Committee Reports > List of Committees > Dáil > 1968 > Committee of Public Accounts > Interim and Final Reports of the Committee - Appropriation Accounts 1966 - 1967

MIONTUAIRISC NA FINNEACHTA

(Minutes of Evidence)

Deárdaoin, 21 Márta, 1968

Thursday, 21 March, 1968

The Committee met at 11 a.m.

Mr. E. F. Suttle (An tArd Reachtaire Cuntas agus Ciste) called and examined.

VOTE 48—HEALTH.

Mr. O. P. Hargadon called and examined.

916. Chairman.—Mr. Hargadon has come here to help us. This is his first time coming before us and we are very happy to see him.

Mr. Hargadon.—May I express the Accounting Officer’s regrets for his inability to be present and may I thank you for allowing me to appear?

Chairman.—We are sorry to hear the Accounting Officer is ill. On behalf of the Committee, would you kindly convey to him our hopes that he will be back with us shortly?—I will.

917. Chairman.—Paragraph 82 of the Report of the Comptroller and Auditor General reads:

“Subhead G.— Grants to Health Authorities

82. To ensure that the cost of approved health services falling on local rates in respect of the year 1966-67 would not exceed that of 1965-66, supplementary grants provisionally calculated at £1,305,000 were paid during the year on the basis of estimates supplied by the health authorities.”

Have you anything to add to that, Mr. Suttle?

Mr. Suttle.—I have nothing to add to the information in the paragraph.

918. Chairman.—I take it, Mr. Hargadon, the expenditure by local authorities in respect of the year we are now discussing was frozen at the 1965-66 level?—Yes.

919. Deputy Molloy.—On subhead D.— Expenses in connection with International Congresses, etc.——who in the main attends these international congresses? Is it the officials of the Department or members of the medical professsion?—It is officials of the Department, medical advisers and some senior administrative officers. It is mainly concerned with meetings of the World Health Organisation.

920. Would any of these civil servants in the Department of Health be actually qualified doctors?—Yes.

Roughly how many?—About 15.

Out of a total senior staff of?—Forty, approximately.

921. Deputy Healy.—Is there any help given to the medical officers of local authorities going to congresses?—Not from this.

922. Chairman.—In respect of subhead G. —Grants to Health Authorities—the expenditure advanced from £15,000,000 odd in the previous year to £18,000,000 odd in the year under consideration. I take it that was due to the fact that the Central Exchequer had to meet extra expenditure arising from the fact that the vote was frozen as regards local contributions?—Yes, and also the fact that the over-all expenditure had increased in any event.

923. With regard to subhead H.—Contributions to Local Authorities for the Improvement of County Homes and for alternative Accommodation for certain classes hitherto maintained therein—the expenditure increased from £30,000 to £44,000 odd. I wonder if the Accounting Officer can give us some more information as to the nature of this expenditure and where it went?—Yes. These are schemes under which County Homes are replaced and renovated. The local authorities draw up schemes which are subject to the approval of the Department. The money to carry out the work is borrowed from the Local Loans Fund. Of the loan charges 50 per cent is recouped subject to a cost limit per bed of the new accommodation. It has accelerated in recent years and there are now over 2,500 beds in new or improved accommodation as a result of schemes completed or in progress. In some cases complete renewal of the institution has taken place, such as in Mountmellick where the County Home has been practically completely renewed.

924. Is that type of subvention limited to the County Homes or is it available to local authorities for small units?—The wording is, “County Homes and similar institutions”—any institution that would accommodate the same type of patient would qualify.

925. Deputy Healy.—If a local authority wanted to put some money into the improvement of a small institution in their area, I think it would be subject to the consent of the Department of Health?

Chairman.—I expect it would?—Yes, it would.

926. Deputy Healy.—With regard to subhead I—Grants to Voluntary Agencies— what sort of agencies would they be?—They are mainly societies which look after children, boarding out agencies and institutions for unmarried mothers and their children. I could give the names.

927. Deputy Healy.—No. It just occurred to me that there are private homes. For instance, in the case of chronic patients or aged people under private auspices, is any help given to those institutions out of the Fund?—Not directly out of this subhead. It is open to a health authority to make a grant.

It would be the health authority rather than the Department?—Yes.

928. Chairman.—If a health authority made a substantial grant would they get 50 per cent?—Yes, it would rank equally with other health expenditure.

929. On subhead P.—Fluoridation of Public Water Supplies—I see that the expenditure has increased from £9,000 to £16,000. I suppose that indicates that more authorities are adopting fluoridation?—Yes, the limitation on this has been largely technical. We experienced technical difficulties in many areas in the installation. Otherwise, it would have gone ahead more rapidly. As it is, the greater part of the programme has now been carried out. There are still a few fairly big towns like Sligo and Kilkenny to be done but otherwise the major work has been done on the big schemes.

930. Are there any authorities still outside the fluoridation scheme?—The scheme would apply to 192 water supplies. That includes quite small ones and it would cover 1,500,000 people taking water from these supplies. To date about 1,050,000 of the population are covered by the fluoridated water scheme and work in progress, that is to say the tenders that have been accepted, would raise that by a further 100,000, so that approximately 1,200,000 out of 1,500,000 will have been covered by fluoridated water schemes, we hope, within the next year.

931. Does the State still cover 50 per cent of the capital cost?—Yes, that continues.

932. In respect of the total expenditure under this vote of over £19 million, an increase of £3 million on the previous year, would the Accounting Officer be able to give me the total contribution from local authorities under all subheads?

Mr. Suttle.—The total expenditure was £34 million and total contributions to local authorities, £18 million.

Mr. Hargadon.—That is correct as regards revenue expenditure of health authorities. That excludes things like fluoridation and county homes schemes which are treated as capital expenditure.

933. Chairman.—Does it also exclude contributions from the Hospitals Trust Fund?—Yes, it does. Hospitals Trust Fund Grants would be paid for capital works on county and regional hospitals, the ordinary rate being 50 per cent, and the local authority providing the other 50 per cent.

934. Can you tell me offhand what was the Hospital Trust contribution?—I do not think I could offer a figure offhand. I cannot separate mentally the figures for voluntary hospitals from health authority hospitals, but I could supply the figure to the Committee.

935. Are the accounts of the Hospitals Trust Fund laid before the Dail?—Yes; subject to verifying it, a statement is supplied to the Dáil.

937. Could the Committee be furnished with a copy?—We can supply statements of the issues from the Hospitals Trust Fund. I am not sure that they are laid before the Dáil.

Perhaps they could be furnished to the Committee and incorporated in the Report? —Yes.* This would be an account showing the headings under which grants were paid and the amounts.

Deputy Crowley.—And to whom?

Mr. Suttle.—It depends on what sort of account is certified by the auditor of the Hospitals Trust Fund. I doubt if they give that much detail.

Mr. Hargadon.—They do not, so far as I recall. Might I mention that in addition to capital grants there are grants towards revenue costs. The Committee would require both, I suppose?*

Mr. Suttle.—The total expenditure from the Hospitals Trust Fund.

938. Deputy Healy.—On the details of the Appropriations in Aid, Item 2.—Fees for renewal of licences to private mental hospitals—may I ask if the number of private mental hospitals is increasing?—Mr. Hargadon.—No, it has been static now for many years.

939. Chairman.—How many such have we?—I think from ten to 12. Most of them are small.

940. Deputy Healy.—I presume there is some supervision by the Department or is it left to the health authorities to supervise conditions in these smaller institutions, private institutions?—They are inspected by the Inspector of Mental Hospitals who is an officer of the Department and a doctor.

Mr. Suttle.—I think he gives an annual report to the Oireachtas on the result of his inspection.

Mr. Hargadon.—He does, yes.

941. Chairman.—Perhaps at this stage we could deal with the three documents we have been presented with, taking first Expenditure by Health Authorities.† The expenditure on turberculosis hospitals is down in a number of counties. The charge for Cork, however, is up and the charge for Roscommon is increased. Is there any special reason why there should be an increase in Cork and Roscommon?

Deputy Molloy.—There are more counties than that in which increases have occurred, for instance, Clare.

Deputy Healy.—And Donegal.

Deputy Crowley.—I think we asked the Accounting Officer last year for an explanation of that and he was unable to give us a satisfactory explanation.

Mr. Hargadon.—It is very difficult. The amounts are not great, as we see. In some areas a very small variation in the number of patients has an influence. There are some counties that in this year showed an increase in the number of new cases discovered. This has influenced it, for instance, in Galway. We found on inquiry that that was one of the factors.

Deputy Molloy.—How do you mean in Galway?—The number of new cases coming forward turned out to be greater than in the previous year.

Are you quite sure of this, because the hospital is steadily being handed over to other types of medical care—geriatrics and orthopaedic?—That is so. It would not involve anything big in the hospital.

942. Deputy Healy.—It would not be hospitalisation. That is the explanation in Cork too, as far as I am aware. As a result of the mass radiography scheme, it is discovered that people need treatment and, where necessary, they are getting short term treatment in hospitals. I have heard the medical officer in Cork warn the people that the danger is not past, that they are only fooling themselves if they think they still do not have to go for periodic examination.

Mr. Hargadon.—That is so. We were given the same explanation, as a matter of fact, in Leitrim, where there is also an increase.

943. Deputy Crowley.—Would it be possible to get the figures of the increase in the number of patients in tuberculosis hospitals in all cases where increases in expenditure have occurred. Could we have the figure showing the increase in the number of patients?—Yes.*

944. Deputy Healy.—On Mental Hospitals, and Hospitals and Homes for Chronic Sick, Mentally Handicapped, etc., I think it is a good thing that in most counties the amount of expenditure is substantially increased because it is my experience—and it is a long one—that the mentally sick and chronic sick have been, if you like, overlooked and neglected for so many years that this seems to be an overdue measure to try to catch up with the position. In regard to my locality, I certainly think from seeing the activity there and what has been done that the increased expenditure is to be anticipated because great work has been done in the last few years and is still being done and I see that this is general right through the counties.

Chairman.—It would seem that Cork and Dublin have got the lion’s share.

Deputy Healy.—They have the biggest population, I suppose and, perhaps, a greater number of mentally handicapped.

Chairman.—I would not say that.

945. Deputy Molloy.—Could this increase, which seems to be standard in all counties, be attributed to increased places in these hospitals or to improved amenities for the patients in the hospitals?

Mr. Hargadon.—Are you speaking now of mental hospitals?

Deputy Molloy.—Yes.

Mr. Hargadon.—Improved amenities rather than places and, of course, the cost of running them has also risen. Salaries has been a factor, and there has been a reduction in the number of working hours of nursing staff which has contributed to the increase. Again, the use of new types of drugs for the treatment of mental illness has contributed to the rise.

946. Chairman.—Would the expenditure in respect of places like Dublin and Cork, which show a greater increase than other areas, cover some patients taken in from outside areas—other parts of the country?— No, because if that were done, the area they came from would be chargeable.

Deputy Healy.—I think the Accounting Officer is quite right when he says that the costs of running institutions are increasing every year, which is one big factor and, secondly, the drugs now used in treating mental illness are expensive. It is very welcome treatment and represents tremendous progress on anything we have had up to now. There is only a £70,000 increase in the mental hospital bills, generally, for drugs, taking the country as a whole.

947. Deputy Healy.—Another heading in this Table in respect of which we should be glad if every county showed a substantial increase is Rehabilitation Services and Allowances to disabled persons. I am glad to see that in most counties the expenditure has increased somewhat. Rehabilitation is a service that is only coming in now. The allowance to disabled persons is going up all the time. It is impossible to do a great deal for the disabled persons by this allowance except to enable them to procure some comforts. Rehabilitation services are most important and it is impossible to estimate the good that can be achieved in this sphere.

948. Chairman.—Perhaps Mr. Hargadon would tell us what “Other Services” include?—In this rather miscellaneous group the specialist outpatient services are included as are ambulances, superannuation and the ordinary administrative costs of the health authorities—the office administrative staff— some of the county medical officer charges are also included. I think these are the main constituents.

949. Deputy Healy.—Could we ask the Accounting Officer under what heading, if at all, are the dental services included?— The dental services would be under this heading also. In some areas where there is a special school dental service it would be included under the child services.

950. Finally, I should like to know if it would be possible to show the cost, percentage-wise, of the administration of the service in each county. I should like, if possible, to have another column added to this statement showing, on a percentage basis, the administrative cost of the services in every county.

Mr. Hargadon.—Would that be the lay administration? Would it include the medical administration as well?

Deputy Healy.—I would prefer the lay administration?—That can be done.*

951. Chairman.—Under “Other Services” there are three or four counties which have an increase in expenditure over the others —Donegal, Limerick, Roscommon and Waterford. Was there any specific reason for this?—We pursued this and we found in Roscommon there were a few items which can make quite a difference. £2,700 was spent on the replacement of an ambulance, the net cost, which in this county would make quite a difference. There were two deaths among the senior medical people and gratuities payable on death amounted to £3,300. That accounts for about £6,000 of the increase, which I think would leave it more or less in line with some of the others. The retiring allowance can have quite an influence on this. In Donegal there was as much as £9,500 for retirement in excess of what one might normally have expected. The coincidence of three or four people in senior situations retiring or dying at the same time, can produce a high variation from normal.

952. In general in respect of the issue of health cards, we are all aware there has been a most inexplicable discrepancy in the percentage as between county and county. Nobody has been able to give any real explanation. Leitrim, for instance, had a very low percentage and other counties a very high percentage. Does that position continue?—It does. But I think it is true to say the variations are reducing. More people are now seeking cards where the incidence had been low. One explanation which used to be given was that in some areas the person gets the attention of the doctor without formally having a card. The doctor knows he is a lower income patient and the card was not formally needed.

953. Would it be possible to give us an up-to-date return of the number of health cards as a percentage of the population of each health authority to see if the figures have varied from what we had a few years ago?—Yes.*

Deputy Molloy.—We got those figures here before.

Chairman.—Yes, but they dated now.

954. Deputy Molloy.—In cases where the helicopter is used on a mercy mission there is no charge to the local authority? Is this borne by the Department of Health or the Department of Defence?—I assume that Defence carry the cost there. Where it is used as an ambulance then there is a charge.

And the full charge is borne by the local authority?—Yes, subject to recoupment in the normal way.

955. Chairman.—Has any progress been made with regard to the introduction of a national formulary?—The situation became confused by the expectation of a change in the system of general medical dispensaries. We have been pursuing the cost of drugs and, as far as they can, the managers are trying to influence the staffs to keep an eye on things from the aspect of cost.

The cost of drugs is a problem everywhere?—It is.

956. Deputy Healy.—In regard to the table showing Minor Receipts.† I cannot understand why the figure in respect of Payment by staff resident in institutions for accommodation, meals, etc., should be down rather than up?—It is difficult to say why that happens. The rates payable by the staff have not been increased in recent times. Even when there is an increase in pay it is not automatically accompanied by an increase in these charges. There may be an increase in the number of staff living out in areas such Dublin. A lot of nurses in the local authority institutions are living out. Some of them are married women. Is it a matter of policy as to what the resident staff are charged for their board and residence in a hospital? Is it a matter for the local authority or the Department? I say this because if people living in institutions have benefited by increased remuneration over the last few years the same as people living outside and the actual food prices have not been increased at all.

Chairman.—Then they are benefiting doubly.

Deputy Healy.—Is it a matter of policy for the health authority or the Department? —It is a matter for settlement as part of the adjustment of pay. It is taken into account when the pay is being adjusted and I can recall at least one occasion where it was an issue and it was decided not to increase the charge. The assumption is that in determining the pay increase regard is had to the fact that the charge is not being varied.

957. Chairman.—Is there a fixed universal charge for nurses all over the country?— Yes, it is a common rate.

958. And a fixed charge for house doctors? They pay so much for their accommodation?—Yes.

959. Is that subject to annual review or pre-audit review?—It is reviewed as part of the remuneration review.

Only when salaries and conditions of employment are being reviewed?—Yes.

960. Deputy Healy.—As we have seen, on the expenditure side wages and salaries are going up considerably but the refunding of a sum by staff resident in institutions for meals and accommodation is going down. I think there is only one explanation that would satisfy me and that is that a considerable number of people who were resident are now no longer resident in institutions?—The fall here is not due to a reduction in the rate.

961. Is the rate here static?—It is a variation of £5,000 which could possibly be attributable to accounting, to bringing to credit of the amount—something of that nature.

962. Chairman.—There is a variation in respect of costs in general. The costs of the health services have been going up. Have receipts from patients gone up proportionately?—They have not gone up proportionately. I think it would be correct to say that they have remained virtually static. The overall income is increased probably due to the overall increase in the numbers receiving treatment. The rate for treatment in hospital is fixed at a maximum of 10/- per day and this has not been varied for the past more than ten years.

963. We are all aware that the charges levied by local authorities are sometimes written off for various reasons—perhaps on representation. Is the Department furnished with any returns from local authorities as to the amount of charges appropriately levied and actually collected by each health authority?—We get a statement of the amount collected but we do not as a matter of routine get any report of the amount not collected.

964. Have you any notion as to whether one local authority are writing off a higher percentage of charges against another health authority?—Not as a matter of routine. The auditor would refer to it if it was worthy of comment. If the rate of collection appeared to be low, we would make a special inquiry as a matter of routine.

Mr. Suttle.—A few years ago we raised a question with the Committee as a result of seeing some reports from the local auditors on this question of arrears of amounts due by patients mounting year by year. This was dealt with by the Committee some time ago.

Mr. Hargadon.—We discovered at that time that in one or two areas it was the practice of the local authority to levy the maximum and then, on appeal, it was reduced. This produced a rather misleading picture of writings-off. It was over-levying in the first instance.

965. Deputy Molloy.—It sounds like Galway. What patients pay towards the cost of institutional services?—All middle-income patients.

966. If I wish to avail of the services of the X-ray Department in the regional hospital in my own town I can do so. I go in and am asked whether I am above or below a certain income. Everyone knows I am not below £1,200 a year so I say that I am above it and I am charged £1. What guarantee has the cashier in the hospital that everyone is telling the truth? There is no check. People can say they are under £1,200 and get an X-ray for 7/6 but I have to pay £1. It seems to be very lax. I am not referring to Gal way specifically. This seems to be general around the country. There are no very strict rules?—The practice is that unless you have a general service medical card you should pay in the case of an X-ray 7/6 for the middle-income group.

967. How do they know if you have not got a medical card, what income group you are in?—The great majority of people who are not in the lower-income group and are looking for these services are insured. You should be asked if you can produce your insurance number or other evidence of entitlement.

968. You are not asked to produce it, or are you?—You should be.

You should be?—The health authority can if necessary verify it by inquiring from the Department of Social Welfare.

I had an experience many years ago when I was asked what income my father had. I was not working at the time. I made a rough guess because I did not know. There was no question of having to produce any evidence of my father’s income. There is a feeling in some of these hospitals that there is no great check. Other people can get off with 7/6?—Only people in the middle-income group should be getting middle-income services.

969. Deputy Healy.—Has the Accounting Officer any explanation for the fact that the first item in this table of Minor Receipts— Payments by Patients towards the cost of Institutional Services—has remained more or less static for years when there are so many people in the Voluntary Health Scheme. You would think this would mean an increase on the receipts side. Is there some explanation for that?—The only hospitals which would be affected by the Voluntary Health Scheme would be the regional and county hospitals in this category. This figure is related to local authority or health authority institutions, so that the people in the Voluntary Health Scheme who go to voluntary hospitals are not reflected here at all. These are mainly county and regional hospitals and in some cases county homes or mental hospitals where there are people with old-age pensions.

970. Are not many Voluntary Health people treated in regional hospitals?—I have no doubt they are but on a figure of £1,400,000 it would not have a very big influence.

971. Chairman.—Perhaps the Accounting Officer would break it down into the amount collected under this heading by each local authority?—Yes.*

Chairman.—Members have also received a statement showing expenditure on medicines in the years ended 31st March, 1966 and 1967.†

VOTE 49—CENTRAL MENTAL HOSPITAL.

Mr. Hargadon further examined.

972. Deputy Andrews.—On subhead E.— Farm and Garden—is the garden produce sold outside?—Only the surplus. It is used in the institution. In fact, all the vegetables other than the potatoes are produced in the garden for the institution.

973. Chairman.—On item 1 of the Appropriations in Aid—Receipts from staff for rations—this item was considerably less than was estimated?—Yes.

974. Is the basis for costing for staff reviewed?—In this institution it is fixed in relation to cost of the food provided so that it does vary with expenditure. What has happened here is that the number living in has decreased.

975. Deputy Healy.—When the number living in decreases, is that arranged so as to provide more accommodation for patients or is it because those who are living in were in overcrowded conditions?—No, it is simply that the number of married male nurses has increased. The unmarried nurses live in and when they marry, they live out. There has been an increase in the marriages of male nurses.

976. Does that mean increased accommodation is available?—In the staff quarters only. The full complement that could be carried is not in residence.

The witness withdrew.

VOTE 5—COMPTROLLER AND AUDITOR GENERAL.

Mr. K. M. Fowler called and examined.

977. Deputy Healy.—As regards the explanation in relation to subhead A.— Salaries, Wages and Allowances—are we still trying to fill these vacancies?—Some of these vacancies have been filled but there are always vacancies and delays in filling them. There is always a time lag of five or six months. We lost two of our senior men during the year and they were not replaced until after the end of the year.

978. Deputy Molloy.—They retired?— No, both went to State-sponsored bodies —better jobs.

Deputy Healy—Is that a general tendency in Departments—that good men are being tempted to go outside for other employment? —That is true.

And only dedicated ones stay?—I would not say that.

979. Deputy Molloy.—How many qualified accountants are employed in this Department?—It varies from time to time but there would be seven or eight at the moment. The staff are encouraged to get accountancy qualifications, particularly the younger people and when they get those qualifications, we give them special increments. When they pass the Intermediate Examination in accountancy they get one and when they pass the Final, they get two more, so that we have three special increments as an inducement to them to get an accountancy qualification.

980. On Appropriations in Aid, for what service is the audit fee paid?—The State-sponsored companies, Nitrigín Éireann Teo. and Irish Steel Holdings. There are certain other services like the Church Temporalities Fund where a fee is called for under a Church Disestablishment Act of 1869. There is also provision for a fee to be paid from the Local Loans Fund as part of the cost of management.

Mr. Suttle.—All Post Office services have to be paid for. They pay an audit fee.

The witness withdrew.

The Committee adjourned.

* See Appendix 28

* See Appendix 28

* See Appendix 29

* See Appendix 30

* See Appendix 31

* See Appendix 32

† See Appendix 33

* See Appendix 34

† See Appendix 35