. I do not say for a minute that we can deal with every single problem, but we can deal with a number of those problems.

The questions are incisive. We will send a transcript of the meeting to Crumlin hospital and other hospitals asking them for their comments. Mr. Scanlan has responsibility for the Department of Health and Children. Has he done anything to redress the problems identified by Mr. O'Byrne in certain hospitals?

Mr. Michael Scanlan

I am not trying to dodge the question, but my responsibility is not to manage either the hospitals or the delivery of the total health service. What we have done is taken up the matter with the Health Service Executive in terms of what the Comptroller and Auditor General has identified and to focus on that small number of hospitals. In fairness to the individual hospitals, I am not in a position to speculate on the reasons behind what one is seeing. I get a sense that in the past year there has been a greater coming together of the children's hospitals in Crumlin and Temple Street and the Health Service Executive. Perhaps it is correct for the Chairman of the committee to chip away at the issue in that sense, because the Heath Service Executive has been pushing it. To go back to what I said earlier, it is not easy, but one needs to change——

We should be more than chipping away at it. This is a scandal.

We need a sledge-hammer, not to chip away.

We are talking about children's rights. If Mr. Scanlan has evidence of what is happening, we need to do more than chip away at it. As Secretary General, if he talked to the Health Service Executive then he should have followed up the issue to see what had been done to resolve it.

Mr. Michael Scanlan

We have been following up with the Health Service Executive. We had a further meeting with it and the NTPF in November. Progress has been made. It is not just a case of writing letters. We do follow up on issues. In the context of the monthly reports we receive from them we try to check what is going one and we continue to raise issues. It is not just a case of saying, "Please do something about it" and we forget about it.

Will Mr. O'Byrne please clarify the number of children in question? Can he confirm that a total of 230 children have been waiting more than 12 months?

Mr. Pat O’Byrne

Yes.

How many children were waiting between three months and six months and six months and 12 months?

Mr. Pat O’Byrne

The number of children waiting between three months and six months for surgery is 1,340. The number of children waiting between six months and 12 months for surgery is 1,174. As I indicated, 230 children are waiting for more than 12 months.

We are looking at a total of approximately 2,700 children waiting more than three months for surgical intervention. Some are day cases and others require inpatient admission.

Mr. Pat O’Byrne

Yes.

Mr. O'Byrne has indicated that with full co-operation between the NTPF and the relevant hospitals that in many of those cases one can intervene and secure faster access to surgery.

Mr. Pat O’Byrne

Yes.

What we are dealing with is professional negligence on behalf of hospital managers who are not co-operating fully with the NTPF. I suggest that we bring them before the committee to answer questions. It is scandalous that the situation has been allowed to persist. I presume there has been full knowledge across the Health Service Executive and the Department that co-operation has not been provided. The hospitals should be statute-bound to provide full co-operation. If they are not, then we should ensure such a change is made.

Mr. Michael Scanlan

My earlier use of the phrase "chip away" was perhaps unfortunate. I would not accept that we knew there was what may be termed "professional negligence".

Mr Scanlan can characterise it whatever way he wants. He knew there was no co-operation and the consequence of that was children did not gain access to surgery as quickly as possible. He can call it what he wants, but the children are waiting.

Mr. Michael Scanlan

To be fair, I am not trying to take away from the core point made by Deputy Michael McGrath, I am just saying that ultimately much of what we are dealing with here – and this is the difficulty for non-clinicians, including the NTPF when it starts looking at the matter — is that they were dealing with clinical decisions, which is as it should be in terms of prioritisation, and it is a difficult area. I do not take away from the Deputy's core point that if there is evidence of non-co-operation, something should be done.

It is a difficult area but there is no excuse for non-co-operation.

Mr. Michael Scanlan

I agree.

There are no ifs and buts. It is clear there was no co-operation or very little co-operation.

Is it the case that five hospitals are not fully co-operating? We did not hear about the other four.

Mr. Pat O’Byrne

We can categorise it between co-operation, non-co-operation and somewhere in between. Currently, we have problems with four hospitals. They are Temple Street Hospital, Tallaght Hospital, Crumlin Hospital and to a lesser extent, Tullamore Hospital.

Should we not investigate all of them to see why they are not co-operating?

Mr. Pat O’Byrne

They come up on my radar because they are the hospitals with the biggest number of patients waiting for more than 12 months.

I will conclude shortly. I have a couple of quick, final questions. The pilot basis on which outpatient appointments have been undertaken has been in place since 2005. Are there any plans to make that more permanent? This goes back to the earlier exchange we had on the outpatient list. Is that a resource issue? What is the barrier to making that system more permanent and dealing with more outpatient cases? From what I can see it is planned to administer fewer outpatient cases next year — 8,000 instead of 12,000 in 2008. I am not sure how many were dealt with in 2009. Even though outpatient waiting lists are growing nationally the intervention on those lists is diminishing. How do we square that?

Mr. Pat O’Byrne

My primary remit is to deal with inpatient lists. They have gone through the outpatient process and they have been longer on the list. They are the ones who have been there longest. To get back to the Deputy's question, we only account for about 0.5% of the health spend so we can only do so much within that. It is a resource issue.

I have two questions for Mr. Scanlan on Vote 39. On the State Claims Agency payments in respect of costs relating to clinical negligence, the costs went from just under €11 million in 2007 to €42.6 million in 2008, which is an increase of 290%. To what did that relate?

Mr. Michael Scanlan

It relates to the way the scheme began. When it began, we knew it would ramp up. I wrote to the committee following a previous appearance here to explain that we knew there would be what is called in the insurance industry a funding holiday for the first year because the previous insurers would have had to carry liability for what happened just prior to that. We knew we would then be taking on more liability, so that was expected.

To clarify, does that indemnity scheme cover all activity in the public hospital system, including consultants?

Mr. Michael Scanlan

Yes.

They are not required to take out their own professional indemnity insurance.

Mr. Michael Scanlan

Not in terms of their work in the public system.

I presume they would have their own insurance for their private work. Are there any consequences for them in terms of the State seeking to reclaim from the consultants private professional indemnity insurance for claims that had to be settled out of the taxpayers' pocket? If a consultant is negligent, a case is taken to the claims agency and it pays out on behalf of the consultant for that negligence, does the State seek to recoup any of that money from the consultant's private professional indemnity cover?

Mr. Michael Scanlan

I do not believe we could do so because the private——

I am just teasing it out.

Mr. Michael Scanlan

It is a fair question. My immediate reaction is that the private professional indemnity cover would cover work off site, not just private work. I will check that for the Deputy.

If Mr. Scanlan would not mind, I would like to clarify the point. My final question, under subhead E1, concerns developmental, consultative, supervisory and advisory bodies, which accounted for €119.5 million in 2007 and rose to almost €139 million in 2008, a rise of approximately 16%. What is involved in that category and to whom were those payments made?

Mr. Michael Scanlan

This essentially concerns the agencies we were discussing earlier. I would have to go down through each one. For example, in the case of the national cancer screening service, I can recall it was given extra money in 2008 for cervical screening to begin.

That is fine. We will look into it on another day.

We will get a note on that. Before I call Deputy Shortall, to return to the issue of outpatient waiting lists, will Mr. Scanlan explain whether the Department has established with the HSE exactly what returns are recorded by hospitals in respect of consultants? Is all of that information obtainable, for example, on the number of appointments outstanding on their books per month with patients unseen; the number that have been seen per month and are scheduled for further action, be it surgery or other therapy; and the number of surgeries performed each month? I thought all that would be obtainable under the new contract.

Mr. Michael Scanlan

To be fair, I do not think this is a contractual issue. It is more a question of what information is collected within the hospital and what information is returned, either at hospital or national level. What we get in the Department are aggregate figures, some of which I was able to provide to the committee concerning the total number of outpatient attendances. That will be built up from each hospital. When we talk about a national outpatient waiting list, I have not seen figures that I could in any way stand over and say that they capture some of the Chairman's earlier points. I do not know whether that information is kept at individual consultant, department or hospital level. The committee will remember the chief executive spoke of the HealthStat data, because they are the operational data he collects from meeting the individual hospitals, but I have not seen the detail of them.

Arising from Mr. O'Byrne's comments to Deputy Michael McGrath, is he suggesting he has sufficient funds to deal with these waiting lists we are referring to in Crumlin and Temple Street, and also that he has sufficient funds to maintain the adult services?

Mr. Pat O’Byrne

I am suggesting that I can do more with the funds I have in Crumlin hospital but it is within an overall number of cases that I can do in the year, based on the funding I have.

I do not understand that response.

Mr. Pat O’Byrne

If there are patients waiting more than 12 months, whether children or not, it is incumbent on us to deal with those first before we move on to other cases. In the case of Crumlin, where we referred to children waiting for longer than 12 months, while I am not suggesting I can deal with every case over 12 months, we can make a greater impact on dealing with those cases.

I welcome Mr. Scanlan and Mr. O'Byrne. This session and previous sessions with the Department of Health and Children have been quite unsatisfactory because of the absence of sufficient data or robust data to enable us to measure the performance of the Department or the HSE. The witnesses present figures which would indicate that progress is being made in regard to the inpatient waiting lists or waiting times but, as the Chairman has said, we do not know whether they actually stand up because we do not have any detailed analysis of those figures and, more importantly, we do not have any proper fix on the waiting times and waiting lists for outpatient appointments. Why is it we do not have those figures?

Mr. Michael Scanlan

The short answer is that Ireland is not alone in running a health system which, if it was being run entirely efficiently, would have much better information systems. Health systems around the world do not have this sort of information. Because I believe the point that was made in the Comptroller and Auditor General's report about waiting times, we have checked with a number of other countries and they too tend to use waiting lists. We have begun to collect more data. It is a long, slow process. That is the reality I face. If I could get the data, I would love to get them.

That is not the question I asked. I am not especially interested in what is happening in other countries. I asked why it is that we do not have data on the extent of the waiting lists for outpatient appointments and who is responsible for doing that?

Mr. Michael Scanlan

We have never collected the data nationally.

Mr. Michael Scanlan

I do not know.

That is not good enough.

Mr. Michael Scanlan

There are a lot of data we have generally not collected in our health system over I do not know how many years. It is not an excuse but it is reasonable for me to make the point that we are not alone in that. I do not have data, for example, on the number of people getting——

I did not ask whether Mr. Scanlan was alone or not. I asked him why do we not have the data.

Mr. Michael Scanlan

Because our system is not up to the point where we are collecting the sort of data that we should be collecting.

We have just come through a boom where endless money was available to spend. Mr. Scanlan said he has been attending meetings of this committee for the past five years. If that is the case, why has he not got on top of it at this stage?

Mr. Michael Scanlan

Got on top of it in what sense?

In terms of being able to quantify the extent of the waiting lists for outpatient appointments and to put in place a modern management system for those services. Why is that our health services are still in such a chaotic state?

Mr. Michael Scanlan

I cannot accept they are still in such a chaotic state. However, if one is going to collect the sort of data we should be collecting, the best way of collecting them is to develop systems where the data are generated when the care is delivered. I know there is a validity in doing audits but that sort of thing will just collect data. The best way to do it is to ensure that as consultants, GPs and nurses deliver care, they use systems that generate the data, which is what will change behaviour, but it will take years for that to happen.

Mr. Scanlan cannot tell us about the extent of the problem. We do not know how many people are waiting to be seen by consultants on an outpatient basis. That is outrageous at this stage.

Mr. Michael Scanlan

I could do that. I heard the previous suggestion. We could talk to the HSE about carrying out a national audit that would audit, for instance, what is on people's books. However, as soon as we would do that, I know, as I am sure does the committee, two issues would arise. One is whether the appointment book captures people who have been referred and sent elsewhere and the other issue is whether it would be up to date, whether it would capture people who have been moved off the list or do not need the treatment.

The best way to get data is to ensure that the information is captured and used to run the outpatient department. I am not trying to dodge the issue, far from it. I have spoken here previously about the child protection system and what is happening in that respect. Progress on that takes time. We have met social work professionals and outlined how they should manage these cases. We have given them an ICT system that allows them to manage individual cases in this way. The ICT system then generates the sort of data the Deputy is seeking, but one cannot do that overnight. One has to work on it bit by bit. It is the core business of the health service.

It is not a question of our seeking this data overnight

Mr. Michael Scanlan

I agree. That is a fair point.

Having emerged from a boom during the past ten or 12 years when money was available to spend, and given that modern management requires performance indicators to be put in place, why is it in 2010 we do not have basic data on the number of people waiting for outpatient appointments? That is incredible.

Mr. Michael Scanlan

The money that has been invested in the health system has shown a return in terms of the number of people treated, improvements in those treatments and ultimate improvements in health outcomes. If the Deputy considers the inpatient figures, she will note that we are getting data and that the position has improved. As Mr. O'Byrne said, it was entirely reasonable to start at that end because those are the people who have managed to get from their GP through to outpatient level and were waiting a long time for treatment. Therefore, one starts there and works back. We are making progress. We have a huge way to go but we are not alone. That is the reality.

Why is it that we still have a huge way to go, given that funding was available?

Mr. Michael Scanlan

This is not just a funding issue. Ultimately, one must examine the core business and the core business in health is how we treat people.

What has the Department of Health and Children been doing in recent years, if not getting to grips with this and getting on top of it?

Mr. Michael Scanlan

If the Deputy wants to know what the Department has been doing during recent years, I can list all of that. We do many things bar doing this, but in this space in particular we have done a good deal of work with the HSE. Each year its service plan includes more data and more ways of measuring what it does and how long it takes to do it. We try every year to develop better performance indicators, at the very high national level and in encouraging the HSE to do what it has done at the operational level with health staff.

We have figures on inpatient waiting times. They seem to indicate progress has been made there, but we need to have the underlying data on what is happening at outpatient level. Is it the case that fewer people are being referred for inpatient treatment and is that the reason the waiting times have reduced? What kind of analysis can Mr. Scanlan provide on those waiting times in regard to productivity in each of the hospitals?

Mr. Michael Scanlan

I did not quite understand the Deputy's point. She said the waiting time or waiting list for inpatient treatment has decreased but——-

The figures Mr. Scanlan has provided on waiting times for all the country's hospitals indicate that waiting times have been reduced or that the number of people waiting within the different timespan has been reduced. We do not know from looking at those figures whether that is due to better performance by the hospitals or whether fewer people have been referred for treatment. To assess those figures we need to have some information from Mr. Scanlan on productivity. Can he provide that?

Mr. Michael Scanlan

I can. I am not sure how much of that information I have to hand. I mentioned the health trends in Ireland report that we published. It shows figures trended over different years and the increase in throughput or activity in our public hospitals. Other figures I have, which show the increase in the number of day cases as a proportion of all cases treated, illustrate what I would term real productivity. The number of inpatients and day cases in 1999 was 759,000 and the corresponding number for 2008 was 1.365 million. The number of day cases as a percentage of the figures for each year has increased from 32% to 56%, which is positive. I gave a figure for the number of outpatient attendances and the latest figure we have is 3.3 million compared to 1.9 million in 1999. The public hospitals are dealing with a huge increase in numbers. I am not sure if that answers the Deputy's question.

That is over a ten-year period, which is fine. Overall, it is a positive trend. We need that kind of data available on a year by year basis and on a hospital by hospital basis to measure performance within hospitals.

Mr. Michael Scanlan

I agree.

Is that data available?

Mr. Michael Scanlan

Yes. I gave the Deputy figures for 1999 and 2008, but the figures are set out year by year in a report I have, copies of which I can give the committee. That is built up then from hospital level. I do not have the hospital level data; I am considering the national data.

Does Mr. Scanlan take my general point on these figures? He could claim credit for making considerable progress on the basis of these figures, but we do not know whether that is because the hospitals have been performing well and have achieved high levels of productivity or whether fewer people have been referred to them, they have fewer people on their waiting lists and they are waiting shorter times.

Mr. Michael Scanlan

I take that point. There is evidence for this. I would not claim that the NTPF has secured this improvement. Part of it is due very much to the focus it has brought to it.

I am not talking about the NTPF but about the performance of the hospitals.

Mr. Michael Scanlan

The hospital system. There is evidence that shows that hospitals are treating more people.

With due respect, it is not good enough for Mr. Scanlan to say that there is evidence that they are treating more people. Can he provide the data?

Mr. Michael Scanlan

I can give the data to the Deputy year by year from 1999 to 2008.

For each of the hospitals?

Mr. Michael Scanlan

No, I do not have it for each hospital. I have the national figures, if we are talking about the national pubic hospital system. I can get the Deputy that information. I have data for the health system.

It is important to get that.

Mr. Michael Scanlan

I have that. If the Deputy is asking me is there still a potential or an actual hidden waiting list, I agree there is.

It is accepted that there is a hidden waiting list and I am asking why. Why has the Department of Health and Children not managed to get to grips with that at this point? Fairly basic data is required to measure performance.

Mr. Michael Scanlan

It is because we have focused on the inpatient end. There is evidence and facts that show there has been improvement. I accept that is not the end of the story. It is a question of having a balance. I am not saying this system is perfect by any means, but it is improving.

Does Mr. Scanlan accept that it was a mistake to focus on the inpatient end and that it does not give us a true picture of what is happening within the health service?

Mr. Michael Scanlan

No, I do not accept that. If one's focus was on those waiting longest, as Mr. O'Byrne said, it was entirely reasonable to start there, but it would be wrong to stop there.

Is anyone saying it was convenient to stop there?

Mr. Michael Scanlan

To stop there?

Yes, and ignore the other factors.

Mr. Michael Scanlan

We have not been ignoring them. We have not gone — Deputy Shortall is right about this — to where we should go in this respect.

As Deputy Shortall and I said, Mr. Scanlan was aware that there was the existence of a third list, but he never attempted to quantify it?

Mr. Michael Scanlan

In fairness, the Chairman raised this here the last day and fed in that information. I was not aware that people were even being refused access to a list. I was aware that there was an OPW waiting list.

Mr. Scanlan is responsible for the health services, but I am not in the health services area. I was aware of it, as were other public representatives. Members of the public were the victims. Yet he is telling me that he and Professor Drumm — both of the people responsible — were not aware of the list. That is incredible.

Mr. Michael Scanlan

I am saying to the Chairman — I think Professor Drumm said the same the last day — that that is not the policy either of the Department or of the HSE and it is not acceptable.

As a member of this committee, I am getting tired of hearing that sort of mea culpa. It is not acceptable and something needs to be done about it, yet it seems nothing is being done about the absence of necessary data. I am asking Mr. Scanlan now who or what body is responsible for collecting data on outpatient waiting times. When will we see robust, meaningful data?

Mr. Michael Scanlan

I am afraid I cannot accept the assertion that nothing has been done about the data. The availability of data in our health system has improved over the years. I can give members a certain amount of data, which is here and consists of facts. In the matter of who collects data and when robust data on outpatients should be available, I do not yet know. We are still talking to the HSE about the best way of doing that, given all the other priorities and the choices we must make.

Who is responsible for overseeing that? Is it the Department or the HSE?

Mr. Michael Scanlan

Ultimately, it would be a matter for the individual hospitals to generate the data for the HSE to assemble and then report to the Department. However, I am not in any sense passing the buck. I accept there are choices to be made about what data to collect in terms of how long it would take and what is the best way of collecting it.

When will key decisions be taken about that? The Department representatives have long been coming in here and saying they accept there are problems and something must be done. When will something be done about it?

Mr. Michael Scanlan

That is a bit unfair, because it suggests that when I acknowledge there is a problem we do nothing about it. We have progressively been tackling the problem. It is not even the Department, to be fair. There are good examples in the system of individual hospitals, clinicians and so on tackling this. What is needed is a more systematic approach. I have never denied that. That sort of systematic, total improvement, frankly, is a goal we will always be striving for rather than achieving. In my view, we need to focus on total waiting time from GP referral to actual treatment. We must determine the cost and the best way of doing that and measure it against other types of information I would like to get. Some time this year we may make a choice on it. However, there are lots of other types of information I would also like to get, and each of them has a cost.

I have a question for Mr. O'Byrne about the expenditure by his organisation on waiting list initiatives. Who sets the limit on how much is available for inpatient and outpatient services?

Mr. Pat O’Byrne

Each year, we are funded directly by the Department of Health and Children. We enter into discussions with the Department and a service level agreement is reached. It is divided based on the volume of inpatient or outpatient cases agreed with the Department, although it must be done within the overall budget.

When the NTPF was before the committee last year, I asked Mr. O'Byrne about the issue whereby GPs often refer patients to consultants with whom they were in college or whom they know for some other reason. I said it was very important that the data on waiting times for different consultants was available, and Mr. O'Byrne said the NTPF was moving towards a system under which it would be available online, so that GPs would know who had the shortest waiting list and could refer their patients accordingly. There is a strong argument, indeed, for having that data available publicly so that patients themselves can decide to opt for consultant B or consultant C because of the length of his or her waiting list. What is the current situation in this regard?

Mr. Pat O’Byrne

I am not sure that question was put to me.

It came up at the time.

Mr. Pat O’Byrne

The last time I was here was more than two years ago. I was not here last year. However, it would be good to have such a system. With the establishment of clinical directors in the various hospitals, we will be moving towards that type of system in the next while.

Is the information on waiting times for outpatient appointments for individual consultants not available within the hospitals?

Mr. Pat O’Byrne

I am sure it is available within the individual hospitals, but I do not collect it.

Mr. O'Byrne has access to that, does he not?

Mr. Pat O’Byrne

I do not. The only information I collect is inpatient waiting lists. I do not collect the outpatient lists.

Could there be a situation in which a GP is referring people to a particular consultant who may already have an 18-month waiting list, while other consultants employed in the public health service have three-month waiting lists?

Mr. Pat O’Byrne

Yes.

That does not really make sense, does it?

Mr. Pat O’Byrne

It does not.

Why is information not available, to GPs at least, on who has the shortest waiting list?

Mr. Michael Scanlan

Is this not the issue I just dealt with? I do not have that information and it is not available nationally.

All right. I would like to move on to——

It is about time one of these bodies — either the Department or the HSE — got its act together. In the past year or so they have renegotiated a common contract. We have evidence they are finding it difficult to collect data — or at least, it is not available to us. There should have been a requirement built into the contract that each consultant, on a monthly basis, make a return on the issues I mentioned earlier. Accountability, transparency and value for money should have been a fundamental part of any new contract. Two years down the line, we cannot get data on the public-private mix or the level of activity within specialties on a monthly basis. The representatives do not seem to have them. Somebody must get their act together on behalf of the patient and the taxpayer. It is chaotic.

Mr. Michael Scanlan

I do not think the contract has ever been a barrier to the collection of outpatient data. I will return to the point the Chairman made about the public-private mix.

Is it built into the contract?

Mr. Michael Scanlan

I would not even regard it as something to which I needed somebody to sign up in a contract, frankly.

If we are not getting the information, surely it should have been in the contract.

Mr. Michael Scanlan

It is not part of my contract, or that of any of my staff, that they must provide me with data. I regard it as a normal aspect of what is required to work in the place. It is just good management, as the Deputy said.

But they are not doing that. That is the point.

Mr. Michael Scanlan

No. It has never been collected in a systematic way, but it is available, I assume, at individual departmental or, more likely, clinician level. I am sorry, but I have now lost my train of thought.

There was another point the Deputy made about activity. One would need to go back to HealthStat; I am sorry not to be familiar with the details of it, but that is its focus. The Deputy made a point about consultants with 18-month waiting lists or three-month waiting lists. What the HSE is focusing on is how many patients — outpatients or otherwise — individual hospitals, departments, specialties and consultants are getting through. It is collecting and using data on this.

I mentioned earlier the type of data we are looking for. We are in a vacuum, in some ways, in that we do not have the information we were promised on the public-private mix.

I took a few notes earlier. With regard to outpatient lists and arising from a number of questions from different Deputies, I asked what returns were recorded by hospitals in respect of consultants, particularly with regard to the number of patients on consultants' appointment books who were not seen, the number of people who were seen and for whom action was recommended, either medical or surgical, and the number of surgical activities performed each month. Those are the key questions that have not been answered.

Mr. Michael Scanlan

I will ask the HSE to give me whatever data it has on activity so I can pass it on to the committee. I am pretty sure it has that data. It depends on the level of detail the Chairman wants. Such data builds into the national activity figures that I have here. That data can be obtained at hospital and sub-hospital level, if that is what the Chairman wants, through HealthStat, but I would need to talk to the HSE about that.

On the issue of the public-private mix, which the Chairman raised, I said in May 2008 that I wanted there to be transparency. Following the disputes we had with consultants over what they were and were not entitled to do in terms of public-private mix, we wrote into the contract an explicit way of monitoring it. I have received reports from the HSE but I do not ask for nor I do not look for names in those reports. I want to ascertain the impact this is having in terms of——

Why does Mr. Scanlan not ask for names?

Mr. Michael Scanlan

It is because I am interested in a number of matters, primarily in the public-private mix generally but specifically for elective treatment to establish if this is changing and improving public patients access to elective treatment. We are starting to get the compliance rate with the contract, about which the Chairman asked. The data I am getting on that at this point is not up to what we would want. I want much more clear data that indicates of all the non-type A consultants the number who are complying and the number who are not complying with their contractual requirements.

We were promised that data by Professor Drumm in November. Is he experiencing difficulties in supplying it to us?

Mr. Michael Scanlan

In fairness, perhaps that is something the Chairman should ask Professor Drumm, but I understand he may well be and that it is due to concerns about data protection if one were to name or identify individuals. That does not mean one should not be able to get the data in some form to make some sense of it.

Following on from that point, it is hard to understand how the Department of Health and Children can effectively manage the health service if it does not collect or insist that the necessary data is collected and analysed. Mr. Scanlan is talking as if this is nothing to do with the Department, to the effect that the data is there and he could get it if he wanted to do so. I do not understand why he is not insisting on collecting it and ensuring that it is analysed in order to improve services. I will not elaborate as we have been over this ground.

I wish to move on to the issue of the consultants' contract and ask Mr. Scanlan about the operation of it. A limit of 20% private work applies to many consultants. Is there a fundamental flaw with that system? If consultants are limited to doing 20% private work and given that approximately 50% of the population have private health insurance, if consultants cannot cater for private patients within that 20% provision, to where can private patients go for consultation and treatment? Is there a major problem in that regard? The point was made that consultants are free to take on extra work in their own time if they wish. Being a consultant is an onerous job by any standards. If a consultant does 80% public work and 20% private work, is Mr. Scanlan suggesting that on top of that he or she would additional private outpatient and inpatient work and possibly NTPF work? Is there a fundamental flaw in the approach of having an 80:20 pubic-private mix?

Mr. Michael Scanlan

The Deputy has raised very big policy issues on which I am not sure how as to how to proceed. On the question of 80:20 public-private mix as against the 50% of the population having private health insurance question, the Deputy asked a specific question on how the 80:20 rule can apply when 50% of population have private health insurance? The simple answer is that the 80:20 rule applies in public hospitals. There are also private hospitals and we have two types of consultant contact. There is no reason private hospitals cannot hire entirely private consultants to treat patients who have private health insurance who would never go to the public hospitals.

Are there not large parts of the country where there is not the option of going to a private hospital?

Mr. Michael Scanlan

Nationally there is not necessarily a contradiction between having an 80:20 provision in a contract in a public hospital and the fact that a certain proportion of the population have private health insurance. As I said on the last occasion I was before the committee, every person in the country has the right to access the public hospital system. My understanding of Government policy is that it allows a public-private mix but that is to be limited. If I have private health insurance, that does not deny me the right to go into a public hospital. One may not be able to go into a public hospital as a private patient but that is not a right one has; one can go into a public hospital as a public patient.

There are implications in that for the public health service if more patients who previously would have been treated privately are accessing services from the public health service. Are there not implications in that downstream?

Mr. Michael Scanlan

I am not sure that there is any evidence to suggest there are. This is an issue about which the Deputy would have to talk to private health insurance companies. If anything, the evidence is that more and more of their business is being done in the private hospitals rather than in the public hospitals, perhaps partly because of the way we have progressively increased charges for those patients.

The contact has only started to be enforced. Under the old contract, consultants did what they liked.

Mr. Michael Scanlan

That is not the point I was making. We have increased the charges, the hospital levies, which we talked about on the last occasion, in trying to move towards meeting the full economic cost. I am not aware of any evidence that suggests that a great number of people who used to be treated in private hospitals are starting to be come into public hospitals.

People could argue it is inevitable that will happen if the new contract is enforced. There is a capacity issue in private and public hospitals that is not being addressed.

Mr. Michael Scanlan

What Mr. O'Byrne said — he would probably have a better sense of this than I have — tallies with my view that there has been a growth in capacity in the private sector. There is not a diminishing capacity available in private hospitals.

In certain parts of the country there are and for certain procedures.

My final question is on the treatment of private patients in public hospitals. Has Mr. Scanlan analysis that shows the percentage of patients who are being treated for elective work and those who are coming through accident and emergency departments and then are admitted to private beds?

Mr. Michael Scanlan

I am not sure if I can answer the Deputy's final question although I have some data on this. I draw her attention to the percentage of inpatients who were public patients and the percentage who were private patients and the percentage of elective and emergency cases, if that is information she is seeking.

The information I have for inpatients suggests that in 2006 33% of all elective inpatients were private and in 2009 the figure was 30%, the figures for 2009 being subject to confirmation. With regard to emergency cases, in 2006, 23.6% were private patients and in 2009, 22.3% were private patients. I have separate day case figures which show that in 2006, 22.9% of patients were private and in 2009, 22.4% of patients were private.

That does not answer my question. For example, of the 20% cohort of patients who were treated privately last year, what was the mix between elective and emergency work in public hospitals?

Mr. Michael Scanlan

Based on the figures for 2009, of private patients admitted, 27,000 were elective cases and 88,000 were emergency cases — I have rounded up the figures. Adding those cases together, of a total of 115,000, 27,000 were elective cases and 88,000 were emergency cases.

What percentage of the overall number of emergency cases did that represent?

Mr. Michael Scanlan

Some 22%.

I thank Mr. Scanlan.

I welcome all the public servants to the committee. How many unfilled vacancies are there now in the public hospital service? I noted recently that almost 200 posts in one area were unfilled due to the embargo. What kind of number does this translate to over the entire public hospital system?

Mr. Michael Scanlan

If I can get it out for the Deputy, I have the figure for the reduction in the number employed in the HSE over the last year, or at least up to the end of November, due to the moratorium, if that is what the Deputy is talking about.

Mr. Michael Scanlan

I beg the Deputy's pardon and ask him to bear with me while I find the information.

There was a reduction of just over 1,200 whole-time equivalents, which does not necessarily equate to persons, between December 2008 and November 2009.

Does that include front-line staff such as nursing staff and some clinical staff?

Mr. Michael Scanlan

Given the way the moratorium is being applied in the health service, certain groups or grades are exempted from it, and there is also provision for exceptions. What I would call allied health professionals, including speech therapists, occupational therapists and social workers, are among the groups that are exempted altogether, because we have been trying to support growth in these areas in primary care and areas such as disability and mental health. On the clinical side, there is a provision that allows the HSE to create consultant posts through the suppression of junior doctor posts. Nurses are not exempted from the moratorium other than in particular exceptional circumstances.

Does Mr. Scanlan have any forecasts on how he expects that number to change in 2010 through unfilled positions?

Mr. Michael Scanlan

Essentially, the way in which the moratorium works is that people who leave, subject to the exceptions I have mentioned, are not replaced. The answer to the Deputy's question is that it depends on how many people choose to leave. In terms of vacancies arising through normal retirement, we do not yet have firm figures for last year other than that there was a much higher level of retirement from the HSE than in previous years, for whatever reasons. This is reflected in the figure I gave. The HSE believes that something similar, although I am not saying it will be of the same magnitude, might happen in 2010, again for various reasons. In terms of speculating on the figure, it depends on the number who leave.

Yesterday in the Dáil, my colleague Deputy Jan O'Sullivan mentioned that there were 33 people on trolleys at Mid-West Regional Hospital. I note also that Mr. Maurice Neligan mentioned yesterday that one day last week there were 500 people on trolleys across the major hospitals. Are these figures alone not a continuing indictment of our failure to organise the health system robustly, and also to provide the kind of care necessary? Another colleague, Deputy Costello, has for four or five years stood outside the Mater hospital every Saturday protesting at the ongoing chaos in the accident and emergency department. Are those accident and emergency figures, after all this time and all the meetings we have had, not an indictment of a key element of our hospital and health systems?

Mr. Michael Scanlan

I can only tell the Deputy two things. We collect data on accident and emergency figures and this shows there has been an improvement. To be fair to the Deputy, I will confirm that in the past — last week in particular — problems were experienced in accident and emergency departments. I was at a meeting yesterday evening with the Minister, other officials and the chairman and CEO of the HSE at which we talked about emergency department issues. This time of year there is always a bit of a surge——

It was after all the fractures and falls resulting from the icy weather, which put grave pressures on outpatients departments. We have come out of that period, yet the figures are still very bad.

Mr. Michael Scanlan

This is an operational issue and there is no point in my pretending I am on top of all the figures. Yesterday evening when the HSE people turned up, they had much more up-to-date figures and were able to show that the situation was improving.

I received a copy of Mr. Scanlan's opening statement the other day, which was very interesting. He said he loved figures, which is something I have in common with him. One must have the key data. I looked at the OECD document Health at a Glance 2009, which is a fine piece of work. I also have here a Nuffield Trust document, which is a detailed analysis of health performance in England and the three devolved UK administrations. How do we know if the relative figures for Ireland are giving a fair account of the Irish health system if our own statistics are so bad?

Mr. Michael Scanlan

It is my understanding that the OECD applies as much rigour as it can to all countries providing data. I would have to see the entire document in order to comment fully, but I recall that there are some returns we cannot provide because our data is not good enough. However, where we do provide data, it is subject to compliance with whatever definitions the OECD has.

I notice Ireland is missing in some tables. That must be the reason.

Mr. Michael Scanlan

Exactly.

Going on the data we have, would it be fair to say, looking at some of the tables, that we are either mediocre or bad? For example, in life expectancy at birth, we are somewhere around mid-table, far outstripped by Japan, Switzerland, Australia and so on. These are figures from 2007. In terms of life expectancy at age 65, we are towards the bottom of the table, with about 20 countries ahead of us, again headed by Japan, with France and Switzerland close behind. If we consider potential years of life lost through failure to obtain appropriate treatment, we see that Ireland is mediocre.

In terms of ischaemic heart disease mortality rates we are towards the end of the table, about 20 countries down out of 30. For mortality rates from all cancers, we are about two thirds of the way down the table. For lung cancer, we are mediocre; for breast cancer, we are the third worst. The situation is similar for prostate cancer. As I said, infant mortality is much better, and Mr. Scanlan mentioned a few areas in which we have a good performance. I note, for example, that in terms of the number reporting good health, Ireland is almost at the top of the list. I suppose we are an optimistic people. However, in terms of disease prevention, in areas such as smoking, we are still performing quite badly. These tables are interesting reading, as Mr. Neligan said yesterday in The Irish Times. We are still high up in the table for smoking. We are one of the champions in alcohol consumption. We are almost the premiership leaders in health prevention. According to the tables, we are either mediocre or downright bad, which is the opposite of what Mr. Scanlan stated in his opening address. This is an indictment of the performance of the Department and the entire health system.

Mr. Michael Scanlan

I do not agree. Would the Deputy expect me to agree? In all seriousness, I will take this at three levels. First, every report I have seen suggests there have been major improvements in the past decade. That is not down entirely to the health system and I would be first to acknowledge that. It is down to all sorts of factors that impact on health but there have also been improvements in the health system. Second, the Deputy mentioned cancer, for instance. I said it in the way I would say it in my opening statement that we are not at the OECD average and I absolutely accept that. We have improved but we are too low. The point I was trying to make is that the policies and services we are putting in place regarding cancer are designed to do that. I agree with the Deputy about the behaviour issues we are facing relating to smoking, alcohol and obesity. It is not a failure report card or an A report card but——

It is a D minus. It is not good enough in the context of the spending increases. There has been a significant increase in expenditure, which has us still mid-table at 7.8% of GDP in 2007, but it is a mediocre performance.

I refer to consultants. When we debated this issue during Mr. Scanlan's previous appearance, 22 consultants had been given warning letters following a lengthy period regarding their failure to observe the new contract. What is the updated position?

Mr. Michael Scanlan

I can ask the HSE. Professor Drumm gave the committee that figure but I can ask for it.

He will be before the committee in two weeks.

The public is interested to know why we were dealing with such people with kid gloves.

I refer to the NTPF. I am not clear about funding because I missed some of Mr. O'Byrne's presentation while I was in the House. A sum of €90 million was allocated to the fund for 2010. Is that the same as last year? It was reported that this was a cut of 10% and it was intended to use the funding better, given the general fall in prices in the economy. Was the allocation cut?

What is the position regarding negotiations with private hospitals? When does Mr. O'Byrne expect a result? How will he achieve value for money? What is the global funding scenario for the organisation going forward?

Mr. Pat O’Byrne

In 2010 we have the same budget we ended up with in 2009. Our budget was reduced by approximately 10% during 2009 and that is the situation in global terms.

With regard to private hospitals, there is an ongoing process. Up to now we negotiated with them once a year to agree prices for the year. The process this year is ongoing and I do not see it being completed for another few months.

In achieving value for money, is the fund negotiating packages of procedures in different specialties or is it negotiating with hospitals individually?

Mr. Pat O’Byrne

As our budget increased over the years, it gave us a certain amount of added leverage in our negotiations with private hospitals but we generally negotiate with private hospital groups. If there are a number of hospitals in the group, we will negotiate on a group basis but if the hospitals are individual entities, we negotiate with them on an individual basis. We compare prices. We try, where possible, to compare them with what we know about private insurer costs and we benchmark against the public hospital case-mix costs. We try to take into account a combination of those factors.

Does Mr. O'Byrne expect that overall in 2010 the fund will do more business for more people across the service?

Mr. Pat O’Byrne

With the same money. That is our intention and I would like to be able to say that we achieved that the next time we are here.

Does the fund have a tendering process, for example, for the purchase of ten hip replacements?

Mr. Pat O’Byrne

No, we have stayed away from that up to now on the basis that we are afraid of a race to the bottom if we get into a tendering process like that. For instance, if we get into a tendering process for a certain number of hip or knee replacements, the danger is hospitals will tell us they can do them for a lower price but I would be worried about the standard and quality. I will try to avoid that if I can because the danger is it will be a race to the bottom. There have been incidents in England over the years where the tendering process worked against standards and patient safety.

Why is the treatment of psychiatric disorders not included in the NTPF's schemes?

Mr. Pat O’Byrne

Because they are not within our remit.

In other words, policy has dictated that the fund cannot deal with them.

Mr. Pat O’Byrne

Policy has not extended that far.

Mr. Michael Scanlan

The Minister asked the Department to concentrate on procedure driven cases and it was largely surgical and then medical whereas, on the psychiatric side, there is more of an ongoing nature to it. Mr. O'Byrne is right that that was the Minister's focus.

With regard to A Vision for Change and palliative care, there was evidence in 2007 and 2008 that funding allocated to those programmes was siphoned off into other areas by the HSE? What is the Department's view on the siphoning off of funds allocated to specific programmes?

Mr. Michael Scanlan

I may have dealt with this previously. In 2008 for the first time we introduced a new subhead in the Vote into which we put specific development funding for a specific service area. The sanction the HSE, like all of us, needs from the Minister for Finance to spend money is clearly subject to guidelines. The HSE cannot take money from that subhead to use for a different purpose without the explicit sanction of the Minister. In managing all that goes on in health, there may come a point where one has to shift money around. The committee's concern was that it was happening without any transparency or sign off.

That has stopped.

How is the number of consultants decided? I am concerned about the issue of capacity within the system, both public and private. There are competition issues. It is difficult to understand why somebody who forks out €180 to attend a consultant privately has to wait four or five months.

Why is it that the numbers of consultants are so tightly controlled and who assesses the demand for services? If somebody is paying €180 for an entirely private consultation, it is not acceptable on competition grounds that one should have to wait several months to see that person. It should be possible to get an appointment within a week or two.

Mr. Michael Scanlan

I am sorry I did not understand the question initially.

How are those numbers controlled?

Mr. Michael Scanlan

I assume the Deputy is referring to private patients waiting for private appointments.

Mr. Michael Scanlan

I apologise, I did not quite understand.

How are those numbers controlled?

Mr. Michael Scanlan

We do not control, in that sense, the number of private consultants, those who are employed outside the public hospital system, other than through the Medical Council of Ireland and through the training and accreditation. We do not control those numbers. In the public hospital system, while I am not saying we control them, there is a question about the numbers needed and the numbers that can be afforded and all of that. The Deputy is correct in that if we were suddenly to try to——

But they are controlled.

Mr. Michael Scanlan

No. Once a person is qualified, to the best of my knowledge, there is no reason, if a person is entirely qualified, that he or she could not get a job in a private hospital and run private clinics.

Deputy Shortall is correct. For instance, in the area of orthodontics, massive sums of money are being spent by parents in dealing with their children's dental problems. Because of the scarcity of orthodontists, the charges are through the roof and no matter how often it has been raised with the Irish Dental Association and other bodies, the intake of people for training seems to be controlled. There seems to be a closed shop which is driving the fees up.

Mr. Michael Scanlan

That is a fair point. I am sorry about that. The Department does not control the number of people or posts in the private sector. The Chairman has a point in terms of the numbers who will be going into training and it takes a number of years to train a person up to that level of consultant status. What one must do in that case is examine the numbers projected to be needed in the country as a whole and how to increase, if necessary, the numbers going into the education system. I do not have the figures to hand but there has been an increase in both undergraduate and postgraduate entry to medical education schools but I think further increases are planned. I might be able to get this information for the Deputy but at a macro level we have looked at projected need and what this will require in terms of training. Apart from the training, we do not control the numbers actually practising in the private system.

However, is it not the case that the Medical Council of Ireland controls those numbers?

Mr. Michael Scanlan

Only in terms of qualifications and capacity to practise, that people are fully trained and accredited.

Can anyone come along and set up as a psychiatrist provided they have the right qualifications?

Mr. Michael Scanlan

I want to be careful in my response. It is a case of being subject to the Medical Council of Ireland as to whether a person is qualified to provide this service.

But is there control on the numbers?

Mr. Michael Scanlan

In the public system.

And in the private system? It is very difficult to understand that.

Mr. Michael Scanlan

I may be misunderstanding the Deputy.

How would a situation arise then if it was a free market? It is obviously very lucrative being a consultant. Why is it the case that people have to wait a number of months to pay somebody €180 for a consultation? There is control there somewhere. Is there a closed shop element in this?

Mr. Michael Scanlan

I am not aware that we control the numbers.

Perhaps the Secretary General would do a note for the committee on this point.

Mr. Michael Scanlan

Yes, I will, and I will also look at the macro piece which is where I think the Deputy is coming from.

Does the same not apply to general practitioners in that a person cannot set up as a GP wherever he or she likes?

Mr. Michael Scanlan

They can, or rather they cannot get a general medical services, GMS, list but they can set up.

That is not my information.

Mr. Michael Scanlan

I would be happy to talk to the Deputy on this point.

Mr. Pat O’Byrne

A qualified person might be able to practise but they may not be taken into the public system.

Mr. Michael Scanlan

I would be happy to talk to the Deputy anyway.

Is there control of numbers in the dental service by the dental association? Does it not limit the number of orthodontists being trained?

Mr. Michael Scanlan

There is a training issue, an education training potential blockage.

That is what they call it, yes.

Mr. Michael Scanlan

Yes, I agree with the Chairman.

Is it not the responsibility of the Department of Health and Children to ensure adequate numbers of people are being trained for different specialties?

Mr. Michael Scanlan

It is an issue we examine and we consult or co-operate with the Department of Education and Science. However, as the Deputy says, there are other ways. If the market is a lucrative one, a person does not have to be trained in Ireland just to practise here.

Yes, I know that. I have another question to follow on from the points made by the Chairman and other members about this lack of information on outpatient waiting times. As a once-off project and to satisfy this committee, would the Department consider getting a departmental official to contact each of the hospitals to ask for that data? For example, I have dealt with people in the Mater Hospital and they can give the information about the length of the waiting lists for all their consultants. I presume that information is available within other hospitals. Would the Department consider delegating someone to pick up the phone and get that information and report it back to this committee?

Mr. Michael Scanlan

I will consider it.

Mr. Tom Heffernan

I will supplement the remarks made by the Secretary General with regard to future medical education training needs. A workforce planning committee takes a long-term view of this matter and it involves the Departments of Health and Children, Education and Science, and Finance. As the Secretary General pointed out, there are no controls on private practice in the sense that there is no public policy controlling those numbers in private practice.

On the issues raised by Deputy Shortall regarding training, more than ten years ago, the Joint Committee on Health and Children issued a report on orthodontic training and treatment services and made certain recommendations at the time but the situation has not changed in that there is still almost a cartel system in operation in which people are charged exorbitant fees for orthodontic treatment. It is all down to lack of choice and is something that needs to be addressed.

Mr. Michael Scanlan

I will check specifically on orthodontics.

I sincerely believe our work as a committee is being seriously hindered by a lack of information and data which we have requested on many occasions. I am very concerned at the Secretary General's remarks that the information promised by Professor Drumm about private-public practice in public hospitals, may be unavailable to us because of legal difficulties. This is a serious issue which is hindering our work in coming to conclusions. I would like an early report on the exact difficulties facing the Department and the HSE with regard to providing that information.

Mr. Michael Scanlan

I was trying to be helpful to the Chairman by giving my understanding of it. The committee would need to ask the HSE as it holds that data. We do not collect them. The Chairman asked why this is so but neither does the Department get names. However, I hear what the Chairman is saying.

Mr. John Buckley

In a few weeks' time the committee will have an opportunity to examine health information because the Comptroller and Auditor General's report has a chapter on HealthStat. This will enable the committee to take up the issue of outpatients with the HSE which collects this data. There has been some gradual improvement in performance management in that area since 2008 which is detailed in that chapter.

We are discussing the National Treatment Purchase Fund, the primary objective of which is to treat those waiting longest. Chapter 36 of the report of the Comptroller and Auditor General raises the issue of certain risks to the achievement of value for money in terms of that primary objective. I wish to make some points arising from this chapter and from today's discussion. From the viewpoint of demand, the validations show that the majority of patients waiting a long time are not actually available for treatment. The other side of the coin is that many public hospitals have negligible waiting lists and this suggests there may be a need to look at and establish overall hospital capacity and perhaps identify whether there is an opportunity for the system to have first recourse to the public system before procedures are purchased from the private system.

One of the risks of programming NTPF activity in advance by agreements between both the hospitals from which it is purchasing and those hospitals from which patients are coming is that, because it is programmed in advance, effectively its activity is a top slice of all inpatient activity. The problem is that if the demand is in fact reducing within the system as a whole, the system would not effectively signal that fact. The public system would in fact be picking up the residual rather than picking up the first slice.

If this had to be looked at, I believe our report would be tending to suggest that these risks may need to be looked at as part of a value for money and policy review initiative study. The risks I have pointed out may well be displaced by facts and evidence in the course of such a study. However, things such as those I have described must be added to the fact that there are different eligibility timeframes used for different hospitals with implications for equality. We do not know how long a patient who is treated using the NTPF has actually been waiting, so we would need more data on the patients who have actually been treated.

These are part of a wide range of things that I would put no higher than at the level of risk to value for money in terms of achievement of the ultimate objective. However, it may be opportune at this point to have a study and look at it in a bit more depth and, whatever about getting information, move on from information to analysis.

I thank everybody who contributed to today's debate. Is it agreed that we note Vote 30, Department of Health and Children, Vote 41 and the National Treatment Purchase Fund 2008 accounts, and dispose of chapter 36, National Treatment Purchase Fund?

Year in and year out there is a difficulty for us having an unsatisfactory meeting and not having the data available to have a view on the performance of the Department and then rubber stamping the accounts. Do we have any choice in the matter? Are there grounds for expecting that the situation will improve? We have had a number of attempts and there is the same frustration and dissatisfaction with the format.

The Deputy is quite right. We shall put down a marker today that if there is a repeat of this performance next year and some of the issues we bring up every year without getting real action, we will not be noting the Vote in future. We will have the facility to follow up on some of the issues when representatives of the HSE are before us in a few weeks' time. I have also expressed my unhappiness with the lack of information we are getting. We are being inhibited from doing our job by some of the lack of information.

Mr. Michael Scanlan

I absolutely note what the Chairman said about that specific information he was referring back to. I hear what the Deputy said about considering on a once-off basis a kind of collection or audit of the outpatient. I stand by what I said that the amount of data in the health system is improving. If the committee has specific data requests it wants to give to me, I am more than happy to try to factor them into whatever process we have in place with the HSE, because we have a long list of where we are looking for data. We cannot get it. That is the only point I shall make.

We can be blinded by data.

Mr. Michael Scanlan

Yes, I agree.

However, the essential data we seek has been unavailable to us. I started the meeting today by saying that, in view of the promises made by Professor Drumm in November, we expected to be facing today's meeting equipped with the information we were promised in order that we could do a more effective examination of the issues raised. We have not received that information for reasons Mr. Scanlan has suggested and as a result we have not been able to deal with the issues related to the National Treatment Purchase Fund in the context of full information.

Mr. Michael Scanlan

I understand that. Just to be fair, I did not promise those data from the Department.

I wish to make a suggestion. The Comptroller and Auditor General is right. It is the management of risk in terms of State expenditure. One very helpful aspect would be to have more geographical hospital information — the type of information the NHS seems to have had for 20 or 30 years. While I know that HIQA is becoming established, we need more of that type of front line feedback.

Mr. Michael Scanlan

I will do my best in terms of pushing data. If I knew what I was looking for it would be a really big help. I take the Deputy's point about something below national level.

I believe Mr. Scanlan knows what we are looking for because we have been looking for it for a number of years. We want information on the waiting lists for outpatient appointments. We want to be able to drill down through the figures on inpatient waiting lists to establish whether it is an improved performance. We need to know about productivity on a hospital-by-hospital basis.

Mr. Michael Scanlan

Okay.

We have put down a marker. Let us note the Vote. I think there is agreement on that.

Next week's business is the 2008 annual report of the Comptroller and Auditor General and appropriation accounts. At 10 o'clock we will deal with Vote 25, the Property Registration Authority as well as chapter 18, Digital Mapping. We shall have a second session at 11.30 a.m. to deal with Vote 10, the Office of Public Works and chapter 8, Central Government and Public Procurement. We shall have two separate sessions next week as well as a private session.

I again thank the witnesses.

The witnesses withdrew.

The committee adjourned at 1.30 p.m. until 10 a.m. on Thursday, 4 February 2010.
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