This part of the meeting consists of a discussion with the Department of Health and Children and the National Treatment Purchase Fund on the operation of the fund. I welcome to the meeting from the Department of Health and Children, Mr. Paul Barron, assistant secretary, and Ms Dympna Butler, principal officer; Mr. Claude Grealy, an official of the Health Service Executive; and Mr. Pat O'Byrne, chief executive officer, Mr. David Allen, director of finance and Ms Anne Lloyd, director of patient care of the National Treatment Purchase Fund. I call on Mr. Barron to make the opening remarks, which will be followed by some questions.
National Treatment Purchase Fund: Discussion.
Mr. Paul Barron
I thank members for the opportunity to make this opening statement on behalf of the Department of Health and Children on the operation of the National Treatment Purchase Fund.
I propose to give the joint committee a brief overview of the origin and functions of the fund. Mr Pat O'Byrne, chief executive officer of the fund, will dwell in greater detail in his presentation on the role and functions of the fund and will provide procedural and statistical information. Mr. O'Byrne and I will be happy to answer any questions following our presentations.
As members will be aware, the National Treatment Purchase Fund grew out of the former waiting list initiative which began in 1993 as a means of tackling the problem of lengthy waiting times for patients requiring elective surgical procedures in public hospitals. A major review of the waiting list initiative was undertaken by the Department in 1998. Following the review, health agencies, that is, health boards and major hospitals, began to use a combination of measures to reduce waiting lists, including having more patients seen on a day-case basis and, in particular, contracting out waiting list work to the private hospital sector.
Subsequently in 2001, while addressing the need for reform of the acute hospital system, the health strategy included a plan to tackle the issue of waiting lists and of waiting times in particular. The strategy's target was that, by the end of 2004, no public patient would be obliged to wait longer than three months for treatment.
The strategy also proposed the establishment of a new treatment purchase fund to be used for purchasing treatment for public patients, primarily from the public hospital system. The fund got under way on a non-statutory basis in 2002 and the National Treatment Purchase Fund was established on a statutory basis in 2004 under the Health (Corporate Bodies) Act 1961.
From its inception, the fund has maintained a fine output record in terms of the number of patients treated year on year. In addressing its primary aim of arranging treatment for people who are waiting longest on surgical waiting lists, it has achieved annual increases in patient referrals, from approximately 1,900 treated in 2002 to almost 17,000 in 2006. In line with the increase in numbers treated, the funding allocated by the Government to the fund has also increased significantly, from approximately €5 million in 2002 to almost €90 million this year.
In addition to arranging in-patient treatment, the fund has initiated a number of developments and I will mention two. The patient treatment register is the first on-line verified database of public inpatient and day-case waiting lists in the country. It is an invaluable tool which enables the fund to fulfil its statutory responsibility for the collation, management and publication of waiting list data from hospitals.
At the request of the Minister for Health and Children, the NTPF commenced an outpatient programme on a pilot basis in September 2005. This has been very successful, with numbers receiving appointments increasing from 4,500 in 2005 to over 6,000 in 2006. The fund aims to accommodate over 9,000 outpatients this year.
In accordance with the provisions of the order establishing the fund, the Minister has issued a number of directions to the NTPF since it began its work. Her primary objective has been, and continues to be, to ensure that, to the greatest extent possible, the fund should source services from the private sector. Since 2005, the Minister has instructed that not more than 10% of total referrals should be to the public system, which is mainly for complex and highly specialised cases which cannot be dealt with in the private hospital system, for example, paediatric surgery.
The need to obtain value for money in the use of Exchequer moneys is a primary consideration for the Department and the NTPF. This committee sought information last year on the cost of procedures carried out by the fund in comparison to the costs of similar procedures in the public sector. Members will recall that the Department responded in writing at the time. However, given the complexity of the respective methodologies and the need to be conscious of commercial sensitivity of the business of the NTPF, it is admittedly difficult to explain the intricacies with clarity. I hope we will be able to give some more information on this today and answer any questions members may have in respect of that and other aspects of the operation of the fund.
Mr. Pat O'Byrne may give his presentation.
Mr. Pat O’Byrne
The NTPF was established in 2002 to treat public patients on hospital waiting lists by acting as a resource to patients of the public hospital system. It is worth remembering that in 2002, one of the biggest concerns in the public health system was long waiting times for elective surgical procedures. Media reports at the time focused on this issue in a manner similar to the current focus on accident and emergency services. The fund was set up as a targeted solution to this particular problem. Today, the average waiting time for the most common surgical procedures is two to five months. It must be remembered that it was two to five years in 2002. Indeed, one early patient treated under the NTPF had been waiting for seven years. In 2002, the fund treated less than 2,000 patients. In 2007, some 27,000 will benefit from this initiative.
The fund purchases treatment primarily from private hospitals in Ireland, with the aim of reducing the length of time public patients have to wait for surgery. The NTPF became a statutory body on 1 May 2004, is subject to scrutiny by the Comptroller and Auditor General and appeared before the Committee of Public Accounts on 27 October 2005.
In mid-2004, the NTPF was given responsibility for the collation of national waiting list data for inpatient and day case hospital treatment. As a result, an on-line national patient treatment register has been launched, based on named patients, enabling the NTPF, for the first time, to write directly to patients with an offer of treatment. In 2005, as a new initiative, the fund offered first-time outpatient appointments to 4,500 public patients. In 2006, some 7,500 patients were provided with first-time consultations at outpatient level. Last year, the fund facilitated the provision of almost 2,000 magnetic resonance imaging, MRI, scans for patients who had been waiting for up to 12 months. Under the new nursing home proposals, the NTPF is to become involved in the negotiation of prices that the State will pay for private nursing home accommodation.
The NTPF is staffed by a dedicated full-time team with expertise in our area of service delivery. For example, we have a nursing team which manages the patient care process. This, in turn, is backed up by our medical team. The NTPF is almost five years in existence and during that period has experienced substantial growth in volume year on year. To date, approximately 70,000 patients have benefited under the fund. The increasing complexity with which the NTPF must deal is evident on a number of fronts. It has been suggested, for example, that the NTPF deals only with minor cases, but this is not the case. Inpatient activity now encompasses all the surgical specialties, with waiting lists from minor to major surgery. The outpatient programme has doubled in volume and has extended to new specialties such as rheumatology. I have set out a table displaying activities on a yearly basis but I will skip over it at this point.
As a matter of policy, the NTPF can purchase a maximum of 10% of its overall capacity from the public hospital system where this does not adversely affect core services. The purchasing of such capacity is necessary so as not to exclude patients whose current surgical needs are best met within the public hospital system. These include children and patients whose surgery or condition is complicated or very specialised. To date, children have accounted for just under 11% of surgical procedures dealt with under the NTPF.
While the NTPF can source treatment outside of Ireland, approximately 98% of patients have been treated within Ireland. At the end of 2006, some 53,000 patients had received surgery, while a little over 10,00 outpatient appointments and almost 2,000 MRI scans were provided. Some of these people are now back at school or work or have had their mobility or sight restored and the quality of their day-to-day lives improved as a direct result of their quicker treatment.
We believe it is important for the NTPF to be a public-facing, patient-focused responsive agency. To this end, patients can self-refer to the NTPF and we accept referrals from public hospitals and work closely with our dedicated liaison officers and, in some instances, with general practitioners to ensure our work is done. We regularly receive representations from public representatives on these issues and invariably these are responded to, usually within a week.
Through the patient treatment register, we can now write directly to patients waiting longer than three months for treatment and we also encourage patients to contact us directly to explore their treatment options. We operate a nationwide lo-call line for this purpose which we promote in all our regular media activity. We have also conducted several public information advertising campaigns to raise awareness of our services. Calls to our lo-call line have increased greatly over the years, from 6,300 in 2004 to over 20,000 in 2006. A total of 46,000 lo-calls have been received to date. For 2007, it is proposed to facilitate approximately 27,000 patients so that by the end of the year, almost 100,000 people will have received care under this initiative.
Our message to patients is that if they have been on a surgical waiting list for three months or more, we would like to hear from them. Patients can be referred to the NTPF by the hospital, consultant or general practitioner. Alternatively, patients can contact us directly. Waiting times for patients have been an issue in a number of health systems internationally. The primary focus of the NTPF is on the time that people are on waiting lists and these times have fallen substantially.
At this time, the overall figures show that for the 20 most common adult surgical operations, patients are treated within two to five months. This is a very significant improvement on the situation in 2002 when, as I previously outlined, typical waiting times of two to five years prevailed. In respect of children, for eight of the ten most common surgical operations, patients receive their treatment within two to five months. This compares to waiting times of two to five years in 2002.
However, it is necessary to point out that not all patients have been offered the opportunity. There is a small minority of hospitals where patient referrals are low and waiting times for patients are high. This is a totally unsatisfactory and inequitable situation as far as we are concerned.
In respect of quality and the standards we operate, the care and treatment that the NTPF offers to public patients is safe, of a high quality and faster. This is our raison d’être and something on which we remain continuously focused. Our systems and processes have been established with this at their core and are maintained and developed as dictated by patient needs.
Our quality systems and programme is overseen by a medical advisory panel led by the director of surgical affairs at the Royal College of Surgeons and includes a professor of paediatrics, a consultant anaesthetist and a family doctor. This panel is complemented by our in-house nursing and health care management skill base. We inspect hospitals before making referrals to them and insist that they meet certain criteria.
The treatment we offer is consultant-provided in private institutions with which we are all familiar and that are accessed and utilised by the NTPF and other health agencies, such as the HSE, VHI, BUPA and VIVAS. The fund insists that each consultant providing services to NTPF patients within these institutions is either on the specialist register of the Medical Council or entitled to be. This is the gold standard.
Patients are referred through robust structures operated by personnel working in the public and private sectors in the patient's interest. These structures are closely monitored by the NTPF and we pursue an aggressive policy of seeking out and addressing issues or concerns. Our patient care team of nurses are on hand to oversee daily processes that see thousands of patients access quicker treatment. This team is available to patients and public and private hospitals to ensure that a patient's journey is as seamless and quick as practicable.
Each occurrence where a patient may have a longer than usual stay in hospital, requires extra tests or procedures, has a need for additional post-operative care, etc., is examined on an individual basis and monthly and annual reviews are carried out. Routine reviews or audits of the experience with particular procedures, specialties or hospitals are also carried out on an ongoing basis. This process is further reviewed by our chief medical adviser. A patient satisfaction survey is sent to all patients who have undergone surgery and a response rate of 45% has been achieved. Patient satisfaction with our systems and the care received remains at 98-99%. We are serious about patient care and the quality of service we offer to patients matters to us.
The patient treatment register, PTR, is the first on-line database of public inpatient and day-case waiting lists in Ireland. It was developed in co-operation with the Department of Health and Children, the HSE and public hospitals. The NTPF has statutory responsibility for the collation and publication of inpatient waiting list information. The register now accounts for 100% of the patient population as measured under the old waiting list system.
The PTR provides patients with an accessible website link to waiting times for each of the top surgical procedures, a general practitioner website link on waiting times for more than 7,500 procedures in individual hospitals to assist the referral process, a separate link for each hospital with detailed information on procedures, patient status and guidelines for using the register and direct interaction capability between the NTPF and the patient. Patients receive a letter from the NTPF so that they can opt for treatment under the fund. The register provides a comprehensive picture of hospital waiting lists in Ireland, including waiting times, numbers and the status of patients, together with consistent national operating guidelines and definitions.
The PTR works by carrying out an analysis of waiting times in different hospitals for the top 20 surgical procedures, which can be viewed on-line. The GP and patient can use this information to decide to which hospital the patient should be referred. The patient attends his or her outpatient consultation appointment and a decision is made on the procedure required. Once the patient decides that he or she wants to accept the procedure, the hospital places him or her on its internal waiting list, which is electronically transferred to the PTR. If eligible patients are still on waiting lists after three months, the NTPF writes to them and offers them treatment under the fund in private hospitals. Upon receipt of such a letter, a patient can opt for treatment under the NTPF or continue to wait in his or her original hospital. The PTR provides wait time information for the most common surgical procedures and empowers patients by giving them options, which can reduce the length of time they must wait for their procedures.
I will now turn to value for money pricing and case-mix comparisons. Obtaining value for the Exchequer funding allocated to the NTPF is a key priority for the NTPF board. In this regard, various strategies and methodologies are applied. The NTPF is not a price-taker and it is not the case that public patients are treated in private hospitals regardless of the costs. Over the years, the NTPF has built up checks and balances to ensure its rates are competitive and suitable for the circumstances. The NTPF has declined to agree prices with private hospitals where value for money would not be achieved.
The checks and balances referred to include comparing the prices we are offered by private hospitals to prices available to the NTPF in other private hospitals, costs quoted in the latest available case-mix data, prices quoted by private insurers where we know them, a projected price built up from our knowledge of the likely constituent costs of a particular treatment, such as estimated fees, hotel accommodation costs, tests, etc, and, occasionally, international data on treatment prices. Armed with this information, the NTPF enters into the negotiating process on individual pricing proposals and, hence, a range of prices are agreed.
Reference to public hospital costs using case-mix data is useful. Case-mix is the classification of hospital patient data into more than six hundred diagnostic-related groups, DRGs, namely, discrete patient groups with similar attributes and resource intensity. Case-mix provides the cost of treating patients with similar conditions and not the cost of a particular procedure.
A number of factors must be borne in mind when comparing private hospital prices to public hospital costs, including that public hospital case-mix data is usually published more than a year in arrears, making immediate comparisons difficult, and that NTPF's prices are for a full package of care, including pre and post-operative treatment. I have set out the differences between case-mix and private costs in more detail in appendix 1 of my submission. Great care is needed when comparing hospital prices with case-mix data. Nevertheless, it is a useful tool in helping to gauge price reasonableness.
While striking competitive rates remains critical, the NTPF has found that meeting patients' needs is affected by other considerations, including where a patient lives and sometimes how willing he or she is to travel, particularly in the case of children and older people. It is also influenced by the availability of suitable private medical facilities, the capacity and limitations of those hospitals for specific specialties or procedures and the complexity of the treatment.
Value for money for the NTPF means getting the maximum number of eligible patients treated at a fair and reasonable price. While this is not a straightforward process, the evidence is there to show that we have delivered both value and quality. The NTPF's budget equates with approximately 0.5% of the total public health budget. The fund operates on an input-output basis, that is, for a known resource, the NTPF can quantify the volume of service provided and the costs of each patient episode are known. Some 94% of the NTPF's budget goes on direct patient care, with salaries and wages amounting to 2% of allocation. The balance funds the development of the PTR and other administrative costs.
Although a public body, the NTPF operates in a competitive environment, which has implications for the way the NTPF board conducts its day-to-day business, its governance and the disclosure of procedure prices. This has been accepted by the Comptroller and Auditor General. For these reasons, the NTPF has not revealed individual surgery prices. If prices were revealed every hospital would look for the highest price with inevitable consequences. This would lead to higher prices and would greatly reduce the ability of the NTPF to negotiate in a competitive market.
Regarding patient referral, the work of the NTPF to date and the results achieved for patients would not have been possible without the co-operation of the vast majority of hospitals in the country. Indeed our figures show that hospitals that engage most with the fund consistently show the highest numbers of referrals and make the most progress in treating patients waiting for surgery. There are a number of hospitals around the country where much work still needs to be done in terms of waiting lists. The NTPF is committed to working with these hospitals to deliver improved results for all patients.
The NTPF has been operating for almost five years. Over 70,000 public patients have accessed faster treatment under this initiative and are no longer on waiting lists. Our annual budget represents just under 0.5% of the total public health budget. The NTPF represents a new way of working. It is part of a culture of putting patients' needs first. We act as a resource for public patients to enable and facilitate faster access to treatment. The NTPF is good news for patients. It give patients choice, it empowers patients with information not previously available and, most importantly, it gives them quicker access to surgery and, increasingly, access to consultants at outpatient clinics. Our experience is that access to quick and safe treatment is the issue for patients and this is what the NTPF provides.
We will continue to focus on reducing waiting times for public patients on waiting lists. We continue to provide an alternative for public patients on waiting lists. Through the patient treatment register, we will continue to provide patients with information to enable them make decisions on quicker access to hospitals. The NTPF is a targeted solution to a particular problem. Its management and controls are designed to achieve its parallel aims of shortening waiting times for public patients and achieving value for public money.
I have provided members with figures for patients treated, ordered by county.
I thank Mr. O'Byrne. Members have indicated they wish to be in the Houses for the Order of Business at 10.30 a.m. I ask them to be concise.
I welcome the delegation. I am concerned about the veil of secrecy, although I understand the need for commercially sensitive information to be withheld. Are we getting value for money for the taxpayer? The NTPF is adamant that we are. What about extending the remit of the NTPF to cover orthodontics and assessments for autism, Asperger's syndrome or ADHD? There are major delays in this area, particularly in the context of a short school life.
The NTPF is a great idea for busy hospitals that cannot see enough patients. Is it true that hospitals may run out of money at a certain point and cannot perform any more operations because of the lack of money? A patient may be referred to another hospital or to the same hospital under the NTPF scheme. It is a lack of money rather than a lack of manpower or resources that causes the problem.
Transport costs are a problem for patients, particularly for a Carlow patient who is referred to a hospital in Galway. The IMO passed a motion expressing concern at the NTPF last year. Can the delegation respond to this? Referral rates are lower in some areas. In the west of Ireland there is a higher referral rate to the NTPF. Where one lives has a bearing on how quickly one will be seen. This is borne out by the statement concerning the NTPF referring patients to consultants. It is amazing that there is a delay between getting an appointment with a consultant and the operation. A woman who came to my office told me she was waiting seven years to see a rheumatologist. I thought she was joking but I checked it out and it was true. This does not take account of waiting for the operation.
Mr. O'Byrne stated that the rights of patients should be enshrined in legislation. Have there been developments in this respect? Mr. O'Byrne referred to the NTPF inspecting hospitals prior to admission. Has the NTPF refused to use certain hospitals? If so, have they been inspected since then?
I will be as concise as possible. The presentation was thorough and answered many questions. The NTPF is one of the better schemes and we are getting visible results for 0.5% of the health budget. When people are on waiting lists it is a great comfort when I can give them a lo-call telephone number to call. What is the degree of co-operation with consultants? I wonder if consultants feel undermined by patients phoning the NTPF.
Does the delegation have plans to write to the patients on waiting lists informing them of the existence of the NTPF? The delegation referred to value for money and much of this related to Ireland. People go abroad for dental treatment because they believe it is better value for money. Have we priced all surgical procedures against international comparisons or must the fund spend its money in Ireland?
Senator Browne referred to surgical waiting lists. People are waiting for services other than surgical services. Are there plans to take a different direction? Children up to six years of age must wait ages to get on a waiting list to get an assessment before treatment. Many patients have given up jobs to care for children and those with children with autism have difficulties accessing child care services. Parents would be prepared to do anything in these situations. In one case parents were sent in a circle, chasing their tail, among statutory organisations. There should be a single person who advocates for a child with a problem. Children with hearing difficulties and speech problems cannot access treatment. Does the NTPF plan on catering for these cases?
Does the NTPF have the same level of co-operation with all consultants and hospitals across the country?
I compliment the NTPF. Many patients are grateful for the work it does.
I acknowledge it. A basic difficulty exists in the policy and obviously this is not the responsibility of the NTPF. The way it is structured means the money follows the patient which is a good principle. However, it also means the enrichment of private hospitals and the impoverishment of public hospitals. This is not good for patient care in either the long or short term.
Quite often, a consultant is unable to operate because a theatre is not available or because of a lack of staff or beds. This consultant is paid to twiddle his or her thumbs and is then paid more money by the NTPF to operate on the same patient in a private hospital. No matter what way one cuts it, it is bad value for money. I appreciate it is not the NTPF's responsibility to determine policy. However, it must be stated this is not good policy in terms of building public capacity and ensuring patients are looked after. Can the role of the NTPF be changed to apply the principle of money following public patients into the public sector in a way which can build capacity there? This seems to be the way to go.
What happens if the budget runs out before the end of the year? Information on this was not forthcoming, but last year it appeared the budget ran out and patients were left on hold. Nobody told us the full facts.
I still have difficulty believing these matters are so intricate one cannot tell us the cost of procedures through the NTPF system and the public system. It is not too intricate to work out like for like costs. We know how much insurance policies cost and what many other items cost. In the US it is perfectly feasible to have information on the Internet comparing like with like and what value the State and taxpayers receive. If the costs of transport and companion costs are included it would be interesting and valuable for us to examine the real cost of both.
The NTPF was given the job of publishing waiting lists. On my way here I tried to remember the last time I saw the publication of waiting lists. I do not recall. Will the delegation remind me? It is worth noting the Taoiseach promised by 2004 we would have no waiting lists. All that happened was that they were not published and the matter was transferred to the NTPF.
I was interested to hear 99% of patients report they were serviced well and I have no reason to doubt it. However, I am concerned about an individual case which came to me. An aftercare issue was raised. No issue was raised about procedure. It is easy to ask people about the procedure and how they were treated. What happens in aftercare?
The patient had a neurostimulator synergy implant in Ballykelly hospital in Northern Ireland by Dr. Cooper. Aftercare required from Dr. Cooper was provided until 2005. The patient states Dr. Cooper was aware reprogramming is vital every year for a span of ten years. This case involved a battery which was inserted into the patient's body. After ten years it must be replaced. Since 2005, the patient has had no aftercare because the NTPF no longer funds follow-up. This woman was told to return to St. Vincent's hospital for reprogramming but its system is completely different and the hospital was not in a position to do anything. She was told by St. Vincent's to return to Ballykelly hospital.
The patient was in contact several times with the NTPF and was informed her care time is up and the treatment is finished. The patient states this was unrealistic as the battery implant was burning and she had to be seen by Dr. Cooper as soon as possible. It was almost two years since she had been seen. She had constant burning pain in the location of the battery.
The patient finds it ridiculous that Dr. Cooper is not allowed come down to Dublin to see his patients once a year. It would only cost the NTPF bed and breakfast and his consultancy fee. People such as this woman find it difficult to travel to Ballykelly hospital because she is so far away and in pain. A carer is also required to travel and stay overnight with each patient which means it costs the NTPF twice as much as it would cost for the doctor to come to Dublin.
I wrote to the NTPF and immediately action was taken. The woman now travels to Ballykelly hospital. It should not take a Deputy to take this woman out of her pain and anxiety. Treating people far away and in a different jurisdiction shows up the weakness which can occur when somebody needs serious aftercare. I do not state this occurs in all cases. It would be better to ensure this type of work was carried out in the hospital system here. The public hospital sector has far better capacity than the private hospital sector to carry out the work. This case shows up the difficulties.
I welcome the witnesses to the meeting. It is fair to state the NTPF is a success story in the main. A total of 98% of the large number of patients outlined in the presentation are treated in Ireland and it is 0.5% of the total health budget. I was struck by a number of points on this matter and not for the first time.
I will quote Mr. O'Byrne's presentation on waiting times:
However, it is necessary to point out that not all patients have been offered the opportunity. There is a small minority of hospitals where patient referrals are low and waiting times for patients are high. This is a totally unsatisfactory and inequitable situation as far as we are concerned.
This puts it mildly. Which are those hospitals? They should be named and shamed. It is a disgrace that for a spurious reason patients are not referred and must wait for procedures which could be carried out expeditiously and successfully by the NTPF. The people and members of the committee should know which hospitals are involved. I am sure the Department knows. If they are known action should be taken. I am delighted to see patients can contact the NTPF. This is marvellous. It is one way around the inactivity of hospitals.
The presentation also stated that the NTPF wishes to hear from patients on a waiting list for three months or more. Is this with regard to patients waiting for urgent procedures or elective procedures? Is there a longer waiting time for elective procedures?
I congratulate the NTPF. Without a shadow of a doubt it is one of the most successful innovations in health care over the past number of years. It is worth repeating that nobody needs to wait for longer than three months to have a procedure carried out.
Does the NTPF have initiatives for patients waiting to get on a waiting list, in other words, patients referred by their GPs as hospital outpatients but who may have to wait inordinate lengths of time before they are seen? I am struck by the fact that a great deal of work on waiting lists must be done in a number of hospitals throughout the country.
I represent Sligo-Leitrim and I note that counties Leitrim and Sligo, with 249 and 383 referrals, respectively, have the lowest referral rate in the country to the NTPF. I can only conclude that either the waiting lists in Sligo General Hospital are short or that the referral rate from the hospital to the NTPF is low. How can that be squared with the fact that patients now have the right of self-referral?
Mr. Barron
Most of the questions raised refer to the operation of the fund. I will address any policy issues that arise.
Mr. O’Byrne
Several questions referred to the so-called air of secrecy. There is no air of secrecy in the NTPF. On the contrary, we probably publish more information on what we do or are trying to do than any other organisation. However, we have reserved the right to refuse to disclose procedure prices. We know the cost of each procedure but we do not disclose that information for the reasons I set out earlier.
Is that information given to the Comptroller and Auditor General?
Mr. O’Byrne
Yes, the information has been examined.
Does Mr. O'Byrne possess comparative information on the cost of the same procedure in a public hospital, taking out all the differences?
Mr. O’Byrne
I have some of that information. I do not know the cost of every public hospital procedure because I only deal with the matter on the basis of the procedures we undertake. With regard to the inspection of hospitals, we have imposed some limitations on hospitals in terms of what they should do for the NTPF. For example, we do not allow all hospitals to perform operations on very young children, so we impose age restrictions.
Deputy McManus raised the issue of after care. I have stressed that individual patient care is very important to us. The Deputy made a representation on the case to which she referred and we have dealt with it as far as I am concerned. I ask Ms Anne Lloyd to explain the circumstances of that case.
Ms Anne Lloyd
I will talk first about the structure through which after care is delivered. Almost 70,000 patients have come through this system, so after care is a routine matter for us. We seek to combine a structure to deal with after care routinely with an ability to respond to individual cases as they arise, for which a team of nurses is employed. In regard to the case raised by Deputy McManus, on which we received a representation yesterday, the person in question had been in contact with us and after care had been arranged. I understand the hospital had contacted her some weeks ago and an appointment has been made.
This is a bright woman, not an eejit. I will not go into the details of the case but that is not what happened. I would be happy to discuss the case further.
Ms Lloyd
Maybe we should discuss individual cases outside of this arena. In general, we work through a structure that routinely provides after care while facilitating patients to contact us at any time with regard to setting up individualised care procedures. After care is a routine matter for us.
I suggest Ms Lloyd should take a close look at the case in question.
Ms Lloyd
We would be happy to do so.
Mr. O’Byrne
Deputy Connolly raised the issue of autism and children with special needs. We are primarily concerned with hospital waiting lists and, while we have provided operations and other services to some children with special needs, our remit does not extend to non-hospital care.
Does the fund intend changing its remit? It did a good job with regard to surgery waiting lists. Children with autism have significant speech and hearing difficulties and I often encounter such cases in my clinic.
Mr. O’Byrne
I do not doubt the Deputy but the remit of the NTPF is dictated by the Minister of the day.
I would like to think Mr. O'Byrne will take my comments on board because significant problems exist in terms of waiting lists for children.
Children are waiting two to three years for appointments to see clinical and educational psychologists. That may be a short time for an adult but, in the context of the length of a child's school life, it creates a major delay to accessing appropriate treatment. Mr. O'Byrne might also address the issue of orthodontics.
Mr. O’Byrne
We started a pilot scheme in 2005 to provide outpatient appointments for people on surgical waiting lists. We provided approximately 4,500 such appointments in 2005 and 6,500 last year, and we will increase the number to 9,500 this year. Bottlenecks exist for patients in terms of having access to consultants. Between 2005 and 2006, we contacted 30,000 patients under our outpatient initiatives and I think the scheme is working well. Last year, we conducted for the first time a rheumatology outpatient initiative in Galway through which 500 patients were seen and, as a result, the waiting time for outpatient appointments in rheumatology has decreased from five to two years. I am not saying that two years is acceptable but achievements can be made.
Is it correct to say there is an initiative in place so that people who are waiting to be seen as outpatients can be referred to the NTPF?
Mr. O’Byrne
Yes. We cannot deal with all outpatients at the same time but we have established a number of pilot sites and have invited every hospital to participate in the outpatient initiative. We have introduced in participating hospitals a range of outpatient initiatives in specialties such as ear, nose and throat, ophthalmology, rheumatology and endrochronology.
Can Mr. O'Byrne explain how this works? Do hospitals say they have long waiting lists for a certain specialty and refer the patients to the fund or do the patients or their GP make the referrals?
Mr. O’Byrne
Every hospital has outpatient lists, so we invite hospitals to participate in the outpatient initiative. We might pick a speciality for which waiting times are particularly long and we tell the hospital that we can look after some of the patients. In Galway, for example, the rheumatology initiative has dealt with 500 patients. The orthopaedic initiative in Cork has also dealt with several hundred patients.
In other words, where outpatient waiting lists are long in selected hospitals and specialties, the fund deals with some of the patients by referring them elsewhere.
Mr. O’Byrne
That is correct.
The initiative comes from the NTPF rather than the hospital or the patient.
Mr. O’Byrne
It is a two-way procedure. We have invited all hospitals to take part in the initiative.
Like other public representatives, I am approached by constituents who have been waiting to be seen by a specialist for lengthy periods of time. What can they do to reduce the length of time they have to wait?
Mr. O’Byrne
One of the problems we have encountered since the start of this initiative is the fact that we do not own the waiting lists. They are the property of the hospitals. The NTPF is a resource to hospitals and we work with them. The Deputy asked about individual representations but we cannot deal with every case in every hospital. However, where there are outpatient initiatives, we can deal with many of them.
If one individual sought our assistance, could we contact the NTPF? I understand what Mr. O'Byrne has said but I am trying to look at the global picture.
Mr. O’Byrne
I have been trying to address the issue on the basis of the specialty rather than the individual. However, elderly people have come to us, either independently or following representation, and it is difficult not to accept them.
If people are waiting for a surgical procedure and have been on the list for more than three months, they are entitled to contact the NTPF directly. If they are waiting for a consultant, the three-month rule does not apply.
Mr. O’Byrne
That is correct. Our initial remit was to deal with inpatient waiting lists. The remit was extended to outpatients in 2005 but our approach has been to use a number of pilot sites around the country because we cannot tackle all outpatient waiting lists.
Can Mr. O'Byrne circulate the list of pilot specialties to members?
Mr. O’Byrne
We published a report this week and I would be delighted to send it to the joint committee.
I have one other question on the low referral rate from certain hospitals. Is a low referral rate an indication of a low waiting list in a particular hospital or do some decline to refer patients, as outlined in Mr. O'Byrne's presentation under issue No. 7?
Mr. O’Byrne
The level of engagement by some hospitals is an issue. Some hospitals which have a low number of referrals have a high number of patients on their waiting lists. We are trying to secure more referrals from those hospitals because we can take more at the moment — it is not a question of funding. The service exists if patients want it and we are trying to encourage both patients and the hospitals to engage with us.
It is worth reiterating that patients can now refer themselves.
Mr. O’Byrne
Once they have been on an inpatient waiting list for three months, they can do so.
Is it the case that the NTPF pays for transport to a hospital for a procedure but does not do so for the return journey? A year ago Mr. O'Byrne spoke about the rights of patients being enshrined in legislation. Can he say to what legislation he refers? How lengthy are the waiting lists in Carlow and Kilkenny?
Ms Lloyd
I can take the question on transport and Mr. O'Byrne will take the others. Generally, patients find their own way to and from hospitals. If there is a clinical reason for a patient not being able to make his or her own way, such as their not being mobile, we will provide transport. Other than that we only provide transport where not having it would be a barrier to a patient receiving treatment. If we spend money on transport, it does not go towards patient surgery. The intention is to provide transport for any person who genuinely needs it.
I notice that in the Dublin area the waiting lists are tabulated by postal area. Can they be tabulated by hospital?
Mr. O’Byrne
We do that. We publish a patient treatment register twice a year, which I will give to the Deputy as it answers his question.
I am sure we already have it.
Mr. O'Byrne might expand on the rights of patients.
Mr. O’Byrne
That was raised in the discussion on the different referral rates in different areas. While I do not necessarily accept the argument, there are different rates of referral to the NTPF. I suggested, as a way to level the playing pitch, a regulation whereby patients would have to be treated more fairly and have greater access to the fund.
It is interesting that there is a difference in referral rates around the country. If some hospitals are not co-operating, as is clearly the case, what does the NTPF do? Has it any powers to penalise them? Does it notify the Minister or the Department of Health and Children?
Mr. Barron
The Department has held a number of meetings with the directors of the National Treatment Purchase Fund and the national director of the National Hospitals Office to address that and other issues where there is a need for closer liaison and co-operation between HSE hospitals and the fund. The results of that will be seen in due course and I expect a greater level of co-operation over time.
What reason do hospitals give for not co-operating?
Mr. O’Byrne
One reason given is a lack of resources for referrals at local level. Another is that patients in a certain locality did not want to follow the NTPF route, although I have difficulty accepting that point. There will always be some such patients but our experience is that the percentage is very small. An array of reasons has been advanced.
Mr. Barron
Mr. O'Byrne has answered most of the questions. A few questions were on policy, which is the Minister's area, rather than that of the fund. In particular, questions as to the extension of the remit of the fund are a matter for her. A number of suggestions have been made in this committee and elsewhere to the effect that the remit be extended. It is to the fund's credit that people seek that extension.
The fund has been successful in reducing surgical waiting lists and we would not want to do anything to impede its work in that area. Two years ago the Minister extended the remit of the fund to outpatients, as Mr. O'Byrne said. We keep the question of further extensions to its remit under review. An option currently being examined is an extension of its remit to orthodontics, which was discussed at a meeting of the joint committee some weeks ago. Preliminary discussions have taken place between the Department and the fund on that subject.
Senator Browne asked about disability. One of the reasons the fund is so successful is that it is able to deal with once-off situations, where a person needs a procedure and can arrange it, hopefully living happily ever after. It is more difficult where a person has a chronic complaint which requires continuous care and treatment. The treatment purchase fund model does not lend itself well to continuous contact with a patient over many years. That is how the fund operates in reality. I mentioned that we have intervened with the HSE to try to deal with the low referral rates issue and I hope we will see a diminishing of the existing problem this year.
Deputy McManus mentioned the possibility of introducing a similar funding arrangement, where the money follows the patient in the public system. I know the HSE is actively considering that, although I do not have the details here today. The HSE has an exercise under way to consider the issue and as part of its funding of hospitals, it has already created some incentive schemes designed to ensure that specific performance can be verified in return for specific funding. That is on the same track.
Senator Browne raised the question of the rights of patients, which goes to the heart of eligibility for health services generally. Members will be aware that a review of the eligibility arrangements for health services generally is under way and will be progressed during the year. That may pick up some of the ideas floated by Mr. O'Byrne.
I welcome that the Department is looking to extend the scheme to orthodontics but there is still the critical group of children up to six years old with autism or hearing and speech difficulties who are left out of the loop. What are the plans for such children? There is a waiting list of 12 to 18 months to get on a waiting list.
Mr. Barron
I am not sure whether the National Treatment Purchase Fund is the most appropriate route to deal with such people. As the Deputy knows, there is quite an amount of additional funding going into the disability area. Perhaps the particular needs of those children might be better addressed through the disability services rather than the National Treatment Purchase Fund. I am open to suggestion on the matter and we can certainly look at it.
Their needs are not currently being met and it is a very critical group. Time is of the essence with such people.
Mr. Barron
I am happy to take that back and have a look at it.
On behalf of the committee, I thank the delegation for attending and answering all the questions. We have had a good hour of exchanges.
The joint committee went into private session at 10.45 a.m. and adjourned at 10.55 a.m. until 9.30 a.m. on Thursday, 7 March 2007.