I am accompanied by national directors, John O'Brien from the National Hospitals Office, Laverne McGuinness from primary and continuing community care, and Liam Woods, national director for finance.
This is my first opportunity to address the committee since the commencement of the 30th Dáil and I wish to comment on several issues.
The transformation programme is a five-year programme which began just over two years ago. It is making progress and we will continue to drive it forward. We are continuing to provide more and better quality services to more people than ever before. Everyone is well aware of the progressive and dramatic increase in the population of the country which has occurred.
The Minister has referred to some of the issues, not least being the HSE involvement in bringing about savings in the area of expenditure on drugs. We expect savings of a minimum of €100 million a year based on current prices as a result of the agreed deal reached with the manufacturers of drugs and the change in the application of the wholesale margin for the distribution of drugs.
The Minister mentioned the development of the children's hospital. I emphasise that this will be a network for paediatric care at a national level and not simply a Dublin service. It is extremely important that it is closely and comprehensively linked up and down the country.
I acknowledge the tremendous commitment of the general practitioners in north Dublin to the roll-out of the out-of-hours service in that area, which has been another significant step for the people of Dublin. There is now a GP out-of-hours service serving 500,000 people in north Dublin. This service is a great success, due largely to the commitment of the general practitioners who serve the area during daytime hours.
In the north-east region, the services in five hospitals have been brought together to provide a comprehensive service. There are plans for the development of a new regional hospital which we hope will result in a change from the current situation whereby significant numbers of people from the north-east region must make their way to Dublin to access services which in other geographical areas are fully available.
During the period ending last September the HSE has provided more services across a wide range of areas than it was contracted to provide and we are happy to do so. These services include home help and home care services, in-patient and day case procedures and outpatient services. We are caring for more expectant mothers than had been envisaged and we are dealing with that challenge.
The number of people being cared for in accident and emergency departments is ahead of target. Every day, the HSE services treat approximately 3,000 people in the accident and emergency departments and approximately 1,000 patients a day are admitted to hospitals. It is not often acknowledged that approximately 90% of these are admitted immediately. It remains a challenge that the balance of approximately 100 patients must wait for admission. However, many patients wait for less than six hours. Last year the target was to have no patients waiting for admission for more than 24 hours and our target for this winter is to have no patient waiting for admission for more than 12 hours and this goal is being achieved in the majority of cases. In time it is hoped to reduce this waiting time further. However, we must accept also that given the nature of accident and emergency departments and their work, there will always be times when people have to wait for care and admission, appropriately so at times, because of the tremendous amount of work patients require from accident and emergency clinicians prior to admission.
Much of this improvement has come about through the work of the winter initiative, which we introduced last year. This mainly revolves around better hospital processes and interaction between hospital services and community services. We said at the time that simply building more of the same structures and operating through the same processes would not resolve, and never had resolved, the accident and emergency issue in previous years. Essentially, processes have been streamlined and service improvements are being targeted where they will have the greatest impact. Staff are 100% focused on the issue. The commitment of staff to resolving the problems of accident and emergency services must be acknowledged. The achievements to date have been made by staff focusing on processes, rather than adding more of what was already there.
How we use hospital beds is closely related to this issue. During the year we carried out a major study on bed dependency which found that, on average, approximately 40% of people in acute hospital beds on the day these beds were surveyed did not need to be there. They could have received their treatment at home or in an alternative setting. I cannot over-emphasise the importance of that finding. Nobody should be in a hospital bed unnecessarily and it is unfair to put people in that position.
When we examined why people were admitted in the first place, we found that 13% did not need admission. To this we can add a further 12% who were admitted for intravenous treatments alone, which is normally provided outside the acute hospital setting in other countries. We cannot continue with a situation where elderly people have to be transferred from a care of the elderly facility to an acute facility, totally discommoding them, simply because they need intravenous therapy. We have to change these types of practices. Up to 25% of people did not need admission in the first place.
These figures clearly tell us a lot about how we are using our hospital infrastructure and, in particular, that the solution to improving access to hospital services is to use the acute beds we have more efficiently and to build up a wider range and volume of community-based services. We can improve access by concentrating on getting people out of hospital and either into a facility closer to their home or directly home where they can receive further treatment if required. Over the previous winter months we had a hospital-in-the-home facility running in the Dublin area which made provision for a doctor to come to the home when necessary and which also allowed for the provision of 24-hour nursing in the home.
Compared with what is being achieved in other countries, this is a realistic expectation. In the longer term, given our ageing population we have to change how we do things. We will need more rehabilitation beds, long-term care beds and, most importantly, more community-based facilities.
The idea of keeping people in acute beds for longer than is needed is not fair on patients and their families. Indeed, for older people the evidence is that the longer they stay in acute facilities, the more detrimental the effect it can have on their overall well-being. It also greatly diminishes their chance of returning to an independent life, which they may well have had prior to admission to an acute facility.
Many hospitals are operating practices and processes which enable patients to move in and out of their hospitals more effectively and we need to build on what has been achieved. For example, the Mater Hospital now delivers 64% of all its surgery on a day-case basis. In St. James's Hospital, 82% of surgery patients are admitted on the day they receive the surgery. This is in marked contrast to what goes on in other parts of the country. At Cork University Hospital the number of surgical patients that are discharged at the weekend is twice the rate of other hospitals. If we could spread that practice across the country, we would free up a significant amount of resources.
These three practices alone; more day cases, more admissions on the day of surgery and improved discharge planning, can have a very significant impact on the availability of acute hospital beds and reduce our average length of stays in line with what happens in other countries.
A recent study of one of the major Dublin hospitals showed that by improving the internal practices and processes alone by 50% of what would be considered achievable, without the addition of any new resources, 60 beds could be freed up and the waiting times in accident and emergency departments could be addressed. As a result of the hospital's commitment to change and improvements made to date, a cross-hospital project is under way at this hospital and the benefits are being realised thanks to the commitment of staff to engage in process change, which is always challenging.
Performance measurement is an area to which we are paying particular attention. We will shortly introduce a system allowing us to easily compare, hospital by hospital, community facility by community facility, how facilities are functioning in three performance areas, namely, access, integration and resources. It is now clear that the application of resources in the Irish health system is inequitable when comparing one area with another. In the area of access we will measure how long it takes to access particular services in one part of the country as opposed to another and share the learning from the best with those that are experiencing difficulties.
We will look to see how well services are integrated between the hospital and the community. We will compare day case rates in one versus another, day of surgery admission rates and average length of stays, which vary significantly throughout the country. Patients being admitted with the same condition can stay in hospital for totally different periods of time. This will enable us, based on facts, to identify if and why some facilities are achieving better results in these areas than in others.
This will, in turn, support the third area which is how well each facility is using its resources, including staff ratios, the number of staff a facility has per bed, the ratios of junior doctors to consultants, comparison of absenteeism rates between institutions and across grades, etc. In an environment with a continual stream of demands for more resources this approach will enable us to identify where our resources are having the greatest impact and where remedial work is needed. For example, we will be able to ascertain whether the waiting lists in a particular facility are justified when considered against the resources provided to the facility.
Waiting lists have been the subject of much comment. At the end of September there were almost 39,000 people waiting to have elective inpatient or day case treatment. In isolation this seems like a high number, but relative to our workload it is not necessarily so. It represents a little over 3% of the number of inpatient and day case procedures we will carry out this year. It represents approximately two weeks' work in the system. However, the important point is not how many people are waiting, but how long people are waiting. Just under half of those waiting are waiting less than three months and two thirds are waiting less than six months. These waiting times have come down significantly in recent years. In the past they were years long. Now, in the majority of cases they are months. I believe we will be able to bring them down further.
When looking at these figures it must be kept in mind that sometimes patients do not take the first available slot as it may not suit them or they may not be ready to have their procedures for a variety of reasons and may wish to defer. While some patients may not choose to avail of the National Treatment Purchase Fund after they have been waiting for three months or more, it is a service that is available for people and there is an onus on local hospitals - and for us to put that onus there - to refer patients to the National Treatment Purchase Fund.
The Minister referred to the national cancer control programme, which took a major step forward this week when Professor Tom Keane joined the HSE as interim director. The development of the eight specialist cancer centres will reduce the likelihood of the types of errors which have been reported in the past and will improve survival rates. This is not to say that error will no longer occur, but we need to minimise the risk of it occurring. Quality cannot be maintained where there are low activity levels. We therefore are failing the public if we insist on maintaining facilities that do not provide the best possible outcomes. I sincerely urge all community leaders, communities and clinicians to recognise and accept that quality cannot and must not be compromised ahead of convenience.
I refer to the financial situation. Earlier this year, we advised service units and agencies around the country that due to the increase in the level of services we are providing and other supports such as the drugs repayment scheme, we were experiencing increased pressure on our annual budget, which amounts to approximately 1% to 1.5% of our total budget. We operate within a very strict budgetary environment and are legally required to balance our budget. All managers and agencies, in turn, have a clear responsibility to operate within their designated budgets and deliver on their service targets. Delivering contract levels of services can only be achieved where funds are available through substantial value for money initiatives. We are fully delivering services in line with our commitment and in some instances, as I outlined earlier, over and above our commitment.
National and local initiatives required to address the potential end of year budget overrun are in place. These included the following: cost containment measures in non-direct costs such as travel, hotel hire and training; reductions in non-frontline expenditure and non-frontline pay such as, value for money initiatives; efficiencies in energy use; and patient debt collection.
At the beginning of September, we introduced a recruitment pause to apply to all posts - except in certain circumstances which are considered weekly by a derogation committee, which approves a range of frontline posts. More than 450 posts have been approved by this derogation process since the recruitment pause began. We continue to monitor carefully the impact these initiatives are having to ensure that everyone who requires urgent and essential care receives it.
There are a number of significant reasons for the current heightened financial pressure including, in particular, demand-led schemes. The cost of demand-led schemes, in the main drug demand schemes, is likely to be over €150 million in excess of the budget provided for 2007. This year we received a capital budget of €545.95 million and we have put a strong focus on ensuring that it is fully invested as it is critically important that we develop and upgrade our infrastructure.
There is much commentary about employee numbers in the HSE and I would now like to address this issue. The health service employs almost 130,000 full and part-time personnel. There is often confusion between whole-time equivalents, WTEs, and the number of personnel, because clearly all these people do not work full time. A key HR policy of the HSE, since its establishment, is that priority be given to frontline staff. This is what has been done and will continue to be done.
Since the establishment of the HSE, the number of medical and dental personnel has increased by 15.5%, and nursing personnel by 13.6%. The number of health and social care professionals increased by 23% with a 32% increase in dieticians, a 35% increase in occupational therapists, a 24% increase in physiotherapists and a 30% increase in speech and language therapists. Those are very substantial increases in frontline staff and we must ensure the public is getting a better service.
Contrary to much recent commentary, the vast majority of clerical, administrative and management staff work in hospitals and community-based services, and perform key functions in regard to patients and service planning, without which the health service could not function. The suggestion that the health service can function without a significant administrative support is totally unreasonable and it is impossible to know how a service of this size could be seen to work without very significant administrative support across the system.
The recent Health Information and Quality Authority, HIQA, national hygiene services review is welcomed, particularly its findings on service delivery which are a validation of the focus the HSE has placed on hospital hygiene in the last two years. The HSE has recently put in place a significant number of strategic, structural and governance initiatives which, unfortunately, have been too late for consideration in this year's HIQA report.
The HIQA review emphasises that a lot of good work has been undertaken and positive assessments were made in hospital hygiene and, in particular, to service delivery areas such as hand hygiene, equipment, medical and cleaning devices. The review notes good hand washing practices, the commitment and attitude of staff, their adherence to mandatory staff training and a good standard of management of hazardous waste. HIQA states, "It is clear from the report that work to drive improvements on the front line has paid dividends." We believe that the review reflects the significant improvements in hospital hygiene that have been driven forward by two national hygiene audits and a range of HSE initiatives.
The HSE's previous two hygiene audits in 2005 and 2006 focussed exclusively on how clean our hospitals were. The HIQA review differs from previous hygiene audits in placing a much greater emphasis and weighting on governance issues, including management structures, monitoring systems and processes.
The HSE has been addressing these issues and in March of this year established a national health care associated infection, HCAI, governance group to develop and implement a strategy to reduce hospital and health care acquired infection. The "say no to infection" programme has produced and identified actions that will reduce the potential for infection to pass between people in the health care setting and to reduce antibiotic use and antimicrobial resistance. A reduction in the use of antibiotics is without doubt the single most important issue in terms of reducing these infections.
The plan's five year objectives are to reduce health care acquired infections by 20%, MRSA infections by 30% and antibiotic consumption by 20%. Through a range of measures now being put in place, such as training and education, standards for health care facilities and specific targets for hospitals and governance structures, we strongly expect to see our "say no to infection" strategy reflected positively in the next HIQA review.
These are some of the key areas I wanted to cover. Together with my colleagues we will do our best to respond to members' questions.
