COMMITTEE OF PUBLIC ACCOUNTS debate -
Thursday, 4 Mar 2010

HSE Financial Statements 2008.

Professor Brendan Drumm (Chief Executive, Health Service Executive) called and examined.

Chairman

I welcome everyone to consideration of the 2008 Annual Report of the Comptroller and Auditor General and the appropriation accounts, Vote 40, Health Service Executive, chapter 38, performance measurement and improvement in the HSE, chapter 40, the Dublin Ambulance Service and the HSE financial statements 2008.

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. The committee cannot guarantee any level of privilege to witnesses appearing before it. I further remind members of the long-standing parliamentary practice to the effect that members 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. Members 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 policies.

I welcome Professor Brendan Drumm, chief executive, Health Service Executive, and ask him to introduce his officials.

Professor Brendan Drumm

With me are Ms Laverne McGuinness, national director for integrated services, Mr. Liam Woods, national director, finance, Mr. Brian Gilroy, national director for reconfiguration and business support services, and Mr. John Hennessy, regional director of operations for the western region who also has a national role in the implementation of the consultants contract.

Chairman

I call on the officials from Department of Health and Children.

Mr. Jim Breslin

I am an assistant secretary in the Department of Health and Children. I have responsibility for overseeing the HSE's finances and service plan. I am accompanied by Mr. Fergal Goodman, principal officer in the acute hospitals division.

Chairman

I call on the officials from the Department of Finance.

Mr. Tom Heffernan

I am a principal officer in the sectoral policy division of the Department of Finance.

Chairman

I now call on the Comptroller and Auditor General, Mr. John Buckley, to make his opening remarks. The full text of chapters 38 and 40 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

Under a conventional accrual basis of accounting the HSE incurred expenditure of €14.7 billion on services in 2008. A further €563 million was spent on capital works bringing the total to €15.3 billion. The net cash outlay of the State on the HSE as recorded in its 2008 Appropriation Account was €12.7 billion. The balance of HSE funding came from health contributions which are collected through the PRSI system and various charges. The HSE costs break down into the following categories: €5.8 billion went on hospital services; €8.2 billion on primary, continuing and community care and; €700 million on central and shared services.

I draw attention to the fact that my opinion on the appropriation account contained a reservation in the following terms:

Owing to the nature of the HSE's accounting system, I was unable to satisfy myself that the outturn on any of subheads B1 to B8 and subhead B16 is accurately stated although the amounts charged in aggregate to those subheads and the Vote is correct.

This reservation was necessary because expenditure on long-term residential care could not be separately identified for purposes of reporting under subhead B16. The charge recorded is therefore an estimated amount. Two chapters from my annual report fall to be considered today. First, the HSE has instituted a performance management system called HealthStat designed to give performance information about key activities in most hospitals. It is planned to extend it to other hospitals and the community care area in March 2010. The HealthStat system was reviewed during the audit with the aim of examining the relevance of the indicators produced and the reliability of the underlying information. In this respect we examined six key indicators and visited hospitals to review the base information used. In general, we concluded that the system, while needing to be enhanced over time, increases accountability for performance, allows for comparison of performance across hospitals and facilitates a performance improvement drive by the organisation.

Looking first at our recommendations for improving the indicators, we thought that it might be worth considering whether in the case of planned or elective admissions a waiting time indicator should be calculated that captures waiting time up to the point of treatment of the patient rather than, or perhaps as well as, up to the date he or she is given an appointment. We also considered whether, in the future the average actual waiting time for patients seen by outpatient departments should be calculated rather than, or as well as, the current measure which focuses on how long a new patient will have to wait for an appointment. An alternative might be to time-band the numbers waiting as is done for elective procedures.

Since an overall efficiency objective is to reduce inpatient cases there could be value in tracking the extent of procedures conducted in an outpatient setting in addition to day cases. There is need to consider how greater consistency can be got into the measurement of delayed discharges and whether the setting of a target to guide bed management decisions might improve capacity. We also need to devise a suitable productivity measure that relates inputs to outputs perhaps in terms of cost per patient day or whole-time staff per patient day to replace the abandoned measure that captured the ratio of WTE staff to beds. Another consideration is whether in the measurement of the public-private split of activity it might be necessary to refine the associated target to take account of consultant categorisation under consultant contract 2008.

No doubt there will over time be a continuous process of refinement of the measures and associated targets and the foregoing comments are not meant to detract from the progress achieved to date. There is a saying that what gets measured gets managed so the HSE's move in the direction of performance reporting is to be welcomed. In addition, I recognise that the quest must be for the most relevant set of indicators upon which to base a performance dialogue with hospitals rather than a proliferation of measures, indicators and targets which could ultimately create confusion.

Turning to the results reported by HealthStat; these are useful in that they point up some areas where greater efficiency may be achievable following detailed review of the underlying figures. In particular, I instance the fact that combined with the information set out in the chapter on the National Treatment Purchase Fund, which has already been considered by the committee, the elective waiting time results may suggest need to focus attention on the timely treatment of children and in the case of adults on delays in a small number of hospitals. In the first instance, it would be useful to review the extent to which any spare capacity in the public system could be used. In the case of outpatient waiting, the overall impact of the measures identified by the national improvement project outlined in the chapter should be tracked through this waiting time measure to gauge the result of any administrative changes made.

Since the overall performance in the area of day cases falls well short of the 75% target there should be scope to treat a greater proportion of elective patients on a more cost-effective basis. Delayed discharges can impact on the capacity of the hospital to treat patients with the highest priority. In addition, depending on how overall demand is managed, there could be some scope for savings since the daily cost of inpatient beds is much greater than that of a nursing home bed. It would be necessary to take account of a wide range of factors in determining the likely extent of savings arising from step-down facilities. My report on emergency departments, which was laid before Dáil Éireann on 12 February, discusses this issue in more depth. Staff per inpatient bed measure has been dropped in the area of resource utilisation. However, it is necessary to have some measure to stimulate dialogue on resourcing, taking account of the intensity of care in individual hospitals. While this debate may not be suitable to the forum which accompanies the HealthStat process, the relationship between resourcing and activity could be a useful area for the HSE's value for money unit to explore.

The measure on the public and private split is useful as a global indicator of the extent to which patients are being treated on a public or private basis. However, ensuring treatment on a public basis of the quantum of public patients for which funds are voted is something that can only be effectively enforced at the level of individual contracts.

The report also contains a chapter on the ambulance service in Dublin where emergency ambulance services are provided by both the HSE and the Dublin Fire Service. The report outlines some effectiveness issues that were noted by a review group and which have existed for some time. These include the existence of two control centres and limited integration in ambulance deployment, as well as the fact that the nearest ambulance is not always dispatched. The report suggests that it would be desirable to review the economy and efficiency of the overall arrangements, taking account of manning levels and the cost of each service.

The Accounting Officer has outlined his views on the way forward and these are recorded in the chapter. The core of the desired change would entail equipping the ambulance service with the capacity to separate life-threatening situations from others, as well as the dispatch of ambulances on a priority basis. He feels that the integration of the dispatch function is key to this objective.

Chairman

Thank you Mr. Buckley. I now call on Professor Drumm to make his opening statement.

Professor Brendan Drumm

A number of queries have been submitted to us on specific issues. We have responded in writing to these, but we are happy to answer any further questions today that seek clarification on those queries.

The year, 2008, was a very challenging one. It demanded a very rigorous and continued focus on cost containment, cost reduction and achieving better value for money. If staff had not achieved the success they did in these areas, we would have been unable to meet the service targets as set out in the national service plan for 2008. As Accounting Officer, I am pleased to confirm that in 2008 the HSE succeeded in achieving, and in many instances exceeding, its targets for health and personal social services, within the Voted allocation of €14.41 billion.

The most significant cost growth during 2008 was the increase of approximately €320 million in the cost of servicing the various demand-led schemes, which include the medical card and drugs payment schemes. We have no control over the demand from patients and clients under these schemes, and therefore meeting the extra costs, which are not included in the annual budget, represents a major challenge each year. The increase in this area in 2008 represented an 11% year-on-year increase. However, to offset the impact of these extra costs and extra service demands in other areas, we delivered value for money savings of more than €280 million.

We have repeated these savings and added more in 2009 and again this year. By reducing expenditure in non-front line areas and delivering significant savings in areas like procurement and the cost of medications, we have been able to protect front line services. While we continue to focus on achieving better value for money, the capacity to offset increasing costs in front line services with non-service cost reductions or savings is diminishing.

Financial control remains a very important issue for the HSE. We reviewed our financial controls in 2008, and while we found that they are appropriate, we are implementing a range of measures aimed at strengthening them, enhancing the assurance provided to me as Accounting Officer by the finance directorate and further developing our finance function. The success of financial regulations ultimately depends on individuals adhering to those regulations. I have established a steering committee to oversee the implementation of these measures and excellent progress has been made.

I would like to conclude by making reference to HealthStat, our national performance measurement and improvement system, which has recently been the subject of review by the Comptroller and Auditor General. We have been planning and implementing HealthStat since 2006, and it is proving to be a highly effective tool to enable staff appreciate and understand their performance, and how it compares with those of their colleagues in other parts of the country. Every time a problem arose in a hospital or community service, the first call was always to claim underfunding when compared with a similar service. The system was poorly equipped to challenge what I used to call the "Morning Ireland" calls. Our comprehensive data today, coupled with the monthly HealthStat forum, during which I review with managers their performance and the improvements they are making, makes this system a very effective management tool. It informs people of their resources in comparison to others, rather than having them rely on stories they might have heard. It also allows us to set standards based on international criteria for productivity.

Up to now we have been publishing data on the performance in our hospitals each month on the Internet. We have been gathering data on community services over the last year, in addition to monitoring and publishing hospital performance data. This is very challenging. Collecting data for systems like HealthStat has not been done anywhere in the world, and not very successfully at community level. I am pleased to say that the performance data on community based services will be published on the Internet very shortly, after a year in which we have dealt with the data without publishing it.

Publishing detailed performance data allows the public and the media to study critically our weaknesses as well as our strengths. We are well aware that putting this data into the public domain has generated great challenges for the organisation and those who work in it. The HSE remains committed to this unparalleled level of transparency, which is essential in promoting continuous improvement in services. There are reputational risks associated with this, but if it drives improvement, those risks are well worth taking.

Finally, I would like to take the opportunity to congratulate Waterford Regional Hospital for being the first facility to achieve three green lights in HealthStat in its three key measurement criteria, namely, access for patients, integration of services and resource management. This is a great achievement for all staff at the hospital. People have commented on the difficulty in obtaining three green lights. This is because we have set the bar extremely high for performance. I know that hospitals across the country are moving up the performance ladder and are eager to achieve this level of success. I encourage them to continue to work towards this level of achievement. This system has moved our institutions from constantly explaining away difficulties with performance based on resources, to accepting that they now have the information that may confirm or undermine the argument. This has often led to underperformance by convincing people that they are not adequately funded.

This concludes my opening remarks and I welcome any further comments or questions.

Chairman

Thank you professor. May we publish your statement?

Professor Brendan Drumm

Yes.

Chairman

Before I call on Deputy Fleming, you stated that you would answer any questions on information supplied to us since the last meeting. At that meeting, which was in November, you volunteered to provide us with full information on the public and private mix in public hospitals. A letter from Mr. Ray Mitchell to the committee on 5 February stated that the HSE was unable to provide that information to us, other than in anonymous format, because concerns were raised about a potential breach of the Data Protection Act 1988. Who raised these concerns? Why does the HSE feel prevented from providing the information that you promised to give last November?

We received a letter from the Irish Hospital Consultants Association last year regarding public and private medical practice. In a letter which we have not had time to consider fully but which we did note and publish this morning, the Irish Hospital Consultants Association makes four points on the data that was given to us in anonymised form. The letter states, first, that the information currently provided by the HSE does not accurately reflect the clinical activity of hospital consultants as significant parts of their activity are not recorded or analysed. Second, it states that it is the patients themselves who determine whether they are to be in a public or private capacity. Third, it states there is incontrovertible evidence that the reports currently in circulation are inaccurate. Fourth, it states that due to the present fiscal difficulties, there is growing pressure on hospital managers to maximise the income to hospitals that is generated from private patients as this will support the maintenance of services to public patients that would otherwise have to be curtailed.

Will the professor answer the questions I have just asked and then react to the issues raised by the IHCA?

Professor Brendan Drumm

In regard to the first issue raised, the Chairman asked us to supply him with the data and we proceeded to do that. We then received a representation from the Irish Hospital Consultants Association essentially telling us that this would be in contravention of the Data Protection Act. In order to check if this was the case, we sought our own legal opinion, which confirmed that the submission from the IHCA is correct and that giving the information is in contravention of the Data Protection Act. That is the situation as we have had it reported to us.

With regard to——

Chairman

This committee is facing the problem it faced when considering issues within FÁS. Now, when considering the HSE, we are being prevented from obtaining the data we require in order to determine whether the taxpayer is getting value for money and an efficient public service, and, therefore, we cannot reach any conclusion. In other words, the provisions of the Data Protection Act override our rights to receive what we term legitimate information so we can determine whether the taxpayers' money is being spent effectively. This again raises a major issue for the committee in doing its job. We have made our views known to the Government on this matter and we have asked for changes so that our committee would have powers which would override the provisions of the Data Protection Act.

I appreciate what Professor Drumm has said. We are all governed by the law but, at the same time, we consider this committee to be inhibited and handicapped in coming to grips with problems that are of concern to us and to the public.

Deputy Thomas P. Broughan

On a point of information, are we prohibited from asking Professor Drumm and his colleagues about information which is now in the public domain?

Chairman

We are not prohibited from asking those questions. Whether we get answers is another matter. We will deal with that aspect. I know Deputy Flanagan also has questions in this regard. I have asked this question arising from Professor Drumm's statement and arising from the substantial correspondence which was received late last evening and which we, as members, only received at approximately 9 a.m. today. The four issues that were part of the IHCA letter allege that some of the information supplied to us is inaccurate and false.

Professor Brendan Drumm

In that regard, a group was established between the representative bodies for consultants and the HSE subsequent to the negotiation of the contract to agree a measurement system. We are operating that measurement system. If there is inaccurate data in regard to any individual consultant, I am sure consultants will bring that to our attention very quickly. If it is the case, we will certainly rectify it.

In a system as large as this, I am sure there will be inaccuracies in the data at some level. The only person who can bring that to our attention if we have not caught all of an individual consultant's activity is, I suspect, the individual consultant. We are perfectly happy to take that on board if it turns out to be the case.

Another point made in the letter was that patients have a right to pick a public or private consultant. That is true and we have no argument with it.

A further point was that hospitals want to maximise their income generation. Again, we have no difficulty with that. Hospitals should be maximising their income generation. We fully accept there are parts of the country where there is a significant number of patients presenting as emergency cases who will be insured and have to be dealt with. However, the contract allows for this, so they will be admitted and treatment will be delivered. The contract also allows for the repayment of moneys above the 70:30 or 80:20 split, depending on which contract applies.

Chairman

Notwithstanding what I said about the impediments to our dealing with all of the issues, there is sufficient evidence, even with the anonymised data we received, to suggest there is widescale breach of the new common contract. In view of the failure to monitor the old contract, how did Professor Drumm's people enter into a new contract given all of the problems inherent in the contract which are preventing him from providing us with all of the data so we can assess that the taxpayer is getting value from the new contract?

Professor Brendan Drumm

I did not believe we entered into a contract that had anything to do with the Data Protection Act. That is an issue the Chairman probably knows more about than we do.

I can tell the committee the contract is being implemented as written down. We have better information than has ever existed on consultant performance. I genuinely believe the vast majority of consultants want to work within the contract ratio. In some situations where there is no private hospital locally, this will mean that even if they are outside the ratio, that money will have to be repaid. While there is little they can do at times to prevent themselves rising above the ratio, the issue is that we have to recoup that money. While that process has not yet been achieved, it was planned to allow a nine-month period. We would foresee the contract being measured in great detail, unlike previous contracts, and it has been measured in great detail, with the support of many consultants who hold that contract.

Mr. Gilroy might want to comment on the issue the Chairman raises in terms of the operation of the contract.

Mr. Brian Gilroy

A point that does not seem to be fully understood is that the contract that was signed allowed for a rectification period because it was appreciated that some consultants were way in excess of that level. We currently have 226 consultants who have been written to and who are now in that process. There is a period of time in which they have to rectify the matter. Although the list you see is now a month or six weeks old, there will be some change in that——

Chairman

It is a month old.

Mr. Brian Gilroy

It is now a month old. By about May, we will begin to see the first maturing of those initial letters of rectification but that is the process which is laid down in the contract. It is being adhered to and worked on at present.

To address the issue of the accuracy of the data, it is appreciated that there are some nuances that may or may not be included, and we continue to work with the consultants on that. There are some figures which are so far in breach that any amount of rectification and various other means of measurement will not bring them back within the range. This is what informs our approach to compliance.

Chairman

We have published the Irish Hospital Consultants Association correspondence today. To be fair to the consultants, I believe the HSE should give a considered response to all of the issues raised by them in the interests of justice.

Professor Brendan Drumm

We are perfectly willing to provide the Chairman with that. I reiterate that, in essence, the public health system deals with the vast majority of emergencies that occur in Ireland, which is 80% of the admissions every day. I do not think it is unfair to say that people with serious medical conditions generally turn up on the public side of the thing. The private side of the fence is often used much more for elective work. By virtue of the nature of the services we provide, and given that 50% of the people are covered by insurance, there are several places in this country where these figures will continue to be significantly out of line. We need to decide how we can recoup those funds. The consultants have signed the contract, as I have said. The vast majority of them accept it as a means of generating income for the health service.

Chairman

We will give the HSE the correspondence we have received. Perhaps the HSE will respond to it.

Deputy Seán Fleming

I thank Professor Drumm for attending this meeting. We are dealing initially with the 2008 accounts. I would like to ask about the statement on page 17 of the accounts, to the effect that 375 children were in residential care in 2008. Over the last decade, how many children died while in the care of the HSE? I acknowledge that children in the care of the HSE have many difficulties in their families and, in vulnerable cases, need special care. How many reports have been prepared on such children? How many of those reports have been published? Since the HSE was established, how many reports on children who died in its care have been published? When was the last such report published? Professor Drumm might respond to those specific points.

Professor Brendan Drumm

The percentage of children in residential care in this country is extremely low by international standards.

Deputy Seán Fleming

It is 7%.

Professor Brendan Drumm

It has been a huge achievement for the HSE to keep bringing that figure down. Most children in the care of the HSE are in foster care. When considering the issue of deaths in residential care, a distinction needs to be drawn between people who actually die in residential care, and those who are lost from residential care, which has been a significant issue, or suffer injury having been lost from residential care. I ask my colleague, Ms McGuinness, to provide the specific figures.

Ms Laverne McGuinness

The number of children in care is 5,300. Some 90% of them are in foster care, or in foster care with relatives. Twenty children have died in the care of the health services over the past ten years. Some of them died from natural causes, as a result of congenital defects, or by misadventure. The reviews and investigations that were carried out in such cases did not all take the form of reports. Our intention is always to publish reports where appropriate. A process needs to be undergone in that regard. Members will understand that there are many complexities and sensitivities in this area. Two reports are nearing conclusion and publication. The relevant recommendations in those cases will be published over the next couple of weeks.

Deputy Seán Fleming

When was the last time the HSE published a report on someone who died in care?

Ms Laverne McGuinness

We have published a number of reviews. We have not published any reports specifically on child deaths, per se, to date.

Deputy Seán Fleming

Why not?

Ms Laverne McGuinness

We have not done so for a number of reasons. Many investigations were carried out under the former health board areas. There was no standardised way of carrying out such investigations. The reports contain an awful lot of personal data on the children, the families and the extended families. We have taken legal advice on the publication of such material. We have been advised that it could not be published in that format. The Health Information and Quality Authority has come up with a standardised format that will allow elements of reports to be published. Previous investigations were carried out by different people — the same people did not carry out the investigations. This information is very sensitive. Legally, we are not able to publish the information that is available in the reports, although we can publish the recommendations.

Deputy Seán Fleming

It goes without saying that we do not have a prurient interest in the details of individuals. The committee is more interested in dealing with the HSE response than the particular circumstances of the child. The purpose of these reports is not to highlight the details of the unfortunate person who has died. When did the Health Information and Quality Authority finalise the new report format? When was that accepted by the board?

Ms Laverne McGuinness

The new HIQA system is coming to conclusion now. We have not used that format yet. It is not quite ready. It is almost finalised. When we carry out a review or an investigation, our intention is always to see whether mistakes have been made, to ascertain whether we can make improvements in certain areas and to drive service improvements. It is on that basis that we publish and use the recommendations of each report. As I have said, two reports are ready for publication over the next number of weeks. We operate within a transparent system. We need to separate the recommendations from the very personal issues that are the subjects of these investigations. Some of the reviews are of a highly sensitive nature, but the recommendations are published. HIQA has come up with a format that will be readily available to be used in all future investigations. As it will contain the recommendations only, it will be capable of being readily published. We have put in place a process to be used when an incident happens with a child in a particular area. We will examine how the recommendations can be rolled out across the country, in a way that ensures improvements are carried out. We have made great improvements in recent years. We have put in place standardised case management processes for social workers. We have changed the manner in which child care cases are allocated. We have set a target of drawing up care plans, or review of care plans, for 100% of children. That represents an increase on the previous 90% target. We are hugely compliant with that in a number of areas. We are continuing to drive for 100% in all areas. That is really what will drive our child care service improvements.

Deputy Seán Fleming

I am a little confused about some of what Ms McGuinness has said. Her comments gave me the impression that two reports will be ready for publication within a short period. She said that new guidelines for the production of these reports have been prepared by HIQA, but have not yet been fully implemented. Is the HSE proposing to issue reports that have not been prepared in a manner that conforms to the HIQA guidelines? Will the HSE have to restart all the investigations that were commenced before the new HIQA guidelines were drawn up? Will they have to be carried out under the HIQA approach? Does Ms McGuinness understand? She threw in a reference to HIQA, but she seems to be ready to issue a report that is not HIQA-approved. Will this be another stalling mechanism? Will the HSE claim that it needs to revisit and reformat everything it has done to date in reports that are being prepared?

Ms Laverne McGuinness

There are two issues — the investigation and the review, and the publication of the report. The investigation and review stage is carried out when a child dies, or is involved in a serious incident, while in the care of the State. The circumstances of the incident — what happened and how it happened — are investigated. Recommendations are drawn up to ensure such an incident does not happen again. A report is compiled by the reviewer and the investigator, based on all the information that has been collated, having met the family and all the professionals and workers who were involved in the case. In the two cases to which I refer, all of that work has been done and a report has been compiled. The report is not in a format that can be readily published, however, because it contains many personal details. We need to get legal advice in that regard. We have separated the recommendations from the rest of the report so that they can be published, in the interests of protecting children and families. They will be available in each of the two reports that are coming to finality. The recommendations were drawn up before the HIQA template was produced. The HIQA piece is a new piece — it is just coming to finality now. It has been decided that a standard format is needed so all future reports can be published to some extent. That does not prevent us from using the work we have done in the cases of these two reports.

Deputy Seán Fleming

Is Ms McGuinness saying that the HIQA guidelines relate to the presentation and format of reports, but do not deal with how investigations into the circumstances of deaths should be carried out? That is what I am getting from her.

Ms Laverne McGuinness

HIQA will dictate what the best practice is, in relation to what the content of a report should be, so that we will be able to publish each report in its entirety. Elements of each report will be——

Deputy Seán Fleming

Are the HIQA guidelines designed to protect the HSE so it cannot be sued?

Ms Laverne McGuinness

No, they have been drawn up in the interests of transparency. The Health Information and Quality Authority is trying to ensure there is full transparency in relation to what can be published in relation to any report. Some very disturbing personal issues can arise in reports, particularly in relation to child care.

Deputy Seán Fleming

We understand that and do not need to see those details.

Ms Laverne McGuinness

Exactly. What the HIQA piece is about is how we can show in a particular format the elements of the reports that need to be seen. We have to do that.

Deputy Seán Fleming

Would it not make sense to apply best HIQA practice before issuing the two reports that are almost ready for publication?

Ms Laverne McGuinness

Our reports are ready and pre-date the HIQA piece. We have taken legal——

Deputy Seán Fleming

Do they conform with HIQA guidelines?

Ms Laverne McGuinness

We have taken legal advice and the reports which we can publish will be in line with the HIQA standard. They will not be in the same format but we will be able to publish the recommendations, which will be of benefit to the public and the services in showing where improvements can be made in future in relation to that. They will show the recommendations and what needs to be done.

Deputy Seán Fleming

On "Morning Ireland" this morning, a member of staff at the HSE indicated that 20 reports were in preparation.

Ms Laverne McGuinness

Yes, there were 20 reviews of child care.

Deputy Seán Fleming

How many of the reviews will result in a report?

Ms Laverne McGuinness

There were 20 reviews of cases involving children who died in the care of the HSE or a former health board. They go back a number of years. Two are ready for publication at this stage and another two are going through a legal process to see what elements of them can be published. Some of these reports go back over eight or ten years. As the Deputy rightly said, he does not want to see all the personal details. What we need to do is see how we can extract the recommendations from the reports which were written at that time so that we can make them available for publication.

Deputy Seán Fleming

I understand that some of the 20 children who died in care died from natural causes——

Ms Laverne McGuinness

Yes, that is correct.

Deputy Seán Fleming

——or hereditary issues. What I am trying to establish, however, is how many of the reports on the 20 children who died will be published, whether today, tomorrow or next year. The HSE must have a schedule of what it wants to be published in a report.

Ms Laverne McGuinness

The recommendations of the reports will be published. I believe that in about ten of the cases, the children died from natural causes or natural defects. We will be able to publish the recommendations of the reports in the balance of the cases.

Deputy Seán Fleming

Does the HSE have a timetable setting out when the ten reports will be published?

Ms Laverne McGuinness

We can get a timetable.

Deputy Seán Fleming

Does the timetable exist as we speak?

Ms Laverne McGuinness

There is not a timetable in relation to the publication of the reports at this stage.

Deputy Seán Fleming

I refer to the other cases, of which there are approximately ten.

Ms Laverne McGuinness

As I said, there are two reports available for publication over the next number of weeks.

Deputy Seán Fleming

We know about the two impending reports.

Ms Laverne McGuinness

We are getting legal advice on another two reports. The other reports are in a format that could be published at this stage.

Deputy Seán Fleming

At what stage during the course of an investigation is it decided that a report will be published? Is this decision made before the investigation commences or when the information is gathered? How does the HSE arrive at a decision on which cases merit the publication of a report?

Ms Laverne McGuinness

To answer the Deputy's question, which is why HIQA has the standard now available, it will be possible to publish all future reports and investigations straight away. That decision will be taken the minute an investigation commences. That was not the case in the former health boards. In their current format the reports would libel and damage——

Deputy Seán Fleming

We understand that. How many children have died in the care of the Health Service Executive since it was established?

Ms Laverne McGuinness

I do not have a breakdown of the figures.

Deputy Seán Fleming

Ms McGuinness will know roughly the years in which the 20 cases occurred. When was the HSE established?

Ms Laverne McGuinness

The HSE was established in 2005.

Deputy Seán Fleming

Since 2005, how many children have died in the care of the HSE?

Ms Laverne McGuinness

I will get the figure for the Deputy.

Deputy Seán Fleming

Has the HSE published any report to date in respect of a child who died in its care?

Ms Laverne McGuinness

No, not in respect of a child who died in care.

Deputy Seán Fleming

The HSE has not published a report on this topic since 2005.

Ms Laverne McGuinness

That is correct.

Deputy Seán Fleming

That is a matter of grave concern to the committee.

Ms Laverne McGuinness

The recommendations will be published because, as I said, the reports have been viewed by the Minister and legally. The investigations were conducted appropriately, taking in all the circumstances of the cases. They were not written in a format which would enable them to be published as they stand. The best we are doing, having gone through all the reports legally, is to see how the recommendations can be extracted. That is what will be available for publication. The purpose of publication will be to inform learning and make sure we can drive forward improvements in the area. That is why the HIQA piece is very relevant. It means that in future when an investigation starts into the death of a child in care we will be able to publish the report in its entirety.

Professor Brendan Drumm

I wish to make a point.

Deputy Seán Fleming

We are trying to understand the system.

Professor Brendan Drumm

Let me be clear on one thing. We have a culture of transparency and will place anything we can in the public domain. We do not have a reason not to publish these reports. There is a danger, however, that if every report gets published, we will have very limited investigations because we will end up in the courts for months before people contribute to the investigation and report because it will become a public document. Through the HIQA approach we may be able to find ways to give people reassurance. While the publication of a report is ideal, equally if we opt for a process under which every report will be published, getting the co-operation of the people one requires to participate in the process could be a prolonged and enormously expensive process.

Deputy Seán Fleming

As a way of short-circuiting this discussion, is it possible for the committee to write to HIQA asking for its recommendations so that we can find out what is its approach? I am sure HIQA can directly supply to the committee the guidelines it issues on the publication of reports.

Professor Brendan Drumm

There is a timeline for recommendations.

Deputy Seán Fleming

I stress that none of us wants to see details about the poor, unfortunate children involved in these cases. We all agree on that.

Mr. Jim Breslin

The Department has been working with HIQA on the guidelines and would be happy to supply them to the committee.

Chairman

I have a few questions arising from what Deputy Fleming has said.

Deputy Seán Fleming

Before the Chairman does so, I will raise one further issue. Speaking on "Morning Ireland" this morning on the report published yesterday — we know who published it and it was not the HSE — a member of staff of the HSE stated that the HSE wanted the report to be withdrawn and referred to the constitutional rights of two children who are having to deal with the report's publication. Given that the issue of the two children was brought into the public arena by a staff member, will Professor Drumm confirm that the HSE contacted these children in the 24 hour period prior to a member of his staff highlighting the issue of the two children on "Morning Ireland"? The staff member expressed grave concern. When the issue of the two children was raised on this morning's programme my immediate thought was that the HSE should have contacted the children in question yesterday. Even if the HSE did not issue the report, if a member of its staff believed it was appropriate to refer to the children in question on "Morning Ireland", one would have expected the HSE to contact the children prior to the staff member making the comments on radio this morning. Did such contact take place?

Professor Brendan Drumm

I have not heard the interview on "Morning Ireland" but we will have to——

Deputy Seán Fleming

Speaking at about 8.50 a.m., the HSE staff member, Mr. Phil Garland, specifically brought into the public arena the issue of these two schoolchildren.

Professor Brendan Drumm

It is unfortunate that we ended up discussing anything about this report. We will check the position.

Deputy Seán Fleming

Does Professor Drumm understand the reason for my question? I am concerned about the two children in question and I would hate to think the HSE was paying lip service to them on "Morning Ireland" when it may or may not have done something about the issue in the previous 24 hours.

Professor Brendan Drumm

I understand the Deputy's position.

Chairman

The Deputy used the word "unfortunate". The most unfortunate aspect of this matter is that it has been going on for eight or ten years in some cases. It shows scant respect for the memory of the children who died that internal reports have been languishing for eight to ten years. The HSE has been in place for five years. Are the reports done by the HSE? Will the witnesses flesh out how exactly the investigations are carried out?

Ms Laverne McGuinness

The reports are not carried out by the HSE. We get an independent investigator, an independent reviewer, to carry out the investigation. Normally someone who is highly regarded within a particular profession carries out the investigation. There is, therefore, a level of independence. Sometimes two or three people may be involved. The investigation can take a number of years to carry out given the complexity required and the level of co-operation one may receive, even from family members. One must also leave a period of time to enable co-operation to take place because sometimes the investigation is over time and goes back and forward. There are different people carrying out reviews and investigations and normally we look for an expert in the field to carry out the review. A timescale is set but may not be kept for various reasons and sometimes the investigators seek more time to carry out a report.

As I said, I believe the process will be greatly improved when the new standard has been introduced because it will mean recommendations and personal issues will not be mixed up together. People write differently and what happens is they bring together personal issues and recommendations. Our difficulty has been extracting the recommendation and what is useful to put out in public to give a level of assurance to the public. We have no wish to conceal anything. It is to be transparent. The investigations have been very good and have allowed improvements to be carried out from the professional practice point of view but they have not been easily available for publication. That is why legal advice has been sought in order to provide the required level of clarity without exposing the committee.

Chairman

Maybe all this must be done but it is inexcusable that reports can go on for eight or ten years. That is unacceptable.

Ms Laverne McGuinness

In any case that has been going on for eight to ten years there are specific issues involved.

Deputy Seán Fleming

We will move on to another topic. I respect what has been said about specific issues that may be involved in each case. Have admissions to accident and emergency units increased or decreased over the past year?

Professor Brendan Drumm

The total number reduced from 2009 to 2008.

Deputy Seán Fleming

I am trying to establish where primary care teams were established and whether this has resulted in a reduction in the accident and emergency admissions in those towns. At the beginning, we were told the establishment of primary care teams, including the local GP and various health professionals, would result in a much better service with more issues dealt with in the community and less need for admission to the accident and emergency unit. Primary care teams seem to be up and running. If a large provincial town has many accident and emergency unit admissions, can Professor Drumm prove that the establishment of primary care teams in a particular town has resulted in reductions in admissions? That was the purpose and there is no point in having primary care teams in place if we have the same number of accident and emergency admissions as always. That would be a pointless exercise. Perhaps some of the longer established primary care teams can be considered. What is the minimum definition of a primary care team? Local health centres had a GP, a local health nurse and perhaps a chiropodist or a physiotherapist. What is the minimum number of health professionals required in order for it to be termed a "primary care team"? Health centres doing what was always done are now called primary care teams. There is no major visible difference. The local health nurse was always there.

Professor Brendan Drumm

In response to the first question, the establishment of primary care teams has been far more successful at a distance from accident and emergency units than close to them. There are many reasons for this. Getting GP co-ops with an out-of-hours service up and running in towns with small accident and emergency units was extremely challenging. Accident and emergency units essentially provide 24-hour, on-call service at the primary care level. Historically, coming up with a figure for reducing admissions will not answer the question because one is twice as likely to be admitted to an accident and emergency unit if one lives in a town with an accident and emergency unit than if there is not one.

Deputy Seán Fleming

That concerns the availability of the facility.

Professor Brendan Drumm

There is no evidence that longevity is improved. The true figure is that last year there was a slight drop, less than 1%, in accident and emergency unit figures. That follows a constant increase over many years. We planned for the reduction to be a few percent higher. We are planning further reductions this year. We were aiming for 2% reduction but the reduction was less than 1%. We are planning a further reduction this year. It is extremely difficult for us to tease out how much this is due to primary care teams, having more senior decision-making upfront in the hospital or having medical assessment units where people can get diagnostics organised without coming into hospitals. We are beginning to see a reduction. Tying it specifically to primary care teams is difficult because there are many other hospital avoidance measures coming into play.

Deputy Seán Fleming

What is the minimum requirement for a primary care team?

Ms Laverne McGuinness

The minimum requirement for a primary care team is that it holds a clinical meeting about a patient. There must be at least a GP, a public health nurse, a physiotherapist, a speech and language therapist and an occupational therapist. In some cases there might be half of the whole-time equivalent of an occupational therapist assigned to the team. Many primary care teams have a more extended team, including a home help organiser in the majority of teams, many teams have a community mental health nurse and some teams have tried child psychologists and dieticians. These are not all new staff.

Deputy Seán Fleming

Did Ms McGuinness say speech and language therapists are available to every primary care team?

Ms Laverne McGuinness

Yes, to the majority of primary care teams.

Deputy Seán Fleming

That is a revelation. It is very hard to find one anywhere.

Professor Brendan Drumm

Our figures for speech and language therapy waiting times have improved dramatically over the past number of years. That is in the figures on HealthStat.

Deputy Seán Fleming

Perhaps Professor Drumm can provide the figures for the long-stay repayments scheme. The last time I heard, it amounted to €450 million. I am always curious whether there are people who had an entitlement to claim but did not do so. I know the process is managed by an outside contractor. A figure of €1 billion was mentioned early on. I suspect there are families whose loved ones were quite happy and the families did not want to come back for money.

Professor Brendan Drumm

Before we respond to that, on the subject of primary care teams, I am not sure how many members of the committee have had the opportunity to visit the infrastructure in place. Perhaps they have been to Ballymun. There is a facility beside the Oireachtas in Ringsend and there is a great deal to be learned from seeing one in action. Deputy Fleming is challenging us on virtual primary care teams. In areas such as Abbeyleix, primary care teams are successful in providing these services. We would be happy to facilitate a meeting at a location close to here or in one of the impressive locations in the Chairman's county. There is something to be learned here. That is what we must demand.

Mr. Woods will comment on the long-stay repayments scheme.

Mr. Liam Woods

There is anecdotal evidence of people not claiming because they or their relatives felt they were fairly treated. There is also a formal donation fund within the legislation. Donations to this amounted to €332,000, a relatively low figure in the context of a potential total payment of over €460 million. The evidence on that, which is also anecdotal, is that if people received reimbursement, they may donate locally and may not go through the donation fund.

Deputy Seán Fleming

When will that operation be wound up?

Mr. Liam Woods

The closing date for applications was December 2007. Final payments will close by the middle of this year.

Deputy Seán Fleming

We are just about there. The HSE provides revenue grants of €4 billion to voluntary and non-HSE organisations, including some of the major hospitals. It also provides some €190 million in capital grants. What contractual arrangements exist in respect of capital grants if the facility is not used for that purpose after a period of time? We have had discussions on this with other Departments. With the national lottery payments there is a threshold. For example, the Department of Arts, Sport and Tourism will not pay out a grant over quite a small sum of money without title deeds and the intervention of the Chief State Solicitor's office. What protection does the HSE have for the taxpayer?

Professor Brendan Drumm

We welcome this question on what is an area of major importance. Mr. Gilroy will comment on this.

Mr. Brian Gilroy

It depends on the percentage of funding we are contributing. In the larger voluntary organisations to which Deputy Fleming has referred, the largest sum was the €100 million development in the Mater Hospital. The State has an indefinite lien over that asset. In the case of some smaller grants we would take a 15 or 20 year lien, which will be repaid if the hospital stops providing the service.

Deputy Seán Fleming

Is that in place?

Mr. Brian Gilroy

Yes.

Deputy Seán Fleming

Must that go through the Chief State Solicitor's office or is it dealt with by the HSE legal team?

Mr. Brian Gilroy

No, we deal with it.

Deputy Seán Fleming

That is good. The phrase "below the threshold" is used. What is the minimum threshold?

Mr. Brian Gilroy

There is none. We have removed it.

Deputy Seán Fleming

The phrase is the note we received from the HSE last night which stated the grant aid scheme section 39 below the threshold document was developed for use with smaller organisations and national lottery funding. We received that 12 hours ago.

Professor Brendan Drumm

The phrase "below the threshold" refers to what a "section 39" is.

Deputy Seán Fleming

What is that?

Mr. Liam Woods

There are two categories of contract the HSE can have with voluntary bodies, a "section 38" and a "section 39". Typically, the "section 39" agencies are smaller. For us, "section 38" agencies could be St. James's Hospital, St. Vincent's Hospital, and the Mater. The thresholds that——

Deputy Seán Fleming

What is the financial amount of the threshold?

Mr. Liam Woods

I will come back to the Deputy on that.

Deputy Seán Fleming

To receive €150,000 in lottery funding, Departments other than the HSE must have lien on the title.

Professor Brendan Drumm

To take the confusion out of it, the threshold is what decides whether it is classified as "article 38" or "article 39". What Mr. Gilroy stated is that he no longer applies a threshold to capital spend. He is taking a lien——-

Deputy Seán Fleming

Is that on everything?

Professor Brendan Drumm

——on everything that is spent on capital, which is a very new approach——

Deputy Seán Fleming

When was that introduced?

Mr. Brian Gilroy

We introduced the lien with the large voluntaries approximately two and a half years ago. Until then it had not been in place. We have progressively rolled it out through the smaller ones.

Deputy Seán Fleming

Is it fully operational?

Mr. Brian Gilroy

Yes.

Deputy Seán Fleming

The HSE is to be commended on that because other Departments did not seem to tie down this issue as well. Grants were being given out but the organisation wound up its bag and moved on. There were difficulties getting the grant so I am pleased to hear about the HSE.

Professor Brendan Drumm

It is a much bigger issue for us as hospitals that cost several hundred million euro can end up in the ownership of voluntary agencies.

Deputy Seán Fleming

There is no protection for the taxpayer.

Professor Brendan Drumm

That is why Mr. Gilroy went this way.

Deputy Seán Fleming

I am happy to hear that.

Professor Brendan Drumm

Ms McGuinness can bring clarity to an earlier question about informing.

Ms Laverne McGuinness

The HSE was in contact with the foster parents and the maternal grandparents of the children in question in the past 24 hours.

Deputy Thomas P. Broughan

I welcome Professor Drumm and his team and our colleagues from the two Departments. I will begin with some brief questions on an important small report that the Comptroller and Auditor General did for us in chapter 40 on the HSE and the Dublin ambulance service. The situation outlined in the report seems incredible, particularly in the current era. We have two ambulance services with different computer systems, namely, the HSE system with its 55 ambulances and Dublin Fire Brigade with its 11 ambulances. They operate out of the same control centre with different computer and call systems.

There are constant arguments between Dublin City Council, which is the lead local authority, and the HSE. I remember some of that from when I was a city councillor, when people would state that the HSE would have to be chased for money owed to the city council. It seems an incredibly dysfunctional area of the HSE's operation after almost five years of its existence. There is no memorandum of understanding between the two bodies, which is utterly astonishing. We do not have a modus operandi

Perhaps what is most annoying from the point of view of our constituents is that the levels of meeting the key eight minute response time are very low. Only approximately 25% of calls are reached in eight minutes and we are nowhere near the 75% target. It seems to be a damning report by the Comptroller and Auditor General on the ambulance service and I would like to hear the HSE's response.

Professor Brendan Drumm

To be honest, we are not here to defend the indefensible and we have much sympathy with what Deputy Broughan stated. Everything he said is true. I will ask Mr. Gilroy to comment on where we are going.

Mr. Brian Gilroy

A lot of progress has been made and that information may be in some of the written responses which Deputy Broughan has. There has been further progress since. The ambulance service provided by Dublin Fire Brigade is an excellent service. The core issue is the control centre and duplicity of control centres. It is not an issue unique to Dublin. We have multiple control centres throughout the country.

Having one control centre would be a solution, but for safety and risk reasons one could not have that so our solution will be to have a main control centre with a hot stand-by. We have transferred services from Castlebar to Ballyshannon and we will continue with the rest of the west; that will be the hot stand-by unit which will operate as a control centre so it will always be available.

We will relocate all of the other control centres to a single centre in the greater Dublin or Leinster area. We are down to four sites for selection for that single centre. That will address, in a fairly short timeframe, the long-term issue of multiple dispatch which cannot be tolerated. It is not dissimilar to the direction of travel in which the Garda is going. Its recent report also recommends two control centres.

We have purchased an advanced medical priority dispatch system. That is in place and training has been carried out. Unfortunately, it is tied up in the public sector dispute. In a strange way, the memorandum of understanding with Dublin City Council is also tied up in the same dispute because we met with the council in December as the start of a process of drafting a memorandum of understanding. Rightly, Dublin City Council insisted on stakeholder involvement, particularly representative bodies. The second meeting has been pushed back and will not happen until the dispute has concluded as the stakeholders will not engage.

Deputy Thomas P. Broughan

Therefore, there is no prospect of getting a memorandum of understanding service agreement between the two bodies.

Mr. Brian Gilroy

It will be very hard to get a meaningful one without stakeholder involvement. We could agree something with Dublin City Council but it may prove undeliverable if we do not have the representative bodies tied into the same memorandum of understanding.

Deputy Thomas P. Broughan

Putting this in the context of the outputs, and I acknowledge that many of them have been achieved, it is totally at variance with what the HSE management has been trying to achieve. It cannot be sustainable. It is appalling that any situation would arise whereby the nearest ambulance would not be sent to somebody who is gravely ill.

Mr. Brian Gilroy

That is why we are moving to the two-centre model. We have purchased the systems and we are moving to a digital radio system. All of that is in train and we will have one centre by the time we return to the committee.

Deputy Thomas P. Broughan

What about the eight-minute rule? Have targets been set? Can we get around this issue using the existing terrible situation?

Mr. Brian Gilroy

We can get around the measurement of that and we are working very closely with HIQA. We expect to finalise what measurements will be appropriate for our jurisdiction within a two to three-month period.

Deputy Thomas P. Broughan

We should not sign off on this chapter because the consequences for the public are not good. We should come back to it.

Professor Brendan Drumm

It is important to state that the industrial relations environment is not supposed to be affecting patient services. The implementation of the new dispatch system would dramatically improve the experiences of patients in getting the appropriate and closest ambulance dispatched in the quickest response time. It seems unfair from the perspective of a patient waiting for an ambulance that an industrial relations dispute is preventing the implementation of a state-of-the-art IT system that has been purchased.

Deputy Thomas P. Broughan

On that broader point, how is the HSE coping with the current work to rule? We are experiencing it as we do not get information from the officials who are generally very responsive to queries about various aspects of our constituents' health.

Professor Brendan Drumm

We are managing in an environment in which we are trying to ensure tensions are not ratcheted up unnecessarily. We hope there will be a national approach to resolving a public service dispute that is much wider than the health services, even if we are the largest component of it. The Deputy raised a good example of a block in the administrative process which seems to be having a significant effect on patients' experiences. One could even draw that out into a parliamentary inquiry where there are significant effects on patients and their needs.

It is fair to say at present that we are managing in an environment of ambiguity in terms of how this is going to evolve on a national scale. We are conscious that if we ratchet up the dispute by taking specific actions, it could spread rapidly into areas that will affect patient services. It is difficult to develop contingency plans for that because we cannot even predict how large it may be. I have not been specific in my answer because we are living in a grey zone. We see our clear responsibility as ensuring that patient services are not damaged and that has been successful to a large degree, although the Deputy identified a case that might not have come to my mind. We must be careful that we do not reach a point at which the situation begins to deteriorate.

I would also note that large proportion of the services we provide are not pertinent to our day-to-day core mission, which is clinical services. If these backroom support services are not being provided we will see how best we can provide them.

Deputy Thomas P. Broughan

We are coming to a milestone in the history of the HSE and the delivery of Irish health services. Does Professor Drumm intend to retire later this year and is an international competition being put in train to appoint a replacement for him?

Professor Brendan Drumm

I understand a search company was appointed and the board is pursuing an appointment to replace me when my term of office comes to an end in the middle of August. The timeline it is following will see someone being identified well in advance of my departure.

Deputy Thomas P. Broughan

Will the successor have an opportunity to work beside Professor Drumm in this vast organisation?

Professor Brendan Drumm

The HSE is a massive organisation and the transition will be extremely important. Obviously the new appointment would bring new ideas to the post and this is why change is critical. I have always held the view that an organisation as large as the HSE needs fresh ideas and new people. There certainly should be enough time for a reasonable transition.

Deputy Thomas P. Broughan

Professor Drumm does not have to answer my next question. Would it be preferable to select a clinician than a manager with entrepreneurial experience?

Professor Brendan Drumm

There is no easy answer to that question but one should select the best person. It is not a uniquely Irish problem that health and other professionally driven services fail unless the professionals are close to leadership and delivery. I do not think that has to happen at CEO level but professionals have to become much more involved in managing day-to-day services and strategies. One of the HSE's major successes has been to bring clinical leadership to the reconfiguration of services across the country. People are not interested in hearing from me about how their local accident and emergency services are going to change but they are more receptive to their local clinical leaders. From the point of view of confidence and delivery our entire HealthStat process can only drive change if clinicians hold each other to account for their performance based on the figures. If we let them abdicate their leadership roles they will just blame the system. A major step in this regard has been the appointment of consultants across the country as clinical directors. We have been amazed by the commitment of clinical directors not only in terms of taking on leadership roles but also in their desire to do so.

Deputy Thomas P. Broughan

Are they all in place?

Professor Brendan Drumm

We have appointed 35 posts across the general services and 14 in mental health services. The process was limited to this extent to begin with because we wanted the people concerned to develop true leadership skills. What is remarkable is that throughout the system they are taking up the challenge of planning and driving change. We must now be clear about how they are accountable as compared to managerial accountability. In the best services in the world, the two should work hand in glove. Who leads the process as CEO is almost a secondary issue. I do think, however, that there is considerable naivety about the difference between managing in the public and private sectors. Deputy Broughan will be aware of that issue. The idea that one could just come in and implement a change programme in the public sector in the same way as one could in the private sector is naive in the extreme.

Deputy Thomas P. Broughan

I have some questions for Mr. Gilroy and Mr. Woods. While we are constitutionally constrained from inquiring into certain issues, I asked the HSE on the last occasion it appeared before the committee about the consultants who are not obeying the public-private mix under the B contracts. I understand the total figure has gone past 200 at this stage and we are approaching the end of the grace period. What sanctions are available to the HSE against consultants who do not perform or fulfil their contracts? I am grateful for the detailed information which has already been submitted to the committee. While this information does not allow us to identify consultants, we can clearly see that the public-private rules are being broken.

Mr. Brian Gilroy

The sanction covered in the contract allows additional income earned as a result of a breach of the level to be recovered by the hospital.

Deputy Thomas P. Broughan

Is that the basic penalty?

Mr. Brian Gilroy

Yes.

Deputy Thomas P. Broughan

Is there a point at which more serious disciplinary measures arise?

Mr. Brian Gilroy

No. The IHCA may also wish to comment on the issue but during the negotiations it was felt the mechanism was strong enough. If a consultant surrenders all of his or her earnings from additional private work, why would he or she pursue unnecessary additional work?

Deputy Thomas P. Broughan

I wish to ask Mr. Woods about the appropriation accounts for 2008. It is astonishing that, three years after the establishment of the HSE, the Comptroller and Auditor General has qualified the accounts. In regard to subheadings B1 to B8, inclusive, and B16 of the appropriation accounts, the statement for 2008 cannot be reconciled with the figures for the Government accounts. Will this disappear with time or is it a fundamental problem of accountability?

Mr. Liam Woods

I think the Comptroller and Auditor General is referencing the area subheads from B1 to B8, which related to the old area boards and contained all expenditure, including older persons' residential expenditure up to 2008. In 2008 a separate subhead, which is B16, was put in place and now reflects the cost of older persons' residential services. That subhead is now clearly associated with the fair deal legal arrangements.

We are dealing with the issue and it will improve over time. Now we have an issue with our systems in terms of recording expenditure nationally on a programme basis as against a traditional area basis. Since the 2008 accounts we have undertaken a study of the costs of residential care and looked at the fair deal legislation, as some costs are within that and others are not. We have identified those and in the 2009 and 2010 accounts, there is €979 million in the latter subhead, which is a much more precise figure. Until we have a single national system that reports on a Vote basis, there will not be traceability at a single transaction level back to the locality.

There will always be some complexities and there may be people working both in respite care and long-stay care who must be allocated on a cost basis across services. Some of those costs may stay in subheads B1 to B8 and some costs will move below the line. We will always have to do that but with a single system, which we are progressing with the Department of Health and Children and the Department of Finance, we will address the substantive concern being raised.

Deputy Thomas P. Broughan

Will it arise again with the 2009 accounts?

Mr. Liam Woods

The issue will probably persist in 2009 but the Comptroller and Auditor General will take a view on that. The underlying issue is that the estimate in 2008 was based on the use of 7.84% of the cost of each of the subheads B1 to B8 and that will persist for some time. The issue will improve but not be entirely resolved. The improvement is that we have studied every care facility throughout the country and looked at all the costs associated with those. We have also put in place an interim reporting measure using accruals based information to understand those costs better. The data in the 2009 and 2010 accounts are much more precise but the underlying issue will exist technically until there is a single system that reports on a Vote basis.

Deputy Thomas P. Broughan

With regard to the €280 million, how do we know there was a saving?

Mr. Liam Woods

That is a fair question. We monitor and report on that in our monthly reports and publish them on the Internet. We can provide a list of the areas to the committee. Many of our non-pay headings, and some areas such as overtime, have been targeted directly. Areas such as travel have been substantially reduced before the general reduction in public sector travel. We have kept a very clear record of that benchmarked against costs at the start.

Deputy Thomas P. Broughan

One of the most fascinating aspects of the reports we receive is HealthStat. That is a very important initiative and I commend the HSE on bringing it forward. The Comptroller and Auditor General has said it was based on city services in Baltimore in the US and could be applied to every service, including our own.

I will deal with chapter 38 and the outcomes of hospitals and the traffic light system. There is a wide discrepancy between the performance of different hospitals in the indicators. It strikes me that there are many red lights with regard to resources, as was referred to by notes sent by the consultant this morning. Taking a good performer, such as Waterford Regional Hospital, and comparing it with a poorer performer like Cork University Hospital, what do the poorer performers need to do to become more like the hospital in Waterford? What is the model to which those hospitals need to aspire to become like the Waterford hospital?

Professor Brendan Drumm

I can tell the Deputy why I think the hospital in Waterford works well. Other places vary and some are quite close to that level. Hospitals in this city like St. Vincent's and St. James's, and more recently Tallaght, have shown significant improvement. The Deputy is right in that this system can be used anywhere, although it has never been done anywhere in health. There is now international interest in how we have applied it in Ireland. I compliment the people here as it has not been used in the way I thought it might have been to beat us up. People have accepted it, warts and all, which has been important. The red indicator for finance is perhaps a little unfair as it applies if anybody is any way in financial arrears. At certain times of the year certain parties will be in financial arrears and have a plan to correct that later.

Waterford Regional Hospital has the largest accident and emergency department in the country outside of Tallaght and is twice the size of some other accident and emergency departments in Dublin. Over a number of years people have practically never had to wait. It has set up processes that are best in class. When a person goes to the hospital, he or she does not enter an accident and emergency department. That only happens if a person has a fracture or something the department should deal with. If a person enters the hospital with a medical problem, such as a chronic chest pain, he or she would be immediately triaged to a physician connected with medical services. In many other systems a person may end up going through the accident and emergency department and waiting for the physician to arrive some hours later. In Waterford, a person goes directly to such a physician's responsibility.

The hospital runs very successful minor injury treatments through nurse-provided services, so minor injuries do not have to enter the system. It has rapid access to diagnostics as well. The secret to its success would appear to be a remarkably coherent clinically led leadership programme. It is led by a very committed manager who is a nurse by background and, ahead of practically anybody else in the country, it has a very close working relationship with the clinician leadership. That is even ahead of us putting in clinical directorate models.

The hospital knew early on that we had flagged it for success through a programme where we tried to reward success on an accident and emergency department level. That led to a significant uplift. The most important person in how the hospital works is an accident and emergency liaison nurse. That person knows everybody from the radiologist who would do a CAT scan rather than having an 80 year old admitted to the local St. Vincent de Paul representative who might light the fire at home if that 80 year old had a CAT scan done without being admitted. The hospital has focused on what processes will make the patient's journey simpler.

There are many other institutions which are getting there and this is central to our transformation programme. Waterford has got there ahead of everybody else and there have been many explanations of mitigating circumstances. The bottom line is that Waterford has one of the biggest accident and emergency departments in the country and its resourcing levels for that department is very low compared with others. Process and leadership are the big issues. Clinical leadership is central to the success of Waterford.

Deputy Thomas P. Broughan

The Comptroller and Auditor General has outlined three elements to the process, including access. My colleague referred to emergency departments. In late January, my party's health spokesperson, Deputy Jan O'Sullivan, indicated that 500 people were on trolleys throughout the country on a particular day. In January 2009, we had 37,000 people waiting for procedures, with 18,500 people waiting for more than three months. We raised the matter with Professor Drumm a few months ago at this committee. Some 61% of children were waiting longer than the target waiting date of three months and 21% of adults were waiting more than six months.

We can also consider the other elective waiting times. It is difficult to get a true measure because the Comptroller and Auditor General believes the waiting time measure for elective admissions should be calculated for people up to the point of treatment. In the outpatient section, there are 175,000 people on waiting lists, as has been outlined to the committee before. There are 175,000 people on waiting lists, with 19% waiting for more than two years. There was an astonishing example of the longest waiting time for an individual clinic, which was eight years. In one hospital doors and lists were closed and it did not accept referrals. Is the entire area of access in emergency departments and in elective and outpatient waiting times not still a bit of a disaster?

Professor Brendan Drumm

I shall take each point. It is a question of what one might call a disaster. Emergency department waiting times were a huge problem in every accident and emergency department in this country five years ago. I can take the Deputy from Letterkenny to Sligo to Kerry which all used to have trolleys out the door. None of them has trolleys out the door any longer. We have sick units that have significant problems. We absolutely put up our hands about it. A number of these are in this city and yet there are units in the city that perform extremely well. As to picking a day and a year, there will always be a day in the year when we will have problems. The point is how we perform over the year. There will be outbreaks of flu or the winter vomiting bug in our hospitals——

Deputy Thomas P. Broughan

Is it true there were 12,000 fractures during the recent bad weather?

Professor Brendan Drumm

Yes. That had some effect but probably not as big an effect as was thought because many of those people were ambulatory and went home. I would not like to use that as a full excuse. If somebody broke a hip, yes, but many of those injuries were relatively minor so it does not explain the situation completely. A bigger issue would be an outbreak of the winter vomiting bug in a hospital.

The emergency departure situation must be challenged in the relatively small number of hospitals where it is still a big issue. One of the biggest problems goes back to what we mentioned earlier, namely, a huge level of specialisation, especially in some of our Dublin hospitals. Having somebody there to respond professionally to general and medical problems can be very slow and people wait a long time in emergency departments for that. Those departments are now the subject of a very focused campaign for putting in place medical assessment units and trying to bring about the corrections that have been seen in many other institutions throughout the country and applying them. For example, Tallaght Hospital, which historically has had some of the worst problems, has recently appointed Professor Kevin Conlon as its new medical chief executive officer and we have seen some very significant changes even over a couple of months. If bought into by the system, process changes can greatly improve this situation. The emergency department issue is down to a relatively small number. That does not mean there will be no blips at times.

The Deputy touched on two other issues, one of which I believe to be huge, namely, the outpatient situation. I shall deal with the easier matter first, that of elective surgery. The figure of 37,000 elective procedures is one we will take on this year and I believe we will get on top of it. That was the figure given me by the Deputy. We deal with 1 million people per year as inpatients and day patients. When one puts 37,000 in that context it works out to be less than half a day's work. Again, we must put up our hands and say this is so.

We will see changes. There are some issues regarding children's hospitals where there may be a specific problem. There may be only one or two people in the country who can actually provide the service in question and that can create some outliers on the children's side.

Equally, there are some blackspots in ear, nose and throat, ENT and orthopaedics and we have to see some significant changes and process changes. We know this from taking on specific blackspots. In the north west, in Sligo, we had something wrong with ear nose and throat waiting lists. We changed processes. It is now the only hospital in the country with no ENT waiting list. That was achieved with very little added resources. Similarly, in the same institution where there were huge problems with orthopaedics, changing processes has made huge changes. An example in orthopaedics are the hospitals that have dealt with orthopaedic waiting lists by ensuring all referrals are seen by a physiotherapist rather than an orthopaedic surgeon. One can see then that up to 50% or 60% of patients do not need to go to the next step of seeing the orthopaedic surgeon. That means agreement to new changes across professional lines.

In the outpatient scenario the numbers are found in ENT, orthopaedics, rheumatology and dermatology where we continue to have major waits. When one sees a figure such as eight years, it is clear we must go back and validate those lists. Clearly there are people on them——

Deputy Thomas P. Broughan

Is the average waiting time for outpatients falling? In the last report by the Comptroller and Auditor General it seemed to be static.

Professor Brendan Drumm

When one looks at outpatient waiting times, one must look at the individual specialties. If one looks at the HealthStat figures, one will see the waiting times for each hospital for, say, general health medical clinics which have the biggest attendance. The majority of those at individual hospital level have been significantly reducing during the HealthStat process. However, there are a number of institutions where we still have unacceptable waits. That is talking about those areas that are relatively good, such as general medicine. In the areas I mentioned such as orthopaedics and ENT, it is fair to say we have totally unacceptable waits and these have not reduced by anything like what we want. They are now being focused upon and this is in the Comptroller and Auditor General's report. We are focused on an improvement process to try to deal with those. When one goes to validate the lists one finds that a huge number of people are no longer on them but that does not get away from the fact that many are. That is a major focus for this organisation. It is the biggest access problem and always has been.

I should say, again from a transparency perspective, that these lists were not historically measured. We went out to do this ourselves knowing that it would create a huge problem for us to measure the figure because it had not been done.

Chairman

With regard to what was last discussed, are more consultants required in some of the specialties?

Professor Brendan Drumm

There are. For example, I mentioned Limerick where we have just appointed another dermatologist. There are a number of such specialties where, shall we say, the need is not as urgent. If a person's need is urgent, he or she ends up going into hospital or being seen very quickly. When one takes specialties such as rheumatology and dermatology, sometimes people have vaguer symptoms and end up being put on long waiting lists. I do not think those specialties have been resourced adequately to deal with the situation.

There are a number of specialties where there is a clear need for more consultants. Our future need for more consultants must be balanced with a reduction in the number of junior hospital doctors. That is a significant challenge to our processes because hospitals and doctors like junior hospital doctors. We run on approximately 5,500 junior doctors for 2,500 consultants. Clearly, we do not need to train more than approximately 1,500 a year to replace our consultant body, even if that consultant body was at 4,000 to 5,000. We need to reverse that and must buy in to the fact that it has to change. We need more consultants in specific specialties.

Deputy Thomas P. Broughan

I meant to ask this question at the start. When this report was done, 36 hospitals featured in HealthStat. Has it now been rolled out to every hospital?

Professor Brendan Drumm

It has not. There are a number of hospitals which are of a size that is probably not really that relevant in that it is not really relevant to try to deal with figures at that level. We are probably focused on the 36 hospitals for the present.

Deputy Thomas P. Broughan

I shall take the second major element of the measurement, namely, the integration stage, the day case rates and the delayed discharges. In the report there seems to be a significant variation of day case activities across the hospitals, ranging from 22% to 82% across a basket of 24 specialties. Professor Drumm has said repeatedly at this and other committees that dealing with issues on a day case procedure is obviously one of the ways forward. Despite this, when we look at the figures, we do not see the kind of measures being taken by hospitals in the day case area that would support this ambition.

Another point to mention is the key role of delayed discharges in clogging up beds. There still seems to be a figure of 5.4% for delays in discharging patients because of the lack of step-down facilities. If we look at both areas nationally, while the information is valuable, the results are a bit depressing.

Professor Brendan Drumm

There are two areas regarding day care. Surgery is a big part of day cases. Our day case figures are improving and some institutions are now doing much better. The HealthStat forum is where we meet every month in five or six of the hospitals. We challenge the reasons for our not reaching targets. Those figures are improving. Where we have struggled more is with the issue of the day of admission for surgery, in other words with why someone needs to come into hospital a day or two in advance of surgery when being admitted, even if they will have to stay for three or four days after surgery. Why can they not come in on the morning of the surgery? This issue has been tied up to some extent with the accident and emergency issue. Consultants have felt they will not get a bed available on the day of the surgery and there is almost a perverse incentive to get somebody in before the weekend. We are trying to remove this need by protecting a number of beds, irrespective of what is going on in accident and emergency. This may cause an outcry but it is the only way we can run the system efficiently so that patients are guaranteed they can come in on the day. Day case rates are increasing, but day of admission for surgery is still an issue that is a challenge for us. Admission on the day is something the public should be demanding. I refer often to the fact that hospitals are places where people sometimes suffer injurious events and that they should spend the least possible time in them.

The issue of delayed discharges was also raised. There has been improvement with regard to this issue and there is no doubt the Fair Deal is beginning to have an effect.

Chairman

One of the speakers we heard previously showed there was an increase of 50,000 in the number of days lost between 2008 and 2009. It went from 220,000 to 270,000.

Professor Brendan Drumm

That is true. What happened is, we built or opened huge capacity during 2006 and 2007. Then, owing to the reduction in funding during 2008 and 2009, we did not have the capacity to continue to meet that demand. Our capacity to meet the demand was not as good. The introduction of the fair deal has created that capacity again. I may get into trouble for saying this but I should stress that this is a limited resource which we are trying to spread across the year. Now we are beginning to see the figure the Chairman mentioned reduce significantly, as a result of improved funding through the fair deal. However, there is a danger we could be deluded into thinking that is a permanent solution. In fact, if there is an excess of demand above the amount of money voted for the fair deal this year, we could have a problem.

Chairman

With regard to the days lost, the Comptroller and Auditor General brought it to our attention that there is a lack of uniformity with regard to how "days lost" is defined by hospitals. Has anything been done to address the Comptroller and Auditor General's concern?

Mr. John Hennessy

What is being referred to here is the breakdown of the beds that are not available for acute admissions on a regular basis. There are several categories in question. The category of beds that are unavailable because of delayed discharges is probably the major issue. Substantial inroads are being made on this currently through the fair deal process, and we are beginning to see huge numbers of patients moving through and bringing those beds back into commission. Beds are also unavailable in the acute system owing to refurbishment, infection control or cost control or containment. The overall number will probably not change significantly in 2010. The beds returning to the system through the fair deal process will be used in a different manner and may be day beds rather than inpatient beds.

Professor Brendan Drumm

The job is to standardise reporting on them. Beds that are out of action are being reported differently by different hospitals. The Comptroller and Auditor General wants more standardisation with regard to how we report beds that are related to days lost.

Chairman

In his report, the Comptroller and Auditor General states there is a lack of uniformity with regard to how days lost are defined.

Mr. John Hennessy

That is a fair point. We will try to address that.

Chairman

We were told that one of the key solutions was that there would be an increase in the number of step-down beds. Can we have the figures for 2008 and 2009? What are the projections for 2010?

Ms Laverne McGuinness

With the fair deal, all public and private beds will be dealt with as part of the same pot. It is intended to have approximately 400 new beds this year in the public capacity area and to replace approximately 600 beds as some facilities are outdated and need to brought up to standard. These beds will come on stream this year. Last year we put 270 contracted beds in place, pending completion of some of the public facilities we had. Now, as patients are released or move on from those beds, those beds return as part of the overall fair deal pot.

Professor Brendan Drumm

We can comment on the number of new units we have built shortly. The fair deal has changed the agenda hugely and there has been significant building of long-stay facilities in the private sector. In essence, we are now in a competitive environment and families will look right across the system. I suspect there is no shortage of beds when we look across the system at both the private and public areas. Families make the call as to whether they want to place their relative or parent or whoever in a public or private bed. That is their call. There may be some dependency issues and our system is equipped to deal with a very high level of dependency. Perhaps Mr. Gilroy would like to comment on the number of facilities being built. I suspect our problem will be utilising the beds we have built because of staffing, the moratorium and the fact that people may choose to use another facility in their local area.

Mr. Brian Gilroy

Just over 1,100 new beds are being built in the capital programme in 2010. Some 420 of these are additional beds and 699 are replacement beds. I do not have the figures for 2009 with me.

Professor Brendan Drumm

The replacement beds are a huge issue. While some of the infrastructure is not great, the care provided is superb and I would defend it. Care in the long-term area of the public sector is probably the best in the world, but some of it is provided under extremely antiquated conditions. This will present a huge challenge to the sector in the context of competing with up-to-date private facilities. Perhaps this is not a bad thing because it will make us more competitive.

Deputy Thomas P. Broughan

With regard to the final two indicators in HealthStat, apparently the HSE dropped the staff per inpatient bed index because it was considered it did not encourage good practice. Has it done anything to replace that index which seems to us to be a useful indicator? With regard to a bottom line on the cost per discharge, I notice the January 2009 cost for each hospital showed large variations. In other words, the cost per patient discharge at January 2009 varied from €733 to almost €1,200, with an average of approximately €1,000 per discharge in the ten best hospitals. Another variation showed an average of €742. The HSE has dropped the staff per inpatient bed indicator which seemed worthwhile. The cost per discharge indicator also seems to us a useful measure of how the health system and hospitals perform. Has Professor Drumm any comment to make on this?

Professor Brendan Drumm

This has been a learning process for us as well, especially in terms of measures we put into practice and found subsequently did not work very well. There was a significant amount to be learnt from this. For example, we included the average length of stay for a hip replacement and discovered it was three times as long in St. James's Hospital as it was in Cappagh Hospital. Then somebody pointed out to us that the people who go to St. James's Hospital have multiple problems and would not be accepted in Cappagh Hospital. Therefore, errors like that had to be corrected.

The cost per inpatient bed is a perverse incentive to keep beds open and people in them rather than to use them effectively. Therefore, the indicator now is a case mix adjusted cost per patient. That is the critical indicator. In other words, this is ESRI analysis of our HIPE data. The cost of having a leukaemia patient in for chemotherapy who ends up on a ventilator because he or she got a bad case of pneumonia is very different to the cost of a leukaemia patient who is sent home down to a local hospital following that episode. We must be able to measure the intensity and that is now possible. It is possible to see the variation in percentage up or down from the mean in terms of the case mix adjusted cost and this is the measure we will use. The criticism of that measure which arises in our entire case mix system is while that system was one of the first in the world to be put into place, it is now relatively crude. Consultants, etc., maintain it does not accurately measure the variation in the intensity of activity. In fact, the really sick leukaemia patient with pneumonia may be measured in the same way as the leukaemia patient who comes in for chemotherapy and then walks home.

There is a highly-developed system used by people in Germany which, ironically, started after ours and its case mix adjusted system is a good deal more accurate. We are now working with them and we receive a good deal of support from the German system and we have tried to take that support on board into our system. I believe the committee will find it very accurate. Even as it stands, the ups and downs are the same throughout the system and, therefore, it is a better measure. It is included in HealthStat now.

Deputy Thomas P. Broughan

What has been the cost of the HealthStat project so far? What is the ongoing cost of putting this material into the public domain and before us today?

Professor Brendan Drumm

There were some consultancy costs involved. The cost of setting up the system, not including our staff, was approximately €1.6 million. The ongoing costs for our staff commitment are relatively minor. We have reconfigured staff who measure performance data regularly. One expert is included and we have the normal processes of replacement as well. Mr. Mark Turner, who is with us today, is an expert in industry, decision support and the measurement of these figures. There is no additional staffing, it is simply a reconfiguration of the people already within the system. The ongoing cost of it is relatively minor.

Deputy Thomas P. Broughan

As time goes on, it will become an increasingly valuable tool to help us to assess our progress.

Professor Brendan Drumm

Ultimately, as it becomes further rolled-out it will allow the committee to examine the detail. Earlier, the Deputy mentioned how individual hospitals performed and behaved and the need to challenge this. We are already beginning to see the way in which the system allows local communities to challenge their own institutions in terms of how some score very well in certain areas but very poorly in others. I have been in parts of the country where the media are able to ask me why an institution may be best in class in terms of how the surgeons perform but may be among the worst performers in terms of the waiting time for a medical clinic although they receive the same funding. It has given a great amount of potential power to the public as they have become more educated about the process.

Deputy Thomas P. Broughan

I refer to the GMS, General Medical Services, and the medical card system. According to various reports, there are €1.35 million people in the system. However, there appears to be a good deal of variation. In the north east, for example, there has been a good deal of stress for constituents who are constantly being invigilated. We have lost local input into the system. Matters related to medical cards were at the discretion of local management. Elderly people with serious medical conditions are terrified that they may lose their card. They are examining their financial situation and savings and are very upset about the prospect.

Recently, a pharmacist informed me that in parts of our region near the top of the north east, review dates for medical cards to 2020 were approaching, whereas in my neck of the woods, the northside of Dublin, everyone is waiting on the review. It is a centralised system and there are industrial relations issues at the moment and so on. Is this not very cruel on the very vulnerable citizens who need their medical card and the full service?

Chairman

I receive complaints from people everywhere concerning the centralised system that was introduced. Does Professor Drumm agree that at this stage it is an absolute and expensive failure? It has taken out local input. People are left waiting for 15 minutes, 20 minutes or half an hour on phone lines to receive information and sometime they simply hang up. The system is an absolute failure.

Professor Brendan Drumm

I can understand the Chairman's frustration and that of everyone in this regard. However, we must deal with some of the facts behind it. I refer to the need to centralise the system. It operated totally differently throughout the country. The system at present does not take away from anyone with a discretionary card and if someone is very sick it remains a local matter. All advice in respect of how to apply for a card and the necessary support should be available through a local health office, which should provide such advice and support for a person immediately.

For anyone who wishes to examine it, our GMS system in general operates as a model for the public service and in particular the way in which it operates in Swords is notable in terms of how it deals with vast numbers of payments to pharmacists, general practitioners, etc. It has been seen as a model system by the entire public service. This issue has more explanations and it would be wrong for it to fail now simply as a result of not enough people being available to answer the phone. We have centralised the system for over-70s medical cards and are quite confident that we can turn around all of these within 15 days. Initially, we went into two areas, including Deputy Broughan's, which were the first areas to take on all medical cards and we discovered very substantial backlogs in the system that was supposed to be so efficient. We discovered thousands of cards backlogged in our system that had not been processed.

We must separate the process from what is actually happening. Now, our telephones are overrun in an industrial relations dispute. Everyone who phones the local health office is redirected by staff in those offices. Only two health offices are affected by this. They are redirected to a line in Swords essentiality to undermine that line in Swords.

Chairman

This was taking place long before the industrial relations dispute and the go-slow or whatever term one wishes to use. This problem has been apparent for months. It is not possible to explain it away by saying it is because of the industrial relations dispute.

Professor Brendan Drumm

We can measure the calls made every day. Almost everyone would have to have been called in the two areas affected. These calls are not coming from the two areas affected, they are coming from throughout the country on the basis of people being redirected. Why are people calling us from the 30 other areas not affected? They call us because they have been directed to do so. We have carried out our own mystery shopper exercise and we have been redirected to call a number that we should not be directed to call.

The bottom line is the need for a centralised, standardised process throughout the country. We fully accept that the matter of discretionary medical cards is a separate issue. Since we centralised the system of medical cards, we have encountered people with several million euro in the bank. As the Accounting Officer, my position is that the purpose of the system is to be fair to everyone in terms of probity and in terms of people throughout the county having fair access. It can be done highly effectively through a centralised system. More important, it could save €20 million per year and it has introduced approximately €4.5 million in savings. Such funding could be redirected immediately to home care packages, etc., and out of the administrative system.

This need not affect the discretionary element and we must get agreement from the unions to allow this to take place. There is no reason calls would not be answered if they were made on that basis. However, as in the case of the swine flu, we will put in place a new call system very quickly. This will allow people better access and it would put everyone into the on-line assessment. This is a very good system that anyone can use once they he or she has the client's number to establish exactly where the process is at.

I refer to the issue of the number of medical cards. Some 85% of cards were issued within 20 days. The phone call issue is a matter of great frustration. We accept that are we are trying to work around it.

Deputy Thomas P. Broughan

Why do we need continual reviews?

Ms Laverne McGuinness

The Deputy may recall that several years ago there were duplicate cards and cards for people who may have died or moved out of the country. Therefore a number of reviews are called to ascertain if the circumstances are still valid for a medical card. Predominantly medical card eligibility is based on a financial assessment. Financial circumstances change over time. Therefore it is good governance, good probity and good assurance to carry out the review.

Chairman

Since Professor Drumm mentioned the swine flu, the campaign run by the HSE was top class. I noticed a recent comment that the HSE dealt with the problem and the problem did not evolve as seriously as it might have. Had the HSE not dealt with it and had there been a problem it would have been criticised. The experience on the ground was that the operation and management of the campaign was top class. When compliments are due they should be given to the organisation.

Deputy Thomas P. Broughan

Is the vaccination programme still open?

Professor Brendan Drumm

We are leaving it open and we are still vaccinating in the schools. I should say, to be fair, that it was not a singularly HSE operation — we had huge input from the Department of Health and Children. Also schools are critical to the success of this campaign in terms of co-operation. At present we are still vaccinating children. The public uptake is now quite low because the fear factor has diminished significantly but the programme will be open for several weeks yet.

Deputy Thomas P. Broughan

The bar has changed. Is it an evolving virus? Professor Drumm used to give the committee very detailed information at the start. Clearly, as it did not become a pandemic, he has eased off.

Professor Brendan Drumm

Viruses can always rotate and evolve. We accept this one has not changed hugely since it appeared. It will now be included in the regular flu shot that will be administered to older people especially and those who are vulnerable in 2010. Therefore, it will be covered by that. As to whether it is likely to reappear in another format, there is no doubt that one of the fears is that there could be a second wave. One of the predictions is that if more than 35% to 40% of people have been vaccinated that greatly mitigates against that second wave being very severe. That remains a concern.

Deputy Thomas P. Broughan

How much as it cost so far, or is it too early to make a determination?

Professor Brendan Drumm

The cost of the vaccine has been very significant.

Mr. Liam Woods

The spend — this is not audited data — to the end of 2009 would be €28 million. From memory, there is a provision for €55 million for the current year.

Deputy Thomas P. Broughan

Was the HSE given additional moneys for that?

Mr. Liam Woods

Yes, additional moneys were voted in 2009 and in 2010.

Professor Brendan Drumm

We have been able to avoid some of the costs for vaccine that we ultimately will not require. It became clear, certainly for one of the vaccines, that one needed only one shot rather than two shots. We were significantly over-purchasing in that respect. Surprisingly, we have been able to reverse out of some of the contractual agreements. Clearly, there is still an international demand for the vaccine.

Deputy Thomas P. Broughan

On a related point on drug costs, people have told us, including the Minister, and it is mentioned in some of the reports, that there is a 15% cut in costs. We have had the long struggle with the pharmacists and so on. Our constituents on the drugs payment scheme tell us they do not notice significant cuts at the counter when buying these drugs. What has happened? Is it a figment of the imagination or is something really happening in terms of drug costs?

Professor Brendan Drumm

If the Deputy goes back to 2006-2007 when we first started this process, it is clear that we reduced costs by 20% and subsequently a year later by 15%. We reduced the costs by 35% in the first wave off patent medications. That cost is now being further reduced. Therefore, drug costs in Ireland, from the point of view of what the HSE will pay under the drug payments scheme, are very significantly reduced. What we would pay under the GMS for a medical card or across the counter are very significantly reduced.

We always assumed that costs would come down for the private purchaser at the same level. That has varied across the pharmacies. That is an individual arrangement between the pharmacists and their customer and for the customer to, perhaps, inquire as to whether those cost reductions are being passed on to the across-the-counter purchaser. We certainly will not advise, we will only remunerate at those levels.

Deputy Thomas P. Broughan

It lies in the mark-up area.

Professor Brendan Drumm

It is a reduction in the manufacturer's cost but if it is not being reduced at the front counter it lies in an increased margin to the retailer. It is an issue about which the customer needs to be sensitive. We cannot interfere with that arrangement but where we can interfere is in regard to what we pay for. The biggest challenge going forward in medication costs is the patented medications. We expanded the basket three or four years ago to include countries such as Spain which is a low cost country but we still are relatively high payers but not compared to, say, the UK which has higher costs but it has a huge pharmaceutical industry and it suits them to keep costs high.

The second issue is to set a price for generic medications. There has been a big clamour to bring in generic medications here. There are no gains in bringing in generic medications here beyond a minimal gain because they are priced so highly. We are working with the Department in a process that will set the amount we will pay for any medication, be it generic or not, once it is off patent. That will reduce costs significantly. If that is passed on to the regular purchaser who is not using our schemes it will bring about a very significant saving.

Chairman

During the past 12 months or so this committee has looked at procurement practices within the public services. We are coming from a position where we have been advised by experts in procurement practice that there is a potential saving of about 10% in respect of procurement in the public services if good practice is followed.

Recently we asked the Office of Public Works to provide us with information on the price of goods and services procured by all Departments and agencies within the State. A letter received from the Office of Public Works in recent days states that €8 billion is being spent on goods and about €7 billion on construction. These figures quoted by the Department of Finance were part of a broad analysis it conducted in November 2009. This is the latest information available to the committee. As I understand it, the procurement unit within the Department of Finance does not receive all information from Departments and agencies. That is the reason I ask this question. Of the €15 billion, on the basis of a possible saving of 10%, that would give us a saving of €1.5 billion per year. That may be a simplistic calculation. In relation to procurement practices within the HSE, is Professor Drumm happy that all of the procurement guidelines, as published by the Department of Finance, are being followed in all instances within the hospitals and agencies for which he is responsible.

Professor Brendan Drumm

We can honestly say that from day one when I started in this job I said that procurement was the one area where we could make huge gains. Drugs are our biggest procurement. Anybody in the public service would see us as the leaders in procurement. The question is whether we have driven it as far as we possibly can. Certainly there have been gains and I will ask Mr. Brian Gilroy to speak on this issue in a moment. The gains we have made in procurement have been critical in balancing our books in difficult environments and not cutting services in recent years. What is probably central to that is good IT systems. The last part of the Chairman's question is critical, whether we can get procurement down and ensure that it is delivering at an individual hospital level or a sub level within a hospital. The bottom line is that one can get procurement down for big items but it is the many small items that make up much of the money — it comes back to the pencils. Without good IT systems and common financial systems nationally, that can be a challenge. In terms of the major systems, we had a system where one form of CAT scanner was bought in one place because a doctor had used that type in America and a different scanner was bought at top price somewhere else. Last week, although it only got a few lines in the papers, we launched the biggest IT contract in Europe for the year, our new NIMIS system, a digital system for X-rays right across the State that will ultimately link to all our lab systems and be the beginning of an electronic patient record, a major launch for us. If that had been introduced at individual hospital level, it would have cost about €80 million but it is being delivered for €40 million through centralised procurement, about half the price, with a major American supplier.

Mr. Brian Gilroy

Referring to our service plan, we expect procurement activity to take €100 million worth of savings in 2010. Of the €14 billion, the majority is pay so procurement savings do not apply to that. Around €4.5 billion is procured.

In the case of capital procurement, we saw in recent years reductions in excess of 10%. In all of our capital procurement, I am confident that we are in complete compliance and we get the savings. For the targeted categories, within the HSE we lead across the public sector in that we have centralised our procurement and have taken a category and portfolio approach, so we stream the purchases with dedicated procurement managers who understand the market in those areas.

We could do more; we have been working hard with the representative bodies on getting more people involved in the national issues. Unfortunately, with the dispute in the public sector, that has been put on hold but we are nearly there.

With the resources we have, we can get the €100 million and when we arrive at our complement of 80, pulling people from regional procurement into a single national structure, we will produce in excess of that in savings. In consultation with the OPW, we take a lead in this area.

Professor Brendan Drumm

It is important that we could engage with the committee and other agencies in terms of bringing forward what we have done. The Chairman is right, there are huge potential savings. We have pushed the boat out a bit but we could go much further.

Mr. Liam Woods

For staff in the HSE, much of the ordering of goods is done by care staff as part of their day to day work. We want to give them an on-line shopping arrangement with grocery stores, where we have national contracts where relevant, that are drawn down at a local level. We would then integrate that with payment in one process. A single system achieves that.

We have also looked at logistics in terms of how we store, warehouse and deliver. We have separate savings targets in those areas.

Chairman

If that information could be provided it would be welcome. We are preparing a document on procurement practices.

Professor Brendan Drumm

We have a great deal of information. Mr. Gilroy touched on one of the critical areas: category management. Whether buying pencils or CAT scanners, it should be done nationally by someone who knows the business inside out. There is work being done on this across the public service and this could be applied more widely as a single entity.

Chairman

We have looked at the Prison Service and at FÁS. There is huge potential. We have spoken to experts who tell us a minimum of 10% can be saved of the €15 billion spent by the State every year. With cutbacks being made on an annual basis, this is a huge amount that could be saved.

Professor Brendan Drumm

We brought in external consultants from the private sector to start with, including those who had experience in large companies, and it was the best money we ever spent because they have experience of driving down costs. People could look at the annual reports of major suppliers and tease out the advertising cost as a percentage of what we were being charged. They could then object to paying advertising costs. It is a science in itself.

Mr. Brian Gilroy

We will send the committee a paper.

Chairman

It was mentioned that it is difficult to get to the individual hospital basis but what about the provision of MRI scanners? There is an ongoing controversy about the contracts being given to those working within the public hospitals. In Cork, MRI services are provided by a private company. How long has that contract been in existence? Has it been put to tender on a regular basis to ensure we get value for money?

Professor Brendan Drumm

That is an old arrangement. There is a similar arrangement in Galway where a CAT scanner went in on that basis. It is not a model we use.

Chairman

It is still in operation.

Mr. Brian Gilroy

Recently, and it was misunderstood when we did it; we advertised to create a framework to regularise those arrangements where they exist. It was picked up externally that we were outsourcing our diagnostics but the framework was to put in place the mechanism that formerly procured and regularised those arrangements.

Chairman

I refer to situations where hospital consultants are operating businesses within the hospitals, providing services to the HSE. Are those open to regular tendering processes?

Professor Brendan Drumm

I suspect that instance went in on a long stage tender. There is a similar situation in Merlin Park Hospital in Galway. It is not something we have done but we must go back and get the information.

Chairman

I note from information provided that for October 2009 there are 147 health service employees on paid leave for more than six months, with 127 of them on long-term sick leave. More than €11 million has been paid to employees from the date their leave commenced, with one person on paid leave for 13 years. How does the sick leave scheme operate and how can it run to such a high level of expenditure?

Mr. Liam Woods

I am not aware of the details of that but will come back about it. The scheme is working on the basis it is set out. I am not sure if all the leave is referenced there, I would need to see the document to which the Chairman refers. Sick leave is worked on the basis of up to six months.

Chairman

There is sick leave and paid leave combined.

Ms Laverne McGuinness

Operationally, some of them are on leave and are still being paid. They might be on administrative leave or the circumstances may exist for an investigation. The example mentioned in particular falls into that category. In each of the four regions, we have reviewed them in full and many of those cases have been brought to a conclusion. There are still some cases but there are valid reasons for them. I am happy to provide the committee with a report, particularly regarding cases on administrative leave.

Chairman

How could someone be on paid leave for 13 years?

Ms Laverne McGuinness

There were particular circumstances in that case and legal implications. Judgments were made that pertained to the High Court. That has since been resolved. It is a particular case that I am aware of but I am not privileged so I cannot give full details. We can communicate on it in a different forum.

Chairman

We would like a note on it because the figure of €11.2 million being spent on paid leave is out of kilter.

Professor Brendan Drumm

We will give the committee a report on the matter.

Chairman

On the employment of external non-medical consultants, the delegation said it got value for money in one case in terms of procurement. What are the figures for 2009, vis-à-vis 2008?

Mr. Liam Woods

In 2008 the figure was approximately €15 million. I do not have the figure for 2009; it is still being concluded as part of our annual financial statements. I can get it for the Chairman. We have put further mechanisms in place to reduce the figure further. It has been reducing for several years and we make sure to keep it to a minimum.

Chairman

Will the delegation give us details of the companies?

Mr. Liam Woods

We have details for 2008 which we can give to the committee. We will do the same for 2009.

Deputy Seán Fleming

On procurement, Mr. Gilroy referred to driving down costs. The major point which strikes me is that the HSE is by far the largest advertiser in national and Sunday newspapers. What reductions does it get in terms of the normal list price for a page of advertising? It normally fills a couple of pages every week. Many of the staff vacancies are in voluntary or non-HSE organisations. Given that the HSE is paying these organisations, is Mr. Gilroy ensuring that what he negotiates while wearing his HSE hat is also being delivered by them? It is important.

Mr. Woods mentioned a central purchasing system for care staff. That is very important. I received long-winded letters from a person in the HSE last year regarding a situation whereby care staff wanted to install a bed in an old person's house. It was rented for a couple of years at a cost of €10,000, which was several thousand euro more than the cost of purchasing a bed. I presume, because some people at local level had the authority to process an order for several hundred euro per week, it never appeared on the radar as a capital asset. Equipment was rented and leased. In a letter last year the HSE said it had no plans to deal with the issue. Mr. Gilroy seemed to touch on the issue, which I welcome. It is extraordinary that one could rent beds which are installed in people's houses for years on end.

On a similar topic, I wish to discuss the issue of central billing, invoicing and debt collection of accident and emergency bills. Last week Mr. Woods mentioned that work is ongoing to move it to Kilkenny. I would like a brief update on that.

Mr. Brian Gilroy

I will answer the question on procurement first. If one examines the papers in question, the HSE advertisement is always very small and refers to our website. We deliberately took a decision to move in that direction. As the Deputy said, the majority refers to funded or private agencies. One difficulty in the make-up of the health system is that there are independent agencies which are funded by the HSE. We are somewhat limited in terms of how much we can impose restrictions. We provide a certain level of funding and try to ensure value for money, but we could not instruct an agency to use our tender for procurement. When we conduct national procurements now, in most cases we include the ability to add on those agencies, but we cannot instruct them to use it.

Deputy Seán Fleming

No, but surely the HSE, given that it is the paymaster, should encourage them to come under the umbrella of the HSE's price structure which it negotiated. It defeats the purpose of saving money.

Mr. Brian Gilroy

No, we did not, but that is the point.

Deputy Seán Fleming

We would encourage the HSE to pursue that.

Mr. Brian Gilroy

In the future we may take actions. As national procurement is rolled out and becomes more vigorous, and our financial systems become more robust, one may see a scenario whereby we determine that we will only fund a service for the amount of money which we will pay in our framework, and if an agency pays more it will create a deficit.

Professor Brendan Drumm

One will not find much of the HSE in the past three years in the Sunday newspapers. It gets mixed up——

Deputy Seán Fleming

I refer to medical advertising. One can understand a layman's point regarding medical advertising.

Professor Brendan Drumm

Absolutely.

Mr. Liam Woods

The point is taken. We are currently centralising all of our advertising and publications budgets within the HSE to get further control and value. Where we feel advertising may be excessive or may not make enough use of Internet opportunities, which are much less expensive, we can adjust the budgets of voluntary bodies by what we deem to be the excess. We already have a mechanism in place and have had some discussions on the issue.

On the broad area of aids and appliances in the community, work is ongoing to examine moving that to a high standard nationally. The Deputy is correct. A single financial and procurement system would make the management of those sorts of issues much easier, in terms of putting them in place and reviewing the value achieved over time.

On central billing, having received approval for amending our system in Kilkenny, we have gone to market to get external assistance to do that and we are already engaged in a project to move all of our income collection to Kilkenny. We have an established a unit for that purpose. I have appointed a person to lead that project.

Deputy Seán Fleming

The delegation might give us a brief outline, for whichever year is suitable, of the out-of-hours service, that is, MIDOC, Shannondoc, the call centre, the doctors' costs, transport costs and wherever they are based. How much does that cost per night?

The medical card centre posting was mentioned. I heard local GPs are now insisting that people produce a valid medical card, and because of the central nature of the system sometimes cards are not valid and they have to charge for their services. Is there a way that a GP can link to the system on-line from his or her surgery? There has been confusion, starting at ground level, in recent times. Will the delegation explain the situation clearly so that GPs can do that. They are starting to charge clients who do not have a valid medical card and they should not do that.

On in-patients admissions during last year, I understand some 600,000 people went into hospital. The delegation must have the figures. A person may be discharged and return to hospital within 48 or 72 hours. How many of the 600,000 people were repeat admissions within a 24, 48 or 72 hour period? There is such an emphasis on throughput and efficiency in bed management that the policy may be to get people in and out the door as soon as possible. It would be a useful guideline to know how many people return within days. I am sure the delegation has some information on those matters.

Ms Laverne McGuinness

On the GP out-of-hours service, the cost is currently €108 million. There are ten different out-of-hours services in operation nationally. We have reviewed them one by one. We are concluding a report with an implementation plan, which will bring about significant savings because we will change how the service is delivered. Different arrangements were put in place by various health boards. We hope to significantly decrease the cost. We have done a comparative analysis with the United Kingdom and Belfast. They are not directly comparable but there are processes——

Deputy Seán Fleming

The figure is approximately €300,000 per night. The service also covers weekends. The figure is €108 million for 365 days. The out-of-hours service costs at least €250,000 per night.

Ms Laverne McGuinness

Yes. On GP access to the medical card system, GPs have full access to it and can view whether a patient has a medical card.

Deputy Seán Fleming

That is good. The delegation might send us a breakdown of the figures of the out-of-hours services between different categories.

Ms Laverne McGuinness

We have the breakdown.

Deputy Seán Fleming

The last question concerned re-admissions.

Professor Brendan Drumm

On admissions, 17% of admissions are for under 24 hours and 30% are for under 48 hours, which is a major issue for us.

Deputy Seán Fleming

They could almost be called day cases.

Professor Brendan Drumm

One is twice as likely to be admitted if one lives close to an accident and emergency department. One can work out that the need for beds can sometimes——-

Deputy Seán Fleming

It can be self-fulfilling.

Mr. John Hennessy

We may be able to help the Deputy with a figure. It does not extend to cover all of the hospitals, but a number of newer patient administration systems pick up re-admissions within 48 hours. We will conduct research on that and see what we can extrapolate from it.

Deputy Thomas P. Broughan

What is the name of the computer system? We had the traumatic experience of trying to invigilate PPARS in the past. I hope this system that will cross the whole of the health service will be of great benefit to us. Is it also linked into primary care teams?

Professor Brendan Drumm

This is the NIMIS system. Does Mr. Gilroy wish to comment on that?

Mr. Brian Gilroy

The system in question is referred to as NIMIS, the national integrated medical imaging system. The contract for it was placed with a company called McKesson. It is a specific module that handles diagnostic images. When one goes into any of our X-ray departments in the future, one's scan will be available in all such department throughout the country across the single backbone of such provision, so to speak. We will have a similar system for our laboratories, which we are in the process of procuring.

The information flowing from those systems will be available to GPs and will be on the electronic health record. The GPs will not constitute the electronic health record. The other element that bolts much of this together, to which Mr. John Hennessy referred, is patient administrations systems in hospitals, which we are continuing to roll out. More than 20 hospitals are on a single common patient administration system, which provides functionalities. This is where they start to link together.

Our next largest phase of development is to bring this to the community. We have developed Healthlink, which allows many GPs throughout the country to order and get results from tests and that will be expanded to include imaging as well as laboratory results.

Deputy Thomas P. Broughan

Do the representatives have a figure for the cost for NIMIS?

Mr. Brian Gilroy

We do. It is under €40 million. It is split into capital and ongoing running costs. This system will save money. Apart from the improvement in quality and the communications aspect, it will remove the cost of film and on film savings alone, it is justified as an expenditure.

Professor Brendan Drumm

It also has a huge clinical impact. I have often cited the example of a man from Ballybofey who had to go to three different places before he got an opinion. This development means that if that man had tests done in Letterkenny General Hospital and was diagnosed as having an aneurysm or a big dilatation of his aorta, the people in Beaumont Hospital, the Mater Hospital or vascular units could check his scans on-line and, to a large extent, could make a decision on his treatment and plan his admission without he having to leave Donegal. This contrasts with the old system where the man would have had to leave Donegal with a package of X-rays and on presenting them find that the people in the hospital might not be satisfied with their quality and the first thing they would do would organise for them to be repeated. Therefore, this system has great capacity to improve the effectiveness of a patient's journey in terms of what it can deliver.

I will explain one of the differences between this system and PPARS. The Deputy might have concerns about such large projects. As someone who stopped the progress of the PPARS project, I would say, in retrospect, it is a pity it had to be stopped, and I put my hand up in that respect. PPARS did not work because we were not running a performance-managed system that demanded the need to work with absenteeism rates and so on. Therefore, it was not really in anybody's interest. However, the position would be very different now; people would be glad to have PPARS in operation throughout the country because they need the data it would generate to manage the system.

Patients will benefit greatly from NIMIS. At the launch of it, it was evident that it would foster tremendous commitment among clinicians. It also has other add ons, such as in terms of cardiology. For example, a person presenting with a chest pain could have an ECG done and one's consultant cardiologist could read one's ECG results at a distance from the emergency department in his or her home.

Deputy Thomas P. Broughan

If he or she had a good broadband connection.

Professor Brendan Drumm

Exactly. This is all about using technology in a way that we have not done very well very often in the health service.

Deputy Thomas P. Broughan

I wish to ask Mr. Woods about note 23 of the statement. An actuarial assessment of pension liabilities for this huge organisation has not yet been carried out. Is it planned to do that in the future? This issue was discussed yesterday at the launch of the national pensions framework by the Minister and in terms of the overall funding demands of the State in the years ahead. Is it intended to carry out such an assessment?

Mr. Liam Woods

In terms of our accounting policies, we are exempted from the requirement to crystallise the actuarial value of future payment in respect of pensions. We will consider in the short term of the next five to ten years the trend in payments we envisage will be necessary to make reasonable provision in respect of pensions on an annual basis.

Deputy Thomas P. Broughan

Will Mr. Woods be able to give us that kind of information?

Mr. Liam Woods

Yes, when it becomes available to us.

Professor Brendan Drumm

It has huge implications for us in terms of being able to run services year on year because such funding will come out of the base budget, it is not an added sum.

Deputy Thomas P. Broughan

In case I do not get to meet Professor Drumm at a future meeting, I wish to ask him a question on an issue to which the great journalist, Vincent Browne, often refers regarding the report of the Institute of Public Health in Ireland on inequalities in mortality. Depending on a person's class and level of income, differences of 100% to 200% can emerge in health outcomes. For example, this report found that poorer people were 120% more likely to die from circulatory diseases, 100% more like to die from cancers, 200% more likely to die for respiratory diseases and 150% more likely to die from injuries and poisoning. That report showed a steep gradient in that respect. I understand it covered the period 1989 to 1998 but if we were to complete a similar report now in regard to these parameters, would the findings be any better? In other words, is Vincent Browne's fundamental point that the health system is ruthlessly biased against people on lower income still true?

Professor Brendan Drumm

I believe it is true but not for that reason. It is not the health system. I spent years teaching and I always told medical students that if they went into medicine with an altruistic streak in that they wanted to help society, they picked the wrong faculty. International data have always shown that it is improvement in the economy that improves longevity far ahead of anything done by the health system. That probably goes back to experiences very early in life. For instance, whether one develops stomach cancer — an area I worked in for many years — which used to be the biggest killer of cancers and is now one of the rarest among people with solid tumours, it came down to how poor one's health was as a two year old. If one picked up an infection as a two year old, it could manifest itself 50 years later and give one stomach cancer. It had nothing to do with what the health service was doing but with the fact that the quality of water became cleaner, sanitation improved and people stopped picking up infections. There is no doubt that the poorer societies and poorer people within rich societies continue to have much higher mortalities but one cannot simply extrapolate from that finding that if those same people were provided with the same health care, their mortality rate would be reduced. I do not believe there is any evidence in Ireland that care for critical occurrences is any worse for public patients than private patients. It is different for those who have hip replacements but there is no difference in terms of care for critical occurrences.

The issue is much more complex than just improving health care. The effect on mortality of socio-economic status, which is massive, is poorly explained. The decline in cardiac mortality, for instance, is still poorly explained and appears to have more to do with improved economic circumstances than——

Deputy Thomas P. Broughan

Major socio-economic and political change.

Professor Brendan Drumm

We are talking about many unidentified factors. It is the Barker hypothesis, namely, how poor one is in the first five years of one's life that appears to have a massive impact on one's longevity. It is a much wider issue than health care and many of the facts probably have not been identified.

Chairman

We might arrange a spot on Vincent Browne's programme for the Deputy if he would like that.

Professor Brendan Drumm

I will avoid that one.

Chairman

I address my question to the representative from the Department of Finance. To return to the question of procurement, I note that for a long period the HSE was excluded from the Department's guidelines. When did the HSE come under the guidelines on procurement?

Mr. Tom Heffernan

The HSE is subject to the normal public guidelines on public procurement, in current and capital guidelines. An issue arose about a year ago and it was confirmed to it subsequently that it was subject to the guidelines. The relevant sanctions in terms of public expenditure require that it complies with public expenditure guidelines and guidelines on procurement and project appraisal.

Chairman

I understand the HSE did not have to make an annual report on procurement, is that right? Is it now making an annual report?

Mr. Jim Breslin

As I understand it, the Chairman is correct. My colleague from the Department of Finance is also correct that the HSE is covered by all public procurement guidelines but, until recently, did not make a declaration in its annual report as other Departments do regarding compliance and procurements outside that. It has now been agreed that it will do that in future.

Chairman

Thank you. Will Mr. Buckley make his concluding remarks?

Mr. John Buckley

On the latter point, I understand that from 2009 the HSE will make a return on non-competitive procurement.

I will confine anything I say to the information situation and the HealthStat. Obviously, it is to be welcomed because it positions the HSE to manage health delivery as a national service and to identify the process changes to which Professor Drumm referred. While the indicators and measures might be crude in the beginning, it is always better to make a start and to adjust as one proceeds and, as was also pointed out by reference to the comparison with Germany and so forth, by taking account of case complexity and intensity of care and so on, refine the indicators on an ongoing basis. Also, I understand there will be data quality audits, which should address the reliability of the input information. We should eventually get more relevant indicators based on more reliable information as it moves forward. The challenge is to use this information in the future to drive performance and, as well as through the forum, there is an opportunity to have national improvement programmes that are targeted at specific areas.

One area that probably has not taken off to the extent it probably could have is the value for money drive in the HSE. Perhaps it should connect with the indicators and focus some of its value for money work on using the information generated through this. One key area where much more needs to be done is the outpatient area. There are almost 4 million appointments. It is quite difficult to figure out the level of the waiting list but the next move in this area must be to tie down the waiting list and time band it, as is done for the elective waiting list.

I could talk for a long time on this. As well as having the crude information and indicators being generated, we must align those with quality indicators. Presumably, at some point there will be a connection with HIQA. As we will see when we deal with our report on emergency departments, one must take time cost and quality into account in all these things. Longer term, the challenge will be to make re-adjustments and re-allocations based on the information.

To summarise, all of this is positioning the HSE to become more managerial as it moves forward. That is to be welcomed but, clearly, to make use of it is the next challenge.

Chairman

Thank you. In view of the comments earlier by Deputy Broughan, we will defer noting Chapter 40 — the Dublin Ambulance Service. We also have a report that was published by the Comptroller and Auditor General in November last year on the emergency departments. We will refer back to those at a later date this year, as well as a review of what has happened between now and then with regard to the common contract, as we are awaiting further information on its implementation. I hope that will take place some time in the autumn.

By then Professor Drumm will have departed. I note he is smiling. Thank you for the work you have done and your constant courtesy when you appeared before this committee. We did not always agree on issues but, like you, we have a job to do. We pay tribute to you for your attendance before the committee and your courtesy, and wish you well in your future career.

Professor Brendan Drumm

Thank you, Chairman. Sometimes one's passion can come across as a challenge but I have never encountered anything in this committee other than really constructive input. The Committee of Public Accounts process has much to teach. One can see changes in other committees across the system because people have seen how this is a model. I have found this a hugely constructive interaction, although not always easy. The HealthStat process will make this interaction even better.

Chairman

Is it agreed that the committee note Vote 40 — Health Service Executive and HSE financial statements 2008, dispose of Chapter 38 — Performance Measurement and Improvement in the Health Service Executive and defer noting Chapter 40 — the Dublin Ambulance Service? Agreed.

Next week our agenda is the Office of the Revenue Commissioners, that is, Chapter 10 — revenue collection, Chapter 11 — revenue checks, Chapter 12 — random audit programme and Chapter 13 — risk evaluation.

The witnesses withdrew.

The committee adjourned at 1.07 p.m. until 10 a.m. on Thursday, 11 March 2010.