I welcome the Minister for Health and Children, Deputy Martin, and his officials to this meeting to consider the Revised Estimate for the Department of Health and Children -Vote 33.
Estimates for Public Services, 2003.
Vote 33 - Department of Health and Children (Revised).
I am delighted to be in a position to address the select committee on the Estimate for the Department of Health and Children this year. It is my fourth time to do so as Minister for Health and Children. The Revised Estimate shows a gross total Estimate of almost €9.2 billion for the health service. In ongoing revenue terms, the spending level is over €8.6 billion, representing an increase of almost €1 billion or 12.4% on the equivalent figure in the 2002 Revised Estimates volume. On the capital side, the 2002 spending level is increasing by 3.6% to €514 million.
As a percentage of GNP, gross non-capital health expenditure in 2003 is estimated at 8.13%, the highest figure in 20 years. The rate of increase in gross non-capital health expenditure has outstripped the rate of increase in GNP in each of the past six years by an average of almost10%.
While OECD data show Ireland's spending per capita on health increasing by 28% between 1997 and 2000, the EU average increase for the same period was just over 13%. Data for 2000, the latest year for which comparable figures are available, show Ireland’s per capita health spending at US$1,953 while the EU average was US$2,000. Estimated per capita figures for 2001 are: European Union, excluding Ireland, US$2,064; Ireland, US$2,099.
We have received almost £5.3 billion in increased revenue funding over the past six years. This represents a 157% increase on the 1997 figure of just under £3.4 billion and brings us to a non-capital Vote in excess of £8.6 billion. General pay, special pay, superannuation, etc., account for almost £1.9 billion or 36% of the increased funding of £5.3 million. Technical items account for over £900,000 or 17% of the overall increases. This includes non-pay inflation, demand-led schemes and other costs associated with the administration and operation of the health service. The costs of the GMS alone account for €600,000 or 11% of the overall increases.
In regard to the service developments figure of almost €1.9 billion or 36% of the total increase, an analysis by programme shows the following breakdown: continuing care, €995 million - 52% of new developments; acute hospitals, €562 million - 30% of new developments; and primary care, €294 million - 15% of new developments. This extra investment in recent years has brought about significant results, including record levels of activity in the acute hospital system and a whole range of additional services provided on all care programmes.
Recently, there has been much talk of the need to bring greater value for money into the health service. Considering the size of the overall budget and the range and complexity of the work done, resources are allocated and utilised in a very efficient manner.
There is a clear need to move towards a resource based allocation system in the future where funding is allocated on the basis of service outcomes linked to sound VFM objectives. In the context of the present proposed reforms of health funding and management, it has been agreed nationally that there is a need for equity, efficiency and transparency in the way our systems are funded, managed and delivered. It is also agreed that there is a need for greater stakeholder participation and accountability in the management of their own resources.
The Casemix budget model is an internationally developed system, in use since the 1980s and currently being used in most developed countries for health funding. It has been developed to deal with these complexities. As has been stated in the health strategy: ". . . the most developed system for assessing comparative efficiency and for creating incentives for good performance is Casemix." A comprehensive review of the entire Casemix programme is under way. Proposals for the broadening of the national Casemix programme are at draft stage within my Department.
I will outline some of the features of this year's Estimate, beginning with acute hospitals. In-patient and day case discharges from acute hospitals amounted to 963,000 in 2002. This figure represents approximately 2,600 patients per day being discharged for each day of the year and is an overall increase of over 4% on the number of discharges in 2001. There was an increase of 13% in the number of day cases between 2001 and 2002. The total number of patients on the public hospital waiting list represents just over 3% of all discharges from acute hospitals. While the increase in acute hospital discharges can be clearly measured, there are other improvements which are clearly patient focused. With the additional funding the Government has provided for acute hospitals many new, improved and enhanced hospital services have been made available to patients.
I would like to outline some of the services in question for Deputies in order that they can see the range of services involved, which are providing much improved services and facilities. They include minor injuries units at the Mater Hospital, Dublin and St. John's Hospital, Limerick; rehabilitation teams established in the Midland Health Board which provide a service for those elderly patients who have been discharged from hospital and have the potential to rehabilitate; sexual assault unit at the South Infirmary Hospital, Cork; new chest pain clinic and the extension to haemodialysis unit at Cork University Hospital; extension to haemodialysis unit at Tralee General Hospital; MRI scanner at Waterford Regional Hospital, Limerick Regional Hospital and UCHG; a new medical assessment unit at St. James's Hospital, Wexford General Hospital and St. Luke's Hospital, Kilkenny; a new coronary care unit at St. Luke's Hospital, Kilkenny; a new oncology service, breast care service and day service unit at Sligo General Hospital; a new oncology service, haematology service and respiratory service at Letterkenny General Hospital; new operating theatres in Portiuncula Hospital; a new observation unit at Limerick Regional Hospital; an oncology day service at Cavan General Hospital and the Louth-Meath hospital group; reconfiguration of orthopaedic services in the NEHB; and a consultant provided accident and emergency service at Our Lady of Lourdes Hospital, Drogheda. These are examples of the improvements and developments that have taken place.
Last year I announced the commissioning of an additional 709 acute hospital beds at a cost of €65 million - €40 million, revenue and €25 million, capital - under the bed capacity initiative as the first step towards achieving an additional 3,000 beds in acute hospitals over the period to 2011. To date, 551 beds have been put in place. The funding of €53 million that I have provided in 2003 for the ERHA and the health boards is intended to pay for the full year cost of those beds and bring the remaining beds on stream before the end of 2003.
Since 1997, there has been a cumulative investment of approximately €400 million in the development of cancer services, including an additional €29 million, which has been provided in this year's Estimate. This ensures we continue to address increasing demands in cancer services in such areas as oncology-haematology services, oncology drugs and symptomatic breast disease services. To date, 85 additional consultant posts, together with support staff, in key areas such as haematology, medical oncology, palliative care and radiology are funded from these additional resources. The benefit of this investment is reflected in the significant increase in activity which has occurred.
For example, the number of new patients receiving chemotherapy treatment has increased from 2,693 in 1994 to 3,519 in 2000, representing a significant increase. An additional sum of approximately €18 million was invested in oncology-haematology, including oncology drugs in 2003. This increased investment will ensure we continue to meet the demands placed on this service in terms of increased patient volume and the increased costs associated with new drugs. Breast cancer is the individual site-specific cancer which has received most investment in recent years and in-patient breast cancer procedures have increased from 1,336 in 1997 to 1,839 in 2001, an increase of 37% nationally.
A cumulative figure of approximately €39 million in revenue funding has been invested in BreastCheck since 1999. To end December 2002, the programme had invited 110,636 eligible women, of whom 83,035 had been screened, an uptake rate of 75%, which exceeds international standards. The extension of BreastCheck to a further three counties was announced in February 2003. The complete national extension of BreastCheck was announced in March 2003. Under the extension, two static units are proposed in host hospitals - one in Cork and the other in Galway - at which breast surgery will be performed for women in the south, west, mid-west and north-west.
Sitting suspended at 11.50 a.m and resumed at 12.05 p.m.
Additional funding was provided for the cervical screening programme this year in support of developing laboratory and colposcopy services which involved staffing, equipment and new liquid based technology in laboratories
We will continue to tackle the waiting lists in this year's Estimate. A total of €43.8 million is available in 2003 to enable hospitals to pursue continual reductions in waiting lists and waiting times. The initiative has produced tangible benefits for those awaiting hospital treatment. The in-patient waiting list figure of 18,390 at December 2002 represented a reduction of 15% on the figure at June 2002. The number of adults waiting more than 12 months for in-patient treatment in the target specialties decreased by 30% between June and December 2002.
The waiting lists for cardiac surgery and gynaecology have been reduced by 47% and 45%, respectively. The number of children waiting longer than six months for in-patient treatment in the target specialties fell by 31% between June and December 2002. The waiting lists for general surgery and plastic surgery have been reduced by 52% and 44%, respectively.
This year we have provided further funding for the national treatment purchase fund. It referred its first patients for treatment at the end of June 2002. As of 4 June 2003 approximately 4,500 patients who have been waiting a long time have been treated. In 2002 the NTPF paid out about €4.4 million in respect of 1,920 patients who received treatment in private hospitals in Ireland and the United Kingdom.
The work of the NTPF has raised issues regarding the accuracy of numbers reported to be waiting longer than 12 months for treatment. As a result, I recently announced my intention to bring forward proposals, in consultation with the NTPF, the ERHA and the health boards, for a new system of management and organisation of waiting lists nationally.
We have provided further funding in 2003 on top of the €15 million provided since 2000 for renal dialysis services. It has been a main acute hospital priority of ours for the past two to three years. The number of patients on dialysis has increased by 44% in four years. We have recently taken steps to establish a group to formulate a national strategy for renal services.
An additional €4.544 million is provided for the heart-lung programme at the Mater Hospital, bringing the total available funding to €7.9 million to facilitate the commencement of the lung transplant programme. Considerable preparatory work has been completed, and the first patients have recently been admitted for pre-operative assessment prior to their transfer to the Freeman Hospital for surgery.
Additional funding was provided in 2003 for services for people with hepatitis C. In April 2002 legislation was enacted by the Dáil to extend the Hepatitis C Compensation Tribunal Act 1997 to persons with haemophilia who contracted HIV through contaminated blood products, and also introduced new headings under which damages could be claimed. An additional €60 million has been provided for the hepatitis C and HIV compensation tribunal and reparation funds, bringing the total available to €100 million in 2003 in line with expected demand, the impact of High Court awards and the anticipated effects of the 2002 Act. The total cost of the compensation tribunal to December 2002, including awards, reparation fund, legal fees and administration, is approximately €495 million.
A total of €7.494 million in additional funding is available in 2003 for child care services. Details are included in the printed copy of my speech which has been circulated to members. In terms of services for people with disabilities, additional funding in 2003 of €13 million has been made available to try to deal with service pressures identified by the health boards, additional resources for the voluntary sector, Disability Federation of Ireland co-ordinator posts, the provision of aids and appliances and the implementation of the national physical and sensory disability database.
An additional €2.1 million was provided for services for people with disabilities in sheltered workshops. Additional funding of €2.66 million was made available to health boards and the authority towards the implementation of Homelessness - An Integrated Strategy, on top of the base funding in place. Additional funding amounting to €13.3 million has been made available for services for persons with an intellectual disability or autism in 2003 to meet identified needs in existing services. The details are in the printed copy of my speech circulated to members. In terms of mental health services, €7.67 million has been provided in 2003. This does not include €2.24 million allocated to the new Mental Health Commission. The details are included in the printed copy of my speech.
I am pleased to say the provision for nursing home subventions increased by almost €7 million to €129 million in 2003. The numbers in receipt of subvention increased from 3,271 in 1994 to 8,300 in 2002. It is interesting to note that in the first full year of operation of the scheme, the total worth of subventions amounted to €15.194 million and in 2002 the cost was €102.94 million. The increase in the provision of the scheme will allow for extra clients to receive subvention towards the cost of their long-term care in 2003.
I propose to launch later this month the expenditure review of the nursing home subvention scheme with the Mercer report on the future financing of long-term care in Ireland compiled under the aegis of the Department of Social, Community and Family Affairs. A review of the nursing home subvention scheme will follow.
Inappropriate occupation of acute beds by older people in acute hospitals continues to be a problem for the acute hospital system, particularly in the Dublin and Cork regions where there is a lack of suitable places. The provision of additional community nursing units through public private partnership initiatives in Dublin and Cork should alleviate this problem. I will deal with the issue later under the heading of PPPs.
An additional €7.1 million is available in 2003 to support the appointment of nine consultant cardiologists and for the further appointment of eight additional consultant cardiology posts, complementing the geographic spread of posts funded in 2002. These additional 17 consultant cardiologist appointments in 2002 and 2003 represent a 60% increase in the number of consultant cardiologists. Funding has been provided for the Heartwatch programme, which is also under way.
The GP co-operative and primary care development is covered in the Estimate, as is the GMS scheme and personal management and development. We have provided funding for risk management while nursing has received significant additional funding in terms of recruitment, retention and training.
I have dealt with the national development plan. We can deal with other issues later.
I thank the Minister for his rapid delivery. There is some advantage in looking at the Estimates halfway through the year in that we can see their impact. Despite what has been said, we can see how severe the impact of the cutbacks has been. Only now are we seeing their impact, though we will see further savage cutbacks later in the year as service providers realise they cannot provide the same services they did last year. If they try to do so, there will be disastrous effects, as it will be the first charge on their budgets next year. We are only seeing the beginning of this.
This annual budgeting shows how intrinsically inefficient this method of funding the health services is. It is too impractical and too rigid as a time horizon in both good and bad times, though particularly true of the latter. As householders, we know we must live within our budgets but we can be flexible and plan for repairs and so on over a number of years. Businesses can also invest for the future to reduce inefficiencies and increase output, but health services do not have that flexibility. It is bad enough that they may have control over their funding for a year but last year they did not even have an annual budget as directly after the election some of their budgets were withdrawn. Some seem to have forgotten that they did not even have the meagre certainty of a budget last year. The reality is that no one can live like that - certainly no household could.
Annual budgeting is only useful as a management tool if the budget is realistic to start with and that was not the case for health providers this year. They also need input into the planning of the budget, which is not the case. Hospitals and health boards do not have that input. The legislation which provided that overspending would be the first charge the following year came in before my time as a Deputy but I was a member of the health board when it was introduced. I understood the intention was that it would prevent health boards going off on unplanned, entirely new spending programmes. It was never intended that once one reached one's quota one stopped treating one's patients or they become a charge on next year. It is unrealistic to plan to treat 100 patients in a year when one may treat 110 one year and 90 the next.
In recent months we have seen visible cutbacks: patients on trolleys and waiting lists, cuts in community care, disabled services and home help services. There are other more serious cutbacks we cannot see which will come home to roost, as there are long-term effects to such cutbacks. There are thousands of examples. For instance, there are six highly trained heart surgeons in the Mater Hospital who have four beds each and are doing two operations every week. One imagines it takes them five minutes per day to do their rounds. Therefore, what are they doing for the rest of the day? Twiddling their thumbs? It is not just the expensive skills of these surgeons which are being wasted: their entire teams and the other overheads, such as insurance, nurses and porters are all still in place when beds are closed. It is a very inefficient way to save money and will cost us in the long run.
The other cutbacks which arise when beds are closed are essential repairs which are never undertaken, resulting in essential equipment being replaced at enormous expense or worse, causing enforced idleness for teams. A missing valve may close a theatre and leave a team idle. Those frustrating cutbacks are a result of inadequate budgeting. When the Minister or anyone from the Department speaks, they seem obsessed with value for money but that is a sham and a distraction. It is not happening.
The Deloitte & Touche report might as well not have happened. It recommended investment in IT, probably the most important investment the health service could make. Nothing has happened. If one does not have adequate information one cannot make good decisions but in the health service if one does not have the right information, the decisions are dangerous. There must be a lesson in investing in IT and communications systems. Half a billion was spent on the hepatitis C tribunal on blood products up to last year - imagine what could have been done in the health service with that money. These are accidents waiting to happen again if we do not invest in IT and communications technology.
Every time the Minister speaks he mentions reforms he is going to announce but I have heard nothing about the changes needed in the health service. It is nonsense to talk about reducing the number of health boards from 11 to three as if that was going to solve all our problems. It is akin to rearranging the deckchairs on the Titanic when we need to build a new ship. We are all agreed on quality access to a quality health service, but that will not happen with the current system, no matter what the Minister does to the structures. Under this system the Minister is the provider and procurer of the service and no matter what management structure he puts in, no matter how hard-working people are, no matter what the reforms, the reality is that all the inefficiencies will re-emerge in time. There are no market forces involved in the system. The health service is not robust enough to withstand the kind of challenges that are ahead unless a new system is introduced.
Dealing with the Estimates is like sticking one's finger in the dyke. We cannot deal with what is ahead without fundamental reform in the entire system of the health service.
Listening to the Minister makes me realise yet again that we are dealing with two parallel worlds, one of which is inhabited by the Minister for Health and Children, where things are going beautifully and he is in here promoting all the good work he is doing and where his view on the health service is very rosy. The other - the real world - is inhabited by sick people and those who care for them and it is in very poor shape.
That is not to say some good has not happened. Some good things have happened, particularly in areas where there have been targeted initiatives. The cardiovascular strategy is one of them. The reality is, however, that the health service is in a mess. On the one hand, the Minister is talking, with a lot of confidence, about opening new beds but he just happens to omit the fact that almost an equal number of beds in the hospital service are now closed. He must be aware of the grave situation in Our Lady's Hospital for Sick Children in Crumlin where 25 beds are closed and for the first time ever children are being left overnight in the accident and emergency department because there is nowhere for them. There are grave concerns about treatment being accessible to these children. If anything can be said about the public's view on the health service, I think I can say with confidence that each person in the country would want to ensure gravely sick children will always have the certainty of getting full and quick access to the treatment they need, including the very best quality treatment. The information coming out of Crumlin from various health professionals causes deep worry.
Meanwhile the national treatment purchase fund has been advertising on radio that it will send adults and children to hospitals in Britain. This indicates contradictions within the health service as it currently stands whereby a Department is spending money to fund British hospitals to treat Irish patients, while at the same time it is responsible for closing public hospital beds in Ireland where standards are excellent, doctors are waiting to provide treatment and nurses are keen to do the work they are well qualified to do, yet they are unable to do so because funding is not available.
The Minister is now trying to rejig the waiting list figures in order that they do not look so bad. I thought he had done this but the figures were still not to his satisfaction. Rejigging the figures will not produce the results he promised during the last election campaign, that is, that there would be no hospital waiting lists by 2004.
The Minister itemised in his presentation certain services. I would like to know about dialysis in Beaumont Hospital where commitments were given to develop a greatly expanded unit. I note that he is talking about a group being set up. What is happening in regard to the dialysis service at Beaumont Hospital?
It is important to note the point made by Deputy Olivia Mitchell that almost half a billion euro was spent on the hepatitis C tribunal. There is still a lot of concern that haemophiliacs who asked the Minister to reconsider payments made had the door shut in their face. Perhaps he would comment on this issue as it is something which greatly disturbs people.
In relation to disabilities, people are not standing outside the gates of Leinster House for the good of their health to campaign on behalf of people with disabilities. People have already been campaigning in here this week in relation to disabilities. Today the Irish Wheelchair Association is campaigning outside the gates and being marginalised. Not one cent has been allocated to additional residential places. When young people with disabilities reach their 18th birthday, they have nowhere to go. They are put on a waiting list because there is no capacity.
I would also like to raise the issue of medical cards. A single man who is over the limit of €138 per week came to me recently. He is not young but old enough to get an increase in the medical card threshold. He went to his GP who charged him €40. He went to the chemist where he had to make a payment also. This man's health is being put in jeopardy because he does not have a medical card. The issue has been debated on many occasions. Huge promises have been made in relation to medical cards, yet not one additional medical card has been issued. It is all part of a pattern. The health strategy promised by the end of last year indicated that adults would not have to wait for more than 12 months for medical care and children would not have to wait for more than six months. Some 5,000 adults and more than 1,000 children are in this category. We were promised additional hospital beds, yet we are just treading water in this regard. We were promised that accident and emergency departments would be sorted out but there is no sign of this happening. What occurs occasionally in such departments is deeply worrying. We were promised €1.12 billion additional money in the Fianna Fáil manifesto for capital expenditure but we got just a 1% increase in the Estimates.
I would like to hear from the Minister about three reports, one of which has been commissioned by his Department and one by the Department of Finance. The spin is that the reports will be published next week. Will they be published and will we have a debate on them?
I would like to recall what happened to another major report for which the Minister is responsible. He produced a health strategy approximately 19 months ago amid a blaze of publicity which cost a lot of money. People were heartened by what they heard. People in the health service believed something real was happening, that this was a new dawn. We now know, however, the reality behind this. The health strategy was promoted on a false premise. There was no substance behind it because there was no funding behind it. The Minister was warned about this. Is he not ashamed that he went out and sold the health strategy, together with the Tánaiste, the Taoiseach and the Minister for Finance, having received a letter from the Minister, Deputy McCreevy, which stated he wished to make it clear the initiatives contained in the strategy involving expenditure implications for 2002 were included without his approval and carried no commitment on his part to allocate any particular sum to the Department of Health and Children in the budget? The Minister did not tell people there was no money to back up the health strategy.
People have learned this by degrees and seeing the health strategy fall apart. The things that were not going to happen anyway are now being exposed and will never happen. These include the medical card scheme, waiting list elimination and all the other aspects of the health strategy which required additional funding over and above what the Minister was getting. Will we see the same approach being taken in regard to these three reports? Will another set of groups and committees be established, which will prolong any real change? Most importantly, will these be simply about administrative changes which will save money for the State but will not deliver for patients?
We have a deeply inequitable system which nothing that has happened has lessened. If one looks at those trying to access primary care, one will see that the situation has got much worse. The charges doctors are levelling have increased significantly, but the income limits for patients on low incomes have not increased at all. Such people are being totally priced out of any chance of seeing their family doctor. This has serious health implications for them.
What does the Minister think of the fact that in order to facilitate a constituent in County Kildare the Minister for Finance is promoting small private day care hospitals, thus ensuring there will be €63 million less available to the Department of Health and Children? The Department of Finance costed this change. Nobody has argued for small day care hospitals, which are not necessarily being promoted by the Department of Health and Children. The loss of €63 million at a time when there are such cutbacks must be a matter of grief to the Minister for Health and Children. Where is the benefit of facilitating a constituent in County Kildare in terms of improvement in the health service?
I am glad to be able to speak on this. I came to Dáil Éireann to see what I, as a general practitioner, could do. I have been at the coalface for many years and suffered great frustration in trying to get patients seen in hospital. Nothing being done gives me any confidence that things are going to change. For example, people have to travel as far as Galway from Mayo General Hospital to get ear, nose, throat and urology services, etc. These services should be available in County Mayo.
Initially when I became involved in orthopaedics in County Mayo, people had to travel to Galway for these services. This did not make sense because of the distance involved - about the same distance as from here to Galway. The same problems apply to ear, nose, throat and urology services. People who have to get up five times a night have often to wait five years to get to Galway for an operation that takes half an hour. This does not make sense.
Major money is spent in the health service and I agree the amount has risen. The Minister shows that spending per capita increased by 28% between 1997 and 2000, whereas the EU average increase for the same period was just over 13%. However, the problem is that we have been way behind in regard to what we should be spending and are really only at catch up level. These figures actually show a false aspect of the situation. Because spending was so low we certainly needed an increase to get us up to par and it is only recently that we have reached that level of spending on health.
Not only the Minister for Health and Children, but the Minister for Finance and the entire Government must see the reality and ensure adequate funds are provided for health. As someone working on the ground, I do not understand the reason there is such reluctance to face up to the serious issues and problems.
Before the election, the Government laid out the health strategy, which gave people great expectations that something would be done. However, from an early stage it was obvious that the money would not be put into the strategy to ensure improvements would be made. It must have been obvious at the time that the money would not be available. Although the health strategy stated there should be an increased number of consultants in the health service, it never mentioned the number required. I will not say the strategy was dishonest but I do not understand how the Government felt it was going to fund it.
The strategy also stated waiting lists would be reduced. The projection was that the waiting time would be reduced to one year for an adult and six months for a child. However, that did not take cognisance of the fact that 100,000 people were already waiting to be seen, which means the premise was false at the start.
Money is being made available to promote private hospitals and for the treatment purchase fund. While I agree this has had some effect, it is a vote of no confidence in our public health system. It would make much better sense to put the money into, for instance, creating urology consultancy posts and facilities in Castlebar. We have a consultant who comes once a month or once every two or three months and probably only sees ten new cases on each visit. Considering the 1,000 people waiting to be seen, what good is this? There is imbalance in the whole arrangement. The Minister has talked about centralisation, which does not give a true picture of the situation. Mayo General Hospital, Castlebar, should be a regional hospital.
The general medical services provide health care for 1.2 million Irish citizens, 30% of the population. It makes more sense to put money into these services which have not had the investment they should. The drug budgeting schemes, etc. in this area are hit and miss and depend on whether a doctor will make drug savings or not in order to provide money to invest in his practice. However, there is no proper funding arrangement for investment in general practice. I made a comparison between using a machine that costs only a little to run and one which is expensive to run. It makes sense to use the machine that costs less to run. There is talk of changing the general medical services system but as the saying goes, "If it's not broken, why fix it?" This appears to be what the Department is trying to do.
There has been very poor investment in the development of cancer services and only €29 million has been provided between 11 health boards. This is poor considering what is given out in other areas. For example, €400 to €500 million was to have been provided for a national stadium. While talk about that was going on, people had to wait three to four months for a radiotherapy service. If the money was available, the service could be provided tomorrow. Health apartheid exists, especially in the west and the cancer care area.
We are now hearing about the expert report on radiotherapy which was never released. It should have been released at the end of 2000 but where is it? It is years overdue. We know, from leaks, that there will be no radiotherapy service in the south-east, although for a third of the cost of bringing people to Dublin we could have a facility in Waterford. It would make sense to provide this. In this regard, centralisation is costing more lives. The Minister pointed out the large increase in the number receiving radiotherapy - over 3,800. However, there is a demand for services for 9,000. We are not at the races in this regard as we have only ten machines, each capable of treating about 350 people a year, 3,500 people in total.
In Dublin, however, a person with money can have treatment. I understand from what is happening in regard to private hospitals that this will happen more and more. The facilities are available and there is Government support for private medicine rather than for public medicine. It makes more sense to me to put the money into the public health system and ensuring people have these services locally. Why not put the money for the treatment purchase fund into, for instance, urology or ear, nose and throat services for County Mayo? That would make more sense than supporting hospitals in England or private hospitals elsewhere.
Before the general election, people had difficulty regarding the guidelines for medical cards. It is obvious that these guidelines have not kept pace with inflation. The average couple earning €220 a week would not be entitled to a medical card on income grounds. There is major health apartheid with which the Government is not getting to grips.
Regarding Deputy Olivia Mitchell's point, language can vary depending on how people use it. I am living in the same world as everybody else and meet ordinary people all the time. I regularly meet ordinary people who have come out of hospital. I do not deny that people have difficulties with the service from time to time. Most people who are admitted to hospital speak very highly of the quality of service they receive. I accept the criticisms made about the service and its inadequacies, but we need to keep a balanced perspective when debating health. Some of the headlines and commentaries bear no relation to the reality in terms of the progress being made in recent years.
I regularly open new facilities such as the rapid breast cancer diagnostic service in Tallaght Hospital. It offers a triple service - women are assessed, diagnosed and given the results on the same day. It has a multidisciplinary consultant-led team. There was no fanfare at the opening ceremony, no big media splurge. That unit is quite illustrative of the dramatic progress being made in cancer care from the point at which it had been.
It is not good enough to use particular incidents regarding cancer care that might be wrong and which should not have happened, as an example of how cancer care is a disaster or is very poor. That has been attempted from time to time. We have moved a long way from the mammography machine, paid for by individual voluntary efforts around the country, as the sole provider of breast cancer diagnosis. We still have some distance to go, particularly in terms of radiotherapy facilities.
We did not withdraw budgets from health boards after the general election. If one examines the financial statements of the health boards for 2002, one can see allocations being made after the election in respect of certain items, not least for services for the elderly. What happened in 2002 was that health went over budget quite significantly, as we know from the Supplementary Estimate last year. Despite all the screaming and roaring about cutbacks in the latter half of 2002, I was forced to come to this committee to secure a Supplementary Estimate——
Because the Minister had not managed it. He was pushing that money up to the day of the election.
——of well over €200 million, if I remember correctly.
It was €212 million.
It was to do with GMS payments and many other things such as demand-led schemes. We had to readjust and make decisions. We did not take budgets from health boards. In the case of one health board, where there were dire predictions in August, it turned up a surplus at the end of the year. We need to take a reality check and should not always just react to the latest headline or statement. We must stand back from the statements. That is what happened last year.
That is not what happened last year. I am a member of a health board and know exactly what happened.
I did not interrupt the Deputy. I do not accept——
Money was taken back——
It was not.
——from people who were already employed by health boards. They were then told they could not employ them, even though they were already employed from earlier in the year. That is a withdrawal of funding. That is the reality, no matter how the Minister dresses it up.
May I clarify the point?
That is what happened.
The opposite is the case. At the end of 2002, as a result of the employment census undertaken throughout the health service, we discovered that jobs were not taken back but instead 4,000 extra jobs were put in place, over the employment ceiling, for which we secured regularisation with the Department of Finance. That was the picture in 2002. Even in the midst of the 800 posts in August, the employment census and the assessment of the benchmarking implications showed that there were 4,000 above the ceiling. One could argue that the ceiling traditionally used was a crude one, but the reality is that the existing ceiling and health services collectively exceeded that ceiling by 4,000. We went to the Department of Finance to seek sanction for the maintenance of that figure, which we succeeded in doing. That is the reality but people do not wish to believe it.
In terms of the 1996 accountability legislation, Deputy Mitchell made the point that it was never meant to deal with planned levels of activity, it was just meant to stop people from doing mad things. Legislation does not specify whether one can do this or that but not the other. The 1996 accountability legislation had its origins in the Fianna Fáil-Labour Party Government and the tax amnesty. I believe £100 million of tax amnesty money was used to clear a build-up of debt that the health boards had accumulated over a number of years. The idea was to clear the amount once and for all. It fell to the rainbow coalition Government to implement it. All parties in one shape or form were in agreement with the principle of accountability legislation, which was to work towards planned budgets and levels of activity and bring some discipline in financial control on a yearly basis. People did not relish the prospect of yet another cumulative build-up of funding on a year-on-year basis. That is the origin of the 1996 accountability legislation, which is not easily circumvented.
Will the Minister come forward to the present? We are dealing with the 2003 Estimates. We really do not need an historical lecture. We are running out of time. I ask the Minister to answer some of the questions.
I am responding to the specific points raised by Deputy Olivia Mitchell, one of them being the 1996 legislation. It is clearly relevant to 2003 because of the overspend of the Dublin teaching hospitals.
The Minister is spinning it out until 1 p.m.
I can stay here until 2 p.m. if the Deputy wishes.
That is fine. I am glad to hear that.
I am under no pressure to leave. I will not show preference to one Deputy over another. I have noted the points made by Deputy Mitchell and one of her key points was about the 1996 accountability legislation.
The Minister covered none of my points with any validity.
Some of the Dublin teaching hospitals and some of the health boards went over budget and the 1996 accountability legislation kicked in, unfortunately.
I understand, but it has been implemented in a manner that was never envisaged.
The Deputy is mistaken.
If hospitals cure people, they are penalised for dealing with patients who turn up. That is how it is being implemented. It means they can treat fewer people next year. Can the Minister imagine a hotel closing downs its bedrooms?
That is wishful, retrospective thinking. It was about having planned activity and planned financial controls. It was a matter for the managers of the health boards to operate within that structure. We must find a resolution to these issues in the context of the statutory framework in place.
The sum of €500,000 spent on the hepatitis C tribunal is significant funding. We made additional changes to that Act last year to facilitate compensation to haemophiliacs which the Government was committed to doing. That will have significant impact on this year's Estimate. A national health information strategy to deal with IT issues will be presented to Cabinet. There has been investment in IT but we are aware that more needs to be done.
Deputy Olivia Mitchell mentioned inefficiencies in the health service which has been quite efficient in many respects. One of the significant international benchmarks for efficiency would be the numbers and percentage of day cases in the acute hospital system. In 1987 there were only 85,000 day cases per year. In 2002 the number was 406,000. That is an important illustration of efficiency within the system. Another illustration of efficiency is that the average length of hospital stay is significantly lower than the European average and in other jurisdictions. In-patient productivity levels have been rising 4% to 6% year on year since 1997. There are 180,000 more people now being treated than in 1997. That is a significant increase in activity levels and reflects on productivity within the hospital system.
Deputy McManus raised a number of issues, particularly regarding Our Lady's Hospital for Sick Children, Crumlin. I accept that the provision of tertiary treatment for children is critical. Long before the national treatment purchase fund was instituted, we decided to shorten the waiting lists for children waiting for heart operations. We sent children abroad for treatment because there was not the capacity in Crumlin to provide it.
That has been going on for years.
We have been doing it for years.
It has been happening for a long time. Is the Minister referring to the present?
It was never at this scale. Yes, I am speaking of the present. The Deputy referred to the national treatment purchase scheme. There was no capacity, in terms of operating theatres and so on. I visited Crumlin hospital two weeks ago. I do not believe the closure of 25 beds is the most efficient way to save money
In that case, what does the Minister suggest?
I have spoken to——
The Minister said the action taken was not the most efficient. What does he suggest should be done?
Will the Deputy allow me to finish? When I visited Crumlin hospital, I met the management and some of the staff and there were some presentations. Since then, we have spoken with the regional health authority. Last year I believe the hospital had a cumulative deficit of about €2 million, which creates a particular difficulty. It was stated the closure of 25 beds might save about €800,000, about which there was no certainty. The closure of 25 beds at a saving of €800,000 is a totally disproportionate response. I acknowledge that the hospital has difficulties and certainly has financial problems this year, on which we will work with the RHA in an effort to resolve the situation. Bed closures do not result in any permanent staff being laid off in any hospital. They are still paid.
Is there a better way to solve the problem?
Options are being considered, either on the basis of permanent or temporary savings. I am not suggesting it is the best approach.
Is the Minister saying it is better to lose staff than to close hospital beds?
That is certainly not what I said and the Deputy should not imply anything of the sort. I am simply making the point that as far as I am concerned——
The Minister said it was not the most efficient way to reduce the cost.
Deputy Olivia Mitchell also said it and I agree with her.
What is the most efficient way, in the Minister's view? Since he has made this judgment, will he share his view with the committee as to how Crumlin hospital could save money?
There is a whole range of other ways.
Will the Minister tell us one of them?
I do not intend to manage the hospital. We have——
The Minister is constantly referring back to management.
Will the Deputy, please, allow me to finish my point?
The Minister keeps referring to the responsibility of the hospital management. Will he tell the committee what is his view?
There are several alternative areas for consideration, including overtime and so on.
Is the Minister suggesting a reduction in staff?
We have actually increased the number of staff in the hospital in recent years.
I have asked a simple question. Why will the Minister not answer it?
I have answered it.
The Minister has made a judgment about the management of the hospital.
Yes, I certainly have and I stand over it.
Will the Minister tell the committee the most efficient way to manage the problem?
We will work with the ERHA and the hospital on all the issues.
That is not an answer. The Minister has made a judgment. Every time this issue arises, he criticises, in effect, the management of a hospital. What is his view, in terms of managing this problem?
I will repeat what I said. The closure of 25 beds is a disproportionate response towards trying to save €800,000. It is not even clear that €800,000 will be saved by that action. It could be a lower figure.
What is a proportionate response?
I have no intention this afternoon of going into the detail of managing a hospital.
The Minister is quite happy to criticise the hospital but he is not willing to stand over what he is saying.
We should move on.
I am not being allowed to move on. Deputy McManus should relax, rather than trying to make headlines.
(Interruptions).
Every time the Minister states in the media that he is going to work with a health board to solve a problem, some other area of the health service suffers a cutback to prop up the one which is in the media focus. What service does the Minister intend to cut in the ERHA to give money to Crumlin hospital? That is his approach to solving every problem - he moves the problem around within each health board. This has happened repeatedly in the last couple of months.
That is absolute nonsense.
It is true.
It is not.
What happened in the North-Eastern Health Board area when there was a problem in Drumcar? The home help service was cut to provide the money.
That is just not true. It is a gross distortion.
It is exactly what happened. The money was taken from the home help service.
No. That is a gross distortion.
May we deal with the questions which have been raised?
The Minister refuses to answer the questions put to him.
Deputy McManus insists on interrupting whenever I try to answer, with a view to getting a headline. That is my view of this debate.
I am doing my job. If the Minister is doing his job, why will he not tell the committee what he is doing in relation to——
Deputy McManus has referred to the national treatment purchase fund. There has always been resistance within the system to the scheme, to a certain extent. However, the fact is that about 4,500 people who had been waiting longer than 12 months have now been treated since June of last year. We are not rejigging lists or anything like that. I do not know how familiar members may be with the treatment purchase fund. Some interesting observations have emerged, including the fact that some people should not have been on waiting lists. The figures are available from the scheme - I am not sure if Deputies have received them, but I did. We wish to work with the health boards and the treatment purchase fund in getting to the bottom of the situation. We are not rejigging lists; we are trying to get a more accurate picture of the situation.
The bulk of the expenditure from the treatment purchase fund has been in this country. The amount of overseas expenditure has not been huge, by any standards. I gave the figures for expenditure in 2002. I consider the scheme an important instrument in facilitating treatment for people who have been a long time on waiting lists because of historical issues.
We have made very significant investments in accident and emergency departments. My information is that 19 accident and emergency consultants have been appointed since the announcement in this regard in 2001. However, more is required than simply investment. There have been very good innovations across the country, including the medical admissions unit in St. James's Hospital and similar initiatives in St. Luke's in Kilkenny and Wexford Hospital. This has involved not just using the additional money for appointments and staffing, but also changing the way the overall hospital community dealt with admissions. The provisions for people arriving at accident and emergency departments with chest pain symptoms have been particularly effective. The ultimate model in that regard was St. James's Hospital, but there are other models involving GP referrals which have been very effective.
In relation to the health strategy, to which Deputy McManus referred, there has been very significant investment in general practice co-operatives in every health board area to which we have added further in 2003. In relation to the primary care strategy, a fundamental part of the national health strategy, we have set up the steering group and provided funding of approximately €8 million between 2002 and 2003 for approximately ten implementation projects across the country, to get the model right and assess how it works on the ground. Over 80,000 people will benefit.
In 2002 more than €40 million extra was allocated to services for the elderly, which were clearly identified in the health strategy. The €30 million provided for the treatment purchase fund is clearly derived from the national health strategy. The full year costing, in terms of additional beds provided in 2002 and 2003, is €90 million. I can provide a list of the relevant locations and financial provisions. Accordingly, it is not true to suggest that funding was not provided for the implementation of the national health strategy.
On the non-funding aspects of the national health strategy, the reform programme and proposals, which will go to Government shortly——
When?
——represent the impact of the national health strategy on the whole issue, not just of organisational structure reform of the health service, but also medical manpower reform, the reform of how we operate and deliver services in hospitals and also the configuration of hospital services. That is more applicable to the Hanly report and the national manpower report. Work has commenced on about 70% of all the actions committed to in the national health strategy. If one compares this to the 1994 health strategy - which was good in terms of being the first in its time - there were no targets and no provisions for the following years.
Deputy McManus asked if I was embarrassed or ashamed. On the contrary, I am quite proud of the national health strategy, which will be the essential blueprint governing the evolution of health care in Ireland over the next ten years. I am very confident that will be the position over the next decade because the process has been informed by a far broader consultation programme than ever before.
Deputy Cowley raised issues in terms of——
I asked the Minister about the three reports. When will we see them?
Shortly.
Will we see them next week?
It is a strong possibility. The Deputy will appreciate that it is a matter for Government to consider.
I just want to know.
While I appreciate Deputy Cowley's genuine commitment to health issues, I must point out that in the Western Health Board region - in counties Mayo and Galway - there has been significant investment since 1996. In County Galway there has been a cumulative investment of about €130 million in infrastructural development. In regard to phase one of UCHG which commenced in August 1996, the investment was about €26 million. The phase two development commenced in June 2000 and will, I hope, be completed in September 2003 at a cost of €103 million.
I could list many other projects, including those involving the medical records department, the admissions unit, cardiology-orthopaedic wards, cardiology-orthopaedic operating theatres, the intensive care unit, the high dependency unit, the burns unit, the radiotherapy department, MRI radiology facilities and medical social work. We are looking at a complete transformation of acute hospital facilities in County Galway and the west because of that investment and it is time somebody acknowledged it.
People must wait four years for a rheumatology appointment. That is not the exception but the rule.
I accept that there is more to be done.
A patient of mine died while waiting for radiotherapy.
Construction of the phase two development at Mayo General Hospital began in January 1999 and the contract was completed in August 2001. That project involved administration, the medical records department, the admissions unit, the chaplaincy, the accident and emergency department, CSSD, the pathology department, the pharmacy education centre, wards, medical geriatric assessment, gynaecology and obstetrics.
The orthopaedic unit has been empty for years because there is no money to employ orthopaedic surgeons.
The investment in County Mayo in recent years by the Fianna Fáil-Progressive Democrats Government has outmatched any previous investment in any era. It is time that was acknowledged.
No other Government ever had so much money.
I agree with the Minister but point out that because the area was starved of investment for so long, there are still significant problems.
Deputy Cowley referred to consultant appointments, of which there have been an extra 439 since 1997. An average of 103 doctors per annum have been appointed over the past three years whereas, in the mid-1980s, the figure was 40 per annum and, in the early 1990s, about 50 per annum. Significant progress has been made. I agree that certain specialties are at a low level relative to a EU-wide comparison.
The national health strategy did not mention a specific figure because it was decided first to conduct the overall Hanly review. The review is motivated by the EU directive to reduce the working hours of junior doctors and also by the idea of moving to a consultant delivered health service as opposed to the consultant-led service in place. In advance of that review, it would have been foolish to pluck a figure from the sky. Nonetheless, very detailed work has been carried out by the Hanly group in terms of ascertaining what it would take to arrive at a consultant delivered service. It is in that context that we can plan for an expansion in consultant numbers with a consequential reduction in non-consultant hospital doctors in order that the service would be reconfigured as a consultant delivered one.
To come to the Deputy's other point regarding centralisation, there would be implications for the configuration of hospital services. We cannot have tertiary care provision everywhere.
I know that. However, the national cancer registry stated the system was a lottery and that people were dying because of the unavailability of radiotherapy services where they lived. If the Minister continues to centralise radiotherapy, as is intended for the south-east, people will continue to die. That is the problem and where centralisation will lead.
The radiotherapy report will go to Government in the next four to five weeks, if not sooner. Regarding the principles underlying the report, there is no argument but that there is an under-provision of radiotherapy services. There has been heavy investment in St. Luke's Hospital and modest investment in the Cork centre, which until recently were the only two centres. The former Minister, Deputy Cowen, also decided to invest in a radiotherapy centre in Galway.
There is a certain logic in developing the three centres in place to sufficient scale and volume. The report will identify a need for a second centre in Dublin. The idea is that before trying to develop other greenfield sites, which are inadequate and insufficient in terms of volume and case throughput, it makes sense to get strong multidisciplinary teams in place in the existing centres.
The Galway unit is a priority in terms of investment to try to get it started up and fully equipped with more machines. The Cork centre also remains a priority because it has only two machines. The indications are that a minimum of about six machines with the consequential multidisciplinary teams are required to justify the status of a centre of excellence in terms of what is internationally accepted.
We have gone over our time.
There was a vote.
I have considered that. I propose that we continue to 1.15 p.m. by agreement. Is that agreed? Agreed.
If the report was published, we could get to grips with it but it seems to state the situation will continue as before. It is costing three times as much to bring people to Dublin from, for example, County Waterford, to avail of a service they could access locally. While I agree totally with the Minister that we need multidisciplinary units, comprising surgery, radiotherapy and oncology, there should be a minimum standard. It does not make sense to pay three times as much to bring people to Dublin when they do not want to go in the first place. That is costing lives, as is the lack of a radiotherapy service. Why continue like this, especially as there are cutbacks in Dublin? The services are being centralised but even central funding is being cut back. What will happen to the services?
The issue is not one of cost or transport but concerns the best outcome. No matter where a patient lives, he or she will want the best survival rate and the best outcome. That is the fundamental principle that guides our thinking.
I agree totally.
I am told that a high volume, high population catchment area is required to have the necessary patient throughput and to attract the right personnel because such personnel need to be in a strong multidisciplinary centre. That would give the kind of results we want and is the model which has been seen to work internationally. To place one or two machines in locations all over the country will not give the best outcome. That is what I am told.
I am not talking about centres in every parish but one in Waterford and one in Limerick, which would make a lot of sense. There are models to follow such as the Norwegian model.
With regard to numbers, from leaked parts of the report we understand that in 2010 or 2015, such centres will be required in any case. The present centralised model of radiotherapy services is costing lives. If it is planned not to have such services in the south-east or mid-west, lives will continue to be lost.
The Minister spoke about large volumes and the report states this would be justified by 2010. There are two smaller machines in the Mater Hospital which are working very well for private patients. What is sauce for the goose is sauce for the gander. If the services are provided locally, it would be like the saying, "If you give a man a fish, you feed him for a day but if you teach him to fish, you feed him for life." The Minister should stop investing money in the national treatment purchase fund and private hospital care and invest instead in the public services, in which he should have confidence. That would help solve problems in the long-term rather than looking for quick fix solutions.
The model is inadequate because of capacity, not because the service is centralised. The fundamental problem with radiotherapy is that there is not enough coverage for those who require it. We would like a service in Galway which is coming on stream, as is an enhanced facility in Cork. County Galway is not far from County Clare and significant parts of the mid-west.
There is an issue in regard to Waterford which is not simply about outcomes.
It is a very big issue.
It is also about quality of life. Some consultants are saying they are extremely concerned about the fact that patients have to travel so far to these centres.
That is what is costing lives.
One cannot concentrate the issue on outcomes only, as everybody is in agreement in that respect.
Are they?
Of course, they are.
I am not so sure.
Okay. Let us say those of us in this room agree that we need to centralise to a degree. There will be a private service in Limerick in order that those who can afford to access such services will be able to do so. The consultants in Dublin who are treating people from Waterford are pointing out that people are being forced to travel unnecessarily far in order to access a good quality of treatment.
Can I make a comment about the comparison between private and public treatment of cancer? I would be happy to go to a public teaching academic hospital.
I have not said I disagree with that view.
The Deputy has included certain hints in her comments——
No.
I ask the Deputy to hear me out.
I was speaking about availability.
That is another issue we need to explore when analysing cancer care in Ireland. The treatment provided for cancer patients in the private and public systems——
I agree with the Minister.
It is important in terms of outcomes and survival rates.
I do not think that is the issue about which we are talking.
It is. People may claim, for example, that the Mater Hospital might be the best in the world for private patients because it has one machine. I suggest that it may not be the best thing in the world, in terms of patient outcomes and survival rates, to have just one or two machines in a private hospital.
Sure.
Perhaps that needs to be said also. We need synergy between the two. Best outcomes should be the number one priority. Deputy McManus is right to raise issues of convenience, quality of life, transport and accommodation. All such issues are being considered and will be factors when the distribution of radiotherapy facilities is organised. Ultimately, it is possible to envisage that linkages will develop - certain hospitals may become satellites. I am trying to be realistic by saying the clear initial priority has to be to get the service in Galway up and running and to get sufficient capacity.
Yes.
When will that happen?
It has already started. The posts have been sanctioned.
Yes.
I think it will be the middle of next year by the time the commissioning of the building will be signed. It will be 2005 by the time——
How come?
We will have to commission the buildings, equipment, staffing, etc.
I know it is difficult. I am not arguing about that.
Can I ask about the position in Galway and overall capacity? I was going to ask the Minister, if outcomes depend on throughput, whether he feels private hospitals are providing as good a service as public hospitals. Perhaps he is suggesting that perhaps they are not.
I am not a doctor.
That is not my question. I agree that the Minister is probably right in that regard, but if we need to increase capacity in the public sector, perhaps we should provide two additional machines if the private sector does so. We could buy the services from them. Perhaps that is the way to go, rather than looking at every parish.
We have invested a great deal of money in the area of cancer, in laboratories, backup, pathology, radiography, etc. The multidisciplinary approach, in terms of critical mass, is to be found in the major teaching academic hospitals. Many consultants who wish to return to this country are signalling that this is where they want to be. Most of them want to be where there is critical mass, in any discipline, in order that they can work in teams, relate to other consultants in other disciplines, etc. It is clear that it is the way forward and it is happening. We have a responsibility to give leadership in this area and explain to people that it means a change in the way we have been used to doing things.
The question I asked was really about capacity. Whatever about the geographical spread, will we have sufficient capacity in the country as a whole to treat patients when the unit in Galway is up and running?
In radiotherapy?
Yes.
No, we will not have sufficient capacity as more capacity will be needed in Dublin.
And Cork.
Yes. There are only two machines in Cork.
The Minister is talking about more decentralisation. He has decentralisation on the brain, if he does not mind my saying so.
There are only one and one third units, in effect——
The Minister has spoken of all the consultants who are abroad. There are only eight radiation oncologists in Ireland, but there are 157 in Holland, which has half the land area of Ireland. I admit that the population of that country is about four times that of Ireland, but we should have at least 40 radiation oncologists. The doctors are abroad because the jobs have not been provided for them. I agree with the Minister that outcomes and what is best for patients are important, but this should be applied to the case of those who have to travel from Waterford for two parts of the treatment. All parts of the treatment should be given together. I agree that it is best to have the three disciplines - surgery, radiotherapy and oncology - together, but how can that happen if someone has to travel from Waterford to Dublin to receive one part of the treatment? There is no co-ordination in such circumstances and it is the reason Ireland is below the EU average for cancer survival. I agree that we do not need a unit in every parish, but one is certainly needed in Waterford and the west. Consultants are needed but they will never come unless there are jobs and opportunities forthem.
We did not have oncologists outside Dublin until about three years ago, to the best of my knowledge. There were very few of them.
We have no oncologists in County Mayo. We need an oncologist in the county.
There is one in Galway and two in Cork.
There are no beds in Galway.
Perhaps we should have a highway from County Mayo. I thank the Minister and his officials for attending this meeting and the members of the select committee for their usual co-operation.