Will Mr. Scanlan announce any changes to his team?
2004 Annual Report of the Comptroller and Auditor General and Appropriation Accounts.
Vote 33 — Department of Health and Children.
Mr. Scanlan
The only change is that Ms Helen Minogue replaces Mr. Richard Nolan. Ms Minogue is from the finance unit.
Will Professor Drumm introduce his team?
Professor Drumm
I introduce Mr. Pat McLoughlin, director of the National Hospitals Office, and Mr. Aidan Browne, director of the primary and continuing and community care directorate of the HSE.
I presume my first question applies to Mr. Scanlan. Subhead A7, appropriately enough, deals with consultancy services. I am amazed that only one third of the estimated spending on consultancy services was spent. Does the figure of €510,000 include the funding we just discussed in regard to PPARS or is it separate?
Mr. Scanlan
Subhead A7 is the Department's administrative budget.
Mr. Scanlan might explain the figure.
Mr. Scanlan
The A subheads relate to money spent by the Department to run the Department as opposed to running the health service. It refers only to the Department's internal spending.
Therefore, the Department only spent one third of what it had estimated, which is a good sign.
Mr. Scanlan
Do I get any reward?
Mr. Scanlan will not get any kudos yet. An article in The Irish Times of 17 January last referred to the question of casemix which probably comes under subhead B1. Casemix was a scheme brought forward to try to get a good turnout from hospitals. I was delighted to read that Cork University Hospital was one of the most efficient in the State, and that it gained €1.9 million. What concerns me more, however, was that St. Mary’s Orthopaedic Hospital lost money. I understood a casemix was to create a spread of procedures across the disciplines. How could this be in a specialist orthopaedic hospital such as St. Mary’s?
Mr. Scanlan
I would never pretend to be an expert on casemix, although I began to get into the issue when the Comptroller and Auditor General was examining the National Treatment Purchase Fund. My understanding of casemix is that it is an important effort to adjust hospital budgets by reference to performance. However, it only operates at the margin. I also understand — my colleagues may correct me — that it tries to adjust for the differences in and the complexity of procedures. There does not necessarily need to be the same mix of procedures in two hospitals — a casemix could be applied to a specialist hospital but one would take account of the complexity and number of the procedures.
I was chairing a board, for my sins, when casemix was introduced. I understood it was to help to create a degree of expertise and standards in a variety of disciplines.
Mr. Scanlan
Absolutely.
The report in The Irish Times referred to the orthopaedic hospital. I could not understand why a single discipline hospital would be penalised.
Perhaps Mr. Magan could add to the discussion.
Mr. Dermot Magan
The specialty of a single specialty hospital can fall into a diagnosis related group, DRG, category. Therefore, it can be compared with a major hospital which has the same specialty, which is what casemix is trying to achieve. It is trying to examine like deliveries and procedures, of which there are 600 under the DRG. These are grouped and the performance of individual hospitals is assessed under each of the DRGs. The DRGs are assessed in order that the calculated cost determines the materials cost that goes into each DRG. That is the standard and the process results in the comparison of the cost of delivering cases in the various hospitals against that standard.
The DRG sets a standard which is based on the type and complexity of case involved. Some cases might be of high complexity while others in the same DRG are of low complexity. This is taken into account. The process takes into account that some hospitals might have outlayers — patients in a particular DRG who were there over or under a certain period — who might prove more costly, and it adjusts for this.
While I will not suggest the system is perfect, it tries to be as compliant and reasonable in regard to that comparison. However, specialist hospitals can be compared with general hospitals. If the same work is done, the DRG is applicable.
Subhead F.4 refers to the Ireland-Northern Ireland aspect of INTERREG, for which the outturn was more than doubled, from approximately €206,000 to approximately €460,000. Is that extra spending a positive indicator with regard to our working with the North to establish joint projects?
Mr. Scanlan
I would like to think so. However, the specific subhead was spent. In the short time I have been in this job I know of much contact across the Border because health is one area where contact is practical. Quite a number of projects are under way.
Subhead I deals with payments for the State Claims Agency in respect of the costs relating to criminal negligence. Actual spending was just over one third of the estimated figure. What does this indicate, considering some of the negative publicity in this area? Is the Department improving the situation in regard to criminal negligence given that only one third of the estimated outturn was spent?
Mr. Scanlan
I would not like to claim credit in this regard. While I would have to verify the facts, this is a new scheme we have introduced and my sense is that we were trying to estimate the volume of cases with which the State Claims Agency would have to deal on our behalf under the new scheme. It could be said that we over-estimated the spending or that the number of cases was not as high as we had anticipated. I would not like to claim that we have managed to crack the issue of clinical negligence claims.
I ask for a note on this matter because we will be referring local authority issues to the State Claims Agency. I would like to know how the issue is progressing.
Mr. Scanlan
Yes.
The Irish Independent recently referred to the issue of private care which may be an issue for Professor Drumm to address because it relates to our friends at the head of the force, the consultants, and the common contract which came in during the 1970s. Will it ever be possible to stop the practice of having private patients in public hospitals which is referred to in the article, with Mr. Fitzpatrick defending it, needless to mention? Is progress being made on the issue of breaking the link with the common contract?
Professor Drumm
The first point of which we must be aware is that 52% of the population now has private insurance cover. The most obvious large centre of population in this regard is Limerick, which has no private hospital. Therefore, up to 50% of the population of that area must be able to access Limerick Regional Hospital or St. John's Hospital if they want to access care. One cannot just set a barrier at the door and tell people they are private patients and cannot come in. In moving forward we and the Department hope to bring equity to the situation in terms of public patient access. We are beginning the process of negotiating a new consulting contract with a major focus on achieving this equity for public patients.
As Sunday Business Post and the Irish Independent ran articles on this issue, I want to give credit where it is due. With regard to expenditure, a report has been produced on Coovagh House, a special care unit for at-risk children in the Chairman’s area in Limerick. Sadly, the centre, which was ready to operate for years, closed due to staffing difficulties. The committee has previously discussed the difficulty involved in recruiting and training staff. People do not wish to work in such centres. Is the health service capable of running such centres? I hope this question is framed in a positive manner. Does the Health Service Executive’s ethos permit it to run such centres or does it need to investigate whether they should be run by the Department of Justice, Equality and Law Reform or another Department or agency? The HSE is being blamed for the closure of Coovagh House, a story covered by The Irish Times. That article dealt with the building and equipping of the facility. Is the HSE capable of providing this service?
Professor Drumm
I will ask Mr. Browne to answer the Deputy's question. It is fair to say the HSE's remit is very broad.
Mr. Aidan Browne
The core of the Deputy's question relates to whether the HSE has the ethos to deal with this area. We have probably ten different types of ethos because of the health board structures over the years and we have developed different ways of dealing with these issues. One of the initiatives within the unified structure is to establish one national approach to dealing with out-of-control children.
Coovagh House suffered greatly because of its inability to secure the appropriate staffing mix to open the unit. We have attempted to recruit an appropriate manager for the unit which speaks, in particular, to the issue of ethos. It is very important that the management of the unit has a particular approach. I hope we will have established a national management approach to this particular care area within the first six months of the year and that we will be able to open the unit. The running of such units is within the remit of the HSE. It is appropriate that it develops the ethos if it is not fully present. There are very good examples of the HSE running such units in other parts of the country.
I asked this question because responsibility for special needs children fell between the Departments of Education and Health for many years and it took a Supreme Court decision to force people to take the matter on board. From its reports to this committee, it is clear that the Department of Justice, Equality and Law Reform carries out work relating to special needs children that is quite similar to that carried out by the HSE. Could the executive and the Department co-operate on this issue?
Mr. Browne
The recent decision to establish the office of the Minister with responsibility for children probably addresses this issue to a major degree. We are very closely related to the Departments of Justice, Equality and Law Reform and Education and Science in this initiative.
My final question relates to——
Mr. Scanlan has indicated that he wishes to speak.
Mr. Scanlan
I will clarify matters for the Deputy. The recent decision means that child care, which was formerly dealt with by the Department of Justice, Equality and Law Reform, child protection and the National Children's Office are now being unified within the Department of Health and Children under one director general, Sylda Langford. Personnel from the Department of Justice, Equality and Law Reform who deal with youth justice and youth detention will be located in the same building. A process is under way to pull the justice piece together and we will also co-locate some personnel from the Department of Education and Science who deal with early childhood care and education in the hope that, as we link in with the HSE, we can also link in with the wider parts of the public service in the areas of justice and education. It is not a panacea but I met the staff for the first time recently and hope this initiative is a good step forward in tackling these issues.
We heard with astonishment some of the figures quoted. An almost identical situation has arisen with the Department of Justice, Equality and Law Reform. The process is very expensive. We all subscribe to spending money properly but these children must receive care. I am concerned that these children, many of whom are very vulnerable, are caught between two stools. However, if matters are coming together, it is good news.
Mr. Kelly's final comments today related to enhancing internal controls. He raised a fascinating point when he mentioned the Mullarkey report, strengthening internal controls, enhancing security monitoring control procedures and disaster recovery planning. He stated it had been carried out by the Department of Health and Children and had identified key risks associated with the transfer of functions to the HSE. What were the key risks that would have been anticipated?
Mr. Scanlan
I should probably——
It was Mr. Kelly's final note on the Vote. He spoke about enhancing internal controls.
Mr. Scanlan
I am familiar with the area but I do not have the material to hand.
I was not aware that there were major risks involved in handing over control other than people's concerns about losing their jobs.
Mr. Scanlan
I will discuss a few of these risks as I am still dealing with them.
With regard to casemix, we are working with the HSE to transfer the responsibility for casemix over to the HSE because it will be responsible for funding individual hospitals. It is not a major risk but one stands to lose considerably if one transfers the responsibility for casemix but does not supply the skills and expertise the Department has built up over the years. The same situation applies to the Department's hospital planning office which contains architects, engineers and quantity surveyors who have managed particular capital projects. As the management of such projects is now a matter for the HSE, we must transfer this expertise to it. I am working with Professor Drumm on approximately five or six areas. Certain work areas will transfer from the Department to the HSE and if we do not manage the process, the risk is that we simply transfer the responsibility for the work but not the expertise and ability needed to carry it out.
Is Professor Drumm satisfied matters are progressing smoothly?
Professor Drumm
We have a very constructive relationship with the Department in terms of this transition. The process is difficult but we are dealing with it in a very constructive fashion.
Subhead F3, which deals with the hospital treatment purchase group, reveals that there was an increase of €13 million or 42%. What was the context of such a major increase?
Mr. Scanlan
This was the National Treatment Purchase Fund, NTPF, which we dealt with in chapter 14.1 in a previous meeting. The context was a volume increase. We were gearing up the NTPF and funding it to arrange for the treatment of a greater volume of patients.
My next point concerns consultants who are paid from the NTPF and who probably work in the public and private sectors and for the NTPF. We spoke earlier at great length about human resource management. Do the consultants in question fill in time sheets? How is their time allocated? They are very highly paid.
Mr. Scanlan
The Deputy probably knows the answer to that question.
I do not know the answer to the question. I have read much about human resource management. People fill in time sheets in the private sector and much of their charges are based on them. I understand a similar arrangement has recently been proposed for lawyers.
Mr. Scanlan
Professor Drumm may wish to comment on this issue. From my perspective and understanding, the contracts of consultants employed by the Department in the public system contain provisions about the overall hours they are supposed to deliver. There are provisions to schedule some of these hours because if, for example, a consultant was delivering an outpatient service or a ward round, one would want to know what time these services were scheduled for. The contracts do not provide for the scheduling of all the activities. At the risk of straying into what is really an on the ground or operational issue, my sense of it would be that it can be difficult to know where consultants are at particular times owing to the various demands made on them. Professor Drumm may say more on the subject.
Professor Drumm
I do not know the answer to the Deputy's question on the NTPF as it is a separate organisation. I suspect payment is made on the basis of procedures as most are surgical procedures.
I am aware of the fact that the Deputy and the Chairman have touched on the issue of value for money and how it relates to human resources but I did not have an opportunity to return to the issue. I was reassured when the Chairman stated the public was beginning to ask significant questions about the value it got from the health service in return for its investment. That is a justifiable question.
We are a remarkable organisation in that one will find that most of the criticism we suffer comes from within the organisation. The Irish Society for Quality and Safety in Healthcare carried out a large survey on more than 4,500 people. Of respondents, 93% were satisfied with the service they received, more than 80% who had attended accident and emergency units had been seen within three hours, nine out of ten would return to the same hospital and three quarters had been admitted to a ward within six hours of arriving in an accident and emergency unit.
The public survey showed many positive aspects but we suffer much internal criticism. Of the criticism of our system's performance, much comes with the caveat that people do not want to hear figures. They hear that someone is suffering on a trolley but do not want to listen to the figures on how many go through or work in the system, a matter the Deputy and the Chairman raised. This would be irresponsible of any of us in the system, as we are responsible to the taxpayer. What are the figures? How efficient are we? We must be interested in figures as they are a challenge.
In the Irish context, we constantly tend to deal with figures on health care without referring to age, which is mischievous, as the largest factor that determines how much money one must spend on health is how old the population is. If one is working with one of the youngest populations in Europe, one should be spending significantly less money than if one were working with an older population. To cite the same figures and compare us with Germany and the United Kingdom is remarkable.
There is a challenge and one that the human resources programmes we would need to get in place in the terms we spoke about earlier would allow us to take on. We are in a situation that I compare with the Ford motor car company. If it is found it produces 100 cars from its lines every day but that Volkswagen beside it produces 120 from its line in the same time, the response I get is that we, as the Ford company, should build another line. This is very easy when the taxpayer pays the bill, but it is clearly not the way we should approach matters.
We hope the new human resources systems will allow us to examine the effectiveness of the system across the board. Within our system, there are places in Ireland that are significantly outperforming others in terms of throughput for the number working there. We have very little measurement of this area, which is important if we are to even recognise those who work very hard, never mind calling into question the statement that we are not producing.
I went the long way around but I hope this addresses the issues raised of how we bring accountability to the system, which is an important question, and the need for the system to take on internally the Chairman's challenge to assume responsibility for being accountable.
I am interested in reading reports from the United Kingdom, many of which focus on health outcomes. For example, one can know levels of success in relative terms, such as the death rate for certain types of surgery, for the specialisations of particular hospitals. It is important that we focus on this type of output as much as the monetary output.
Forgive me for asking a local question but in 2004 the James Connolly Memorial Hospital in Blanchardstown was fined €1 million in connection with the casemix formula. Until the middle of that year, it had been unable to open its new wing, which ultimately cost the hospital approximately €64 million or more. Other Deputies and I desire to know how the casemix formula works. Given that this year's fine is €700,000, has the performance improved or worsened now that the new building is fully open? What is the story?
In terms of human resources, it is deeply depressing for hard-working hospital staff to have this as the hospital's major story at the beginning of a new year, as it is for many other hospitals. There are stories that this has to do with accounting. I confess that I was originally an accountant and know it is possible to be creative with figures. Would it be possible to get an explanation? While the issue of whether they are fined or rewarded on their casemix formulae has not been directly accounted for here, it is a major story for hospitals throughout the country. This year, my particular example received the fifth or sixth largest fine levied on a hospital.
Mr. Scanlan
I will get the Deputy a note on that hospital. If we follow through on the theme that has emerged about trying to measure performance and reward it, we must face up in some way to the fact that we must keep publishing information. I accept that it often only gives part of the picture and is perhaps not entirely fair, as it were, depending on someone's perspective. If one waits for perfection, one will never get it. We must start examining and publishing facts and figures across hospitals.
I sometimes wonder whether we publish figures to use them as sticks to beat people with. The same seemed to happen in respect of the hygiene audit, which said that the situation was terrible. However, if we use them as a means to set a benchmark and measure ourselves against them, it is a more positive way of working. I respond to people working in the system in this sense in that it should not always be seen as negative, rather as a challenge.
It may have nothing to do with the individuals working in the system, which is perhaps what Deputy Burton touched on. All I can do is get her a note on the hospital. While we should face up to publishing the figures, we should not always treat them as negative, which I accept is easier said than done.
In my language, "fine" is a negative rather than a positive.
Mr. Scanlan
Where was it written that they were fines? Was it in the media?
Yes, but that is the way they are normally written.
On subhead E, there is an overrun of just over €9 million as payments for legal settlements and representation at tribunals of inquiry were greater than anticipated. The Presidency costs under subhead A.3 overran by €926,000 while under subhead H, costs overran by €609,000. The latter related to anti-smoking campaigns. I did not think the Department of Health and Children had such a significant involvement in the Irish Presidency to this level of costs overrun which strikes me as very high.
Mr. Magan
We must understand those were Estimates as they were in the first Book of Estimates. People estimated the cost of the Presidency but it clearly cost us more. During the Presidency, we had a large job to do across a number of the services and policy items we provide such as blood services and services in respect of migrant workers. I was involved in the Irish Presidency in regard to our responsibilities under Regulation 1408/71 which saw Ireland introduce the European health insurance card throughout Europe. While not every member state was able to introduce it at the time, it was introduced in more than 50% of them. The card replaces the necessity for people to visit their local health board to obtain an E.111 form. It was a major issue for Ireland's Presidency, during which a number of other issues were also raised. A number of conferences were held regarding medical subjects. It cost more than we had anticipated. In many of these cases, initial views are taken on how much would be spent under a particular subhead, and that sum was exceeded.
Mr. Scanlan
To add to that, subhead A.3 covered the expenses of our staff travelling to and from Brussels. We had to increase our presence in Brussels. Subhead H covered our hosting of EU events. As I was not in the Department at the time, I am not familiar with the details. However, my memory is that the Department had quite an active role during the EU Presidency, just as other Departments did. As a country we put our best foot forward.
The original provision under subhead E was €15 million. That was exceeded by €9 million and a total of €24 million was spent. I am advised that of that €24 million, €22 million was spent on tribunals of inquiry and approximately €2 million was spent on legal settlements. The majority of that €22 million, approximately €18 million, was spent on the Lindsay inquiry into hepatitis C and HIV. The spending on the post-mortem inquiry, originally chaired by Ms Anne Dunne and now chaired by Dr. Deirdre Madden, was approximately €2.5 million. Spending on the inquiry into Our Lady of Lourdes Hospital was €1.3 million. The amount spent on the Ferns Report, the Laffoy commission and the inquiry into the circumstances surrounding the death of Róisín Ruddle was much less. The costs of tribunals of inquiry were higher than we anticipated.
By the end of 2004 had any queries arisen on nursing home subventions? I do not see them reflected or mentioned in any of the accounts. Was that an issue by the accounting year end?
Mr. Scanlan
Does the Deputy mean legal actions when she says "queries"?
Was it flagged on the Department's radar as an issue by the end of the accounting year?
Mr. Scanlan
I am trying to get my mind around the timing. The repayment scheme and all that followed became an issue in 2005.
I have a few short questions. The committee previously discussed with Mr. Pat McLoughlin general issues on the plan for putting in place a national transport programme for cancer patients in need of radiology treatment. Will Mr. McLoughlin update us?
Mr. Pat McLoughlin
We examined this issue and found quite a myriad of arrangements in place such as transport provided by health boards, minibuses, public transport and taxis. We are examining whether we can implement improvements and bring some equity into the situation. Developments specifically regarding radiotherapy have improved access for patients and obviate some transportation requirements such as the extension of the Cork service and the establishment of the Galway service last year. The Limerick service is now up and running, a proposal has been made for a service in Waterford, and a link is being established with Northern Ireland regarding a service in Belfast.
The extent to which we can fund some public patients through those services will obviate the need for a significant amount of transportation for radiotherapy. We have not finalised any scheme. However, our assessment is that it would be extremely expensive to provide a dedicated service in its own right to radiotherapy patients without examining the broader movement of patients for outpatient clinics. Approximately 2 million people attend outpatient clinics per annum throughout the State.
Will Mr. McLoughlin provide the committee with a note on that issue?
Mr. McLoughlin
Yes.
Screening for cervical cancer is carried out on a pilot basis in the Limerick area. What is the possibility for a national screening programme? I address that question to Professor Drumm.
Professor Drumm
Mr. Scanlan might be able to answer that question more directly as it is a policy decision which must be taken by the Department.
Mr. Scanlan
My understanding is the introduction of a national screening programme is still under consideration by the Department.
I previously raised the issue with Mr. Browne of orders of nuns who provide sheltered accommodation for the elderly but no longer have the personnel or resources to meet the ongoing costs. Has any progress been made on that issue?
Mr. Browne
Some progress was made. This year we assigned some funding in the category of elderly persons for sheltered housing to support the health service provision to sheltered housing initiatives. I hope that agenda will be advanced.
Will Mr. Browne provide the committee with a note on that issue?
Mr. Browne
Yes.
As with many hospitals, a group in Ennis is looking for seven-day accident and emergency services in its hospital and for the HSE to appoint the consultants necessary to deliver them. What should we tell them when they write to us?
Professor Drumm
The provision of accident and emergency services will continue to present us with a challenge. Under the European working time directive, providing 24-hour cover on as many sites as we do is an enormous challenge, and its provision will cost the health services a significant amount. Our ability to provide cover in terms of the number required will be a challenge. I do not think it will be acceptable in the future for trainee doctors to provide cover. We may have a fully trained doctor in the system from 9 a.m. to 5 p.m., but in most systems we end up with trainee doctors outside those hours. Many are not part of formal training programmes. At a governance level that raises extremely significant questions.
The HSE has undertaken a review of the safety and the quality of its services in the north-eastern area. Deputy Burton raised the issue of quality of service. When that review has been carried out, we will be in a much better position to deal with individual groups throughout the country on how we might provide services. It is fair to say the situation whereby most of the working day cover for accident and emergency services is provided by trainee doctors, many of whom are not in a formal training programme, cannot continue. It is a major challenge and is high on our agenda.
On the issue of patient funds, Professor Drumm previously indicated to us he was seeking legal advice to establish the HSE's obligations and scope to manage patient funds. Will he return to that issue and give the committee any information he has? I presume patient funds are increasing due to the repayments to nursing home patients. Does Professor Drumm have any indication of the amount of money now in patient funds and whether different practices occur throughout the country regarding the management of those funds?
Professor Drumm
The internal audit committee is still dealing with the issue of how to approach the use of patient funds. There is still a need for more clarity in what our role is in managing those funds, particularly the challenge of how those funds are invested and the security of the investments in which they are placed. There has been some interaction with the Courts Service which is also involved in managing many of these funds in terms of awards made into accounts for juniors. We hope, with the help of our internal audit committee, to develop a policy in the coming months but we are not there yet.
Has Professor Drumm a figure for the amount now being handled?
Professor Drumm
I do not think we can issue a definitive figure. We have a very good idea of what it is but we do not have an official figure that we can put on the table at this point.
Mr. Scanlan
To refer to the previous question which arose in the context of a previous report from the Comptroller and Auditor General, we did get advice from the Attorney General on the bigger issues. We are now talking about implementing that advice. My memory is that there was conflicting legal advice about the nature of the relationship between the health boards and patients in that context. There were bailers, bailees and so forth but we obtained clarity at a broad level from the Attorney General and now it is just a question of applying the advice and determining how best to do so in legal terms.
Does Mr. Scanlan have a timetable for the repayment of moneys taken from patients in nursing homes?
Mr. Scanlan
That will depend on when the legislation is enacted. We are anxious, not just to start but to repay as much as possible this year. A sum of €400 million is provided in our Vote for 2006. We are trying, in close co-operation with the HSE, to be as geared up as possible and ready to go in order that we can proceed as soon as we have the legislative authority to do so. The repayments will be made this year and next year.
Has a policy decision been made to spread the repayments over a number of years?
Mr. Scanlan
No.
Will the Department pay up front as soon as it receives the legal authority?
Mr. Scanlan
Yes and as soon as we can physically administer the scheme, although that will be the responsibility of the HSE. There is no policy decision to spread the repayments over a number of years.
Mr. Browne
We are in the process of securing an external company to oversee the repayments and are hopeful that we will have that completed before the legal instrument is enabled.
Mr. Purcell
I have nothing more to add, other than to remind members that this is the last occasion on which they will have an opportunity to look at the Vote for the Department of Health and Children in this manner because there is a separate Vote for the HSE which will be taking on the vast bulk of the expenditure of the Department from 2005 onwards.
: Is it agreed to dispose of value for money report No. 51 and note Vote No. 33? Agreed.
The witnesses withdrew.
The next meeting will take place at 11 a.m. on Thursday, 26 January 2006 when the committee will consider the 2004 annual report of the Comptroller and Auditor General and Appropriation Accounts, Vote 26 — Office of the Minister for Education and Science, chapter 7.1, superannuation schemes. The committee will also consider the draft fourth interim report for 2003.
The committee adjourned at 3.15 p.m. until 11 a.m. on Thursday, 26 January 2006.