I welcome Mr. Michael Kelly recently appointed Secretary General at the Department of Health and Children and accounting officer for that Department. This is Mr. Kelly's first time to attend the Committee of Public Accounts and he is very welcome. I hope it is the first of many visits and that by the time he is finished all the problems in the health service will be resolved. Perhaps he will introduce his accompanying officials.
1998 Annual Report of the Comptroller and Auditor General and Appropriation Accounts.
Vote 33 - Department of Health and Children.
Mr. M. Kelly (Secretary General, Department of Health and Children), Dr. J. Kiely (Chief Medical Officer), Mr. D. O'Shea (Chief Executive, Eastern Regional Health Authority), Mr. P. McLoughlin (Director of Planning Commissioning, Eastern Regional Health Authority), Mr. J. Thompson (Principal Officer, Department of Finance) called and examined.
Mr. Kelly
I made a point of bringing as many members of the management team as I could. On my right is Mr. Tom Mooney, Deputy Secretary; on my immediate left is Mr. Dermot Smith, Assistant Secretary on the finance side; Ms Helen Minogue, assistant principal in the finance unit; Mr. Paul Barron, Director, blood policy division, mental health services and services for the elderly; Dr. Jim Kiely, chief medical officer and Mr. Frank Ahern, director on the personnel side.
You are all very welcome. What was called the Eastern Health Board is now called the Eastern Regional Health Authority. I welcome the new chief executive, Mr. Donal O'Shea and Mr. Pat McLoughlin, the outgoing chief executive and accounting officer for the year in question. It is also Mr. O'Shea's first time to attend the Committee of Public Accounts.
It is my first time as chief executive of the new authority but I have attended here in my capacity as chief executive of the North Eastern Health Board.
Very good. So Mr. O'Shea will not be too intimidated.
I hope not.
Perhaps Mr. O'Shea will introduce his accompanying officials.
As the Chairman is aware, the transition took place last week so some new and some outgoing officials are in attendance. Mr. Pat McLoughlin was the chief executive of the Eastern Health Board up to last week and he is now the new director of planning commissioning in the new eastern authority. On his left is Mr. Martin Gallagher, finance officer for the Eastern Health Board and is now working with the new East Coast Area Board. Mr. Tom Larkin is the financial accountant of the Eastern Health Board and Mr. Liam Woods is the new director of finance for the Eastern Regional Health Authority.
You are all very welcome. Mr. John Thompson and Mr. Gerry Kenny from the Department of Finance are also in attendance.
Paragraph 1 of the Report of the Comptroller and Auditor General reads:
1.Outturn for the Year
The audited accounts are summarised on pages x and xi of Volume 2. The amount ot be surrendered as shown in the summary is £370.83m arrived at as follows:-
|
£’000 |
Estimated£’000 |
Realised£’000 |
|
|
Gross Expenditure |
|||
|
Original Estimates |
14,102,44 |
||
|
Supplementary Estimates |
0 |
14,497,698 |
14,130,439 |
|
395,258 |
|||
|
Deduct:- |
|||
|
Appropriations in AidSupplementary Estimates |
1,231,076 |
1,280,227 |
1,283,796 |
|
49,151 |
13,217,471 |
12,846,643 |
|
|
Amount to be Surrendered |
£370,828 (470,854) |
This represents 2.81% of the supply grant as compared with 2.43% in 1997.
Mr. Purcell
There is one paragraph on the Vote for 1998 which draws attention to an accumulating funding problem for the General Medical Services Payments Board which built up over the period 1996-9. The worsening shortfall first came to my attention during my audit of the 1997 accounts of the GMS. At that stage what was an immaterial shortfall of £2 million at the end of 1996 had grown to about £18 million at the end of 1997 and was already increasing at an alarming rate; projecting forward to the end of 1999 it was heading for £100 million. Following a review of the board's finances during 1999, the Department of Finance agreed to an additional allocation of £95.7 million. This was part of a Supplementary Estimate which was passed in December 1999. Some £55.7 million of the £95.7 million was provided as a once-off payment to eliminate the accumulated debt which had built up in the previous two to three years. The remaining £40 million was made available on an ongoing basis to avoid a recurrence of the problem. In the years prior to the elimination of the shortfall, the funding deficit was financed by bank overdraft which was an inappropriate and costly way of dealing with the problem. As the committee will see from the paragraph, the board incurred bank and interest charges of more than £500,000 in the 1996-8 period.
In the normal course the GMS would need an overdraft of anything up to £15 million from time to time to cater for timing differences which arise in payments and receipts. The funding shortfall was over and above this normal overdraft requirement. The Department has since implemented revised arrangements which will give it a better handle on variances in GMS expenditure profiles and it is also supplying additional information to the Department of Finance in this regard on an ongoing basis.
Before I allow the Secretary General an opportunity to make a few opening remarks, I should have drawn the attention of the witnesses to the provisions of section 10 of the Committees of the Houses of the Oireachtas Compellability, Privileges and Immunity of Witnesses) Act, 1997. Perhaps Mr. Kelly would like to make a brief opening statement.
Mr. Kelly
On the facts of this matter the account as given by the Comptroller and Auditor General is accurate. Within the GMS a situation had developed by the end of 1998 where an overdraft facility in the order of £54 million was required. It was becoming clear at that stage that the basis on which the costs in particular of drug spending in the GMS was, putting it mildly, not totally accurate. That position became clearer during 1999 and the overdraft position was worsening. We have looked at the reasons which relate mainly to the escalating cost of drugs within the GMS and not so much on the pay side which has to do with the fees paid to doctors. The main cost driver was in relation to drugs and medicine cost trends and, to a lesser extent, doctors fees. The arrangement agreed with the Department of Finance following a review of the funding arrangements was that there would be a once-off injection in the order of £50 million to handle the accumulated overdraft and that there would be an ongoing injection in the order of £40 million and a number of other corrective measures were also agreed as part of the package of measures to ensure this would not recur.
The first of those was that the GMS would be regarded as a demand led scheme in the same way as a number of other health schemes. That makes a significant difference because in the Supplementary Estimate it is possible, where there is a shortfall, to pick that up within a particular year and to avoid having a serious overdraft. The second area involves the way in which the costs are estimated in advance and whereas previously the trends over the previous three years were the basis on which the estimating was done, the new situation involves giving a lot more weight to the most recent cost data on the drugs side which leads to more accurate estimating.
In the current year, an additional £25 million, apart from picking up on the outstanding problem, has been included in the year 2000 provision to cover anticipated growth and the reporting arrangements between the GMS Board and the Departments of Health and Children and Finance allow us to monitor more closely what is going on. The latest financial data from the board, cumulative to February 2000, indicate that adequate provision has been made for the GMS in the year 2000.
I congratulate my old colleague Donal O'Shea. He has done an excellent job in the North Eastern Health Board and I know the Eastern Regional Health Authority is in very capable hands.
If Mr. Kelly was in private business, he would be in receivership, if not closed down. Is it because public funds are involved that the control of finance is allowed to run riot? The taxpayer is being asked to pay £500,000 in interest charges alone. Does Mr. Kelly agree that the drugs and medicine schemes are being abused, particularly with regard to medical card holders? Does he agree that the cost of drugs supplied by pharmaceutical companies needs to be examined? In purchasing drugs, is he confined to Irish sources or does he seek tenders from outside the country, in accordance with EU regulations?
Mr. Kelly
The Deputy's first question raises a serious concern. He suggests that we do not consider ourselves accountable for spending on interest charges simply because we are using public money. In the Department of Health and Children and in the general health system we take our accountability for public funds very seriously. The accountability framework, which has been significantly strengthened in the past number of years, is a reflection of that concern. The new framework also enables us more effectively to control public spending, the volume of which in the health system is enormous.
Our interest liability arose from the method of funding which obtained in the GMS for many years after the scheme was introduced. In a determined way, we have worked with the GMS Payments Board and the Department of Finance to bring about a set of arrangements for funding this service which will avoid a recurrence of the previous situation. We are making adequate provision for a particular year's spending. First, we have improved the methodology on which the estimate of future cost is based. Second, we are building in provision for growth in a particular year which, based on trends in recent years, is something for which we must provide. Third, the monitoring and reporting relationship between the board and the Departments of Health and Children and Finance provides for an ongoing read of what is happening. With these new arrangements I hope there will not be a recurrence of the previous situation.
Deputy Bell suggests widescale abuse of drugs within the GMS scheme. I am not clear if the abuse referred to is in prescribing by doctors or not.
I refer to over-prescribing.
What are the comparative consumption rates of medical card holders and others?
Mr. Kelly
Comparisons between the consumption of drugs in Ireland and the rest of Europe are available. Those data indicate that we have one of the lowest drugs consumption rates in the EU.
Do you have an answer to my question? Are comparative figures available for drug usage by medical card holders and others?
Mr. Kelly
I do not have those figures with me today.
Are those figures available?
Mr. Kelly
It is something we can examine.
This is the core of the point made by Deputy Bell. Is there excessive consumption of drugs by medical card holders because they do not pay for them? That is the question.
I recently visited a house where the woman of the house, a medical card holder, by accident opened a press to reveal several thousand pounds worth or drugs, unused.
Many houses have drawers full of expensive drugs.
Mr. Kelly
Unused drugs will be found in many homes, whether the families are in the GMS or not. I do not have the sort of comparative data you ask for, Deputy. I will examine this matter and see if such figures can be drawn up. Drugs are prescribed to GMS patients presumably on the basis of medical need. It is not possible for a patient to get drugs except on the prescription of a medical practitioner. Through the general practice development units and the various schemes operating within the GMS on drug budgeting and so on, mechanisms are in place to educate general practitioners and encourage them towards efficient drug prescribing.
Is the supply of drugs and medicines open to tender on an EU basis or is it done on a contract basis with pharmaceutical companies, who are part of the biggest profit making sector in the world?
Mr. Kelly
Drugs are supplied on the basis of an agreement with the industry. Within that agreement prices have been frozen for the past few years. New drugs prices are fixed by reference to a basket of prices which is UK related.
I am not clear on this question. Is the supply of drugs to the Eastern Regional Health Authority open to tender, nationally or internationally, or is it confined to a limited number of pharmaceutical companies?
Mr. Kelly
A number of issues are involved. For a number of years after a new proprietory drug is introduced and before it is sold generically, there cannot be a tendering process. There could be a tendering process for generic drugs.
Deputy Bell has asked very specific questions and let us go through them. In the tendering process is that confined to a small number of companies or is it open to any number?
That is the question I am asking.
Mr. Kelly
The Deputy asked if there is open tendering for all drugs supplied, the straight answer is no. Different regimes could apply to proprietary and to generic drugs.
Thanks a lot.
Mr. Kelly
The best I can do is to give the committee a note which sets out the position clearly.
I am suggesting that-
Just a second. We allow exceptions to accounting officers to resort to providing the committee with notes. This is your annual hearing to provide your responses to the committee. If you have not got the responses to some of these questions now, get them while the committee is still in session. I am sure you can do that. We need to know this. This is information which should be available to the committee today.
The Comptroller and Auditor General highlighted this in his report and it is highlighted in the accounts. I respectfully suggest to the Secretary General that if one wants to get 100,000 Aspros it should be on a tendering basis and not "hail fellow well met" with a small group of pharmaceutical companies. You can, as a cartel, fix the cost of drugs the same as in other sectors. It should be done on an open tendering basis and that information should be available to the public. It has been highlighted by the Comptroller and Auditor General that this is one of the biggest sources of a substantial overdraft which is costing the taxpayer £500,000 in interest charges alone. Surely the accounting officer can come back with a positive approach to that. These pharmaceutical companies should be told this is an open market and that the best bid gets the contract. Should that not be the same as in every other area of the public sector?
Mr. Kelly
Chairman, as you suggest I will come back to that during the session.
Deputy Howlin, when Minister, wiped out many of the overdrafts that existed effectively on a once off basis. An additional £4 million was given to the North Eastern Health Board - the board with which I am most familiar - on the basis that it would put its house in order and that it would not seek another £4 million next year or the year after. Can I assume that if the Minister has said he would give a once-off payment that would be conditional on your staying within budgetary terms?
Mr. Kelly
On the £100 million, the guarantees made at that time by the Minister in relation to health spending and the control of spending in health boards and in the larger voluntary agencies has in fact held. What we are talking about here is where the GMS Payments Board has been funded in a different way up to the present. Based on the changes made in putting the finances of the board on a correct footing, improvements in the estimating process and better management of costs, we would hope this would hold into the future. We certainly do not anticipate any disimprovement on the scale which has obtained in the past. It is a matter that will have to be taken up each year in the Estimates, that we anticipate the costs on the GMS and that those are provided for within the annual estimating process and to the extent that there is any shortfall that it is dealt with like any other demand led schemes in the Supplementary Estimate.
There are two other supplementary questions which Mr. Smith may be able to answer. What negotiations, if any, took place with the banking institutions to deal with interest of this magnitude? We read in the newspapers and hear in the Dáil and at this committee frequently of the shortage of staff, nursing staff, consultants, doctors and other staff in all the health board areas. I find it difficult to understand how there is budgetary over-run of this magnitude given the huge backlog and waiting lists for operations of every kind, particularly in the Eastern Health Board area. Can you indicate what that overdraft might be if the staffing was at the correct level? In other words, in budgetary terms I cannot understand how there could be such an overrun when everybody in the health service says there is a shortage of staff, which is the main element of financial use.
Mr. Kelly
There is a whole series of questions there.
That is why I was given the lead in today.
Mr. Kelly
The overall budgetary situation and where the GMS Payments Board fits into that is the first question. The GMS Payments Board has been funded in a particular way in relation to the GMS scheme up to the present, within a self-contained framework where, as a result, the overdraft was run up. That has now been corrected. In relation to the spending level right across the rest of the health system, during 1998 the shortages of staff, which were most acute at the end of 1999 and 2000, particularly in the Dublin area in relation to certain specialist skills, but that does not mean the hours are not being worked. By a combination of agency employment and overtime working the service has to go on. To provide for that, the hours have to be worked and cover has to be put in place. I can deal with that matter in more detail if the committee wishes. It does not automatically follow, just because there are shortages of particular skills, that the overall volume of employment which has to be paid for within the health system to provide a given level of service falls. There is not necessarily any relationship between the savings that might be made if we could not get people to work the service and the funding problem that emerged on the GMS Payments Board.
Perhaps I could ask Mr. O'Shea to give us today, or at some future date, an indication of what subsidy is paid to private beds used in public hospitals as against public beds. What is the difference between the State's contribution to a private bed as against a public bed?
I could not give that information off the top of my head but it would be available to the Department of Health and Children because a document was published recently on the question of private beds, within the context of the private-public mix and health insurance. That information may be readily available to the Department of Health and Children.
Would Mr. Kelly agree that it should not be necessary for the taxpayer to effectively part fund private beds for use by private patients?
That is a policy question. That is out of order. Can you answer the statistical question?
Mr. Kelly
In relation to the level of subsidy, as the Deputy termed it, we estimate that the charges in the larger teaching hospitals run to about 50% of the average cost. There is a policy——
Of the private beds?
Mr. Kelly
It is the cost of private beds in public hospitals. The charges for private beds in public hospitals represent about 50% of the average cost in public hospitals.
So it is costing the taxpayer 50% of the cost of a private bed in a public hospital?
Mr. Kelly
Yes. The rate charged to a private patient in a public hospital represents, in the teaching hospitals, about 50% of the average total cost. In the White Paper on private health insurance, in which this question was most recently discussed in a formal public policy document, the Government indicated that it would like to see that situation phased out over a period of years. The principle in relation to moving to full economic charging for private patients in public hospitals is set down by the Government in the White Paper on private health insurance. The argument is that if that were done overnight it would represent, in terms of the economics of voluntary health insurance, a sharp shock to the system. The culmination of that could be that many people, particularly high health risk groups like the elderly or people with a chronic health condition, might drop out of voluntary private insurance and fall back on the public system. There is a good public policy reason for not trying to administer the change in a sudden way, but the Government has said that it is something that is intended. As the charges are increased year on year, it is something we would intend to move towards over a period of years.
On that question, how does the cost of 50% of the private bed compare to the full cost of the public bed?
Mr. Kelly
The charge represents 50% of the full cost of a public bed. In other words, if one calculates the cost of running a hospital and the number of beds, the charge per night that is currently levied reflects about 50% of that.
Of the public bed?
Mr. Kelly
Yes.
Effectively that means that the taxpayer is subsidising the VHI and other insurers. Is that not so?
Mr. Kelly
That is one way of describing it.
It is a mathematical fact, is it not? The ordinary Joe Soap working in a factory who is not a member of the VHI or the other insurer is effectively subsidising the private patient.
Mr. Kelly
Again, a lot of issues run through the point the Deputy makes. In the debate about voluntary private health insurance, which has been a feature of the health system for 40 years, we tend to discount the fact that the people who subscribe to voluntary health insurance also pay tax. If they voluntarily opt to enter the health system as private patients, they drop their entitlements to public services at that stage. The point the Deputy makes about the charge made on them in public hospitals not representing the full cost and that it has to be picked up by the taxpayer is true but it is not just picked up by the taxpayers who are outside of private health insurance - and over 43% of the population are now covered by private insurance - but by the generality of taxpayers. That is a point running through that argument which we ought to bear in mind. The key aspect in terms of principle and policy is that the Government has set down a position on this question in relation to bringing up to full economic cost the charges that are levied on private patients and moving towards that over a period of years.
I wish Mr. Kelly well in his new appointment.
Deputy Lenihan, we are on the GMS paragraph so perhaps we will deal with that first and then have a general questioning on the health services and issues arising out of that.
I have no particular question on the GMS but I was hoping to broaden out the questioning on the interesting report on the accident and emergency services.
On the GMS, we did ask for questions about competitive tendering. Is Mr. Kelly in a position to talk to us about that now?
Mr. Kelly
Not just yet, Chairman. I am waiting for someone to come back to me.
Okay, we will leave the GMS for a moment. Sorry, Deputy Cooper-Flynn, did you want to ask questions?
I want to ask one question about to the bank charges. What banking system does the board use each year and is it examined on a yearly basis to try to get a more competitive overdraft facility?
Mr. Kelly
To the best of my knowledge, and I will confirm this during the hearing this morning, the board does tender for its banking services.
On a yearly basis?
Mr. Kelly
I am not sure about the frequency but it does tender.
Who is currently doing the banking for the board?
Mr. Kelly
We understand it is Bank of Ireland.
On the information systems, is the Department of Finance satisfied that there are adequate information systems and controls in the GMS?
Mr. Thompson
We are happy with the changes that have been made. The GMS system, as members know, is an open-ended one in that medical card holders are entitled to whatever services they need from their GPs and whatever prescriptions are written for them so it is impossible to predict or control that in quite the same way as other expenditure. In that context, the reporting of the outcome is vital and we are now seeing prompt monthly reporting from the GMS which was not the case previously. We are much happier with the system as it currently operates.
What steps have you taken to ensure that we do not fall into the same problems again?
Mr. Thompson
As I said, because this is an open-ended entitlement scheme, the key to it is reporting to see the way the money is being spent. We now have that. We have also accepted in principle, as the Secretary General referred to, that this is an open-ended scheme and one which can be brought into a Supplementary Estimate if required towards the end of the year. We are in a much better position than we were previously to see how the system is evolving and we are also open to the idea that, if necessary, we will run with a Supplementary Estimate in the autumn to keep the board from an overdraft, as we did last year.
So you get a four weekly report. How many weeks in arrear?
Mr. Thompson
I received the February one this morning——
That is very good.
Mr. Thompson
——which I must say is very prompt.
And that is against a certain profile that you have already developed as part of the budget?
Mr. Thompson
That would be the way, yes.
The figures for accident and emergency attendances are for December in Tallaght hospital in my constituency and show that 80% of people who attended are self-referrals and only 10% were referred by GPs. A New Zealand survey indicated that one of the most common reasons for inappropriate attendance at accident and emergency departments is ignorance of GP services or the inconvenience associated with the out-of-hours service supplied by GPs. What is the Department going to do as it is clear that GPs are not able to market themselves?
Figures indicate that 80% of attendances are self-referrals and a large percentage of these must be inappropriate. This is a sample from one busy hospital and I am interested in the Department's view on tackling the obvious ignorance about the service provided by GPs and the fact that the out-of-hours service is so poor in urban areas that it is easier for someone to go to a hospital because there is a 24-hour service. What are we going to do to cut down on these unnecessary attendances at accident and emergency departments and the unnecessary delays being experienced?
The figures show that 35% of those attending Tallaght were waiting for four to eight hours. That is a large percentage of people waiting long hours for something that does not happen. I am interested in the views of the health board and the Department on dealing with this situation where people are left waiting and do not receive clear information from the health providers as to their condition or how long they can expect to wait. I have come across innumerable cases in which people are not told basic information about how long they are likely to be waiting. In some cases their names are not even recorded so they wander in and out of the hospital and do not appear on the out-patients register.
Mr. Kelly
The Deputy referred to material received by the committee and I apologise that this information was received only yesterday. We spent some time assembling it and there has not been much time for the committee to absorb it, so I will make some general points.
How we manage the emergency load on the hospital system has a huge influence on how we manage the total service. To the extent that we do not manage it well our capacity to deliver on elective work is undermined. Issues such as waiting lists are influenced to a large extent by what we do here.
The relationship between the accident and emergency department and the GP, what happens to a patient while in hospital, what happens when a patient is due to be discharged from hospital to step-down or long-term care, the high proportion of elderly people in medical admissions, particularly at this time of year, are all part of the general jigsaw. Deputy Lenihan raised the issue of GP services. It is striking that the number of self-referrals is so large.
The data from Tallaght is analysed by category of urgency and it is striking that people with non-urgent problems, which probably could be dealt with by a GP, are prepared to wait in the department for up to eight hours. This tells us a number of things. First, a characteristic of behaviour in Dublin towards accident and emergency cases is that people prefer to go to an accident and emergency department. This is not a new phenomenon. If GPs can deal with a lot of these problems then why are people not going to them, and is there a problem with supply, particularly out-of-hours cover? A number of things are happening to address both these issues. There has been a fairly prominent media campaign run by health boards this winter to educate people about the purpose of accident and emergency departments. The campaign makes the point that these departments are for serious medical emergencies and there are other ways of dealing with minor health problems.
As regards GPs, a number of initiatives are under way linked to particular health boards. Such initiatives are under way in the South Eastern Health Board and the North Eastern Health Board.
There is one in Carlow. What is happening there?
Mr. Kelly
I will deal with the one in Dublin first which gets at the immediate relationship between GPs and accident and emergency departments. There is a scheme called Dubdoc in St. James's Hospital whereby GPs are provided with facilities on the hospital campus. They attend on a rota basis and see patients. When a patient is triaged this gives the option to stream people into the GP service as an alternative to going in to the formal accident and emergency service. This scheme is working quite successfully and there is a question as to what extent it might work in other situations, perhaps linked to other large hospitals in Dublin.
From talking to the regional chief executive and being present at the launch of the Eastern Regional Health Authority, I know that the issue of accident and emergency services is a high priority for the authority because, for the first time, under one roof we will have all the main players in managing this problem in Dublin - the Dublin voluntary hospitals, the three area health boards and the relationship with GPs through the health boards. The ERHA has a greater opportunity and capacity to get at this problem then we have had before.
As regards Dubdoc, what sort of delays are there in seeing a GP in St. James's? How are the delays cut or how do you categorise it as a success?
Mr. Kelly
I categorise it as a success in that we would argue, and the hospitals would agree, that where people arrive at the accident and emergency department because of the absence of an out-of-hours GP service or for whatever reason, if there is no segregation a crowd develops in the department and everyone has to be seen. One cannot take any chances. People are streamed out of this at triage stage and streamed in to the GP service which is competent to deal with their problem. It means the opportunity for people who genuinely need the services of the accident and emergency department is that much greater. I do not have the statistics with me on the people attending the general practitioner service in Dubdoc, but the number is not huge. A deluge of people are not arriving to see the general practitioner. This is a pilot scheme. Based on the evaluation to date, there is no reason to believe that it could not operate in the larger Dublin hospitals in particular.
How do you categorise that as being successful? What are the measures of success?
Mr. Kelly
The evaluation of it is ongoing. It is not the Department which is conducting that but St. James's Hospital. The Irish College of General Practitioners is also involved. One way to judge it would be to look at the length of time it takes for people to get a service from the general practitioner. One could also look at returning attendances to see if some people are returning to the accident and emergency department or to the hospital in another guise. I do not have the full evaluation with me today. The pilot scheme is under way and it is being evaluated. All the verbal accounts I have to date lead me to believe it is a successful model.
People in Dublin can use cars and public transport to access accident and emergency departments if there is no general practitioner service. However, because distances across country can be greater outside Dublin, there is a higher reliance on general practitioners. The model set out some years ago to develop general practice would have seen it develop as a strong hub of a primary health care system where many of the basic medical services were available at community level and only patients who genuinely needed the services of the hospital would be streamed by a general practitioner into the hospital. That model depended on group practice at general practitioner level taking off. The evidence to date is that it has been less than a full success. It has taken off well in some cases but not in others. The general practitioner working on his own is still a feature of GP care.
My understanding is that the scheme in Carlow - I do not have details with me and I am working from memory - involves a number of GPs agreeing within a rota system to provide cover for each other. That means they have a virtual group practice without being in one setting. My understanding from the chief executive officer of the South Eastern Health Board is that it is working well but it is at an early stage. I do not have a formal evaluation of it.
The key point is that there is some scope for reducing demand on accident and emergency services by developing a GP service on the campus.
Mr. Kelly
Yes.
We would like to hear about any progress in a few months time.
An Eastern Health Board accident and emergency steering group was set up because of the 1998-99 winter trolley crisis in accident and emergency departments. This set a target to eliminate the trolley crisis in the winter months of 1999 and 2000. I know this is related to the need for more step-down beds. Perhaps Mr. Kelly could update us on the position.
This leads us to the general question of staff shortages in the health service, particularly nursing shortages. Perhaps Mr. Kelly could tell us where the shortages are, their scale and what we are doing to fill them.
Mr. Kelly
There are two questions relating to step-down beds and staff shortages.
The steering group set itself an objective to eliminate the trolley crisis. Perhaps Mr. Kelly could tell us if we have eliminated that or are on our way to doing so.
Mr. Kelly
It would be a brave Accounting Officer to claim we had eliminated the trolley crisis because that is not the case. I acknowledge the progress made by the Eastern Health Board and the Dublin hospitals during 1999, which worked with the relevant people in the Department, in analysing the issues to get the acute hospital system to work more efficiently. By that I mean that a pathway was laid out for people who were ready for discharge, having been treated for the acute phase of their illness, but who were not ready to return to their homes.
The demand for that grows accordingly during the winter months when there is a high proportion of medical attendances and among elderly people. The group which examined this calculated that off peak there were approximately 200 such patients in the acute hospital system at any one time and that at peak times, during the winter period, the figure rose to approximately 300. It made arrangements to gain access to up to 300 beds to deal with this.
Were these people on trolleys at any one time?
Mr. Kelly
No. This means that a young chronic sick patient or an elderly patient occupying a bed in a hospital, who has been through the acute phase of their illness but who cannot be discharged because there is nowhere for them to go, needs a step-down bed. Otherwise, the impact in the accident and emergency department means a trolley. We cannot deal with the trolleys by sending those people out so we must try to clear beds in the acute system. Some progress has been made in terms of getting these step-down beds in place. Approximately 200 were in place by the end of 1999. We had a bigger problem than normal this year.
With influenza.
Mr. Kelly
There is still a debate on the extent to which it was influenza. It was influenza and a variety of other viral and bacterial chest conditions. That represented a particular peak on the graph this winter. We were better equipped to deal with that than we would have been if the additional step down beds had not been in place. The job is not done yet. Approximately 30 step down beds have yet to be put in place but we are working on that.
This is one of the key issues in Dublin which the new Eastern Regional Health Authority is addressing. Where hospitals, such as the Mater Hospital and St. James's Hospital, felt they were not supported to the extent they could have been up to now because they were operating and providing a service in an autonomous fashion, they will now be linked in more formally to the ERHA. They will know what services they are expected to provide and what services the ERHA is commissioning in terms of step-down beds, long stay care, and so on. Does that deal adequately with the question on step down beds?
Are we getting close to the target? A specific target was set by this group to effectively - that was its word, not mine - eliminate the trolley crisis. Are we getting there or not? I know it is a blunt question. Are we 70% there? Perhaps the health board has an answer. Are we 70% or 80% there in the eastern area? This is one of the items, along with the A&E delays, which really annoy the public in regard to patient care in hospitals. The issues are the waiting lists, long delays in A&E or a relation having to lie on a trolley in a corridor rather than in a ward.
Mr. Kelly
I cannot put a firm estimate on whether it is 70% or 80%. We are pretty much there in terms of the problem as it is analysed by this group, in other words, that we need to get 300 additional step down beds contracted.
You have got the beds.
Mr. Kelly
The beds are there. That system relies on people moving through those beds. They are not long stay beds but are transitional. For example, if elderly people are occupying those beds and there is nowhere for them to go afterwards——
In terms of nursing home care.
Mr. Kelly
Yes, that is a further dimension. That is being looked at at the moment by the Department and the ERHA.
However, the target was not set by me or this committee. The group set itself the objective to effectively eliminate it this winter. Are we near to accomplishing that?
Mr. Kelly
We are certainly much better equipped than we were this time last year. It remains to be seen. There are ongoing pressures. I do not know whether the regional chief executive wants to comment further on that.
The steering group was the Eastern Health Board. Perhaps it will have a more confident statement in relation to this. The steering group said it effectively wanted to eliminate the trolley crisis. Are we eliminating it?
As you know, the regional health authority was only set up last week. It was made very clear by the Minister is his opening address to us last Wednesday that he expects action from the Eastern Regional Health Authority to eliminate or deal with a number of major issues which are currently of specific concern in the Dublin and eastern region; these are waiting lists, accident and emergency, outpatients, elderly and step down, all of which are interlinked.
For the first time, as was said by the Secretary General, there is a body, the Eastern Regional Health Authority, which creates the statutory framework in which these issues can be tackled on a holistic or integrated basis. Up to last Wednesday, the Eastern Health Board was responsible for delivery of approximately half the services in the eastern region but the other half of the services were delivered by 38 independent hospitals and agencies, all of which operated independent of each other and outside the eastern region. The new authority is responsible for funding all these bodies. In other words, the £750 million spent by the Eastern Health Board has been added to by the other £750 million spent by the other authorities. The Eastern Regional Health Authority has a total budget of £1.5 billion. We are responsible for ensuring there is a planning process to ensure the money is spent on the issues that relate to actual need. We also have in place a monitoring arrangement to ensure the objectives of the authority are being met. Within that context, we have a new arrangement which will facilitate integration between the various agencies and, hopefully, better integration of the services around the patient. Even in the last few days, we have already begun work on dealing with A&E, waiting lists and a number of the other issues which have been clearly put on our agenda by the Minister.
In regard to A&E, the difficulty is that approximately 80% of the patients who come into our major A&E departments are not trauma cases which require major surgery or consultant response. While they require a medical or nursing service, it is not at the level of a major trauma service. We must work with the hospitals to ensure there is an appropriate response to the actual need of the patient. Those who require a major trauma response must get it quickly, but those who require another form of service should get it there and then. There is a very strong culture in Dublin of people with health problems going to their local hospital. I do not think that culture will be changed overnight or even over a period of time.
What is a major trauma? Is a broken leg a major trauma?
Somebody with a broken leg requires an orthopaedic response. However, somebody with a cut finger or a bruised head usually does not require a major response from a consultant. We are talking about somebody who requires the quick involvement of a consultant. The A&E departments in the major acute hospitals are geared up for major trauma but many other cases also turn up. As has been said, some of these could be dealt with by a general practitioner or a nurse practitioner. We must ensure we get the appropriate response for the various kinds of patients that turn up in our A&E and that the time of people dealing with major trauma is not taken up by minor work. We must try to provide an alternative service, even within the hospital, for such cases.
Are we getting there? The group chaired by the health board set a very specific target last year. It said it would happen over the winter months of 1999 and 2000. Are we getting there? I know all about the new structures.
The Eastern Health Board had been chairing it but it had no real authority to implement it.
So it is not happening - the trolley crisis is not solved.
There is some indication that the demand for A&E services is falling at last.
There is a reduction in that particular hospital.
I think it is falling in general. Is that right, Secretary General?
We would like to get some evaluation of this because it was set down as a specific objective last year to do it this winter. I am just trying to get some answers on whether we are getting there.
It is interesting that the population probably increased by 100,000 between 1998 and 1999, yet the demand for accident and emergency services has decreased by a few percentage points. Would anyone like to comment on that? I know the nurses' strike may have affected that.
How would that compare to other regions and the overall national figure?
Mr. Kelly
The attendances have gone down by a small factor of 2% or 3%. There was a small reduction in the period, even apart from the nurses' strike. That is in terms of the nationaldata and is not just a Dublin phenomenon. However, the proportion of attendances leading to admission is going up. What is happening is that the medical acuity of attendances, in other words, the need for a serious service, is, while still a small proportion, going up.
Is that going up as a percentage or in real terms?
Mr. Kelly
The data we have show that 60% of admissions in 1998-9 and 65% in 1999-2000 were A&E admissions. While the overall number of attendances is dropping, those admissions have an impact on the emergency load of the hospital system. The admissions require a much more intensive use of facilities than the "walking wounded" who come in, get a service and leave. That will be an increasing trend over time, as the population ages. The number of serious medical admissions during the winter period can be expected to increase. They will require an acute hospital service and a follow-on service, in terms of step down and so on.
At least there are indications of a drop in non-acute cases.
Mr. Kelly
Yes.
We hear of operating theatres and wards being closed and lengthening queues as a result of staff shortages. Will you give the committee a run down on the matter, Mr. Kelly?
Mr. Kelly
When one looks at the overall distribution of skills in the health service and picks out a number of these where there are particular problems, while nursing is the one about which we tend to hear a lot, in fact the phenomenon goes a bit wider than that. There are issues to be addressed on the medical side, on the nursing side and in the paramedical areas.
On the medical side, the Department is trying to address a whole series of things which come together relating to the working conditions of non-consultant hospital doctors. There are a whole series of things about the training regime, the hours they work, etc., which does not make the Irish health system very attractive to Irish graduates as a training ground. The result is that we have been very heavily dependent on non-EU NCHDs to provide much of the services in hospitals. That was particularly the case in the bigger teaching centres. The Department is trying to redress an imbalance which is in the system anyway as between the number of fully trained doctors of consultant level and non-consultant doctors and, in doing so, improve the quality of the service to the public patient and develop a quality training and teaching environment for junior doctors. The whole debate and discussion about that is taking place within the Medical Manpower Forum, which is expected to reach a conclusion very shortly - next month, we would hope. There would be a series of steps which would follow on from that which would require the making of a number of policy decisions, into which I will not go now.
On the nursing side, we have gone through a number of different periods in relation to nursing. Going back six or seven years, we decided, following consultation and a lot of pressure from the nursing profession, to change the system of training in nursing from an apprenticeship system to a more formal educational system, which involves both registration with An Bord Altranais and the award of a diploma at the end of a three-year practical and university based education. The result of that was that we took about 3,000 students, who were providing a service contribution, out of the system and while we have replaced those pro rata - they have not been fully replaced but they have been replaced in terms of the contribution they made by a mixture of nurses and non-nursing staff - that meant that a large part of the pool of surplus nurses in the system was absorbed. In addition, over the past number of years as the services have developed, particularly in the development of self-sufficiency in various specialties in the regions, again that has absorbed nurses who would otherwise have been in a surplus pool. There was a situation ten years ago when there were actually a lot of unemployed nurses in the Irish system. That has now turned around completely.
Is it not true that there are hospitals telephoning nurses who have not worked for 15 years to take a job for a few hours a day? Let us get to the core of the problem.
Mr. Kelly
There is a whole series of initiatives under way at the moment to improve the supply, starting with the number of people coming into training where the number of places has increased over the past year by 25%. At present there is a whole series of initiatives at hospital, health board and central levels to provide incentives to recruit nurses and, where they are recruited, to retain them in the system. One element of that would involve making contact with the nurses who have been out of the system for a number of years and asking them are they prepared to work again. There are a whole series of things, which I am prepared to go into, if you wish, Chairman.
What about the recruitment of foreign nurses? In particular, is it not true that a number of hospitals are seeking approval for the recruitment of Filipino nurses?
Mr. Kelly
Yes. There is one agency working with one particular hospital, where they are attempting to bring in around 50 or 60 nurses from the Philippines and that is actively under way. I should say that Mr. Frank Ahern, who works on the personnel side, has been very proactive on this in trying to shift the normal barriers which might get in the way, in terms of work visas, experience and getting documentation cleared, etc. There are quite a few hurdles to be cleared in facilitating these people coming into the health system.
Do you mean the recognition of standards, etc.?
Mr. Kelly
Yes, that is the key hurdle. From a public policy point of view, we must be absolutely clear on this. One of the roles of An Bord Altranais is to satisfy itself as to the adequacy of the training of people who are coming in here. That is a job which the board must do in the interests of patient safety. In fact, the number of nurses seeking registration in Ireland, in other words, the number of nurses coming back into the country over the past year, has exceeded by a margin of some hundreds the number of nurses going out. There is a well worn pathway here and quite obviously there is no issue about Ireland as a centre for recruiting nurses and a place where nurses are quite happy to come.
In relation to the Filipinos particularly, the only difficulty which has arisen there is that the equivalent registration body to An Bord Altranais in the Philippines has been slow about sending back the documentation which is required to certify the competence of these nurses in terms of their training, etc. There is a ready welcome for them in the Irish system. The various Departments involved with work permits, etc., have met at the instigation of my Department and we are working closely with An Bord Altranais to make sure that there are no——
Hold on a second. Let me tell you my experience as a Deputy. For the past two years I have been in contact with the Department because nursing homes in my constituency are constantly on the brink of closure because they cannot hold the minimum number of registered nurses required by the nursing homes legislation. These nursing homes have been pleading with An Bord Altranais and, indeed, the Department to be able to recruit from abroad. They say that these same nurses are being recruited into the United Kingdom and America without difficulty. Will you clarify that that is the case, that there is already a mutual recognition of standards between the United States and the Philippines and the United Kingdom registration authorities have got over the problem, and that there is a great deal of bureaucracy in Ireland which is delaying recruitment and thereby keeping wards and theatres closed?
Mr. Kelly
The account of it which I have would be somewhat different, that is, that at present An Bord Altranais has some 25 applications for registration on hand from Filipino nurses. The board has been unable to process many of these applications due to the extremely slow response of the professional registration council in the Philippines to its requests for verification of the applicants' education and training. The board stated that decisions in relation to the requirements which must be fulfilled for registration have now been made on all the applications for which it has received the necessary documentation. Officials of the Department of Health and Children have met with representatives of the Departments of Enterprise, Trade and Employment, Foreign Affairs, and Justice, Equality and Law Reform along with An Bord Altranais to try to sort out the issues. The only issue that has arisen in that regard is the delay on the part of the Filipino authorities in returning the documentation to An Bord Altranais. A similar system operates in relation to non-EU nationals.
What action are the UK authorities taking to overcome the problem?
Mr. Kelly
I do not know, I have not been briefed on that matter.
The debate on this subject has been ongoing for some time. Is it not correct that young girls are no longer prepared to endure the type of bureaucracy practised by the board? When these girls leave school or college, they can take up alternative employment almost immediately whereas if they are entering the nursing profession they must wait for many months without knowing whether they will be called for interview or whether they will be successful.
My daughter left college on a Friday and rang an employer the same day. She was interviewed on the Saturday and started work on the Monday. She had made an application for a position in the public service and, four months later, she had not received a reply or been called for an interview. The same situation obtains in respect of nursing. From dealing with young girls who want to enter the nursing profession, I am aware that they are not prepared to wait for three to four months while the bureaucratic interview and selection process takes its course. That is the major problem which has led to our attempting to attract nurses from places like the Philippines.
Is it possible to quantify the shortfall in the number of nurses? What are the consequences of that shortfall? How many wards, beds and operating theatres have been closed as a result of the shortfall?
Mr. Kelly
I do not have specific answers to all those questions and I am not sure that we will be able to obtain the requisite information during today's session. In relation to the number of vacant posts, the last comprehensive report that was produced on this - I can verify this before the session ends but I am currently working from memory - indicated that there were 1,100 vacancies at the end of September last. However, I want to confirm that information.
That report was carried out on the basis of a technical definition of vacancy. The health service has vacancies every day because we work in a system where mobility is a feature; people change jobs all the time. Normally where a vacancy exists, it is filled on a temporary basis. The alternative to that - this is what the hospitals are resorting to now - is that an agency nurse is put in place. The other way they compensate in terms of hours worked, not just in nursing but more generally, is by working overtime. In other words, other people work additional hours to compensate.
Working from recollection, the actual net number of vacancies was 400 when we discounted the jobs that have been filled in one way or another. We recognise that there are huge pressures on nursing. We are not blind to that and we are working hard in terms of the number of people who are being brought into the training system. The Commission on Nursing has developed an agenda in terms of professional development for nursing. We are working on that and there are new grades of nursing which will involve pushing out the boundaries in terms of nurses' competence and their operation in the health system, giving them additional status. That is all part of the strategy.
How many wards and operating theatres have been closed in the Mater, Tallaght, Beaumont and St. Vincents?
Mr. Kelly
As I said I may have some figures on that in relation to the bed days lost in 1999. However, I cannot provide an overall picture. The total number of bed days lost in 1999 was 112,400 but, within that——
Due to nursing shortages?
Mr. Kelly
No. Within the ERHA region, problems recruiting staff resulted in the following: 22,941 bed days can be specifically counted as having been lost due to problems recruiting staff. As a proportion, that is 1.3% of bed days available. That is some estimate of its impact.
How many wards have been closed?
Mr. Kelly
I do not have that information in my possession. If the Chairman wishes we can obtain a picture from the hospitals - this will be a snapshot picture relating to a specific point in time - in the very near future and forward it to the committee as soon as it become available.
I would like information to be provided, within four weeks, regarding the number of wards and operating theatres closed on a region by region basis as a result of staff shortages. I would also like each figure as a percentage of the total. Will Mr. Kelly indicate the contribution these closures make to waiting lists for medical services. If there are such shortages, why are they not reflected in reduced expenditure? If we are not providing the services, why is the expenditure not being reduced? What steps are being taken to re-open these wards and operating theatres? Does Mr. Kelly have any information in his possession in respect of the competitive tendering?
Mr. Kelly
Yes. First, in relation to the points made about the use of drugs in the GMS scheme, GPs - general practitioners - have the right and duty to prescribe what patients need. The indicative drug target scheme provides incentives for GPs to prescribe rationally. Most of the representations and parliamentary questions that the Department receives in relation to drug prescribing in the GMS actually criticised the scheme as encouraging doctors to under-prescribe rather than over-prescribe. In fact, we are one of the lowest prescribers of medicines in the EU.
Comparisons between GMS and the private population are difficult because the GMS covers a high risk population which includes the elderly and disadvantaged groups in society who, research has shown, have higher levels of morbidity. We can attempt to obtain a more formal comparison of private and public consumption.
With regard to the pricing and tendering question, the agreement that is in place is between the Department and the Irish Pharmaceutical Healthcare Association. That agreement provides for the ex-factory price of new medicines being based on a basket of EU currencies or the UK price, whichever is lower. As medicines are distributed to GMS patients through community pharmacies, of which there are 1,200, each pharmacy orders its own supplies through wholesalers as required. There is no tendering procedure in place for the supply of medicines. Hospitals can negotiate more favourable terms for bulk purchases. The price agreement has provided that prices are frozen for the past eight years.
The pharmaco-economic unit was established in 1996 to analyse the costs of medicines and provide pharmaco-economic data on medicines. This will undertake an analysis of private and public prescribing and costs of same. It is also monitoring the costs of drugs internationally.
Deputy Bell raised the question of competitive tendering.
Obviously this is a closed shop arrangement. There must have been quite some profits eight years ago given that prices have been frozen for eight years and profits are still being made. Open tendering for the supply of drugs should be examined. I would like to come back to that question at a future date.
That is a very good point. Perhaps the Secretary General would write to us within a month and elaborate on the question of tendering generally in relation of the provision of drugs to the health services. We should be given more information about how tendering is organised and why it should not be completely open.
I would like the Secretary General or one of the officials to give us an indication of the length of time it takes from when one makes an application to go into the nursing service and when one is appointed. Every Department of the public service with which we have dealt over the last six months mentioned staff shortages. I keep repeating that the process of making an application, being interviewed and appointed takes far too long in the public service. Young people will not wait around for appointment. There was a time when people thought the best way to get to heaven was to become a nurse. That has changed because people can now earn more money elsewhere for fewer hours work and so on. I would like this to be examined because the lack of qualified nurses is a very serious problem.
Mr. Kelly
In the current employment market in nursing, hospitals are contacting nurses to ask them to work. Nurses are also applying for jobs which are available on demand to trained nurses. I think what the Deputy described related to someone who wished to enter nurse training. There is a cycle in which entry to nurse training works. This is similar to the cycle that operates in relation to all post leaving certificate and further education possibilities, that is, at a point in the year the whole applications process goes into gear. The only explanation I have for a delay of four months is that this person may have written for an application form well in advance of that cycle taking place. I cannot comment on the particular case referred to by the Deputy. However, there is a lot of publicity and work taking place with careers guidance teachers in terms of explaining the regime for getting into nursing. Under the old regime, one applied to a particular school which then dealt with the application. Under the new regime, a central applications system is in place which is similar to the CAO. The plan is that the nursing applications process will be absorbed into the central applications system for university places generally in the next year or so.
I would like the situation to be examined because people come to my clinic on a regular basis to complain about the length of time it takes to get into the public service in general. Mothers complain that their daughters who have been waiting for an interview for three or four months have taken jobs elsewhere. This is indicative of the whole public service, not just the nursing sector.
This is a policy issue, but there is a danger that the purely academic requirements to enter nursing will exclude many good nurses. What is needed in nursing is tender loving care. I do not know how this can be evaluated on a points system. There is a danger that the health service will suffer as a result of this. The exclusively academic requirement to enter nursing or medicine could leave us with many good academics but people who would not make the grade as good doctors or nurses.
Does Mr. Kelly think that the aptitude test is a fair or suitable mechanism for entry into the nursing profession?
Mr. Kelly
I do not know that it would be reasonable of me to make a public comment on the adequacy or otherwise of the entrance procedures. Whether in relation to medicine or nursing, the Department does not specifically set down the criteria. I was involved in the change in the nursing education system a number of years ago and one of the issues of which we were conscious was the point made by the Chairman. We were under a lot of pressure from within the profession itself to get on with a university focused training programme. I understand why there was this pressure for career progression and professional reasons. We successfully agreed at the time with the profession that it was reasonable to strike a balance between academic achievement and aptitude in terms of the qualities required to perform nursing type tasks. I am not close enough to this in terms of what the aptitude test currently involves to be able to comment more intelligently on it. However, that was the rationale for setting down the procedures.
The reason I ask is that a number of unions and others involved in dealing with the recruitment of nurses and so on who came before the Oireachtas Committee on Health and Children did not think the aptitude test was suitable in this area.
There are two sides to the coin. Many people who for generations gained the Irish nursing profession the high reputation it deservedly has will now be excluded because perhaps they are not academically qualified or they have missed out by a few points. On the other side are the people who have the points but who may not have the touch. One could have academic nurses who cannot take blood samples, for example. They might have it in theory but not in practice. This will be a looming problem because enough notice has not been taken of the human factor in nursing.
Mr. Kelly
It would be a concern if nursing moved towards a highly technical, academic discipline, but with the regime in place at the moment I do not think that is what is intended by the profession, which would be as concerned about this as those on the managerial or policy side. The key is that the content of the university modules is well balanced by the amount of practical training - students working alongside trained nurses under supervision. There is an element of apprenticeship still in the training system in addition to the higher academic content that now exists. I hope that balance carries through.
We are moving away from the practical side and making this more an academic, university type course. Are we going in the right direction? I understand the nurses valuing themselves as professionals, but the old traditional nurse, if I can put it that way, seemed to be trained with more hands on experience and would have been better equipped to do their job once qualified than a person doing three or four years of a degree course that is mostly focused on the academic side with a small amount of practical work.
I welcome the new Secretary General and wish him well. I am interested in the funding of various health boards and the procedures that the Department goes through with individual health boards. What are the criteria for determining the funding each health board gets per annum? In relation to the waiting list initiatives - which we discussed earlier in relation to staff shortages - consultants have great power in deciding the clinical priorities in hospitals. What can the Department or individual health boards do in denting the waiting lists? Does the Secretary General have a breakdown of public and private procedures carried out in various health board regions and what guidelines are given by the Department to the health boards on the public-private mix?
Mr. Kelly
In relation to the funding process, the first stage is the annual estimate cycle. I can give a broad brush description of it. When we make our case to the Department of Finance and the Government on the needs of the health system, looking a year ahead - possibly three years ahead in future - within that case we try to ensure that the present volume of service around the country can be maintained in terms of an overall aggregate. We also try to account for normally inflating items such as pay increases, non-pay inflation and so on. We would also have a list of what we regard as worthwhile service developments. Out of the dialogue with the Department of Finance and the Government we get an allocation which is reflected in the Estimates volume. The distribution of that becomes the business of the Department. In working through that distribution we would take the same approach as is taken by the Estimate overall - from our contact with each health board in the previous year we would have good knowledge of their overall funding situation and their priorities in service development. From that we would derive the allocation to each agency.
That process is not a stop-go operation; we keep in touch with each agency over the year and the cycle goes on. One gets a gradual buildup in the allocations and that has been the experience with each agency. This takes account of the ongoing funding requirement and addresses, as best we can, their priorities in terms of service development and for the health system overall. Obviously certain priorities inform that process. For example, in recent years we identify, when making a case to Government, the areas of particular development we see and normally that would be a shared view with the health boards. For example, in the current year services for intellectual disability have got a particular boost. The cardiovascular strategy also got particular funding while the waiting list initiative gets additional development funding on a regular basis. That is the process in broad strokes.
Going through the individual criteria mentioned, maintaining the current volume is fair enough, but I am concerned with, for example, the case of a health board that has been significantly underfunded for a number of years. I know departmental officials keep in contact with health boards and are aware of their priorities, but if two of the three criteria provide for an inflation increase on what they got the year before to maintain the current level of service, what can be done by the Department to address serious underfunding of a health board region for many years? Mr. Kelly is new to the job, but are there significant increases from year to year in health board allocations? Are we talking about increases of 2 to 3 %?
Mr. Kelly
When we talk about underfunding here, and we discussed an example of that earlier in relation to the GMS payments, that type of situation does not now apply to the health boards as the accountability framework provides that expenditure and borrowings are controlled. Underfunding in relation to a volume of service does not really happen. I would have thought that because of the system I have described, in which there is ongoing dialogue between the people in the various policy divisions of the Department and the Department's finance unit, there is a good understanding between each board and the Department in relation to its needs. Whether it is in relation to a major capital development, such as in Galway, or ongoing service development in an area like intellectual disability, we would attempt to meet the case as best we can, year on year. I am not aware of a board currently that I would regard as underfunded.
Maybe "underfunding" was the wrong word; maybe it is no funding. I am talking about services that should be provided in certain areas but that are not being provided at all. That has happened year on year. I am acting here as Devil's advocate. When the Department assesses a health board for funding, how is the non-provision of services addressed? Mr. Kelly says the Department has contact through its officials so it knows what a health board's priorities are, but how is a significant shortfall in services for many years addressed?
Mr. Kelly
I said we would try to address priorities identified by boards. In addition to that, in relation to cardiovascular, cancer services, etc. a deliberate attempt is being made to develop regional self-sufficiency in specialties through those initiatives. That involves positively discriminating in favour of areas where previously there has not been that kind of development. That is how the Department attempts, in broad brush terms, to develop services. The dialogue between the Department and a health board in areas like mental handicap, physical disability and services for the elderly would centre around planning norms. We would say it is a matter for a health board in the first instance to identify where it is in relation to planning norms for particular services. If a backlog or an under-provision exists it should emerge and it is a matter for them to prioritise that area as one they wish to invest in. We would expect to see that happen. That is broadly how the system works.
I understand the role of the health board in establishing its priorities but obviously they can only do that if they have the necessary funding. I am worried that some of the health boards are not getting as big an increase as they should year on year. Do you have a breakdown of the percentage increase for the various health boards over the last year?
You refer to self-sufficiency within health board areas. Does that mean that the Western Health Board will have a heart transplant service in due course?
Mr. Kelly
No.
What then do you mean by self-sufficiency?
Mr. Kelly
Some of the specialties would be national ones incorporated in one centre. Some of them would be supra-regionals and might be incorporated in a small number of centres. Others would be regional and the plan would be to develop self-sufficiency at regional level in relation to the regional specialties. That would not extend to providing heart transplants for the moment. Developments in relation to cardiac surgery and radiotherapy are currently taking place in the west. I do not have the percentage increases available at the moment but we can supply them to the Deputy later.
Perhaps you could furnish me with the figures for the last few years to give me an idea as to whether it is an inflation increase that is being given to health boards.
When is the report on the national cancer strategy due to be published?
Mr. Kelly
Sorry, the cancer strategy?
I am sorry, the report of the forum to devise a cancer strategy.
Mr. Kelly
The strategy has been in existence for some time. A forum has been established within the framework of the strategy to monitor progress in terms of implementation and to advise on certain issues. The current forum has run its lifetime and a new one will be appointed soon. Does that answer the Deputy's question?
With what in mind? What will be the terms of reference of the new forum?
Mr. Kelly
There is a strategy for the development of cancer services and that will be monitored by the forum. The forum will then advise the Minister and the Department on any issues that arise.
So it will be ongoing?
Mr. Kelly
Yes.
Could you deal with my question on waiting lists and consultants?
Mr. Kelly
The question relates to the capacity of the Department or health boards to do anything in this area. The temporary drop in the figures during 1999 is evidence that if one puts effort and investment into this area a reduction in waiting lists can be yielded. Those figures related to early 1999. Obviously, the year-end figures are disappointing - 36,855 is not a figure of which we are proud.
What was that number?
Mr. Kelly
Thirty six thousand, eight hundred and fifty five.
What does that figure represent?
Mr. Kelly
The total waiting list figure.
For hospital admissions?
Mr. Kelly
No. The number of patients awaiting treatment at the end of 1999.
Awaiting admission to hospital for treatment?
Mr. Kelly
Yes.
How does that figure compare to the previous year?
Mr. Kelly
The end-December 1998 figure was 36,883.
So it is line ball.
Mr. Kelly
Well, it is line ball but we had hoped the figure would have reduced as a result of the level of investment during 1999. Particular factors came into play during 1999.
What factors? We hear about this all the time.
Mr. Kelly
There was obviously an interruption in services during 1999 as a result of the nurses industrial action. I am not attributing responsibility to anyone. That was one factor. Progress was being made with regard to the total waiting list up to September 1999. Unfortunately, in the last quarter——
How was that achieved? What did the Department do to bring about the temporary reduction in the waiting list?
Mr. Kelly
There has been dedicated investment in the service for a number of years. It is an investment in temporary additional capacity in the system which involves funding hospitals and health boards to provide a target number of procedures for a given sum of money which they receive under the waiting list initiative. That has been ongoing for a number of years.
Can you give us the figures for September 1998 and 1999?
Mr. Kelly
The figure for September 1999 was 33,555. I can supply you with the figure December 1998. The figure for September 1998 was 35,405.
So it had reduced by 1,700?
Mr. Kelly
Yes, close to 2,000. That is how the system works.
Do we have a breakdown of how many hip operations, heart operations, etc. are carried out every year and are they audited year by year? Is there any way of testing a consultant's productivity?
Mr. Kelly
I will not deal with that question in terms of the productivity of a consultant. A hospital is expected to deliver a certain number of procedures when funding has been provided for doing so.
Have we any way of auditing how many operations are carried out? If, for example, somebody is not carrying out as many operations as they should obviously that will make the waiting list longer. What control does the Department have in that situation? If we have no control and are not auditing the system how can we ever really deal with the situation? Does each consultant have a target number of procedures which he or she must perform per year?
Mr. Kelly
There is a certain amount of planning of that type within the hospital's service plan. No two cases are the same. The length of time and complexity of individual cases can vary enormously. I would imagine it is not the easiest thing to plan for. However, in the aggregate, over a year, hospitals would plan to get a certain number of procedures through theatre. It is a matter for them how well they do.
Is there any level of consistency between hospitals? I am not questioning consultants, good, bad or indifferent. I am merely looking at this from the point of view of managing the problem. At the end of the day, we are accountable for the waiting lists. We are constantly being asked about what can be done. I wonder what can be done. We can employ more nurses and even more consultants but at the end of the day what is the point if only the same number of procedures are done. What control is there? Are there comparisons of the number of procedures done in different hospitals?
Are there performance measurements for consultants?
Mr. Kelly
Performance measurements?
Consultants seem to work extremely hard. Are some people more productive than others?
Mr. Kelly
Yes. The contract between the consultant and the hospital is one of the sacred things in their professional relationship. Each consultant acts as an autonomous clinical decision-maker regarding his own practice. Alongside that, one can involve clinicians in the management thinking of a particular hospital. There are various models for doing that. One of the instruments used to give an incentive to management and the clinical teams is the case-mix system which influences the allocations to the large general hospitals. Data is collected on all the cases within the hospitals and length of stay is monitored. The performance of individual hospitals is judged, and by extension individual clinicians. Hospitals which perform under par carry a penalty in terms of their overall allocation. It is a relatively small penalty in terms of the current allocation. Hospitals which perform above par benefit from it. That is one example.
I agree with the system of providing incentives though I know many disagree with it. I would be very concerned about the way in which procedures are coded within individual hospitals. Is the system throughout the country uniform? Is everyone being evaluated against the same measurement. For example, one hospital, due to bad management etc. may inadequately code procedures and as a result show up as doing fewer procedures than in reality. A person admitted for an operation may be passed on to somebody else and that might not be categorised as two procedures. What type of audit system is in place? It could well penalise a hospital that has bad management, or a bad coding system but which may be doing the work. What measures are in place to ensure the system is a fair one?
Mr. Kelly
A standard system for coding morbidity, based on the international classification of diseases, is in place. There is no arbitrariness in the coding system. It applies to every hospital. If I were judging hospital managers on the basis of how they performed and discovered a manager who was careless regarding coding in the hospital to the extent that that hospital was penalised for carelessness in that area, I would have a very short and sharp conversation with him.
I agree. I wonder if a checking system is in place to see if hospitals are coding correctly? How does one know?
Mr. Kelly
Careless coding would show up in a number of ways. A team of people work full time receiving the returns and data from the hospitals concerned. They are regarded as professionals in this area. The Deputy is referring to systematic coding errors. If there were aberrations I am quite sure they would show up.
How? You are describing what seems to be an internal system within an institution. Is there any independent audit by the Department?
Is there any expertise in the Department for spotting problems in hospitals?
Mr. Kelly
There are many reasons a hospital might come to our notice. It might not - in your words, Chairman - be up to scratch. We would look for managerial indicators in terms of how the hospital budget is managed and what sort of service volume was delivered. That results from the years when funding was extremely tight. We would also look at how it manages its people because we would have industrial relations problems showing. There is a way of dealing with extremes in terms of clinical outcomes when they come to notice. The latter category would be most unusual.
In relation to the figures for clinical outcomes. How do such problems come to notice?
Mr. Kelly
The extent to which caesarean sections have been carried out in particular hospitals with maternity units is one such matter that has come to light recently. The chief medical officer has been in touch with the Institute of Obstetricians and Gynaecologists in relation to how regular or otherwise is the pattern that has emerged. A volume of statistics collected on in-patient episodes, out-patient episodes and everything that moves within the health service is published yearly. In addition to that, the Department would receive integrated management returns from hospitals. That would deal more with managerial data required.
Another development in this area has been the establishment of the public health department in the health boards. Such departments have been developing over the past five or six years. One of their functions is to look at demands for services etc. but also to look at how well or how badly the services are performing in their own areas.
I am not quite sure I would agree that the example of caesarean sections is a good one. I would imagine such a statistic would be a repeating one. If that figure was way out we would be attracted to it and would want to find out what is wrong.
It is easy to spot.
Yes, whereas the same might not be said of other procedures. However, I accept what Mr. Kelly said.
To what guidelines do consultants adhere in relation to the public-private mix?
Mr. Kelly
The way the control system works is that 2,500 beds in the public system are designated as private beds.
Out of a total of how many?
Mr. Kelly
It is 20% of the total bed stock. There are 12,500 overall. It is a matter for the hospitals to manage the use of beds overall so that the bed designation limit is met, in other words, that 80% of bed days are available for public patients. We get a return from hospitals which indicates that, broadly speaking, it is managed and controlled. There is some overlap and spill over from public beds into private beds and private beds into public beds for flexibility reasons. For example, intensive care beds would not be designated as private beds. There would always be some spill over from private beds. On the other hand, where the hospital is under pressure to accommodate a public patient in a private room there would be spill over in the opposite direction. When one looks at the flows both ways the analysis shows that it just about balances out so that the 20% figure holds.
Is that further divided within hospitals between consultants or is it just an overall figure?
Mr. Kelly
The part I am concerned about is that in terms of accountability, the hospital manages the job I ask of it, that is, to manage the 20% overall. How they manage that internally in the hospital is a matter for them.
I note the C&AG's report for 1998 showed that in some cases in some months there was an overrun of staff of about 600. I find this difficult to understand because when the C&AG questioned the chief executive officer he said the budget for employment had not been exceeded yet the staffing levels, as set down by the Department, had been exceeded every month for the year.
That is a matter for the Eastern Regional Health Authority.
Will the Chairman come to that.
Yes, in just a moment. I want to close on the Department of Health and Children.
That is fine. I thought everything was being taken together.
We will come specifically to the Eastern Regional Health Authority in about five minutes.
I want to ask a few general questions. I know the Secretary General has only recently been appointed but his Department has one of the worse records in meeting deadlines for parliamentary replies. This committee is particularly seized of the question of parliamentary questions because it is the main means of holding Departments accountable to the Oireachtas. What steps is the Secretary General taking to ensure the parliamentary deadlines for PQs are met in all cases?
Mr. Kelly
I am conscious of the problem the Chairman raised and it is one I have already discussed with the management team in the Department. Some of the PQs for the Department are answerable directly by it in terms of the information that is on hand. Often the question requires an inquiry to a health board or further afield for the Department to reply. When we have the answer to a question in-house, the reply can be prepared very quickly. Often some field work has to be done by the board to get information. We have issued a protocol to the Eastern Regional Health Authority as we are trying to streamline the whole process to meet our deadlines. We are serious about this and we intend to improve the situation.
I hope the Department is serious about it because I consider it extraordinary that Departments of State would be so contentious as to ignore deadlines of parliamentary replies, etc. We started taking this up in the past year or two because the deadlines were generally ignored. There has been a big improvement in many Departments, including your own, but many deadlines are still being missed. Deadlines should not be missed. It is a contempt of Parliament and a breakdown in parliamentary accountability. It represents a certain attitude of mind that people do not really believe they are accountable. As a new Secretary General and accounting officer it is up to you to get the message across that you are accountable to the Houses of the Oireachtas for the moneys which are being spent and the demands for accountability of the Houses must be met, including the deadlines. I hope that when we get the next report from the Clerk of the Dáil the Department of Health and Children will not appear on the list.
What is the rate of medical inflation for the past year and how does it compare with the normal rate of inflation?
Mr. Kelly
Against a normal rate of inflation of 2%, our figure for health inflation is between 7% and 8%.
That has been a feature of the past ten years.
Mr. Kelly
It has. On a previous occasion we offered the committee a report setting out the underlying reasons.
Yes, I know, but it still puzzles me how it can continue. If we are going to get medical inflation three or four times the normal rate of inflation over a prolonged period, it does not take a genius to know that medical expenditure will grow rapidly as a proportion of GDP. When will we get to a point where we cannot afford it and what will be the consequences for services down the road? We cannot just sit back and say that medical inflation is four times the rate of normal inflation and that we will put up with it and ignore it. It is important we need to be assured that every step is being taken to keep medical costs under control. I know it is not unique to this country but why is medical inflation still continuing at several times the normal rate of inflation? What steps are being taken by health authorities here and elsewhere to ensure the gap is closed and there is not a lack of control contributing to this excessive inflation?
Mr. Kelly
It is a topic on which we could spend a lot of time. The paper given to the committee goes into the subject at some length. We must be concerned first and foremost in terms of the things we can control within the system in respect of our own accountability. If we take the pay spend, which is a huge part of overall health spending, and the non-pay spend, we have in place, through the accountability framework, strong arrangements to manage the spend and bring it within allocation. Other factors such as the aging of the population will add to the intensity with which demand for services will grow. In relation to technology growth, whole industries globally, such as the medical appliances industry and the drugs industry, are daily producing new techniques, new items of equipment and new ways of doing things. The very availability of new equipment, drugs and techniques drives the demand for them. Internationally, this has an impact on costs. Compared with other European countries, either as a percentage of GDP or per capita, our spending on health is not excessive.
How can we ensure that the current organ retention controversy will not occur again? Can policies be adopted in individual hospitals to prevent such an occurrence in the future?
Mr. Kelly
I have expressed the regret of the Department and I have extended the sympathy of the Department to the parents who have gone through this ordeal in Crumlin. I repeat that regret and sympathy here. We must establish the facts of what happened in Crumlin and more generally.
Are other hospitals not involved?
Mr. Kelly
Yes. We must establish the facts generally of post mortem practice regarding the retention and disposal of the organs of children and adults. A formal inquiry is to be established into the matter. That inquiry will form an important part of the basis of future practice.
The pathology faculty of the Royal College of Physicians in Ireland issued a new set of guidelines to members. These guidelines include new procedures, particularly regarding more sensitive treatment of the topic by clinicians and pathologists in relation to the next-of-kin and parents of people who die in hospital. The guidelines deal with the question of consent for the retention of organs for post mortem examinations, other than coroners' post mortem examinations where the issue of consent does not arise. These are simply some immediate steps which are being taken. The faculty does not yet have a full answer to this question. It suggests the formation of a panel of people to decide what needs to be done in the future. The faculty suggests that this panel might include people other than medical professionals. This is an interesting development.
The chief medical officer of the Department has written to all health boards and hospitals sensitising them, in so far as this is necessary, to the issues relating to organ retention. I have also written to the health boards and hospitals. They have been asked to examine their practices, particularly with regard to dealing sensitively with the parents of children whose organs were retained.
Future practice will be influenced by an examination of the legislation and we intend to do this urgently.
How stands the nation's health compared with other countries? I have read that the rate of heart disease in Ireland is among the highest in the European Union. Is this correct? In what areas are we better than average, worse than average or average? What factors contribute to this and what can we do about it?
I recently read of the danger of flu pandemic similar to that of 1918. What are the dangers of that and what preventative steps can be taken?
In some areas we compare very well with other countries. These are infant mortality, child health and maternal mortality. These are indicators of the quality of life and the socio-economic development of the country. Our level of economic development and the quality of the service provided in those areas will ensure that improvement in them will continue.
During the past 50 years, some of the more lethal infectious diseases such as polio and diphtheria have disappeared and are now unknown. Forty years ago these diseases were rife but very good immunisation programmes have eradicated them. The progress made in dealing with some other infectious diseases, such as measles and whooping cough, has been undermined recently by difficulties experienced with regard to vaccines. While we recognise these difficulties, we continue to recommend that parents have their children vaccinated against these dangerous infectious diseases. In those areas we can report good progress.
Is it true that the incidence of measles and whooping cough in Ireland is much higher than in the United States?
Yes. In those areas we compare badly. Children in the United States are vaccinated very systematically. In many states a child cannot be sent to school without a certificate of vaccination. Irish people would probably question such a requirement. Because of their very effective vaccination programmes the incidence of those diseases is very low in the United States.
Our incidence of cardiovascular disease and our death rate from it and from cancers are among the worst in the European Union. The Secretary General has mentioned a number of initiatives which have been taken to combat these diseases. The cancer strategy which was introduced some years ago is now at the end of its first phase. A range of measures have been taken, including anti-smoking promotions and the development of self-sufficiency as regards services in the regions providing easy access to treatment for cancer patients. They will have easy access to local services, the best drugs and therapy and, thus, the cure rate will begin to improve in the next few years. Studies conducted in the United States have shown that provision of effective diagnostic and therapeutic services significantly reduces death rates in relatively short periods of time. We hope we will be able to offer such services in the next few years.
Are we talking about both cardiovascular and cancer services?
I am talking about cancer in particular. Last year the Minister launched a cardiovascular strategy based on a comprehensive report he had earlier commissioned. Within that report there are 200 recommendations, including broad health promotion and population based initiatives related to exercise, diet and smoking. The Minister mentioned some days ago that smoking is one of the great epidemics of our time. The initiatives also include the provision of better hospital, rehabilitation and diagnostic services. We hope that over a five to ten year period we will see significant improvements in survival rates and better public health.
Is this purely a question of diagnostics and resources, or is it a question of lifestyle?
There is a range of questions. Lifestyle certainly comes into it. A person does not develop cardiovascular disease in his forties or fifties unless the basis was laid in his teens and twenties. Nutrition and, most of all, smoking, are very significant contributory factors with which we have not yet come to grips. It is not just a health service issue or an issue for the Department of Health and Children, it is a societal, educational and cultural issue. We can provide evidence to support what we are doing in health promotion activities in areas such as nutrition, exercise and smoking.
How far out of kilter with the rest of the EU are we?
We are third or fourth worst in the EU league table of premature mortality from cardiovascular disease. In relation to cancer we are the fourth or fifth worst. We would be in the bottom third of the health table in the European Union. This is a broad societal issue.
What is being done to identify the contributory causes?
It has been clear for 40 years from studies carried out world-wide that there is a number of contributory factors. There are some genetic factors about which we cannot do anything. We are born with our genes and there is nothing we can do. Upon that genetic predisposition, however, we pile the other risk factors: a sedentary lifestyle, poor nutrition - we eat the wrong food at the wrong times in the wrong proportions - and we smoke far too much.
Surely that is true of other European Union countries?
No, it is not. They have come to grips with this at a societal level to a much greater degree than we have. The United States is way ahead of us. Finland recognised the problem ten or 15 years ago and introduced the sort of measures we are talking about introducing now, measures based on lifestyle, early intervention and screening. Finland has effected a significant improvement in the cardiovascular health of its population. It can be done, it just requires significant impetus across the board from the public policy body.
What is our life expectancy?
It is one of the lowest within the European Union. Women have a longer life expectancy than men but we have a lower life expectancy among both genders than most other EU countries.
Increasingly, people measure these things in terms of quality of life. That is encapsulated in the idea of adding life to years rather than adding years to life. That is why services are so important. Early diagnosis and treatment is vital so people can be rehabilitated; much of the mortality related to cardiovascular disease and cancer is premature, men and women in their forties and fifties. Quality of life is an enormous issue for families because they do not want to lose their fathers or mothers at that age.
Is there a plan in place that will yield those results?
Based on the cardiovascular strategy that was accepted last year, we have put structures in place. A number of the constituent parts of that structure are working toward the achievement of the objectives set out in the strategy. When the Minister launched the strategy, he made the point that we are looking at a long-term issue. We must look five or ten years down the line before we see the real effects of this. It is like watching a large ocean liner change direction. We should be able to report in the coming years how effective has been the process of attacking these problems.
This committee is, unfortunately, only interested in the costs of this. Can we expect cost savings as a result of better health in the next ten years?
This is the trade off. To achieve better health, longevity and quality of life, it is necessary to invest.
I do not mean in narrow health budget terms, I mean overall economic costs and benefits.
In those terms, a significant betterment in terms of premature mortality means that more people in their forties and fifties are contributing to the economy. However, there is a price to be paid at the other end. The person saved from a coronary at 50 years of age could become the 80 year old admitted to hospital with multi-system disease who is then kept alive for another ten or 15 years. There is that ultimate cost down the line but we are offsetting it against the huge increase in the quality of life for these people, their families and, therefore, society over that 30 year period. It is a system of checks and balances.
Are there any signs of improvement in the AIDS or drugs epidemics?
Internationally, particularly in some of the less developed areas, AIDS is still a devastating disease and it is increasing exponentially in Africa and Asia. When HIV and AIDS were first identified in the mid 1980s some very pessimistic prognostications were made about the extent of the spread of the disease. Fortunately, those prognostications have not come true and the disease has not had the impact on public health which was predicted ten years ago. This has happened for a variety of reasons. For example, many of the groups who were at risk have taken control of their lives and behaviour. This has made a huge contribution to the containment of the disease.
The management of people who are HIV positive and are in danger of developing full-blown AIDS is important. Four or five years ago the development of full-blown AIDS would have been regarded as a death sentence but there have been significant and effective improvements in the quality of drug treatments for AIDS. To a large extent, AIDS has become a chronic disease. People with AIDS can live longer with drug treatments which, although quite expensive, allow them to live full and active lives.
In this case a chronic disease is an improvement on what went before.
Absolutely. The chairman referred to the danger of an influenza pandemic. The word "pandemic" raises the spectre of people falling like flies in the street and he mentioned the Spanish 'flu of 1918. The influenza virus is very adaptable, which is why people get the disease every year. It changes its shape and characteristics annually, or at least every two or three years. Because of the nature of these changes, the virus becomes, effectively, a new virus and the population has little or no immunity to it. Every ten or 15 years we experience a slightly, or sometimes significantly greater incidence of influenza than normal. Occasionally, such is the fundamental nature of the change in the virus, resistance to it is low throughout the world. When this happens a pandemic occurs. The last pandemic occurred almost 100 years ago in 1918 and it is unlikely that anything of that sort will occur again. However, such has been the shift in the virus in recent years that there is an increasing likelihood of larger than normal epidemics over the next five years or so.
Last year, the World Health Organisation held a major conference at which the framework within which countries should prepare for these epidemics was set out. Recently, we set up a pandemic committee to prepare for the eventuality of increased incidence of influenza.
I raise the question because I read in The Times of London some weeks ago that there was a danger of a pandemic.
I think that is slightly pessimistic. There is an increasing danger of slightly bigger epidemics.
We must review our lifestyles and eating habits if we are to improve our cardiovascular and cancer statistics.
Yes.
Eastern Heath Board: Annual Financial Statements, 1997 and 1998.
Mr. Purcell
The audit reports and accounts of the board for 1997 and 1998 are before the committee for its consideration. In my 1997 report I draw attention to a number of issues arising from the operation of the supplementary welfare allowance payments system. The first relates to payments to and on behalf of asylum seekers. In 1997, £2.6 million was paid to asylum seekers who were living in emergency accommodation and £7 million was paid directly to bed and breakfast and hostel owners for the provision of accommodation. Those figures have increased enormously since then. An internal investigation in June 1997 revealed that some claimants did not seem to be resident at the addresses to which their cheques were being sent and that accommodation owners might have been invoicing the board for more people than were actually being accommodated. The 195 suspected cases were passed on to the internal audit unit for in-depth investigation. The results were inconclusive. It was found that 158 cases were no longer on record as claiming the allowances and so, could not be traced. Of the remainder, 17 cases were found to be genuine and the other 20 cases had indicative overpayments of approximately £80,000. Of this £24,000 had been recovered. The system has since been tightened up.
The second point in the 1997 report relates to payments being made to accommodation owners without obtaining the necessary tax clearance certificates. This has been rectified. The last point concerns the discovery of an internal irregularity in the payment of supplementary welfare allowances as a result of which an officer of the board was suspended from duty. The amount involved was just over £14,000. I do not know if the personnel issue has been finalised but changes in the way payments are made should reduce the risk of a recurrence of this type of irregularity. I refer to the introduction of the ISTS system for the payment of supplementary welfare allowances.
For 1998, I decided to prepare a substantial report on accounting and audit difficulties in the board, mainly because I was fearful that unless improvements were put in place there would be serious problems in conducting the audit for 1999 and for the two months of 2000 leading up to the establishment of the Eastern Regional Health Authority. This was particularly important as many of the staff of the board would transfer to the new authority. The chief executive officer rightly points to the exceptional circumstances in 1999 which impacted adversely on the audit and on the finance function in the board. These included the additional burden of work falling on the finance division arising from the replacement of the computerised accounts system, year 2000 compliance work and preparation for the establishment of the new authority and its three constituent health boards. To compound these difficulties, there was an exceptionally high turnover of staff in the board and particularly in the finance division during the year.
Traditionally, because of the scale of its operation there have been difficulties on both sides in bringing the audit to finality since my office took over the audit from the local government audit service in 1994. I accept my share of responsibility for these difficulties. I can identify with the chief executive officer's problems because we too have had a high turnover of staff, especially in the past two years. Staff turnover in the board has necessitated the formation of new teams almost every year to carry out the audit fieldwork in the board.
It is not necessary to go through the report point by point. Individually, the issues raised are not a source of concern to me but their combined effect suggests serious problems ahead if the underlying causes are not addressed.
The Eastern Regional Health Authority continues to bear all the responsibility for accountability of the Eastern Health Board. Is that correct?
Under the 1999 Act, all the work of the Eastern Health Board transfers to the Eastern Regional Health Authority and will, in effect, be done by the three area boards.
Given that the authority was established only last week, we cannot expect too much of it yet. Would you like to comment, Mr. O'Shea on the points made by the Comptroller and Auditor General? What steps are being taken to meet his concerns and to ensure that he will have less cause for concern when he audits this year's accounts?
The reports of the Comptroller and Auditor General will be very valuable documents for us in setting up our audit plan and the arrangements to ensure that a good service will be provided to the C&AG in carrying out his work during the coming year. As the financial year has been changed by the Minister to facilitate the changeover on 1 March the accounts of the Eastern Health Board will cover the period to 29 February this year. In particular, staff will be put in place in the ERHA and the three area boards to specifically liaise with the auditor to ensure the difficulties indicated in the report are dealt with and information required is made available as promptly and as quickly as possible.
It would help enormously if Mr. McLoughlin who was chief executive officer in 1999 and present during the audit, even though he was not chief executive officer for the period under audit, dealt with the detail of the report with which he is far more familiar.
In the new situation is there an internal auditor?
There is an internal auditor who reports to me. They also provide a service for the chief executive officers of the three area boards to which they report. There will, therefore, be a combined audit. Under the legislation the ERHA corporate and each of the area boards must produce a full set of accounts. The accounts of the authority will be consolidated accounts of the four components. This arrangement was agreed with the Comptroller and Auditor General before the enactment of the legislation.
The internal auditor has direct access to you. Does he or she have adequate resources and is he or she completely independent of the finance function?
I intend to set up very quickly an audit committee which will comprisesenior management of the ERHA and the three area boards to ensure the auditor will work to an audit committee and to ensure implementation of anything which requires to be done in the context of the audit. I hope to consult with the Comptroller and Auditor General in so doing.
We are very anxious to ensure there is a very independent and suitably resourced independent auditor, especially in an organisation as large as yours.
I will certainly have to look very carefully at the question of audit resources. The current arrangements strictly relate - up to last week - to the Eastern Health Board. I will now have to look at how well they are resourced in the context of the three area boards to ensure there is a full audit for the coming year. The authority is responsible not just for the three area boards but also for moneys voted from the Oireachtas for the 36 voluntary hospitals. While we will not be auditing their accounts, we have to ensure their audit arrangements comply with the requirements of full public accountability. This is another dimension to our work.
Do you have any comment to make on the report, Mr. McLoughlin?
Mr. McLoughlin
We note the comments of the comptroller in relation to financial control. I have provided detailed reports to the senior auditor and the comptroller in respect of the items and taken action where necessary. I have instructed that the audit plan should take account of the details uncovered in the 1997 and 1998 audit reports. Obviously, I am glad to hear that the auditor is of the view that the items are not major. That is also my view but it is important that they are addressed. There are some technical breaches of standards. The system in place has been discussed with the regional chief executive, the financial director and the three area chief executives who are familiar with it.
What about the property portfolio of the health authority? Has there been any revision of the way property is managed given the change in property values? Has there been any review to exploit the value of your property?
Mr. McLoughlin
The property vested in the Eastern Health Board and its estate management function will automatically transfer to the Eastern Regional Health Authority. It will not, however, take over the property of the voluntary hospitals or agencies which come within its remit. Through prudent management of its property the Eastern Health Board has achieved good value in the sale of land banks etc. This is an ongoing process. We have a substantial property portfolio of the order of £600 million.
It occurs to me that through public-private partnerships properties owned by the health board in the city, dispensaries for example, could be knocked down to provide, with enormous additional value to the health board, more modern dispensary services. Is that sort of approach being considered?
Mr. McLoughlin
It is and there are specific properties on which we are working with developers. Where we have a service that is difficult to establish, it is critical that we do not lose it. We also need to ensure we do not lose any planning permissions. The estate manager is looking at the potential to undertake works on some significant properties in conjunction with developers but we need to ensure that in undertaking those developments we would not run into any planning difficulties in providing the range of services currently provided if we subsequently had to apply for planning permission.
Is the drugs problem getting worse?
Mr. McLoughlin
It is difficult to say. One has to look at in a number of ways. We are very satisfied that persons are presenting earlier for treatment. There is significant evidence that the earlier persons present for treatment and have access to services the better the actual outcomes. We have established 53 clinics throughout the region. What this means is that there is access to services locally. That was not the case two or three years ago. There has been significant investment by Government in the areas considered most deprived. This will have an impact as the association between deprivation and heroin use is well charted. We have established a significant number of treatment outlets. Despite this we still have a waiting list of up to 400, the back of which should be broken by the clinics and health centres we will establish this year. It should also ensure there is immediate access to treatment when requested. There has been an independent evaluation of our services by an external consultant who is of the view that we have one of the best drug treatment services in Europe and described the pace of what we are doing as breathtaking.
My perception is that you have arrested the problem. To use Dr. Garret FitzGerald's famous phrase, there is a deceleration of the rate of acceleration.
Mr. McLoughlin
We are still very concerned about the extent of drug misuse, among teenagers in particular who seem to think that smoking as opposed to injecting heroin does not lead to the same problems. It is a highly addictive substance and persons who smoke heroin will very quickly need to inject it to get the same effect. We are also very concerned at the extent to which the teenage population does not seem to appreciate the risks association with needle sharing. They did not grow up in the era of AIDS and associated deaths.
The evaluation will show that in the clinics examined, there was a 70% reduction in heroin use by persons attending them and that there was a 30% to 40% uptake of jobs in rehabilitation. The programme we are now engaged in is to address the rehabilitation issues to ensure people come off methadone and other substances and can access the job market.
Some people are fearful that methadone is just being used as a palliative and that its long-term effects could be considerably worse than anticipated. They fear that it is a case of exchanging dependencies from heroin to methadone which, I am told, can have different effects on the human body. Do you wish to comment on that?
Mr. McLoughlin
The major benefit of methadone is that it provides a degree of stability in the person's life. They do not have to rob or steal and they get a substance that will last for 24 hours or, in the case of long acting methadone, 48 hours. It is administered on site and under supervision where it is deemed necessary. If the person is sufficiently stable, they might be given a supply if the prescriber is satisfied. That allows us to give them counselling and rehabilitation and to bring a further degree of stability into their lives. That is the main benefit of methadone.
There is no doubt that they still have to deal with the issue of addiction. That can only be dealt with as part of an ongoing rehabilitation process. However, the international evaluation suggests that we are well ahead of what other services are achieving in terms of rehabilitation. The focus of our services for this year and the next number of years will be on rehabilitation and bringing more stability into their lives.
Many of these people have broken their family and community ties and they might not be allowed into shops, restaurants and so forth. There is a huge process of rehabilitating them within the family, community and the area in which they live. It is a slow process. However, the job market in Dublin at present is quite helpful in that regard. People are able to access employment now which five years ago they would not have been able to do because of their past record.
We are making significant progress but the problem is still serious among teenagers.
With regard to your point about taking up employment, I encountered a case where an addict could not go for the methadone on a daily basis because he took up a job. In that case, arrangements were made eventually. Is there a mechanism in place to assist people who go back to work to get their methadone on a daily basis?
Mr. McLoughlin
There is. The more stable a person becomes, the more loose is the regime the doctor will put him on. The doctor can give a prescription for a weekly dose which the person can self-administer if they reach that degree of stability. When a person accesses the service initially, they are put on a daily dose which is supervised. They must ingest it on site and give two urine samples during the week to ensure they are not taking any other substances. We have had situations where representations might have been made that a person was working and was sufficiently stable but when we have checked it, their employer would not be aware that they were on methadone and they were taking other substances. We have to be careful before we ease the regime. That decision in relation to prescribing is only taken by the GPs or by the consultant psychiatrists.
There is no doubt that the employment environment has changed the situation in relation to addicts. They are now seeking services outside normal hours where such services can be provided.
Is the protocol from the Department of Health and Children having an effect whereby the prescribing of methadone is now controlled?
Mr. McLoughlin
It is. That had an immediate impact both in reducing the numbers who were getting methadone on the black market and the numbers who were attending pharmacies. The report indicated some concerns at the high rate of prescribing of benzodiazepines and that is an issue being addressed both by the board——
High incidence of what?
Mr. McLoughlin
Prescribing of drugs called benzodiazepines which addicts will try to use as well. That is being monitored by the Department and ourselves to ensure we do not have the same difficulties down the line in relation to other prescribed drugs.
Is the waiting list for all treatments?
Mr. McLoughlin
It is.
Does that include residential treatment?
Mr. McLoughlin
It does. The residential units which we were bringing on stream last year have now come on stream. We intend to bring them up to full capacity. They are a stabilisation unit in the grounds of Cherry Orchard and the down stream detoxification unit. This is where people have had their chemical detoxification in the Cherry Orchard unit and are taken for rehabilitation. That unit has been established in St. Mary's in the Phoenix Park. When fully operational it will bring an extra 32 beds into the system for both detoxification and rehabilitation. It will allow us to use our existing detoxification beds much more efficiently. Normally we would keep a person in the detoxification unit for six weeks in an effort to build in rehabilitation. However, by establishing those units we will be able to let people move out of the detoxification bed, which is high cost and intensive, after two to three weeks when chemically detoxed and into a residential rehabilitation unit.
How long will they stay there?
Mr. McLoughlin
Their stay is six to 12 weeks. We have different units for different needs. We are trying to ensure that the total range of services and facilities being provided by ourselves, Coolmine, Cuan Muire in Athy, Merchant's Quay, Beaumont and the Rutland Centre with whom we contract will suit the person at whatever stage they are at in rehabilitation.
What about the waiting list? Parents must come to you in desperation because they cannot get their child into any facility. He wants treatment but he cannot get it. The parents might have him under control but after a few days have passed with no treatment, he will relapse into robbing and drug abuse.
Mr. McLoughlin
The situation in relation to treatment is that the communities which in the past accepted drug treatment at an earlier stage have now reached the situation where they can take those on demand. Really, it is a question of trying to finish the programme so the service is available locally. We gave commitments to communities that we would not treat persons from outside those communities in their area. Therefore, we cannot go back to those communities and ask them to take other people. It is up to each community to try to accept and agree where the treatment services will be located. That is the best guarantee that we can give them.
The regional services such as detoxification are accessed on the basis of need. However, services such as maintenance programmes can only be accessed through the availability of treatment places in the local area. We have had difficulties in providing central treatment services such as in Trinity Court in Pearse Street. Traders in the communities felt they were taking a disproportionate amount because we were operating a central service. We had to establish the 53 clinics. We had to have negotiations and agreements with communities and it is important we do not break those.
What is needed to address the waiting lists?
Mr. McLoughlin
To finish the programme and establish the services in the five centres which have yet to be established.
Are there funds available for that?
Mr. McLoughlin
Since I took over the programme three and a half years ago there has been no difficulty with funding. The funding has always been in place, the difficulty was either availability of premises, difficulties with communities or planning difficulties.
Secretary General, with regard to the benzodiazepines, how is that emerging problem being addressed?
Mr. Kelly
There are two steps involved. One is the monitoring of practice, to which Mr. McLoughlin referred. The second is what happens as a result of that monitoring. A report has been prepared in the Department on this. It recommends that a group be set up which would look at the reports in relation to GPs where there appears to be excessive prescription and that we then look at what procedures are necessary to deal with that. It is being actively pursued.
We are at a big disadvantage in relation to these accounts. We are dealing with 1997 accounts and it is now 2000. The situation in 1997 must be related to the current situation. For example, on the last page of the 1998 accounts the Comptroller and Auditor General refers to £50,000 per week paid to one B&B owner. That is over £7,000 per day. Assuming, on the basis——
Is that right?
That is what it says in the report - £50,000 per week in 1997, which is over £7,000 per day. Given that B&B accommodation was available then for £20, that means there were 350 people. How many were sleeping in each room? I would certainly like to see a breakdown of that.
Mr. McLoughlin
The rates are the ones that are quoted in the report. Many of these landlords own a number of properties around the city, so they were not all in one location. We try to ensure the numbers we pay for are appropriate to the size of the dwelling. We have become much more sophisticated about that and our systems are now linked in much better with the local authorities in relation to this. We only use emergency accommodation which the local authority has said it is satisfied with, in terms of planning and fire regulations.
We were, at that time, totally reliant on whatever property became available through the private sector. We had to take whatever was available, whether it was hostels, tourist hostels, bed and breakfasts and so on. We are still under serious pressure, particularly in Dublin city, in relation to the availability of accommodation, so much so that persons are dispersed around the country.
There would not have been many cases like that, although there were cases, as the Comptroller and Auditor General has pointed out, of persons who received that degree of funding from the State. However, that would only have been in respect of clients we had approved and at rates we had agreed.
That is a lot of money for one person. Has the tax situation being tightened up? The first £5,000 is exempt with a tax clearance certificate, but a PAYE worker earning £5,000 would have to pay tax. Why should the first £5,000 be excluded?
Mr. McLoughlin
We had to try to take account of what was practical to implement. We have a very tight system of ensuring that persons have tax clearance certificates. The system identifies traders where the certificate has expired or where the threshold has exceeded the limit. Letters are then sent and original tax clearance certificates received from companies are copied and then returned to the company. If no response is received after four weeks, a further letter is issued. If no response is received in a further four weeks, the vendor is blocked for payment purposes. We had to take decisions in relation to the cut off. We have implemented quite a strict system in terms of ensuring compliance.
I am glad to hear that. On page 8 of the 1998 report the Comptroller and Auditor General refers to staff numbers. We have talked about that at length this morning. The figures set down by the Department were exceeded every month of that year, with at times in excess of 600 staff additional to that laid down by the Department. The next paragraph in the report states that when it was queried the chief executive officer said that the pay budget had not been exceeded. I find it difficult to align those two and to understand it. It seems totally contrary to what we were discussing earlier, in terms of the shortage of nurses and certain medical staff. At the same time, the figure for January of that year was in excess of 600 additional staff in the service. We should get a breakdown of that. There are not excess nurses or medical officers.
Will the Comptroller and Auditor General comment on that?
Mr. Purcell
It is just a clarification because I am sure the chief executive officer will go into the detail of what is involved. These were not unauthorised staff in a real sense. This operates at two levels. When new services are introduced the health board will get in touch with the Department of Health and Children or vice versa. They agree to introduce a new service and money is provided for it. However, the staffing levels are not adjusted at that time to take account of that.
My point is made in the paragraph under the table. The approval process did not function as a pre-recruitment control. Even where there were these divergences afterwards, they were not reconciled. There could be a situation where a health board - this is not exclusive to the Eastern Health Board - could be employing people in excess of the authorised numbers. This check was not being used for the purpose of establishing whether they had been or not. That is the net point. I am sure the chief executive officer will be able to expand on the particulars.
Mr. McLoughlin
That was the situation. There was not a synchronisation between the actual moneys being given to us by the Department and the actual reconciliation of the numbers. The numbers subsequently approved by the Department brought our ceiling to 9,855 for the end of that year, although even in December we were 50 posts outside that.
The situation has changed since then. We have submitted as part of our service plan, which is the statutory document, the actual posts we believe are necessary to develop the services in line with the moneys we receive and the letter of determination. There is a linking of the staffing and the service developments.
However, there will be occasions where it will be necessary to bring in staff over and above the limit, perhaps at peak holiday times. We talked earlier about the difficulties caused by the 'flu, which affected staff in the same way. We had high levels of sick leave at that time of the year, when there was also a general degree of morbidity in the community.
Overall, the situation has been tightened up considerably since then, with the synchronisation of the numbers with the pay allocation. The pay element is so large that it is monitored on a frequent basis in the board, because any movement in that would have serious implications for our overall budgetary situation.
It is getting late, Chairman.
We need some more information on this £50,000 per week. How many bed nights did that represent?
Mr. McLoughlin
I do not know. We had that information when we were here before. We will make available the names of landlords and the numbers it relates to. Obviously, persons realised the potential of this. It was much easier to get a large payment from the health board for a large number of clients. I would say persons exploited the capacity of it but were not allowed to exploit it in terms of price per night etc.
Let us have more details about that particular landlord. What price per night were we paying? How many bed nights were there?
Is the question of housing and related issues for refugees and migrants generally under control? Is there better management?
Mr. McLoughlin
I would think the inter-agency management is quite good. However, there are still 250 extra persons coming into Ireland each week. The accommodation situation in Dublin does not allow for all those people to be accommodated there. There are good links between ourselves and the Departments of Justice, Equality and Law Reform and Social, Community and Family Affairs. There is a strict system of registration after which the people receive their accommodation and benefits from the health board. Owing to the accommodation problems in the eastern region, people have had to be transferred throughout the country, and the Eastern Health Board still acts as the co-ordinating agency within the boards to try to ensure that transfers are effected in an orderly manner. The Department of Justice, Equality and Law Reform has agreed to establish reception centres in which it would make facilities available for us for medical screening and community welfare services so that people can receive direct services and direct accommodation in those centres with food being provided as part of that.
Within your area?
Mr. McLoughlin
Within the eastern region. There are proposals to have three centres initially and people would be transferred from those centres within a matter of weeks to accommodation which would have been sourced.
What health screening takes place?
Mr. McLoughlin
It is generally for infectious diseases and depends on what country people come from. It is a voluntary system of screening. It is our intention to ensure that we have the capacity to provide screening in each of the centres. We ran into difficulty because of the size of the one-stop-shop in Lower Mount Street. Obviously the number of people who agreed to be screened reduced significantly because they were waiting for a number of services to be provided. Prior to the difficulties in Lower Mount Street, we achieved screening targets of 60% to 65% and we expect that to increase to 80% to 90% on a voluntary basis when the units have been sized throughout the region.
Why should it be voluntary? Should the payment of subsidy and allowance not be conditional on there being some type of health screening?
Mr. McLoughlin
It is not possible for us to make it mandatory at present. We must offer it on a voluntary basis. From evidence available from other boards to which people are referred, it is possible to raise the level of screening to ensure there is a degree of compliance.
I know, but it occurs to me that the people most likely to have a communicable or infectious disease are those least likely to volunteer.
Mr. McLoughlin
The danger is that such people and their advocates could see it as a means by which the State could block their accessing services, such as the asylum application process or benefits. It is the view of the public health function that we should try to maximise uptake on a voluntary basis initially before we consider mandatory screening. There are also legal difficulties. We do not make mandatory screening a pre-determinant for any services.
It does not have to be mandatory but, if people know that, by volunteering, they receive services and have their financial issues resolved more quickly, then public policy probably demands it. If an infectious disease begins to spread quickly, what should have been done will be done all of a sudden. At the same time, a cost will have arisen and alarm will have been caused among the public.
Mr. McLoughlin
Ultimately it is a policy decision and we feel, if the units are appropriately sized and people can be guaranteed they will receive an accommodation service or their welfare benefits or whatever within a reasonable time, they will be in a frame of mind to accept screening when the benefits of screening are explained properly to them. The difficulties in Mount Street arose because people were waiting for hours outside and inside for services and it was difficult then to try to convince them that they should spend more time availing of health screening. Added to that was the fact that the unit did not have the capacity. I am glad to say that the plans which have been prepared for us appear to give us the degree of scale and accommodation we believe is needed. If, after intensive work with people, the level of screening does not increase, a policy decision will probably have to be made but we believe that, in the interests of fair play, we should maximise our potential in terms of outreach screening and screening on site where people attend for other services.
Are there any more questions? No. We note Vote 43 for the Department of Health and Children and the annual financial statements for 1997 and 1998 of Eastern Health Board. The meeting is adjourned until 10 a.m. on 23 March when we will discuss Vote 23 - Department of the Taoiseach.
The witnesses withdrew.
The Committee adjourned at 1.35 p.m.