Speeches - January 2004

15 January

Questioning of the Secretary of the Department of Health and Children on the Waiting List Initiative

Deputy Boyle: I thank the officials from the Department of Health and Children for visually demonstrating what a waiting list looks like. Perhaps Mr. Kelly could respond to a few observations on the value for money report? The waiting list initiative was introduced in 1993 and is now in its eleventh year. It was initially seen as a short term initiative, which begs the question of how long a short term initiative should be. For the first half of its existence it was not seen to be very successful at all. In fact, in the targeted group the numbers increased significantly until 1998 and I have noticed that a lot of Mr. Kelly's statistics on the decrease are from 1998. However, if one takes the year 1993, when the initiative was introduced as the benchmark and 2002, when the value for money report was compiled, in the targeted group there was no significant decrease in numbers. The decrease since then, in 2003, is, I suspect, only a marginal decrease on the 1993 figures. There may be a number of factors to explain that, such as the initial funding being subsequently lowered. It then decreased until 1998, when it started increasing. Perhaps the greater amount of money was having more of an effect from 1998 onwards. Nevertheless, even from 1998 to 2001, the decrease in the targeted group was just in line with the decrease in general waiting lists.

There are questions about the first eight years of this initiative and its general effectiveness. There are further questions about the ability to measure value for money. That can be examined in a number of areas, first of all the differences between the different procedures - why some increased and others decreased - the differences between health board areas and the differences between hospitals, on which I will ask specific questions as I proceed.

Have my remarks been a fair interpretation of the value for money report and the problems, as opposed to the benefits which have been portrayed in the statement?

Mr. Kelly: It comes back to whether we accept that there were four objectives set in this initiative and that in the allocation of funding, and its deployment and use, it was a legitimate exercise to address all four targets. The initiative was not exclusively established to address target specialities. It was established to address four distinct objectives which I have set out for the Deputy. One of those, very deliberately, was to generally increase the level of elective activity in the acute hospital system. Another was to address the target specialties and waiting times. A large part of my argument is that in all of the documentation describing the scheme, we have been quite clear that this was addressing four separate objectives.

In respect of different performances and different impacts over periods of time, it is a fair comment that during the early years of the initiatives there was some impact but not very significant. That reflects the fact that we are not dealing with a static group of people, rather there are stops and flows in which there is an outward flow every year and an inward flow.

We are trying to ensure that we deal with more people every year than join the waiting list or wait longer than 12 or six months. That is the dynamic that is at work, particularly from the year 2000, and is also related to the general level of funding that was flowing into the health system in 2000 and subsequent years. There was also significantly increased funding for the waiting list initiative, of which we can see the impact. That is clearly shown in the report where the improvement is demonstrated from 2000.

Mr. Boyle: Mr. Kelly referred to the four benchmarks he was using on the introduction of the initiative. The value for money report questions the use of the number of people as being the sole or best indicator in respect of waiting lists. There is the aspirational target of having people at 12 months as adults and six months as children when waiting for these procedures.

There is the aspirational target of 12 months' waiting for adults and six months' waiting for children for these procedures. However, when the value for money report was being done the average waiting times were 15 months and 8.9 months, close to nine months, respectively. Given that this was the average figure, can the initiative be seen to be a success? Surely the delivery in terms of actual waiting time for the individual citizen should have been the scope for this initiative.

Mr. Kelly: Ultimately, what is important to an individual is that they do not have to wait for a service, whatever service it is. From an individual's point of view, that is the most important consideration. That is why, particularly in the context of the analysis of this that was done in preparing the health strategy in 2001, we spent a lot of time, both in the consultation process and in our own discussions within the Department and with hospitals and with health boards, analysing further what needed to be done to improve performance in relation to waiting lists and waiting time. It is out of that analysis that the idea of the National Treatment Purchase Fund emerged and that the fund was put into operation during 2002. I accept that one can take any point in time along the spectrum of this initiative - and December 2002 is one - and say that at that time matters were not good or whatever. What I am saying is that as of September 2003, other than in the eastern region - and Mr. Lyons will comment on aspects of that - that target for adults of 12 months and for children of six months is being met.

Deputy Boyle: It is not being met for all procedures. We know from the value for money report that the figures for ophthalmic surgery, urology and general surgery were higher in 2002 then they were in 1998 and the 1998 figures were higher than those for 1993. What are the conditions that have brought about an increase in waiting lists for these procedures? Mr. Kelly might also outline the individual procedures involved under the heading of general surgery.

Mr. Kelly: I personally cannot go into it. If the committee wants a technical description of the procedures involved in general surgery, I could, with the committee's permission, ask Dr. O'Holohan to comment on it. As to the factors that give rise to an increase in one area. In any particular period there may be a concentration of additional resources in one area, for example, additional consultants are appointed in one specialty. In other areas it may be that the rate at which people are coming on to the waiting list, for example, because the rate at which they are being seen at out-patient departments or are being referred increases. There is a dynamic in this from year to year. From the Department's point of view, the handle we get on this year on year is when we have our discussions with health boards on their service plans for the year. Waiting lists would always be an issue for discussion at those meetings. In the context of the 2004 service plans, in the next number of weeks, once the respective health boards have adopted service plans and submitted them to us, we will be meeting them and these are some of the questions we will be putting to them in relation to the outcome for 2003 and how they intend to address that in 2004.

Deputy Boyle: Let me move on to another area. Mr. Kelly has already alluded in his presentation to the fact that the waiting list initiative led to the funding of temporary consulting and nursing posts over the course of the year, which was welcome, many of which became subsequently mainstreamed. There is a question in the value for money report that this might have led to a potential loss of flexibility in the administration of the waiting list initiative funds. Is that a fair comment? Was there, in effect, a loss of flexibility because of the temporary nature of these points and their mainstreaming and their subsequent relationship with the waiting list?

Mr. Kelly: In an ideal world, if one creates a pool of discretionary funding to be applied to a particular problem, one does not permanently appoint people in a way that lessens one's flexibility. It is a fair to say that lessened flexibility. The question that has not been addressed is whether there was an alternative. There is no particular comment on that in the report. However, I would offer a comment on it. I have made the point already in my statement. In today's employment market one cannot ask people who have trained as medical consultants and who are trained in the more specialised areas of nursing to hang around and wait to see whether something will pop up on the waiting list initiative next year and, if it does, to turn up and take a job. People do not do that. In the areas we are talking about, the staffing that has been put in place is of two kinds, clinical and non-clinical. Clinical staffing comprises medical and nursing people principally. To confirm the Deputy's point, over a ten or 11-year period with additional people employed - and it is a matter of fact that we need people, pairs of hands, skills to do additional surgical work - it made sense to put those into place where there was a continuity of funding coming through year on year and where one of the main objectives of this whole initiative was to increase the ongoing level of elective activity in the hospitals. If the objective had been solely to address a different group of patients every year, that would not make sense. However, in a context where one of the main objectives is to increase the level of ongoing elective activity generally, it does make sense. The other group of non-clinical posts comprises the people involved in waiting list management and bed management and discharge planning in the hospitals. Again - and it is reflected in the report - there are clear benefits to having those people actively managing the throughput of patients in the hospital with a view to gaining maximum efficiency from the available bed stock and, again - the point has been acknowledged in the report - that is in evidence in the hospitals that were visited by the Comptroller & Auditor General in the course of his exercise.

Deputy Boyle: Is it not also true that the use of the waiting list initiative funding did not specify that the staff were required primarily for the patients waiting longer than the target maximum waiting times? In a sense, while there was a value in the additional staff within the health service in particular and for waiting lists in general, the funding was not used exclusively for the waiting list initiative and the effect was not predominantly seen in the waiting list initiative.

Mr. Kelly: The waiting list initiative is a set of arrangements put in place to address four objectives I mentioned earlier - long waiters, waiting times, elective activity generally and, particularly, increasing the level of elective activity in the acute hospital system. In that context I would not agree with the Deputy.

Deputy Boyle: It is a point from the value for money report.

Mr. Kelly: I would not agree with the point made in the report either. I do not accept it.

Deputy Boyle: I have two more questions. The waiting list initiative has been more or less integrated into the National Treatment Purchase Fund, but it will still exist in some form. What form will that be and how will it be targeted in the future?

Mr. Kelly: The waiting list initiative?

Deputy Boyle: Yes.

Mr. Kelly: We are talking this through in the Department at the moment so I cannot give a definitive answer. It is clear that the funding - which has become part of core base funding in the health boards - about €23 million of the total allocation for the initiative in 2004, has been allocated to the relevant health boards on the basis that it is necessary to continue with the level of activity that the posts and so on that are in place will support. In relation to the balance of that funding, we are currently in discussion with the management of the National Treatment Purchase Fund, and will discuss with the health boards when we see them regarding their service plans, how the balance will be struck in terms of allocating that funding between health boards and the National Treatment Purchase Fund.

However, it will involve an increase in the allocation to the NTPF during 2004. This is not the first co-ordinating piece between the operation of both initiatives. For example, the assistant secretary of the hospitals division in the Department is a member of the steering group for the National Treatment Purchase Fund. Similarly, there is liaison with chief executives and other representatives of health boards on that steering group. So, the initiative and the treatment purchase fund have operated with a degree of co-ordination over the last two years. We are now moving on from that and are, in part, informed by the analysis in the report and, in part, by our own analysis, having seen the success of the treatment purchase fund in contracting with the private system, and to some extent with the public system. They have gained that additional activity level and, in particular, have developed this transparency between funding and output. In 2004, we are putting them in a lead role in this respect.

Deputy Boyle: My final question also relates to Mr. Kelly's presentation when he talked about the Department improving its information systems for collecting statistical data for comparative purposes. He did not seem to respond to the suggestions made by the Comptroller and Auditor General in the value for money report, which referred to the need for new and different indicators that might be more effective in measuring the value for money aspect. The Chair has already sought statistics on private hospital patients but there is also the question of waiting times for outpatient facilities for consultants. Does the Department intend to act on these recommendations and will they form part of the review of new information systems the Department will have in place in future?

Mr. Kelly: Yes.

Deputy Boyle: In both areas?

Mr. Kelly: I have not commented on it because at this stage we have not got to the point of specifically setting out what the IT developments will address in 2004. We know broadly what the systems will be but not what reports they will produce. There is an ongoing engagement both by the Department and the health boards concerning a suite of performance indicators on the health system. We have developed a set of performance indicators and are applying them in many areas at the moment. We will certainly address the recommendations that have been made here in that context, in looking how we could build the indicators in this particular area.

Chairman: Mr. Purcell has a point of clarification.

Mr. Purcell: I do not think we should get hung up on the four objectives and I am not really taking issue with what the Accounting Officer has said. However, I think it is fair to say on the basis of documentary evidence - and that is what an audit has to rely on - that these did not emerge until after the review group reported in July 1998. They emerged in a clear fashion in the guidelines issued by the Department in 1999 and 2000. Even in the set of guidelines that were sent to the chief executive officers of health boards and hospitals in 2000, the Department did point out in a covering letter that the overall objective of the initiative was to ensure that the target maximum waiting times were not exceeded. I think it is common cause between us that from around 1999 and 2000 onwards the management of the waiting list initiative improved immeasurably and, together with the effect of the treatment purchase fund, it is having a real impact. On the basis of what I have seen in carrying out this review over quite a long period, it was not so well focused prior to that time. Perhaps that puts into context both what I said earlier and what Mr. Kelly and Mr. Lyons have said.

21 January

Public Service Management (Recruitment and Appointments) Bill - Second Stage Speech

Mr. Boyle: In this mock sitting of the Dáil where the business of the Dáil was ordered before the recess, the Government is determined that three hours is sufficient time to debate a Bill of this type. The issue of public appointments deserves a more wide-ranging debate. It is particularly disappointing that section 7 of this Bill precludes any —

An Ceann Comhairle: Discussion of the Bill will adjourn this afternoon. It will not conclude.

Mr. Boyle: I appreciate that. However, I protest at the manner in which it has been put in at a time when we are not having ordinary business of the Dáil.

There is a need for a more wide-ranging debate on public appointments. Section 7 of the Bill specifically precludes Government appointments. If we are interested in bringing about public confidence in the area of public appointments and to areas of public life outside of civil servants, local government, agencies such as the Garda, health boards and VECs, we need to tackle the issue of political appointments. The Green Party has called for a public appointments commission for several years. If we are to have that, we must have a procedure whereby candidates can be nominated, adequately assessed and appointed by a process in which everyone can have confidence.

Appointments to many State agencies are a mismatch and are direct political appointments. We have those civil servants who are chosen because of the Civil Service culture not to challenge Government decisions and we have those in the social partnership system who have direct appointment rights to such bodies. Some bodies seem to have more direct rights than others and interest groups are not represented at all. For example, in the planning and environmental protection areas, no environmental pressure or campaign groups are represented yet there is constant representation by groups such as IBEC.

We do not have a system whereby candidates can be nominated by a wide variety of sources, including other political and Opposition parties, to go before an independent agency to have their credentials assessed and to be directly appointed. They do not even come before the committee system in this House, as we see in other parliaments which examine the membership of such public bodies. As a result of our appointment procedures we get flawed decisions. We had an example of such a flawed decision with An Bord Pleanála's decision in my constituency last week. An Bord Pleanála is an agency appointed in the manner about which I have spoken. Its members are direct political appointments, members from the Civil Service, local government and IBEC as a social partner. It has no representative of community interests or environmental groups.

We also have the compromising of independent action from standalone agencies because of the method of appointment to such groups. An Bord Pleanála is meant to be a standalone agency, yet decisions are made not on planning grounds but on the nature of Government policy at a given time. What is the point, therefore, of having a Government standalone agency?

If the Government was proposing to introduce a technical measure to bring in a new all-embracing body, it might be welcome. Instead of putting in place systems which will work - I feel the Civil Service Commission works better than the Local Appointments Commission - the two new bodies will create confusion rather than clarity in the area of public service recruitment. The commission for public service appointments proposed by the Government seems to be a type of appointments regulator. The Government has developed a mania in recent years for standalone agencies rather than the direct work agencies to which we have been used.

Secretaries General of Departments now have an option of either going through the public appointments service or of getting a licence to make their own appointments. There is no adequate explanation in the Bill as to the reason the Government wants to do this. If it is a development of the strategic management initiative, this has not been spelled out in the Bill. If the Government intends to bring more able, creative and independent-thinking people into the Civil Service, I cannot see how it will be done through this procedure. This procedure allows either a laissez-faire or standardised approach to public service recruitment. Perhaps, because we have a coalition Government, it does not know what it wants. It is promoting a Bill which is putting forward two different approaches with regard to political appointments.

Despite what other Deputies have said, I agree the Local Appointments Commission is in need of reform. As someone who has been involved in local government for over 12 years, I have often found frustrating the mechanism by which people have been appointed. There have been problems with interview procedures where people being appointed in Cork, for example, had to be interviewed by people from Donegal and Monaghan and people from Kerry and Tipperary had to do the interviews for people from County Cavan. I would like to see an end to this type of practice.

The range of local government legislation we have seen introduced in recent years which allows people appointed through the Local Appointments Commission to write their own job specification is a major flaw in the legislation. The Government should have addressed this issue in this Bill or shown some indication of wanting to address the issue. In Cork City Council, for example, I know of an incoming city manager who, before he even took up his position, asked the council to oblige him with the right to decide whether he could extend his seven-year contract. That request was acceded to. That type of practice regarding contracts offered to public servants demonstrates the need for reform in this area. What the Government suggests is not reform but just a shuffling of the deckchairs.

What is the Government policy with regard to reform in the area of Government appointments. Does the Government intend to continue with political patronage or has it any proposals to fit in with a new commission of public appointments which will take all public appointments into account? Will it carry on regardless and appoint party political people on the basis of services given to political parties, thereby diminishing the agencies to which they are appointed by not taking proper account of their skills and abilities and subsequently watering down any decisions those bodies are likely to make? How does the Minister of State envisage the two new bodies will fit in with his proposals for what I must insist on calling his 'office relocation programme'? I have seen no decentralisation proposals from the Government.

Mr. J. Bruton: It has centralised the health service, not decentralised it.

Mr. Boyle: That is one area in which the concept has been seen. Decentralisation or centralisation relates to the decision-making process. We will continue to have centralised decision-making bodies in Departments wherever they are located around the country.

The difficulties inherent in the Government's rash attempt to move offices have been pointed out by many and are being confirmed by the week. They have been further cited by Civil Service unions. They underline a culture in the Civil Service which this Bill could have addressed but does not. Since the inception of the State, the Government has believed in the concept of generalism among civil servants. It is held not to matter whether a civil servant works in one Department or another or that a Department is relocated from Dublin to another part of the country as long as a certain number of people are available to staff the new office. My experience as a member of the Committee of Public Accounts is that even the limited practice of office relocation has involved the loss moneys to the State due to the poor management of change. Costs have been incurred due to the loss of specialisms within Departments and the difficulties of finding people to make up the numbers between the new centralised location and the old centralised location. As a result, the committee has had to deal with the consequences of ill thought out policies. I fear policies will continue to be ill thought out in the future. I hope the Committee of Public Accounts will not see the same things happen in Laoighis-Offaly in a year or two. They have happened in several Departments already. The manner in which the Government is handling this issue does not inspire much confidence.

This Bill represents a missed opportunity. There is scope for real reform in public service recruitment and this legislation should have embraced public appointments generally to lay waste finally to political patronage. The opportunity should have been taken to instil full public confidence in the process. Instead, the Government has chosen to travel a more narrow road by rationalising two bodies only to replace them with two others. This will further confuse rather than clarify the system. Rather than attempt to amend a Bill of this nature, we should seek to introduce more focused legislation.