Paediatric Services: Discussion with HSE.

I welcome Professor Brendan Drumm, chief executive officer of the HSE, Mr. John O'Brien, adviser to the CEO, Ms Raymonde O'Sullivan, assistant national director of finance, and Ms Fionnuala Duffy, assistant national director of planning and development, National Hospital Office, to the meeting to discuss the paediatric services provided in Dublin with particular emphasis on the services in Our Lady's Children's Hospital, Crumlin.

Before we begin, I draw attention to the fact that members of this committee have absolute privilege but the same privilege does not apply to witnesses. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable. I address a request to the members of the committee, to the witnesses and also to those people in the Gallery to make sure that all mobile phones and BlackBerries are turned off. That is most important because they interfere with the sound system here.

In a personal capacity, I welcome Professor Drumm. There is widespread support for the move to develop a single paediatric hospital capable of meeting the future needs of our growing population. While there may not be unbridled enthusiasm for the selection of the Mater Hospital site for this new development, I acknowledge that it is in line with public policy as enunciated by the HSE, by the Department of Health and Children and the Government. I recognise further the fact that building closer co-operation between Our Lady's Children's Hospital, Crumlin, Temple Street Children's Hospital and Tallaght Hospital will be to the benefit of patients and should allow for economies to be achieved. The building of that co-operation and the entire move towards a single paediatric hospital needs to be led by one individual that can command the support and respect of those involved in that whole process, similar to the manner in which Professor Tom Keane, who has won enormous respect across the country, has led the major progress which has been achieved in cancer services.

I feel I speak for everyone here, when I say we feel that notwithstanding the financial difficulties which obviously exist the maintenance of front-line services to vulnerable sick children must be an absolute priority. Hence it is our view that the closed theatre and the unused beds at Our Lady's Children's Hospital must be brought back into use. That is the context in which we asked the delegation to attend to discuss these important matters. We would like you, Professor Drumm, to deliver your paper, which you have circulated, in about five minutes and then we will go to members for orderly questions. The proposal is that we will take questions from three members at a time, revert to you for responses, and then take the members who are next offering.

Professor Brendan Drumm

Thank you, Chairman. We are here today to discuss the provision of care at the three children's hospitals in Dublin. It is now widely accepted that we do not need three children's hospitals in a city the size of Dublin and that it inhibits the quality of care that can be provided. I have said that consistently for more than 20 years in paediatrics in this city. I am glad this view has been endorsed by leading paediatricians from Canada, North America, the UK and by expert reports. Change on a scale needed to amalgamate the three children's hospitals into one is difficult, particularly given the tremendous care the hospitals provide and the loyalty they have built up over many years. They are now beginning to engage in preparations to move to the new hospital in 2014. I publicly welcome that. It is a huge step forward. The vast majority of clinicians accept this is the right way to go. There is no point now in looking back to try to find out why it was not achieved, but it should have been achieved many years ago if everybody had worked co-operatively on obtaining this outcome.

Our focus here today on activity levels, throughput and associated costs could portray us as being overly focused on data and uncaring of the needs of children. On the contrary we will only be able to maintain and develop the services that children need by focusing on these figures.

During the recent public discussions on the financial challenges facing Our Lady's Children's Hospital, a view seems to have been formed that the HSE runs the children's hospitals. I stress that the three children's hospitals are not operated by the HSE. They have independent boards, independent management and the HSE funds them for providing services to an agreed level signed off on by the hospitals. This authority clearly carries with it responsibilities on the part of the hospitals. When it comes to managing the use of funds provided by the taxpayer, there is a responsibility on the boards and management of hospitals to ensure that they provide the services for which they are funded and use these moneys efficiently. They are publicly accountable in this respect. If a hospital decides to achieve savings by closing patient facilities ahead of reducing non-essential pay-roll costs, more effective procurement or better co-operation in sharing with other hospitals in non front-line roles, that is a decision the independent hospital is taking.

I would like to focus on a number of issues. The first is funding. I know from direct experience the high complexity of care provided to children at the three hospitals and especially at Our Lady's Children's Hospital, Crumlin, where a great deal of very complex care is provided. There is a huge commitment by staff to providing this care. In recognition of this the HSE has in recent years, and since its establishment, been increasing the funding to Our Lady's Children's Hospital extremely rapidly. The annual budget for the three hospitals is now almost €260 million, which is a substantial contribution from taxpayers. The budget to Our Lady's Children's Hospital over the past four years has increased essentially by 37%. The numbers are outlined in an appendix to this document that we circulated in terms of the increase in staff numbers.

Concern has been expressed that the Our Lady's Children's Hospital budget has been cut by €9 million. The hospital budget has not been cut by €9 million. The most recent figures received from the hospital indicate it will have a year end shortfall of €100,000. Talks of cutbacks of €9 million are misplaced because they never existed.

One of the difficulties facing the hospital is that it failed to implement the Government policy which required all health care facilities to reduce their non-front-line spending, such as management and administration costs, by 3%.

Many hospitals across the country including the very large ones have, during the last two years, successfully implemented efficiency measures and used these savings to ensure that essential services were maintained. They are managing to deliver more with less and I wish to publicly commend their management and clinical teams for this achievement. Our Lady's Children's Hospital has not so far made sufficient spending reductions in other than front-line areas and has chosen instead to close front-line facilities.

However, I welcome the recent decision of the hospital not to proceed with further front-line facility closures. Following a high level review of the financial situation at the hospital by Ms Raymonde O'Sullivan, who is a senior director in our finance department and who is here with me today, we are satisfied that the hospital can reduce non-front-line costs by approximately €6 million annually by focusing on just three areas. These areas, which are outlined in our document and can be discussed in detail subsequently, include staff payments, at 74%, which are extremely high compared with other large hospital. It also includes the hospital's considerable overtime and on-call payments amounting to almost €50,000 a day, and yet the hospital only targeted €0.5 million in savings in this category, which amounts to €18 million in the year. We believe all hospitals across the country would be targeting way in excess of this, and at least in the order of €2.5 million from that level of spend.

The hospital has provided a contingency for blood costs which we do not believe is necessary. We would be perfectly happy with the management of this blood supply through St. James's Hospital on a much larger scale whereby, we believe, this cost will not be incurred. There is also significant potential for increased income from adequate billing of private insurers. These savings can be made without any compromise on patient care.

In addition, there are several other areas that we outline such as management/administration functions which are duplicated and sometimes triplicated across the three hospitals, and also some clinical services areas such as out-of-hours services where activity in accident and emergency departments, etc., is minimal after 10 p.m. to 12 midnight, with each hospital seeing eight to nine patients after midnight. Activity in theatres after 10 p.m. drops to approximately one episode across the city per night across three units.

Commentary on wards over the past three weeks has created the impression that there has been a closing of 25 beds at Our Lady's Children's Hospital and that this would result in the loss of thousands of bed days. If the hospital was working at 100% capacity, that would be true. The hospital works at 80% capacity — this figure drops to 70% in Tallaght and it is also at 80% in Temple Street. It is perfectly logical when beds are empty that wards should be closed rather than having half-wards and three-quarter wards open across the hospital, which is not a good use of taxpayers' money.

Summer ward closures are carried out right across the system because acute work drops because there is less illness, and because consultants and families are on holidays elective work drops right across the health care system. It would make no sense not to bring about summer closures in that situation. The bottom line is that the beds are there based on the occupancy and the capacity.

We are beginning a comprehensive review of theatres, including utilisation and comparative analysis. A high-level preliminary review would suggest significant scope for improved utilisation of theatre space. We would hope to have the opportunity to reopen the closed theatres within the existing budgetary framework.

There have been suggestions that there have been widespread cancellations at Our Lady's Children's Hospital. This is unfortunate because it must be very trying for parents and guardians of children who must then worry why their child is being put off when it may be for clinical reasons. When compared with the equivalent period in 2008, activity levels at the hospital in the first five months of 2009 are comparable. Up to the end of May, 8,799 inpatient and day case procedures were carried out at the hospital. During this period a total of 76 procedures of the 8,800 odd were cancelled due to the unavailability of a bed. In only two cases was the procedure cancelled due to unavailability of theatre time. These are the figures from the hospital.

There has been a suggestion in recent weeks that 14 children with scoliosis have had their surgery cancelled due to the hospital's cost-saving measures. We have been told by the hospital that no such scheduled surgery has been cancelled due to cost-saving measures. We have been advised that two pre-assessments, which are not surgeries, for patients with scoliosis were postponed but have since been carried out. We have been advised by the hospital that there are now 67 patients with scoliosis who have had their pre-operative work-up assessment and are ready for surgery. We will work with the hospital to finalise a plan that will enable this surgery to be completed. Finally, we have been assured by the hospital that all children who require emergency care have received it as required and will continue to receive it.

Ultimately, it is our job to ensure the highest quality clinical care is provided to children in Ireland and we are committed to that. I, myself, have spent a lifetime working in paediatrics. It is extremely disappointing that we still have not achieved this across all disciplines despite the strong support of Government and the wishes of many parents for a single state-of-the-art national paediatric hospital.

The new hospital will provide an unprecedented standard of care for children and enormous opportunities for clinical staff to develop it as one of the great paediatric centres in the world. I appeal to everyone in a position of influence to assist in seizing this opportunity that is before us and work together in a concerted way towards opening the new hospital ahead of the current deadline of 2014.

In the immediate term we must cut back on all unnecessary expenses and all available resources must be used to maximum effect in terms of increasing the amount of service we provide to children. We are hopeful that the three independent voluntary children's hospitals and the HSE can work together to ensure this is achieved. On behalf of the HSE, I can give an absolute commitment that we will work with all three to ensure that this is achieved.

I thank Professor Drumm for being so brief and forthright.

I welcome Professor Drumm and his team and thank them for coming to talk to us. If I may, I will ask a few questions and make a few brief comments as well.

We agreed to allocate three minutes per member.

I will be brief. The NTMA stated that €20 million could have been saved by the HSE by altering its banking arrangements. Some €16.5 million is spent on advisers, €60 million is spent on taxis and transport where a 10% saving would yield €6 million, and there is a significant issue surrounding generic drugs.

I received a list from a couple of pharmacists. Losec, a drug used in the GI, is €36.90 for the brand leader and €27.70 for the Irish generic. If one is from Letterkenny, that is what one will pay. If one walks across the bridge into Strabane one will pay €1.

Risperdal, 2 milligram, is €107.74 for the brand leader, the cheapest Irish generic is €86.18 and the UK generic €2. Seroxat is €35 here, the generic is approximately €16.50 and in the UK, it is €4.50. Prozac is €21, and the generic in the UK is 49p. The list goes on. My point is, there are millions of euro to be saved in generic drugs. The HSE has been talking about it for four or five years and it has not been done.

I will make a few other remarks on redundancy, delayed discharge and the point Professor Drumm made about insurance being owed by VHI Healthcare and others to Crumlin. On the latter, the bill for the entire HSE is €160 million and, therefore, it is about average. There has been an increase in day case surgery, theatre activity, OPD activity, and the hospital has 13% administrators, no increase in beds, and no increase in accident and emergency attendances. There are 40 patients, I am told as of this morning, who should have been operated on for scoliosis.

I want to ask Professor Drumm the following questions. Why are we paying so much for generics? Why did the discussion document on co-ordination of the three hospitals, sent by Crumlin to him in August 2007, only get acted on in recent times? What are the waiting lists for cardiac and orthopaedic surgery? Can he confirm to the committee that the research fund mentioned by Deputy White is money raised voluntarily by people for research and capital spend at Crumlin hospital, not for revenue or day-to-day running? Would he, as somebody involved in research in the past, agree that this would be a significant breach of trust to the people who gave this money if it were to be used for revenue? Can the witnesses confirm that no cost benefit analysis exists to show the €20 million saving mentioned if the three hospitals join? It is a putative figure. Why not give Our Lady's Children's Hospital, Crumlin, its budget, given that most hospitals have increased budgets to reflect increased births? Increased births will mean increased activity and demand at the hospital. Given the current financial situation, is the national children's hospital possible in the next five years and where is the €1 billion in capital funding to come from? Is there additional funding for the recently announced new joint service for cystic fibrosis patients in the north east? This was announced by the HSE because the consultant there has been ill for some time. It was mentioned that the budget for Our Lady's Children's Hospital, Crumlin, went up by 37% since 2004, 25% of which went on salaries; what increase was there in the overall HSE budget during that period?

I thank the Chairman and I welcome Professor Drumm, his team and all of the people in the Gallery with an interest in this area. We all want to see everyone working together to find a solution to this; Professor Drumm gave a great deal of detail in his presentation regarding ways of making savings. However, the tertiary children's hospital is at least five years away and, regardless of the savings it might eventually bring, our concern relates to children who need treatment today.

There has been an increase in the budget for Our Lady's Children's Hospital, Crumlin, but there has also been a 30% increase in day cases in the past four years, a 23% increase in outpatients, a 34% increase in theatre procedures and other increases in activity. This has all happened in response to an increase in population and the high complexity levels of cases at the hospital, which Professor Drumm acknowledged in his presentation. No cardiac surgery has been sent abroad since 2007 and this has increased the burden on Crumlin hospital. There does not appear to be any income stream for sickle cell disease, though this has dramatically increased. There are many other areas of concern, such as cystic fibrosis, as mentioned by Deputy Reilly. Professor Owen Smith suggested Crumlin should be a centre of excellence for cancer; significant extra funding has gone into cancer care in Ireland but there is no designated centre for children. Should Crumlin have received extra funding in this regard? There has been increased demand placed on the hospital in Crumlin but it has not been funded in a structured way. The areas I mentioned should be funded because they are placing demands on the hospital.

It was decided that proposed summer closures at Our Lady's Children's Hospital, Crumlin, should not go ahead and a statement was issued in that respect. It said the decision was made in light of the existing pressure on services and the potential impact on children and families of additional closures. There is focus on the demands being placed on the hospital.

I know the HSE does not directly fund the National Treatment Purchase Fund, NTPF, but are there many cases of children's operations and surgical procedures being referred to it? The NTPF's 2008 annual statement indicates that only 9% of patients treated through the fund are children between nought and 18 years of age. Census figures show that more than 25% of the population is between nought and 25 years of age so I suggest that if children got their fair share of NTPF funding it would be possible to provide for the shortfall at Crumlin hospital while we wait for the savings that may accrue through combining the work of the three current children's hospitals and the arrival of a tertiary children's hospital.

It was mentioned that money may be sourced through health insurers but I understand that publicly-funded hospitals can only implement an 80-20 mix. That is to say, beds may be occupied by privately insured patients but the bill for the beds can only be charged for the 20% of beds allocated to patients with private health insurance. Do health insurers really present a realistic opportunity for savings?

We all want to ensure that very sick children in need of complex and expensive procedures are treated. Everyone will agree that Our Lady's Children's Hospital, Crumlin, goes out of its way to provide for the most complex and expensive cases. Some children spend much of the early years of their lives in the hospital and that is extremely expensive. Has a model been proposed to fund the hospital in accordance with the demands on it, as opposed to the crude method of funding hospitals based on what they received the previous year? Professor Drumm inherited this latter method, which has been used historically, and I am interested in his comments. Increases and cuts tend to be based on the previous year's allocation. Does the Professor accept that Our Lady's Children's Hospital, Crumlin, merits exceptional treatment for the reasons outlined?

I too welcome Professor Drumm and his team; like Deputy O'Sullivan, I feel we should acknowledge the interest that has been shown in this morning's meeting. It might be necessary for Professor Drumm to return to this committee to discuss the issue of the three hospitals, Crumlin, Tallaght and Temple Street, for an extended period. We also need to discuss the issue of the site at the Mater Hospital. I do not mean to be flippant but if St. Thomas walked these streets he would poke his finger in wounds and wonder about the situation. I am on the Government benches so I do not wish to be controversial but last week members of this committee were surprised, having gone through a rigmarole relating to Thornton Hall and the Central Mental Hospital, to learn suddenly that it is all over. If Professor Drumm walked the streets of Tallaght he would hear many people express uncertainty about the future of the Mater site. My colleagues have spoken of five more years but many people feel we are wasting our time. It is important to make this point.

What kind of contact does the management team have with the three hospitals? We may have to return to that topic on another occasion because we should remind ourselves why we are here today. The committee was very anxious to talk about Our Lady's Children's Hospital, Crumlin. We visited the hospital; I have been there before and am from the area. Professor Drumm's presentation gave the impression that there is no problem but when we spoke to the board, management team and parents at the hospital a different view was expressed. This was also the case when we spoke to parents outside the gates of Leinster House a couple of weeks ago. If there is a problem it should be dealt with; if there is no problem, this should be made clear. I want to know the absolute truth. Under the chairmanship of Deputy Ó Fearghaíl, this committee has been clear in its determination that front-line services for children should not be affected, regardless of changes to budgets and funding. What effective action will Professor Drumm and his team take to ensure this is the case? I would hate to think we will still be here in two or three months trying to deal with the concerns of parents and consultants. I am sure the witnesses have seen the letters we receive on this issue; they tell a different story to what we have heard this morning.

It is important that Professor Drumm understands — despite his excellent presentation this morning — that the jury is out. We need to know what the real situation is; we need guarantees and assurances. Parents are here today and want to know that sick children will be dealt with in the best and most efficient way. We should remember why we are here today; we are here to discuss Our Lady's Children's Hospital, Crumlin.

At this point nine speakers wish to contribute so I will go back to Professor Drumm and ask him to be as brief as possible so every member gets an opportunity to speak.

To put the record straight, I said 25% of the 37% went on salaries. It is actually 66%.

Professor Brendan Drumm

Some 65% to 70% of the budget of the health service goes on salaries so those figures are of no surprise to me. We need to deal with the financial situation because it will come up throughout the meeting. Ms O'Sullivan will deal with the question of whether the money is available.

Ms Raymonde O’Sullivan

The most recent figures we have received from the hospital indicate an expected overrun of €100,000 in the current year, not a deficit of €9 million. The figure is based on the May 2009 figures.

As the CEO said, the budget was not cut by €9 million for the current year. There was a €5 million cut in respect of value for money efficiencies. This was applied to all HSE institutions in the same percentage as it was applied to Our Lady's Children's Hospital, Crumlin. Indeed, it was applied to all Government Departments and reflects Government policy in regard to changing payroll practices and saving money on such things as taxis. The target applied to Our Lady's Children's Hospital is no different from that applied to any other hospital. The vast majority of hospitals and community services institutions have achieved these savings by reviewing other than front-line services. The detailed examination of the financial position at Our Lady's Children's Hospital, which we carried out in recent weeks, leads us to believe savings in the order of €6 million can be achieved without impacting front-line services.

The CEO has outlined three of the main areas in which this can happen. The first one is overtime payments. As is shown in the CEO's presentation, significant overtime payments were paid to various categories of staff in the hospital in the first five months of the year. If overtime payments continue at the same rate the hospital will incur a bill of €18 million for the current year while its cost containment plan targets only €500,000. My experience of other hospitals and community services institutions indicates that savings of much greater magnitude can be achieved, with my very conservative estimate of this being €2.5 million.

The second main area where savings can be made is in the area of blood. If members visited the hospital they would be told of the high costs associated with blood. We have a national management centre at St James's Hospital for the management of blood products and we suggest that it manages the entire blood budget. This would remove the need for Our Lady's Children's Hospital, Crumlin, to provide for a contingency of €2.2 million in blood products.

The third area, as mentioned by Deputy Reilly, relates to the generation of income. I am aware of the bed designation issue but 44 private beds are designated in Our Lady's Children's Hospital by the VHI and other health insurers and there are 16 designated day beds. The categories are not divided between private and semi-private so I have made a calculation, based on the daily approved rate of €730, and adjusted for the assumption that the beds will not be occupied all of the time, that €12 million can be generated by the hospital from its existing private bed stock. In its present projections the hospital assumes it can generate only €10 million so there is scope to generate an additional €2 million in that area without impacting on front-line services or changing the existing bed designation.

Other questions related to the cost-benefit analysis for the new hospital and the saving of €20 million. I have not seen the details, which are being prepared by the board responsible for the hospital, but having carried out my own examination of the overall budgets of the three hospitals, which amount to €260 million, I believe a savings target of 10% or even 15% is extremely conservative, given the synergies that could arise in areas such as facilities management and staffing, where currently there are three directors of nursing and two directors of finance. I have not carried out a precise cost-benefit analysis.

There has been an increase in funding for the hospital over the years for sickle cell disease and other procedures but it is in the form of contingency funding, amounting to €30 million, and it is at the discretion of the hospital to allocate that funding to meet specific needs as they arise.

Professor Brendan Drumm

The cost-benefit analysis has been done and will be published once the development board has done its work. There are 3,000 staff in these institutions, including approximately 500 or 600 in administrative and management grades. If we could reduce the staff numbers by between 300 and 350 in those hospitals by bringing the 3,000 staff together — and nobody would argue that we cannot do that — we would save €20 million and that is an extremely conservative figure.

The question of generic drugs was raised. Nobody has done more than this organisation to bring down the cost of medicines, despite much opposition in many meetings at which this issue was discussed. We brought down the costs of manufactured drugs by reaching an agreement, without conflict, with the manufacturers of medicines for four years of which one and a half years are left. That agreement brought down costs by 35% for everybody who went into a chemist. In concluding the agreement, we agreed not to impose generics but we will bring them in after this agreement with reference pricing. Pharmacists are making a fortune on generics at the moment because they are priced at a level very close to the mainline drug.

We will have to bring in reference pricing to get the benefits seen in the UK because our pharmaceutical business works on the basis that the price of generics is set by the arrangement between the generic companies and the retailers. That will require legislation because we cannot introduce it without the Government considering it. Reference pricing is absolutely required for drugs in this country and the HSE is 100% behind setting the price the taxpayer should be asked to pay. We are not 100% behind imposing generics, which are priced at a level that suits everybody except the taxpayer.

Other questions were on whether the national children's hospital would go ahead. From a logical point of view it has to go ahead and nobody argues against the idea that it is the right thing to do for children. If it does not go ahead, Temple Street Hospital falls so €200 million will have to be spent and that cannot be allowed. Much of Our Lady's Children's Hospital, Crumlin, is in really bad shape and will require very significant investment. The taxpayer will have to invest between €400 million and €500 million, which we believe would now build the new children's hospital. The development board is proceeding with its work and the savings we are making will pay for it. If it does not go ahead it will be a huge missed opportunity and we will still have to invest the money on the existing sites without any of the cost gains or, more importantly, the quality gains.

Does Professor Drumm have any information on the National Treatment Purchase Fund?

Professor Brendan Drumm

The Deputy suggested that 9% of children availed of the scheme as against 25% of adults but interventions on behalf of children are always much lower than for adults. After the first week of life, children do not have the same burden of disease as do adults, especially those in the over-75 age group, so it is not fair to compare the spend on children with that on adults. I do not have the actual numbers but I can get them for the Deputy.

Is it true that, for example, no scoliosis patients are referred because they are too complex, and the private hospitals will not do them?

Professor Brendan Drumm

There is a huge issue, for example, on much of the work going on in Crumlin. The issue of Ennis came up several times in relation to funding. The reason the funding here needs to be looked across the three hospitals is that there is no doubt that Crumlin is doing the vast majority of the extremely complex work in this country. That goes without saying. It absolutely is. Getting the funding rebalanced is a significantly important issue. Areas like scoliosis, and a considerable number of other areas such as cardiac surgery that are done in Crumlin, are not appropriate to the NTPF. The Deputy is absolutely right.

Should there be compensating funding for that reason?

Professor Brendan Drumm

I do not know that the NTPF is willing. There are regulations on paying to have NTPF work done by the same consultants in the same hospital where the waiting list arises.

I am not suggesting it should be done that way. I am just suggesting that——

It is a point to which we may have to return.

——in fairness, the funding should be put into that area and taken from the NTPF.

I would like the answers to the questions I asked.

No. I will go on to the next round of questions and I will try to come back to them at the end, if I have time.

There are a number of questions not answered.

I am afraid other members want a chance to put their question.

I accept that but there is no point in asking questions if one cannot get answers.

I will do my best to get back to them if I can expedite the process. I call Deputy Kathleen Lynch.

I will be as brief as possible. Having come through amalgamating three maternity hospitals in Cork, I recognise the difficulties that can arise. Despite the people who made the speeches at the opening, maybe those with the experience who put that hospital together should be called upon. Ms O'Sullivan will know about whom I speak. It worked fairly smoothly once the three hospitals came together.

My view is very much like Deputy O'Connor's. Every time we meet about an issue Professor Drumm comes in like the CEO of any big organisation, which perhaps is where the difficulty lies, and puts the case which is an entirely different case to what we hear from the practitioners. I refer not to finances because I am sure they are factually correct, but to the case and the spin which is different. I am not saying that Professor Drumm is deliberately spinning this, but the case or story is different.

We hear from the parents of children who are seriously ill. As Professor Drumm correctly stated, Crumlin deals with high-tech medicine and its staff are the experts in that area. These children are seriously ill. If they do not need immediate treatment, they need ongoing treatment and their parents are justifiably worried about cutbacks in whatever guise Professor Drumm wishes to call them.

One cannot take Crumlin in isolation. My experience is that when a child is referred to Crumlin for a particular treatment, hospitals at local level take up the monitoring in between treatment and are also in regular contact with Crumlin. The funding for all hospitals around the country is now being cut. It is not just about what is a centre of excellence in Crumlin, despite the decaying building around it. It is not just about Crumlin; it is about the entire health service as it is applied to children, and that is our problem. Our problem is that we need to ensure that the service is there for children who either develop or are born with sometimes rare, but most times life-threatening diseases. That is the story we are hearing, which I believe is true. I am not saying that Professor Drumm's story is not true, but they just do not match.

For instance, when will we see a proper paediatric diabetes service in Cork? Because we do not have it, parents are now asking that their children be referred to Temple Street in Dublin where, despite the distance, they get a better service. It is not just about a centralised centre of excellence; it is about all of the complementary issues that arise as well when they go back home. Professor Drumm is quite correct on the National Treatment Purchase Fund in that one does not want to send children far away from home for long periods of time.

The Deputy's time has elapsed.

Can Professor Drumm explain the mismatch in the story? The story we are hearing is clearly true and the story we hear when the professor comes in here does not match up.

I welcome Professor Drumm and his delegation to the meeting. Those of us who visited Crumlin would quickly realise that no child is there unless he or she absolutely needs to be. We are talking about very sick children with life-threatening illnesses. When people then hear of the closure of wards and theatre, the unnecessary and dreadful panic and fear that it sets off among parents is considerable. The one important message that must go out from today is that no child requiring emergency treatment or emergency surgery will suffer as a result of any proposed cutbacks. We cannot have a situation where the most sick children in this country are made to suffer because of budgetary constraints.

Perhaps Professor Drumm would give some consideration to the suggestion by the Vice Chairman, which I support, of having somebody leading the delivery of paediatric services in this country. We would all agree that Professor Tom Keane has done a brilliant job and we need somebody of his ilk who would have the expertise and knowledge to move this along and bring all of the different parties together.

When Professor Drumm speaks of the funding for Crumlin being down €100,000 this year, there is also the problem of Crumlin's outstanding debt of €10 million. How does the HSE plan to deal with that? It is a significant concern for the management of Crumlin.

Professor Drumm also mentioned St. James's Hospital in terms of managing blood products. I want to know whether there has been any dialogue or discussion between Crumlin children's hospital and St. James's Hospital in terms of moving this along because if savings can be made and he can expedite this as quickly as possible, then that needs to happen.

There was also mention of the thousands of days. So that we will get all of this cleared in the media, I want to know how many bed days will be lost.

Professor Drumm spoke about savings among the three hospitals and about the board doing their work. He stated that the cost benefit analysis will be made available as soon as it was ready. There is an urgency to have that as soon as possible. If the positions are bad this year they will probably be much worse next year, and if there is a way where savings can be made by the synergies from the three hospitals, there is an urgency to have that done as quickly as possible.

The new hospital is due in 2014. Realistically, how far down the road are we? What is the position on planning and the delivery of this? Is 2014 a realistic date?

I thank Professor Drumm and his team for coming here today and for his presentation. In line with what a number of my colleagues have said, I suppose the most striking aspect about the presentation is the difference between the way he and his team are presenting the situation in Crumlin today, and the way the parents and the management team speak about it and the briefing we received when we visited. There is a striking difference between the two presentations. For us, as a committee, there is a kind of credibility gap in Professor Drumm's presentation today, given what we have heard already and given what the parents tell us about their own experiences. How does Professor Drumm explain this and what does he intend to do about it? What steps will he take to work with the hospital to deal with the credibility gap and the different explanations given by the HSE and the hospital? That is my first point.

That is an important point. When one looks at the points Professor Drumm made, obviously quite a few of them make quite a good deal of sense. The question that arises in regard to the bloods issue is that if it so obvious, why has it not been done already? Are Professor Drumm and Ms O'Sullivan saying that great savings can be made in overtime payments? The staff we met at Our Lady's Children's Hospital, Crumlin, told us they are not replacing staff on maternity leave, so what is the impact of reducing the overtime payments? I presume there would be fewer nurses on duty. What impact will these reductions have on front-line services? That is a very important question. Are Professor Drumm and Ms O'Sullivan saying that it is easy to reduce the level of overtime? Will that not have an effect on front-line services? The only place in Professor Drumm's presentation where he effectively acknowledges waiting lists is in the treatment of children with scoliosis, and he states he is ready to work with the hospital to finalise a plan for these children. The board and management of the hospital tell us that there are several areas where treatment is being delayed or it is in danger of falling behind best international practices, because it does not have the ability to respond as quickly as it would like because of its budget funding.

The treatment of scoliosis is the area that has got most public attention but the hospital states there are other areas where treatment is falling behind. I raise that because Professor Drumm states in his presentation that he believes the funding is adequate based on the current work loads. Is he taking into account other areas where treatment may fall behind or developing services? We all know the world class services that are being developed. Is Professor Drumm allowing for funding there? There is a belief that the new and emerging treatments that Crumlin are doing are not getting the funding they need.

Is there a possibility that current funding for current patients is being compromised because the plan is for a new general paediatric hospital? How much is that affecting the funding that he is willing to give to Crumlin to deal with the current cases?

I am conscious that time is passing very quickly. If members agree I will take all the questions at this point and return to Professor Drumm for detailed responses. Is that agreed? Agreed.

Thank you Chairman. I welcome the opportunity to air our grievances. Issues raised in the media for some time concern public opinion on services in Crumlin and the treatment of children in hospital. In our constitution we undertake to cherish all the children of the nation. What better way to put this into action than by making adequate provision for health care? If one was to listen to Professor Drumm, one would think that everything is great, but this is not the reality. There are parents from all over the country in the public Gallery. Parents throughout the country are waiting to see what will come out of this meeting today. There are problems for children, particularly those with scoliosis, and there are waiting lists. An assessment for a member of my family, for instance, has been cancelled by Crumlin hospital three times. The statistics provided are at variance with the reality. We need to investigate the problems.

We all agree with the necessity for cutbacks in these recessionary times and value for money. The issue most be sorted. There is an onus on everybody, the HSE, on Crumlin and on service providers to bring the treatment of child patients up to scratch. That is what is important.

Every question I wanted to ask has been asked already. We are here to get answers and I hope we will be able to tell the parents of the children that treatment will be available, whether assessments or operations are needed. We all know that in the treatment of scoliosis in particular if we leave a child without treatment, the scoliosis gets worse and it will be more costly on the HSE in the future. One operation at seven years or eight years of age could resolve the problem, but when the child is ten or 11 years it could involve three or four operations, which is an additional cost. We need to get answers and we need to get funding to ensure we provide treatment for children.

Thank you very much Chairman. We must focus primarily on the patient and the needs of the patient. In this instance we are talking about services for children in Crumlin hospital. We must also recognise that we live with a finite resource. That is always the way. No country in the world has enough money to provide for the demand on the health service. If one provides for need one is doing well. The sum of €16 billion is almost half the revenue that we will take into this State this year. We have to find ways and means of living within our resources.

I have a difficulty as a member of this committee with the conflicting figures that we get. We must find a way of standardising the figures so that everybody is working off the same figures. We cannot do our job as a committee if we get different sets of figures that conflict and we are not in a position to judge the correct figure. Will the delegation provide me with the outturn for 2008 and the allocation for 2009 for Crumlin hospital?

I was very pleased with the contribution of Professor Drumm this morning. I was very pleased that he had identified areas where savings of €6 million could be made, in areas such as pay, on the blood transfusion service and on private insurance. What progress has been made under each of those three headings in achieving the targets that have been set out? On the question of comparative analysis, how is that work progressing not just in Crumlin but right across the different agencies and particularly between the different hospitals and how might we make more savings as a result of finding best practice and applying it across the board? I am all in favour of the new hospital and having it built as expeditiously as possible. It will make a major contribution, not alone to improving the level and quality of service for children but in getting better value for the money spent. I agree with Professor Drumm that in the meantime we must look for ways and means of getting the most efficiency out of the three hospitals. I agree with the points about three outpatients.

I fully support the Mater site. When I was Minister for Health, I initiated the move to bring Temple Street hospital on to that site. That is a long time ago. I fully support the site and the sooner we get on with building the hospital, the better.

I too welcome Professor Drumm and his team. I will reiterate a previous theme. The information presented to us when we visited Crumlin and what we have heard today is almost impossible to reconcile. What is the relationship between the HSE and the board of management of Crumlin? We were told that the hospital could not guarantee that emergency interventions would take place. We were also told that the hospital has the lowest management and administration costs of any hospital in Ireland. Yet it is in those areas that Professor Drumm states that he has the greatest opportunity to make cuts. It is almost like discussing two different institutions from what we heard during our meeting of several hours in Crumlin and what we are hearing today. It is impossible for me to come to a conclusion on the real situation. The board of management and the management we met were very sincere, open, convincing and up-front with us. We certainly came away feeling that we were well informed on the difficulties. We contributed in the Dáil on the basis of what we heard there. Today, we get a different slant on it. What is the true situation or what is Professor Drumm's response to how we reflect on our meeting with the Crumlin management and board?

I welcome Professor Drumm. According to his briefing, the hospitals are beginning to engage in preparation to move, hopefully, in 2014 and we will have the completed centre of excellence. Has a project team been appointed to this move and who is involved in it? Who is co-ordinating and who is overseeing it?

With the increase in birth rates all around the country, what percentage of referrals are coming from around the country, what impact has this on hospital inpatient treatments through elective surgery on any given day or night, and what percentage of surgery has been cancelled in Crumlin?

On the same point raised by Senator Prendergast, Professor Drumm indicated the hospitals were "beginning to engage". How certain is that position? "Beginning to engage" is a vague statement, and yet Professor Drumm has welcomed it in the context of the move to a national paediatric hospital in 2014. With "beginning to engage", anything could happen over the period ahead. Can he give us any greater certainty than that phrase?

Professor Drumm indicated, and one would agree, that this should have been achieved many years ago and sick children should be experiencing its benefits today. While he is presenting, as the Minister, Deputy Harney, does time and time again, the end product in terms of addressing all of these matters, that is, the new national hospital in 2014, what is to happen in the interim? There are five years between 2009 and 2014, if this goal is to be realised in 2014. With respect, there is no acknowledgement on his part this morning that there are services curtailed and operations cancelled and that real suffering continues to be experienced. The reports in various national newspapers outlining the accounts, experiences, suffering and concerns of parents of children about services at Crumlin, from Ms Michelle Murray about her son Simon, through to the family of Ms Jamie Murphy——

It is not appropriate to introduce individual cases.

These are already in the public domain.

We have no control over what is in the public domain. We have some control over——

With respect to you, Chairman, do not be taking up my three minutes.

——how we transact our business.

This is important business. These issues are in the public domain and nothing in what Professor Drumm has said this morning will give solace to any of these families.

I am concerned at the fact that in his own statement, Professor Drumm spoke of a €100,000 deficit or shortfall at the year end at Crumlin hospital, something confirmed by Ms O'Sullivan. He dismisses the budget cut of €9 million that has been reported and referred to continuously over the recent past. If that is not the case, Professor Drumm did not share the information with us that Ms O'Sullivan did, that there was indeed a €5 million cut. Professor Drumm spoke only of the €100,000 deficit, as his statement quite clearly indicates, but nowhere in his opening statement did he acknowledge that there were cuts. Ms O'Sullivan indicated that there had been cuts of €5 million. It was not just €9 million; we were advised it was €9.1 million. No doubt somewhere some factual information will present to give credence to that particular claim. It cannot have been picked out of the clouds.

Regarding cancellations, Professor Drumm said in his statement:

During this period [up to the end of May] 76 procedures were cancelled due to the unavailability of a bed. In only two cases was the procedure cancelled due to unavailability of theatre time.

HSE figures state that in 2008 there were 5,000 procedures cancelled in Crumlin and over the first five months of this year, up to the same corresponding period, some 2,000 procedures have been cancelled. They cover a cross-section of various operative procedures, etc., but these are real cancellations. No doubt many of them are deferrals and have been rescheduled, but can Professor Drumm tell us exactly what the figures are? Will he acknowledge that these cancellations-deferrals have taken place with great inconvenience for the families concerned? Can he tell us how many children are waiting longer than three months for procedures-operations in Crumlin?

I thank the Deputy.

There is one last question. The Chairman took up a little of my time.

I have given the Deputy back some time instead.

What services will be provided? We will take the most positive view of 2014. What continuing paediatric services, if any, can we expect will remain at both Tallaght and Crumlin post the advent of that new facility at the Mater site?

I welcome Professor Drumm and his team. I also welcome people from Graiguenamanagh in my constituency, including Ms Jamie Murphy's mother and aunt, Ms Triona O'Brien. While we will not be dealing in individual cases, I want to address my remarks solely on the scoliosis issue to Professor Drumm.

Let us get it quite clear here. The hospital has reiterated that no child has been denied access to emergency life-saving surgery due to the hospital's breakeven programme. It is my understanding that a patient, a very ill child had to go to Great Ormond Street Hospital because of waiting times in Crumlin and is now so ill that the operation cannot be performed until she has pre-operative work implemented in Dublin prior to, hopefully, an operation to reverse an 80° curvature of her spine. If that case was not an emergency, what case is? I understand that the case was a priority but not an emergency, and a second opinion has now said that this is a gravely ill little girl and the case is an emergency.

I am no medical expert but I have got myself up to speed on the scoliosis issue. Is it true that once a patient gets to a 50° curvature of the spine, an operation should be performed as quickly as possible? There are patients with an 80° curve and a 60° curve who are waiting and have been told that they will have pre-operation assessments in Crumlin but no operation date prior to Christmas. I want to find out what is best practice here and how the pain for the children and the stress and frustration for those families can be alleviated.

The numbers may have dropped since I got this information, but I understand there were 180 scoliosis patients on the list waiting for surgery. That number has dropped to 168. I have been told — I ask that this be confirmed — that only one operation per week is being performed. If there are 168 scoliosis patients waiting and we are performing one operation a week, some of those patients will wait a couple of years.

Since Deputy Reilly mentioned me in the context of the €30 million in fund-raising and stated it was a "breach of trust" to mention putting our fingers into it, in fact, the foundation has stated it is spending some of that money on improvements to the hospital's emergency department. What I have stated on the record of the House is that there may be other essential items that it could be spent on as well as necessary pioneering research.

Those are my questions. I note Professor Drumm, in his opening statement, stated that the HSE has been advised "by the hospital that no such scheduled surgery has been cancelled this year due to cost-savings." The problem is there are very sick children who are emergency cases who are not classified as emergencies who cannot get their operations. This is what is causing great distress to families, not only in my constituency but throughout the country.

For the record, I am substituting for Deputy Bernard Allen. I am pleased to have an opportunity to put some questions to Professor Drumm and the HSE. It is disingenuous to suggest that the HSE merely provides the funding and that all the decisions on cost cutting or management changes in Our Lady's Children's Hospital, Crumlin, are matters for the hospital, the authority or the board.

The Minister has made it quite clear to me in the Dáil. She said: "The HSE is working closely with Our Lady's Children's Hospital to achieve an agreed programme of savings, totalling €6.5 million this year." That is another new figure. Is it €5 million, €6.5 million, €9 million or €100,000? Can Professor Drumm please give us clarity on the issue? Can he also clarify whether there is a programme agreed by the hospital and the HSE for those cost savings or is the HSE simply an observer in the process?

I will ask a question that no one else has asked. I am told the waiting list for scoliosis and general spinal treatment has been lengthened by the retirement of an orthopaedic consultant in Cork. Has that had a negative effect on waiting lists? Are there plans to recruit a replacement orthopaedic consultant?

My third question relates to the National Treatment Purchase Fund. The HSE figures show that 67 patients are ready for surgery. Can some of the children to whom we referred access the NTPF? If Professor Drumm does not know the figure he should know it because parents ask that question of people like us and they expect an answer. My understanding is that 50 scoliosis patients are treated per year so if 67 are waiting for surgery they will be waiting for a year or longer while their spines grow crooked.

On bed availability, the HSE's presentation stated it was perfectly prudent and acceptable to close wards during the summer months but also states 76 procedures were cancelled this year because of the unavailability of beds. Can I assume the beds closed for the summer months will be reopened in the autumn, when the so-called summer lull is over? I have anecdotal evidence that there is a significant problem in terms of the availability of beds in the ICU unit and the transition from the ICU unit to wards. I do not accept that evidence because I am not an expert in the management of hospitals or health care but I will read a text message sent by a doctor in Crumlin.

The Deputy's time is up.

I will finish on this point. The text was written on 16 June. It states:

Five children in accident and emergency waiting for beds on wards in hospital. Six children waiting for discharge from ICU to beds on wards. This is the result of closing ward in hospital and has an impact on spinal service. If a hospital outside of Dublin needs a bed for a critically ill child in ICU today we are snookered.

Is Professor Drumm telling me there is not an issue with bed availability in Our Lady's Children's Hospital when I receive texts such as that from people working at the coalface in the hospital?

Professor Brendan Drumm

A number of points suggested the figures did not tie up but any figures we have put in front of members have come from Crumlin. All we have done is get back to the hospital with recommendations on where savings should be made. The figures we have put on the table are not ours but have come from and been validated by Our Lady's Children's Hospital. The figures relating to cancellations are provided by the hospital. The clinical decisions on whether people go through the NTPF are purely for the hospital and NTPF is available to any child referred by the hospital.

Professor Drumm said earlier that it was not available because of the type of treatment.

The Minister for Health and Children told us last week that scoliosis patients could not go through the NTPF.

Professor Brendan Drumm

This is crazy. I did not say that but that there were children who were very sick but not appropriate for the NTPF.

Professor Drumm said there were exceptional cases.

Professor Brendan Drumm

That is exactly what I said. It is for Crumlin to make a clinical decision as to whether to refer a child through the NTPF if his or her condition is at the appropriate level of severity.

The reality is that there are many exceptional cases in Our Lady's Children's Hospital.

Many members have asked questions and I would like all the questions to be dealt with. I will try to take supplementary questions for clarification if members allow us to get through this set of questions.

Professor Brendan Drumm

The second issue relates to figures. There is certainly a problem in Our Lady's Children's Hospital as 70 cases are waiting for scoliosis surgery. We are saying that the savings can be made so that those operations can be carried out. We need to get on and make those savings as we do not have another bucket of money. Deputy Ó Caoláin said I did not mention the 3% cut in my statement but I did mention it. I clearly mentioned the fact that the cut was being made.

Professor Drumm mentioned the €5 million but dismissed the €9 million and only referred to the €100,000.

Professor Brendan Drumm

I did not. It was in my report that every hospital in the country had been asked to make cuts. Do I want to make those cuts? Do I want to put the Government's policy into action in this regard? I would, of course, prefer not to have to do so.

Were the three maternity hospitals cut by 3%?

Professor Brendan Drumm

Every hospital was cut.

Then it must get an extra allocation at the other end.

Professor Brendan Drumm

Every hospital has to bring in management and administrative costs.

Professor Drumm is leaving at 11 a.m. Either we give him the opportunity to answer the questions or we go home frustrated by not hearing his answers.

Professor Brendan Drumm

We are seeing if we can come up with the money to do these cases because Deputy White is absolutely right — it is not acceptable for us not to do them.

On the interaction between the HSE and voluntary hospitals, members need to look at the relevant legislation. We have very little control over voluntary hospitals. The Comptroller and Auditor General has control but we must seek permission to go in to such places. Our Lady's Children's Hospital, Crumlin, worked very co-operatively with Ms Raymonde O'Sullivan and I give it full credit for doing so. It could just as easily have said it was not ready to meet us for several months. The legislation on the interaction between voluntary agencies and the HSE needs looking at if we are going to be challenged in this regard. We cannot go in and impose on Our Lady's Children's Hospital.

The cost savings were agreed with the HSE.

Professor Brendan Drumm

We cannot go in and tell Our Lady's Children's Hospital it must deliver cuts, apart from the 3% required by the policy, and we cannot even tell the hospital how it is to implement that. It is outside our remit.

Has the HSE agreed the cost saving programme with Our Lady's Children's Hospital or not?

Professor Brendan Drumm

It has not given us a cost saving programme that has delivered the 3% savings. It has delivered very little. We are meeting with the boards of the individual hospitals to ask them to agree a superstructure with a senior executive input in the form of Mr. John O'Brien who has huge experience of running hospitals. We would then begin to get much more interaction between the HSE and the agencies on exactly the issues the Deputy has raised. If we could get agreement, everybody in this room would be much happier, as would the parents who have to suffer from the daily worry of cancellations and other things. It can only be achieved with the full co-operation of the boards and that is where the legal position comes into play.

Mr. John O’Brien

We have been trying to work with the hospitals at board level to come to arrangements that allow us to engage with them in the way we have discussed. It is necessary to do so and the process is ongoing. Until such time as the hospitals agree, our authority to do this does not exist.

Professor Brendan Drumm

It is absolutely the right approach. A number of questions related to occupancy.

Ms Fionnuala Duffy

I can understand from a parents' point of view how they would be very alarmed when they hear of bed closures and believe it will mean the patient will not be admitted. The reality is that there are more than enough beds open to deal with all the work requirements. When we look in detail at the occupancy level in each of the three hospitals, on any given day only 80 of every 100 beds have patients in them. There are always spare beds every day in each of the paediatric hospitals. Ward bed capacity is not an issue. I accept critical care is very different and we are dealing with that differently. Bed closures across the wards are not a reason to reduce activity levels. Even at the busiest time of the year there is never more than just over 80% of the beds filled on any given day in the paediatric hospitals. These are the bed occupancy figures supplied by the hospitals.

Professor Brendan Drumm

In terms of critical care, Deputy Coveney is absolutely right. We have a significant issue in critical care in Crumlin specifically because most of the most complex work is done in Crumlin. We are trying to work with the hospital to open critical care space. The money to develop that new critical care space in the interim period up to the opening of the new children's hospital is actually held in the capital plan and we do not have an agreed capital plan from Government. We believe Crumlin needs that critical care development. While there is no issue around occupancy of regular beds in Crumlin and there is no reason for anybody to be held in the accident and emergency department, there is an issue——

According to Professor Drumm's statement, 76 procedures were cancelled due to a lack of beds.

Professor Brendan Drumm

I did not say that. The figures provided by Crumlin state that 76 procedures were cancelled due to a lack of a bed, but it also reports 80% occupancy.

A bed in ENT is no use to, for example, a cardiac patient.

Professor Drumm

The beds are built in blocks and are used across all specialties. The days of using individual wards other than for critical care specialties are long gone. That is the way the health services of the world are run. I hope the day is gone when somebody is waiting for a bed when somebody has a ward that is empty. The issue of critical care——

Only a couple of weeks ago, a patient was referred to a hospital in the UK because there was no bed for a patient with a psychiatric condition.

Professor Brendan Drumm

I am not going into individual cases.

Let us deal with the facts. This is spin.

Professor Brendan Drumm

As I keep stating, the facts, including the cancellations, are from Crumlin and validated by Crumlin. Crumlin validated 76 cancellations, many of them are self-cancellations.

Ms Fionnuala Duffy

We have the same list as the Deputy. The Deputy is correct that in 2008 there were more than 5,000 cancellations, but when one looks at the detail on the list, more than 3,000 were immediately rescheduled. While the admissions were cancelled on the day, the patients were admitted subsequently. More than 1,000 were cancelled by the clinical team which means the patients were not suitable for admission for clinical reasons. More than 600 admissions were cancelled by the parents of the child. The vast majority of the cancellations were for reasons that had nothing to do with funding or availability of resources in the hospital. When we look at the profile of the year to date, the same reasons come up in terms of normal scheduling of children. Very often the child is not ready or the date of admission is not suitable for the surgery or the procedure.

With due respect, to say that the admissions were cancelled and rescheduled immediately does not mean that they were readmitted immediately.

Ms Fionnuala Duffy

My apologies but the information we have states they were.

To put the 600 cancellations by parents as the figure for the majority of other reasons just does not stack up.

Will members please stop interrupting and allow Professor Drumm to continue.

Professor Brendan Drumm

We were asked about the development of the new children's hospital and getting the savings beforehand. I will ask my colleague, Mr. John O'Brien, who is on the board, to address the questions raised by a number of members, including Senator Prendergast.

Mr. John O’Brien

In terms of the progression of the development of the new hospital, the nature of a project such as this is that an enormous amount of the work needs to be done to get to the point of putting a brick on the ground. This work is quite extensive and planning-based, and the critical issue for the board at this stage is to get a full complete design brief. The most critical part of the design brief from the perspective of the hospital, the clinicians and the patients is the model of care that is used to guide the determinations, the content of the hospital and how it will function. That work is ongoing and again I would like to reiterate that we are delighted that all three paediatric hospitals, including Crumlin, are involved in the process of looking at the model of care and have willingly participated in that part of the process with us. The expectation is that the second iteration of thatdesign brief will appear this month for consideration by the development board and progress is in accordance with the plan and the timeframe to allow the hospital to come in on time in 2014.

One element of the cost-benefit analysis that has been done and is completed is on the saving that will be achieved by building a hospital of this type and the way we are doing it. The board will look at that issue on Monday next when it goes through the detail of that particular cost-benefit analysis. The board of the National Paediatric Hospital will deal with the €20 million to €25 million in that report that the Deputy raised. All of the organisational infrastructure necessary to enable the development to proceed is in position. The full project team is being appointed, a business team has already been appointed and we are about to go to the market for a design team, when the design brief is available, and they will do a preliminary design. The project is absolutely on target in terms of achieving the target date and potentially likely to come in before it.

Two of my questions have not been answered. From where will the €1 billion capital fund to develop this hospital by 2014 come in the current economic climate? I do not think anybody in this room believes this will happen. Will the delegation confirm if there is additional funding for the recently announced new joint service for cystic fibrosis sufferers from the north east?

Will the delegation also deal with overtime?

Will Professor Drumm address the question of provision for those with scoliosis? We need some clarification on the care of people with scoliosis. If Crumlin hospital was to be given ring-fenced funding specifically for scoliosis, could it carry out more than the 50 procedures it is doing at present? I ask that question in the context that the Minister for Health and Children stated in the Dáil last week that scoliosis patients could not be treated through the National Treatment Purchase Fund because private hospitals do not treat scoliosis. If funding were diverted directly to Crumlin for that purpose, because it is one of the tragedies that children must wait——

There appears to be confusion on that issue because in a written response to me last week the Minister indicated that scoliosis patients could be dealt with in exceptional circumstances by the National Treatment Purchase Fund.

I thank Ms Duffy for her response on cancellations and deferrals, but I cannot be happy with the explanation. The addendum question I posed was to ask for the figures for the number of children currently waiting for more than three months for specific operations at Crumlin hospital. It is very important that the question is addressed. With respect, Professor Drumm spoke earlier about being fulsome with the facts. In his opening statement on all the reports on cutbacks and the shortfall, he stated, "Talk of cutbacks of €9 million are misplaced because they never existed." With respect, that is significantly misleading.

The Deputy has made his point.

I do not accept the reasons given for the cancellation of assessments. I have been told by parents that appointments were cancelled on two and three occasions by Crumlin hospital because of cutbacks. The information we are getting today does not add up. When we went to the presentation in Crumlin hospital two weeks ago, we were told the second theatre was closed because beds were not available.

We will not get a chance to hear the responses if we have a great many more questions.

I want to ensure that Professor Drumm does not go before he answers my question. I have a supplementary along the same lines as Deputy Aylward. We know that very ill children have had their operations cancelled. Whether we are splitting hairs between priority and emergency does not matter to the parents of ill children. They want their children dealt with, and it is a tragedy that some children must go abroad for operations because they cannot get the service here. I do not want Professor Drumm to go before answering those questions.

I would like clarity as to the level of savings the HSE is trying to achieve in Crumlin in terms of the spend this year. Is it €6.5 million or is it €5 million? The Minister stated it was €6.5 million. Is it now €5 million? Has there been a change since the Adjournment debate?

I would like Professor Drumm to answer two of the questions, one put by Deputy Coveney and one by me. They relate to a replacement orthopaedic surgeon in Cork and the paediatric diabetes service.

All right. I will allow no further questions.

Professor Brendan Drumm

Perhaps Ms Duffy will answer that because I have no information on that.

Ms Fionnuala Duffy

There was early retirement of an orthopaedic surgeon in Cork. That has added to the pressures overall in orthopaedics. The replacement did not have a special interest in paediatric surgery. However, the hospital has reassured us that it is advertising a further consultant post which is funded and it is seeking somebody who will focus on paediatric orthopaedic surgery. That should divert appropriately some of the workload that is coming up to Crumlin back to where it should be done in Cork. We expect that is the solution for that.

In the meantime, can surgeons from Dublin use theatre time in hospitals in Cork for children from Cork? That is what they are offering and want to do, but they need to be facilitated by the HSE to do that.

That is definitely the last question. Let us hear the answers.

Professor Brendan Drumm

Ms Duffy will address the issue of waiting lists.

Ms Fionnuala Duffy

The hospital provides us with waiting list information every month and the latest information we have is from the end of May. That indicates that there is a total of 411 patients who have been waiting more than three months for admission. When we discussed that with the hospital it transpired that several of those patients were listed as waiting because they require staged surgery, particularly in cardiac surgery, over their lifetime. Many of those may not need to be admitted immediately. I would also like to point out that the figure of just more than 400 is in the context of an activity level of more than 11,000 per annum. That is the waiting list position.

There was another figure of 168 in terms of the waiting list. Again, we spoke directly to the orthopaedic surgeon and asked about that and it transpires that the number of patients that today are ready and available for surgery is 67. A number of those patients are on the waiting list because they anticipate that they will require surgery over the next year or two and are trying to plan ahead. They are not all necessarily waiting for surgery today. The number in that category is 67 and we believe that within the capacity that exists across our hospital system, with theatres, with beds — and there are now many unoccupied beds — and with the staff we have invested in, there is the capacity to do those procedures this year.

They are waiting for assessment.

Ms Fionnuala Duffy

The assessment is a very different thing. What I have been talking about is waiting for surgery, which is related. There is no excuse for cancelling assessments. They do not need theatres. They do not need beds. We have put significant investment, for example, more than €1.2 million in an MRI service. I cannot see a reason for the cancellations.

Professor Brendan Drumm

It is not acceptable to us that people are not being assessed. That does not involve large amounts of money, but I will not go into why that might happen. Does Ms O'Sullivan want to address the issue of money because Deputy Ó Caoláin says I am misleading him?

Ms Raymonde O’Sullivan

There are a couple of issues regarding the figures. The first is the €9 million which was portrayed as being the shortfall at the hospital. In his statement the CEO states that there is not a shortfall of €9 million. The hospital's budget was not cut by €9 million, so the figure of €9 million does not exist. That is the first figure that is out there. The second figure is the €5 million that I mentioned earlier. The €5 million is the amount by which the hospital's budget was cut in the current year. That relates to the 3% target in relation to such matters as management and administration and that is specifically referred to in the CEO's statement. It is on page 5 and it is under the box which shows the table. While the figure of €5 million is not specifically referred to, the 3% cut is mentioned and the 3% of the hospital's budget does equate to the €5 million. That is where the €5 million comes from. The third figure, the €6 million or the €6.5 million to which the Minister referred, relates to savings. Having conducted an examination of the hospital's figures, we feel that savings of the order of €6.7 million, to be very precise, could be generated. They are set out in the CEO's statement. A sum of €2.5 million relates to overtime. I will return to that issue. A sum of €2 million relates to potential additional income in relation to the existing private bed stock. A sum of €2.2 million relates to the blood issue.

To return to the issue of overtime, where we feel the savings on overtime could be made has less to do with the number of hours worked on overtime and more to do with the rate being paid for overtime. It is our understanding that at the moment the hospital is paying a rate in excess of approved rates. We feel that if, rather than cutting back on the amount of overtime, it reviewed the rate being paid that would enable it to generate savings.

Who is being paid too much?

Ms Raymonde O’Sullivan

I refer specifically to nursing overtime, which is the biggest category of payment. We discussed this with the hospital two weeks ago and our understanding is that it had some negotiations with the unions and that, as and from last week, there was a decision that revised rates will be implemented. I do not have the precise date of implementation. Our understanding is that there will be a change in the rate rather than a change in the hours.

Is Ms O'Sullivan saying it is not envisaged that it will have an impact on front-line services?

Ms Raymonde O’Sullivan

I would not envisage that. It involves a change in the rate. The €10 million deficit arose as a result of an overrun the hospital had in 2007. When a hospital overspends it does not have sufficient cash. In 2007, therefore, the HSE allocated additional cash to cover the amount of the overrun. There is a difference between the budget of a hospital and the amount of cash we give a hospital. While there was an overrun in 2007, we allocated additional cash to ensure that all payments to staff and suppliers will be made in full. That overpayment has continued to the present time. What we will need to do, and we will do this with all hospitals, is sit down with Crumlin hospital and see exactly what its cash position will be at the end of this year so that we can ensure it does not find itself in a position of being unable to pay staff or suppliers. While there was an overrun and a €10 million debt in 2007 we have allocated sufficient cash to fund that debt and have continued to do so up to the present.

Does this funding pay the interest?

Ms Raymonde O’Sullivan

Yes.

So the debt remains?

Ms Raymonde O’Sullivan

No. We have given the hospital the cash. We lodged it into its bank account.

Is the debt still there?

Is it just to service the debt?

Ms Raymonde O’Sullivan

No. We gave the hospital the cash. It is in the hospital's bank account. There is no loan outstanding.

The HSE gave the hospital €10 million?

Ms Raymonde O’Sullivan

The debt appears on the hospital's books as an accounting entry but if one were to look at its bank statement there is not an overdraft or debt of €10 million.

Has the €10 million been repaid?

Ms Raymonde O’Sullivan

We gave the hospital the €10 million in cash.

That is not the question. Has the €10 million been repaid?

Ms Raymonde O’Sullivan

Does the Deputy mean has the hospital given it back to us?

No. Does Crumlin hospital owe €10 million?

Ms Raymonde O’Sullivan

Technically on paper, yes, but we have given it to the hospital.

The HSE has given the hospital the €10 million to cover that.

Professor Brendan Drumm

We hope it will not have to happen again in any hospital because every other hospital in the country will get very upset. Deputy O'Hanlon asked a question about the end of 2008 and the start of 2009.

Ms Raymonde O’Sullivan

The outturn for 2008, which is the amount that the hospital would spend was €144.4 million. The budget for 2009 is €134 million. Obviously there was a €5 million cut in last year's budget in relation to the value-for-money target but the other reason for the main adjustment is the fact that the hospital is generating significant additional income in relation to the pension levy, approximately €5 million additional income in the current year. It is generating more than that.

Professor Brendan Drumm

That is a charge by Government on the HSE because that money is coming in directly to the hospital rather than going back to Revenue, so it is budget neutral to the hospital.

Are there any outstanding issues?

I asked a question about the waiting times for children with curvature of the spine, scoliosis. I also asked that if the optimum time for action is when the curvature of the spine is around 50° is the health of children being compromised if they have to wait until the curvature is between 60° and 80°. What is the optimum time?

Professor Brendan Drumm

Look at——

Is that too specialised?

Professor Brendan Drumm

It is. I am not going to give an orthopaedic opinion here. What I am saying is that if a child needs to be operated on, it will be done. Hopefully, we will get co-operation everywhere. What is coming out of this is full support for a cross-hospital approach to getting these children treated and maximising the efficiency of what we spend. We believe the money is there to do that. If any clinical decision is made by any orthopaedic surgeon that the case should be done, then it should be done.

Is Professor Drumm saying that arising out of this he will launch an initiative to ensure that these patients are treated?

Professor Brendan Drumm

We have already launched an initiative to extend to the wider issue of asking the three children's hospitals to begin to engage with us, especially the two major hospitals, to allow us to deal with some of the issues raised by Deputy Coveney, which is our real lack of any input into this process.

They will have to engage with the parents of these children also so that there is a full understanding that parents can look forward with confidence to their children receiving the treatment they require.

Professor Brendan Drumm

It would be extremely helpful if that body had parental input.

Professor Brendan Drumm

That is a suggestion that would be extremely helpful if it resulted in parental input into the body. Deputy Ó Caoláin said we were beginning to see that the terminology is soft. Somebody asked a question about relationships. There is no doubt that the development of the new children's hospital is a huge challenge for three very fine institutions who are challenged by the changes. These institutions have given huge commitment to people in the past but we have to change. We are seeing a significant move in that the people in Crumlin have engaged with the development of the design brief, in terms of what will go into the new hospital. That is a huge step forward. They have not engaged, as yet, with the development board but we would hope they will do so, because this is the only road forward. The Deputy is correct. It is tentative but finally we seem to be moving in the right direction. The suggestion about parental involvement is one we had not fully taken on board but we need to take it on board.

Is Professor Drumm saying that any child who is waiting for a scoliosis operation is only waiting because he or she is not ready for the operation?

Professor Brendan Drumm

We have given the figures for 67 children who are waiting for surgery.

And are ready for it.

Professor Brendan Drumm

We now have to work with those hospitals. When one speaks about the NTFP — I am not an expert on the NTFP — maybe the confusion is about doing such operations in private hospitals. I suspect private hospitals are not carrying out operations for scoliosis but they are done in Cappagh. Therefore, NTFP work can be done in other public hospitals provided it is not within the area of——

The logic is to give the money to hospitals such as Crumlin to carry out the operations for the children who are waiting.

Professor Brendan Drumm

We think there is money to do them.

On a point of clarification, Professor Drumm mentioned that 67 patients are waiting for surgery. Having spoken to Our Lady's Children's Hospital, Crumlin, this morning, 40 patients have been assessed as needing surgery and it is past time they should have been done.

Professor Brendan Drumm

Some 67.

Bear with me for a moment. Given that 50 operations per year are carried out at the hospital, that is the capacity of the hospital, and 40 are on the waiting list who should have been done already, almost a year's work has built up. How is the issue to be addressed? It does not make sense to close theatres and beds in Crumlin where the expertise is in place and open further capacity in Cappagh. If one was to do both, allow Our Lady's Children's Hospital, Crumlin, to operate at full capacity and open up Cappagh, then I would see the sense and we could get rid of the backlog but I do not hear a commitment to that approach.

I will be brief and do not wish to distract from the last two contributions. Professor Drumm talked about the three hospital approach and where we are going so far as the delivery of children's services in Dublin are concerned. I said earlier that I hoped this committee could sit down with Professor Drumm and have a special meeting to discuss that whole issue because it is important. I hope he might be able to give us that commitment.

I seek clarification on the issue of scoliosis. If Professor Drumm is prepared to consider giving money to have these operations done privately by the NTPF, why would he not consider giving that money to Crumlin?

The NTPF.

Professor Brendan Drumm

There may be some confusion here. The NTPF is a completely separate issue and its budget has nothing to do with us. The response is very clear. We had opened up the theatre space in Crumlin to do these cases. Perhaps some of them can be done by the NTPF but that is another issue. We will open up those theatres based on the proposals we have here today. We can now work with Crumlin to actually open that up. We are saying there is a €100,000 deficit, which is a zero deficit as it constitutes .0001% of the budget. If we could make even half the savings we are talking about on the proposals we could open up theatres. We do not need beds as there is only 80% occupancy. What we need is to have the critical care facility, which is an issue for scoliosis, sorted as well as the theatre working and those theatres that are working must do so to the optimum. We are going to work with a group within Crumlin to optimise its theatre throughput. We believe that in co-operation with the group, that can be achieved. Within the money that is available, therein lies our focus. The NTPF separately can take anybody referred to it — that is the rule — by the people at Crumlin.

That would not make sense today and would be a tragedy if Professor Drumm was not willing to put money into Crumlin.

Professor Brendan Drumm

The NTPF——

Children who are referred for examination the first time are being postponed. Several have been postponed two and three times.

For medical assessment.

Yes. I wonder what will happen to them. The longer the problem is left the greater it becomes. I seek a comment from Professor Drumm. I understand there is a benevolent fund in Crumlin hospital raised through charity or whatever. How does Professor Drumm think Crumlin should use that money and should it be used to deal with the backlog of patients being discussed here?

I will take the final remarks from Professor Drumm.

Professor Brendan Drumm

Deputy Reilly also raised the issue of the research funding. I have been a beneficiary, although much of my research was funded independently and in the international field, so I was not dependent on it. I did find it a hugely constructive organisation in terms of funding research. The research foundation money is not an issue for the HSE. It is an organisation that has been a huge support to developing research in paediatrics in Ireland and a huge support to people who needed it to get started. I have nothing but positive things to say about it. On the issue of what it does with its money, it is purely a research initiative and has nothing to do with the HSE.

I thank Professor Drumm and his team for appearing before the committee today and the information he has given us. I wish Professor Drumm well with the new hospital initiative. I thank him for his comments in regard to services for scoliosis patients. I emphasise it is our view that we are going into very difficult times but we must protect front-line services, particularly those for sick vulnerable children. I appreciate that is his priority also and I wish him well.

Professor Brendan Drumm

I thank the Chairman and members of the committee.

The joint committee adjourned at 11.20 a.m. until 3 p.m. on Tuesday, 14 July 2009.