19ú TUARASCÁIL ÓN GCOISTE DÁLA UM CHAITEACHAS POIBLÍ
OSPIDÉAL DÉIDLIACHTA BEARTAITHE BHAILE ÁTHA CLIATH
19TH REPORT OF THE DÁIL COMMITTEE ON PUBLIC EXPENDITURE
THE PROPOSED DUBLIN DENTAL HOSPITAL
1.The Incorporated Dental Hospital of Ireland was established about 1870. The Government in 1963 established the Dental Hospital Board under statute to take over the Dublin Dental Hospital and to establish a new Dental Hospital.
2.In 1967 the Minister for Education announced his intention to rationalise the Dublin Universities and in 1968 a specific plan was published to that effect which provided inter alia for the establishment of one dental faculty at Trinity.
3.At about that time as part of a major Dublin Hospitals Rationalisation Programme, St. James’s Hospital was being planned as an alternative to the members of the Federation of Dublin Voluntary Hospitals. Since these were also teaching hospitals a Health Science Faculty Complex was planned on the St. James’s site to include the proposed Dental School.
4.In 1972 the HEA advised that there should be one Dental School in Ireland based in Dublin and within this planning framework.
5.In 1974 the Government decided that there should be two dental hospitals, one in Dublin and one in Cork. In 1975 approval was given for the resumption of planning for the Cork Dental Hospital.
In 1977 the Government approved the Cork Dental Hospital on which work started in November of that year. It was set back by a fire in 1981 which delayed opening until February 1982. This was built and equipped for a total cost of £3.267m. as a 25 place teaching facility and is now graduating about 36 students annually.
6.Meanwhile in 1981 approval was given to proceed with planning the proposed Dublin Dental Hospital. Financial considerations led to a review in 1983 as a result of which the work was halted. It recommenced after a decision announced by the Minister for Education in May 1985. Tenders were sought for site development work at St. James’s and negotiations were begun between the Eastern Health Board and the Department of Health. This is planned as a 48 place facility, costing £17.5m and the present hospital is graduating about 35 students annually. The intention is to replace temporary medical training facilities on site with shared new lecture and library facilities and to house the Pharmacy School in parts of the old Dental Hospital. There are no plans as yet for the future use of some of the old facilities.
7.The Committee was provided with comparative figures on the adjusted cost of both facilities and their respective unit running costs. The fact that shared library and lecture facilities were already provided on site in Cork while they are being replaced in Dublin was taken into account.
8.The budgeted Dublin cost per square metre at £573 the Committee took to represent good value for money provided the case could be made that the space was essential both in its extent and its purpose. However the Committee could find no justification for the provisions for fees, equipment and inflation totalling £8.3m.
9.The Committee was advised about international patterns in the closure of dental schools, the decline in the incidence of dental disease and in the number of dentists and of surveys in Ireland which indicated that Ireland would need no more dentists than it now had by the end of the century. This would suggest an annual requirement of 45-50, though the case was also made for an annual output of up to 70 dentists.
10.The Committee was advised about the annual cost of dental training and the new training requirements emerging in other countries for dental hygienists dental nurses and dental technicians.
11.The Committee concluded that because the training cost is perhaps 10 times the average cost of a third level education and is a multiple of national average income that training places and throughput should be limited to future national needs. This would require comprehensive manpower needs assessments to determine the appropriate scale of the new project.
12.The Committee also concluded that rationalisation talks should take place between the Cork and Dublin dental schools before the project goes ahead if the annual average requirement for dentists is shown to be less than 70 though the Committee is not persuaded that one college is necessarily a better solution
13.The Committee made a number of recommendations relating both to the project itself and to deficiencies in and non compliance with the prescribed procedure for assessing such major capital projects.
14.The Committee expressed concern about the lack of availability of a Public Dental Service and the reduction of service to those statutorily entitled to it, and recommended consideration by the Dental Council of a 2 year pre registration period for dental graduates to be spent in public dental service in Ireland.
15.On balance the Committee recommends that the project should be processed with after a comprehensive study of future manpower needs determined the extent of the additional facilities which should be added to the present Cork throughput to match dental output with needs and after the allocation for inflation, fees and fittings were considerably reduced.
16.The Dáil Committee on Public Expenditure, under its remit set out in its Orders of Reference, reported to the Dáil in July 1985 on the Control of Capital Projects. Other reports by this Committee also identified problems in relation to the system for selecting and managing major capital projects and made recommendations designed to improve the value for money derived from future capital projects.
17.In its earlier reports the Committee identified remedies to past failures and difficulties. In this case, however, though the project was the subject of a Government approval in May 1985, no on-site expenditure has yet been undertaken. So the Committee, in light of its reports on capital projects considered it appropriate that it should undertake an assessment of the basis on which the need for a new Dental Hospital/School was established and whether, in the opinion of the Committee, this was valid or whether there were less expensive alternatives.
18.The proposed Dental Hospital comes under the authority of the Minister for Education and was submitted by the Higher Education Authority on behalf of Trinity College Dublin. In so far as it is a hospital and is designed to train graduates, who will work in the Health Programme, the Department of Health and the Eastern Health Board were involved and the Committee considered it necessary to hear evidence from representatives of those agencies. The Cork Dental Hospital/School, which is on the campus of the Cork Regional Hospital and is part of University College Cork (UCC) and the Irish Dental Association are also interested parties from which evidence was heard.
19.It is the view of the Committee that the Dublin Dental Hospital operates in inadequate conditions; that it provides a necessary dental service to those statutorily entitled to it and to others; that it should be replaced in an appropriate building as expeditiously as possible at least cost; that in the process no additional provision for training places for dentists or for other grades should be provided for and that the Cork Dental School should be encouraged and supported in continuing to maintain its present graduate output level.
20.The Committee is not convinced that the new Dublin Dental Hospital should be any larger or costlier than the Cork Dental Hospital.
21.No adequate explanation was provided as to the alternative use to which the present Dental Hospital will be put which would satisfy the Committee that it has no cost implications for taxpayers. The Committee further concluded that the St. James’s site on which it is proposed to build the new facility will not become available for those purposes without additional major cost implications for taxpayers through the provision of alternative office accommodation for the Eastern Health Board.
22.The Committee is not satisfied that these implications should be ignored by the promoters of this project or that they can be if the Department of Finance directive of 1983 is complied with. The Committee is not satisfied that the new data coming to light since the project was first mooted on the future need for dentists or the effects of fluoridation and other factors on the pattern of dental disease have been fully taken into account or that the full requirements of the Department of Finance Circular 1/83 relating to Capital Projects have been met.
23.The Committee is not satisfied with the present system whereby the capital projects are not charged to the benefitting Department or programme. In this particular case the role of the Department of Health, both as a prospective employer of dentists and others whom it was proposed to train and as the ultimate managers and co-funder of the proposed Dental Hospital was not adequately reflected in the Department of Education’s role as project promoter and manager.
24.In addition, the Committee is of the view that a Dublin Dental Hospital built primarily as a training facility is not necessarily a satisfactory alternative to meeting the statutory obligation of the Department of Health and the Health Boards in the provision of dental services.
25.In making the case for a new and expanded Dublin Dental Hospital reference was made to the unsatisfactory dentist/patient ratio arising from the fact that there is practically no alternative for the 1.7 million people eligible for the dental service than the 220 dentists employed by Health Boards. The Committee is not convinced that the proposed project will in any way contribute to the resolution of this problem now or in the future. On this basis, the Committee would wish to see a significant reduction in the budget allocation to the project and a comparable increase in the provision to the Department of Health with a view to clearing the arrears on dental treatment through the use of dentists in private practice as heretofore.
26.In making its recommendations to the Dáil, the Committee is concerned that, not only should the project be amended as appropriate, but also that the process through which it emerged should be improved so that taxpayers can have confidence that value for money can be derived from such public capital projects.
Background to the Project
27.The present Dublin Dental Hospital houses a staff of 168 and an average dental student population of 122. They have been obliged to operate for too long in an inadequate building. The Hospital’s relocation to St. James’s Hospital was an incidental part of a wider rationalisation programme for certain voluntary hospitals in Dublin. The new Dental Hospital was added on as part of a major clinical sciences complex at St. James’s since the old Dental Hospital on the Trinity campus has for some time been acknowledged to be in need of replacement.
28.The rather grandiose Dublin universities plan of the 60’s which was part of both a Universities and Hospitals rationalisation programme was trimmed down in the 70’s. Temporary medical training accommodation was installed on the site of the St. James Hospital. The clinical sciences complex then became somewhat reduced in scale and in purpose to a dental school sharing lecture halls and library facilities with the medical school eventually replacing the temporary accommodation.
29.Meanwhile, more important developments took place
-the Cork Dental School went ahead with funds provided by the Department of Education with the approval of the Government in 1977.
-The changing pattern in dental disease, the consequences of fluoridation and the reduced need for dentists throughout Europe and the United States became apparent and in the 80’s it was established by surveys and studies that Ireland was part of this pattern and had a reduced need for dentists.
-In response to these changes and other factors the proposed Dublin Dental School provided places for hygienists, technicians, paradentists and postgraduate courses.
30.In response to increasing financial pressures on Health Boards the use of private dental practitioners by Medical Card holders and the number of dentists employed by Health Boards have been seriously constrained leading to a most unsatisfactory backlog of Medical Card holders awaiting dental service. This may have created increased demand for the only alternative service of a dental training hospital.
31.The Committee is of the opinion that additional dental hospital service is an inadequate and cost ineffective substitute for an adequate dental service.
32.The Committee is also of the view that given the very high cost of training dentists compared with the average cost of university training, every effort should be made to get the balance right. It was on this basis that the Committee undertook its examination of the proposed Dublin Dental Hospital in the belief that whatever the rights and wrongs of past decisions or however well or badly the background investigation work was done into the need for such a project the taxpayers are still entitled to value for money.
33.It is to this end that the Committee has completed this report and lays it before Dail Eireann.
34.This report results from two public meetings of the Committee at which the interested parties gave evidence and were questioned and further private consultations and submissions and a number of private meetings of the Committee. It deals separately with the deficiencies shown up in the review process which led to the various Government decisions affecting this project since 1974 and the question of the project itself - whether given present circumstances the scale of the project now proposed represents good value. This ignores a third and equally significant cost inefficiency - the cost to Trinity College, HEA, UCC, the Departments of Health, Education, Finance and ultimately the taxpayer incurred in formulating, revamping and generally processing the project over the past 12 years.
The Public Capital Project Appraisal Process
35.This chapter outlines the process pursued since the Government was first asked to make a decision in relation to this project in 1974, the required appraisal process which is in place since 1983 over two years before this decision was taken; the information deficiencies identified by the Committee resulting from non-compliance with the laid down procedures and the Committee’s conclusions arising from the examination of the appraisal process.
36.In its report on University reorganisation of 1972 the view of the Higher Education Authority which has a statutory obligation to advise the Government on graduate manpower needs was that there should be one dental faculty and one dental hospital which should be in Dublin under the auspices of Trinity College with an output of up to 75 dental graduates per annum.
37.The Government then decided in 1974 that there should be two dental faculties and in 1977 decided as part of the new Regional Hospital in Cork that a new dental Hospital should be provided with an annual graduate capacity of 25. This went ahead with the funds being provided through the Exchequer under a Department Health vote and the building was completed in 1982 at a total cost of £1.9 million Despite the fact that the facilities were geared for an annual graduate output of 25, undergraduate intake went as high as 44 and 36 dentists graduated last year
38.The HEA in response informed UCC that the Ministers for Education and Finance considered that steps should be taken to ensure that future output should not exceed 25.
39.Trinity began making plans for the new Dental Hospital in the mid 70’s. This coincided with the transfer of Trinity Medical teaching facilities to St. James’s Hospital as part of a wider rationalisation of Dublin Voluntary Hospitals including Baggot Street, Sir Patrick Duns, Dr. Steevens and Mercer’s Hospitals. This phase of planning was being funded through the HEA revenue grant which included a certain provision for such work. Consultation and examination of the project continued from 1975 to 1980 involving Trinity and HEA who in turn sought technical advice from the Department of Education Building unit.
40.The Department of Health and Education then had consultations as to who should fund the project since it was in part a hospital and an integral part of a major hospital programme being funded by the Department of Health and which included substantial contributions to roads, heating and services.
41.Finally the project was agreed by the HEA following approval of the Minister for Education which in turn required the approval of the Department of Finance.
42.Following Government approval in principle the HEA funded the cost of planning the building. The planning was stopped for lack of funds in 1983 and recommenced as a result of a Government decision in May 1985.
43.The Cork Dental School was built by the Department of Health and the operating costs are apportioned between Health and Education. The HEA say that they have been able to meet their share of Cork’s need but problems have arisen as a result of the cut backs in Health. The HEA considered that additional students will inevitably require increased HEA grants for additional staff to restore student staff ratios and expressed concern that standards might suffer and demands for additional physical resources might arise if the present throughput is continued.
44.The HEA has been largely silent on dental graduate needs since 1975 though the authority still believe that provision for up to 75 per annum is about right despite the fact that 50% of Dublin graduates and 90% of Cork graduates emigrate. They discount a survey undertaken by Professor Moran on behalf of the Dental Board and quoted extensively in appendix 5 in the belief that his note of warning was not borne out by the statistical data contained in his report. The HEA also seem to discount studies undertaken and reported on in 1981 and 1982 showing a dramatic decline in the need for dental treatment in Ireland as elsewhere. Department of Health officials informed the Committee that the future needs were for an annual output of up to 70 dentists while the Irish Dental Association quoted studies to indicate a need of from 45-50 but also argued for increased post graduate facilities.
45.The Committee has no evidence to suggest that any new information on manpower needs has been taken into account in the consideration of this project.
The Evaluation Procedure for Major Capital Projects
46.The Committee in earlier reports was critical of a lack of rigorous procedure in determining the cost and the benefit of major capital projects and made a number of recommendations in this regard.
47.The Department of Finance, recognising that there were difficulties in relation to Capital Projects issued Circular 1/1983 in March 1983. This drew on previous manuals and required in particular that procedures set out and updated in an Foras Forbartha’s report on Design Cost Control be adhered to by all public sector capital projects and that major projects follow the standards set out in a Department of Industry commissioned document “Guidelines for Major Projects”.
48.The Department then went on to lay out procedures to be followed by the promoting Department or agency which included:-
1.A preliminary survey exploring all options and determining the degree of need.
2.A detailed appraisal using outside expertise, if necessary, to examine all financial aspects including sources, alternative use of old premises and knock on implications for the exchequer.
3.On the basis of the results the case for the project should then be reviewed.
4.On this basis, approval in principle may be sought and, if granted, a comprehensive brief is prepared to commission design work which should then be revised as necessary and finalised before tenders are sought.
5.A submission for final approval which must be given before a contract is placed must include a final review of the project under 18 specific headings.
49.The Committee, in examining other capital projects in the past, has been able to relate cost over-runs and other deficiencies to the lack of such guidelines. This is the first occasion in which the Committee has examined a capital programme which has been approved but has not yet been undertaken. The Committee considers that it is essential to good order in public expenditure, to proper prioritisation of competing and very different projects and to value for money, that these guidelines are adhered to before the proposed Dublin Dental Project is finally considered for approval.
50.Unfortunately, the expenditure on planning to date on the project under review is in excess of £2 million. This takes no account of the Public Service cost of personnel time and overheads from the Departments of Education, Health, Finance and from HEA and Trinity College not to mention the time taken by this Committee, including the public servants who gave evidence.
51.Part of the task undertaken by the Committee was to seek to establish whether the authorised procedures were followed in this case. Without a full disclosure of the process and the documentation from all the agencies concerned but after informal consultations with officials of Trinity, HEA and Departments of Education and Health the Committee concluded:
that if an adequate preliminary survey as to the need was undertaken before the Government decision of 1974, it was not updated adequately before the Government decision in 1985,
that despite the substantial change in dental and financial circumstances in the interim no adequate assessment of the alternative possibilities of providing a dental hospital as part of existing hospital facilities or of revamping the present dental hospital was undertaken.
52.The Committee was not provided with any information as to the cost of alternatives considered.
53.No adequate assessment of the knock on effects of the project were conveyed to the Committee, despite acknowledgement on the one hand by Trinity College that the old Dental Hospital would be adapted as a new Primary school and on the other hand by the Department of Health as a consequence of this proposal and perhaps as a condition of site availability new office accommodation would have to be provided for the Eastern Health Board. The insistance by the Higher Education Authority and the Department of Education that these are irrelevant is in clear contravention of the requirements of the approval process for capital projects as set out in Circular 1/83, though it is acknowledged that HEA claim to have no knowledge prior to 1986 of this condition attaching to the site.
54.The Committee’s concerns on these issues are entirely independent of considerations of the project itself or indeed of the project management system. They arise from what the Committee can only conclude as flagrant non-compliance with even the most rudimentary provisions of the laid down procedure.
55.That this procedure is necessary was clearly established by the cost of its absence in projects reviewed by the Committee which pre-dated it. For whatever reason, it seems that over £2 million of public expenditure has been incurred on this project as if those guidelines did not exist and that further expenditure is unlikely to be contained within £15 million without any definitive evaluation of more cost-effective alternatives. Furthermore, the Committee considers that additional expenditure on the two sites will inevitably follow from this decision though for different purposes and that no estimate of the extent of those costs has been made.
56.With a view to avoiding a recurrence the Committee recommends that the officials within the Department of Finance with responsibility for the relevant vote be given specific responsibility for ensuring that the procedures for evaluating the need for major capital projects be fully adhered to and that no authority for expenditure be allowed except in accordance with those procedures until it comes to the stage where it is a matter for the Government.
57.The Dublin Dental Hospital Project which was given approval by the Government in July 1985 has its origins in the 60’s.
58.There was concern about the quality of training provided in the Dublin Dental Hospital and a new statutory hospital board was formed in 1963 with the task, inter alia, of providing a new Dental Hospital.
59.In 1967 the Minister for Education announced his intention to rationalise the universities in Dublin which then enjoyed Exchequer support to the extent of £1.4ill. In the absence of agreement the Minister in 1968 issued a plan for university rationalisation which included the establishment of Dentistry in Trinity College.
60.The subsequent NUI/TCD Agreement states that, because of the enormous expense involved, there should only be one dental school and that, with the agreement of Royal College of Surgeons and University College Cork, this should go to Trinity.
61.The Higher Education Authority in its subsequent report of 1972 further considered the proposal to establish at a cost of £750,000 a Dental Hospital in Cork for 25 dental students. On the basis of the Dublin authorised entry figure of 50 students the Authority concluded that the annual output would be substantially higher than the rate of absorption and accordingly advised the Minister that there should be one Dental school and that it should be in Dublin.
62.At the same time the Department of Health was planning the rationalisation of Dublin Hospitals. Out of this process emerged the proposal to establish a major 1,400 bed general hospital at St. James’s to replace the hospitals of the Federation of Dublin Hospitals.
Since these were also training hospitals the plan included a clinical sciences complex. This building was to include the Dental Hospital. It has since become the Dental Hospital having been trimmed through the planning processing from 20,000 to 16,000 and now to 10,000 sq. metres.
63.The planning of a new development on the site of St. James’s Hospital started in earnest in October 1975 when the task of preparing a brief for the development was assigned to the St. James’s Hospital Project Team. The initial membership of this Project Team included:
St. James’s Hospital Board:
Professor D. I. D. Howie - Chairman
Mr. J. J. Nolan, Vice-Chairman
Mr. N. O. Dowling, Planning officer, St. James’s Hospital
Dr. P. J. Blaney, Medical Consultant
Miss N. McCarthy, Matron
Dr. J. O’Dea, Medical Administrator
Professor T. Hennessy, Professor of Surgery
Professor G. Neale, Professor of Medicine
Department of Health
Mr. S. Henesy, Assistant Secretary
Mr. C. Dowdall, Deputy Chief Architect
Dr. P. A. Jennings, Medical Planner
Mr. F. Jackman, Architect
Department of Education:
Mr. O’Richardson, Chief Architect
Higher Education Authority:
Mr. J. Dukes, Secretary
University of Dublin:
Professor J. McCormick, Dean of Medical and Dental Science
Professor R. Dockrell, Director of the School of Dentistry.
64.The brief prepared by this group included a Clinical Sciences Complex of 15,884 square metres. This contained facilities for 250 dental students, 10 post graduate dental students, 15 trainee junior dental hospital staff, 50 trainee dental surgery assistants and 30 trainee dental technicians.
65.This brief was used as a basis for the preparation of a Development Control Plan for the whole of the hospital site that was completed in 1978. The Development Control Plan showed the Clinical Sciences Complex occupying the North East section of the site.
66.An education sub-group of the Project Team prepared a detailed brief for the Clinical Sciences Complex using the U.K. University Grants Committee planning norms to calculate the space needs for academic activities. The space needs for academic activities were calculated using planning norms obtained from a number of British Dental Teaching Hospitals. The detailed brief was completed in June 1979 and submitted to the H.E.A. for approval. It included two phases totalling 23,959 square metres.
67.There followed a period of approximately twenty eight months of discussion with the H.E.A. and the Building Unit of the Department of Education. During this period, the Minister for Education confirmed that his Department, through the H.E.A. and T.C.D. would be responsible for funding the Clinical Sciences Complex including the dental hospital and the brief for the Dental Hospital was revised in the light of the new Dental Teaching Curriculum. The main change was the provision of multi purpose clinics and reduced laboratory facilities. This reduced space requirements. The revised plans were re-submitted to the H.E.A. for approval in October 1981. The project was then divided into two phases totalling 16,239 square metres.
68.This consultation process between Trinity, H.E.A. and the Department of Education continued until March 1983 when the H.E.A. informed the College that planning would have to stop “pending a review of financial circumstances”. Planning was resumed in June 1985 when the Minister for Education informed the H.E.A. that the Government had approved the planning and construction of the project subject to an absolute cost limit of £17,500,000 including inflation, fees and equipment. The scheme was revised once again to bring it into line with this budget under the direction of a small planning group set up by the Board of Trinity College. The group consisted of a core membership of the Director of the Dental School, the Vice-Dean of the Health Sciences Faculty and the Director of Buildings assisted as necessary by various specialists in the field of medical and dental education. The result was a building containing 7,349 square metres of usable accommodation (10,000 square metres gross) for the Dental School and Hospital and associated shared facilities with a cost plan as follows:
This building is now at an advanced stage of design, has Government approval and awaits arrangements being made with the Department of Health and the Health Board in relation to the site.
Cork and Dublin Cost Comparisons
69.A document emanating from Cork was the subject of a short commentary submitted by Trinity College. These two documents are contained in Appendix 6. The Department of Education submitted two documents one on the relative Capital Costs and the other on relative running costs in both hospitals. The tables are extracted from these documents in Appendix 3.
70.The Committee did not consider the examination of comparative data to be the central issue in this examination. After all the Capital Cost of Cork has already been incurred and cannot be recovered. But it was concerned that such information if provided should be reliable and accurate and that spurious comparisons should be avoided. It was also concerned to find that the unit costs of the Dublin Dental hospital were substantially understated in evidence to the Committee though this was corrected following further enquiries.
71.The actual final cost of the building and equipping of Cork Dental hospital taken over for use in February 1982 was £3.267m. This does not allow for any contribution for the lecture and library facilities which were already built in the regional hospital and shared by Medical and Dental students.
72.The actual budget final cost as at July 1985 for the site development and equipping of the Dublin in Dental Hospital is £17.5m. This includes lecture and library facilities to be shared by medical and dental students which replaces such facilities in temporary buildings now on site.
73.Cork expects to have 39 students graduating in 1986 from a total of 105 students while Dublin has an average of 122 undergraduate students of which 36 are expected to graduate.
74.On the basis of the number of dental students accommodated without making any adjustments but simply looking at the Exchequer implications for both projects the Cork hospital cost taxpayers £29,743 per student place in 1982 terms and the Dublin project is sheduled to cost taxpayers £142,672 per student place in 1985 terms.
75.Yet as can be seen in the appendices the Department of Education submitted a number of alternative costs per student place summarised in the attached table.
76.While there is a case to be made for seeking to adjust the total costs to comparable terms for price comparison purposes the Committee considers as is apparent from the foregoing that the comparisons were rendered meaningless.
77.Patients are dealt with in Cork in Poly clinics so that each patient is treated for all problems and is only counted once. In the Dublin Dental Hospital because there are separate clinics for each speciality patients are counted each time they come from one clinic to another from which they might be referred. No attempt was made to adjust these figures before making comparisons. Besides the Committee considers that since it is a training facility undue weight should not be put on this service output.
78.Cork Dental Hospital though designed for an annual output of twenty five graduates can they claim maintain graduate output and standards at 35 without an increase in the numbers of chairs which at present is 64. The planned number of chairs in Dublin is 128 or double the Cork number.
79.The present number of chairs in the Dublin Dental hospital is 78. The suggestion is that its capacity is being increased by 8 by the new project. The number of additional chairs belies this.
80.Though the Capital Cost Comparisons do not take account of the cost benefit accruing to Cork from the shared library and lecture facilities available the running cost comparisons using Department of Education figures seem to suggest a very substantial and variable annual cost to Cork for these shared administration and other facilities. Yet despite that the running cost per dental undergraduate of Dublin is over 50% higher than in Cork.
81.Even taking all other students into account including post graduate students part time in service courses, dental nurses the proposed diploma course in dental hygiene and dental technicians on a like with like basis the Committee is satisfied that Cork was cheaper per student place both to build and equip.
82.This is not to say that Dublin represents less value for money in terms of building. Cork had after all the advantage of being completed 3 years before Dublin was approved and it also had certain on site advantages including access to shared teaching facilities. But the taxpayer gets the advantage of these savings and they cannot be ignored.
83.The Committee reviewed these comparisons primarily because they were made in written and oral submissions to it. Its main purpose was to establish if the comparisons made to it were valid. It does not believe that this project should be judged against Cork but rather after Cork and in light of the need for dentists particularly given the extraordinarily high cost of providing and running each dental student place.
84.A comparison of staff numbers between Dublin and Cork adjusted to full time equivalents was also made showing that the Dublin staff of 168 was greater than the total number of dental students while the Cork staff was 61.5 (breakdown in appendix 3). The Committee considered that the proposed move should coincide with a review of Dublin’s staff needs and appropriate rationalisation.
85.The Committee’s primary concern is to establish whether the project can be justified in terms of the need for dentists and at what scale recognising the considerable beneficial side effects it can offer in terms of dental treatment and para dental training.
Conclusions and Recommendations
The Committee’s main conclusions are as follows:-
86.Neither the HEA, Trinity College nor the Department of Education took sufficient account of the Government decision in 1977 to proceed with the Cork Dental School in their subsequent consideration of the Dublin Dental Hospital project and discounted completely the graduate output over the planned 25.
87.In light of the very high cost to the Exchequer both in Capital and Current terms of dentistry including all the auxiliary training programmes which are not of third level standard, future manpower needs are a critically important determinant of the size of the proposed Dental school.
88.Due weight has not been given to the available surveys and data by the HEA, Trinity College and the Department of Education, which shed light on dental manpower needs and adequate consultations did not take place with the Department of Health to establish a realistic basis on which to project the likely uptake of dentists in Ireland over the next few decades.
89.Adequate consultations did not take place with the Department of Health on the overall project, given that it was under the responsibility of that Department that the Cork Dental School was built, it is to that Department that the Board of the Dublin Dental Hospital is accountable and that Department was being asked to provide the site for the new complex and would be expected to meet its share of the running cost.
90.The Committee has no criticism to make of the very comprehensive planning undertaken by Trinity College at the various stages of the proposal. But the College was the victim of an inadequate system of project prioritisation and of non-adherence by the Government departments and agencies involved with the laid down procedures. This had led to a number of delays and postponements to date. The fixed budget approach of allowing the specification to be built around a figure of £17.5 million is inappropriate given the likelihood that if the budget is exceeded the cost will still accrue to the Exchequer and given the level of provision fees, fitting and inflation.
91.It is inappropriate that the student throughput of Cork Dental School should be reduced and its productivity thereby impaired or that it should otherwise be threatened or undermined by the decision to proceed with Dublin Dental Hospital.
92.It is inappropriate that substantial capital resources be provided to a third level institution to provide for non-third level training for courses which are not yet determined and where no provision has been made through the appropriate professional channels - in this case the Dental Council, a body statutorily established - for acceptance of their training or employment.
93.The number of people willing to use the services of a Dental school reflects more on the inadequacy of the present dental service than it does on the need for greater dental hospital services.
94.The level of fee income derived relative to the level of prescribed charges is evidence in itself of poor administration or decisions relating to welfare being improperly taken by people who are neither authorised nor trained to do so.
95.Given the level of detailed planning over a decade or more which has gone into this project, the system is seriously flawed in the waste of time of senior public servants given to projects before a structured appraisal of need and cost benefit is undertaken. This may be the main reason why it is so difficult for projects to be rejected once they build up a momentum through this process.
96.The present divisions between the administration of the Dental School and the Dental Hospital are untenable and the present ambivelance in relation to Trinity’s role a decade after it was assigned responsibility is unacceptable and should be resolved by disbanding the Statutorily established Dental Hospital Board. The Committee understands that discussions have been initiated to this end. Given that the Dental Hospital is already fully equipped and that the total value of equipment and fittings in many of the Irish universities would not exceed the provision, the Committee feels that £4 million is simply too much to provide for fitting out a New Dental Hospital in the prevailing financial circumstances and suggests it be halved. The Committee cannot see why, in today’s circumstances, a figure of £2.5 million should still be provided to meet inflation and suggests rather a figure of £500,000, being over 6% of the total cost of the building and site works. A figure of £1.8m is simply too much to allow for fees on such a project. The provision should be cut to a maximum of 12% of Site Development and Building Costs. A total of 10,000 sq. metres is simply too much to accommodate the appropriate number of staff and dental students if the output of the two Dental hospitals is to be matched to Irish dental needs even allowing that some of the facilities may be shared with medical students.
97.The Committee considers that in light of the fact that the average annual exchequer cost per dental student in Dublin is in excess of £18,000, that this project will not reduce that and may in fact increase it, it is imperative that each additional dental place provided can be justified within the Irish Health Service.
1.There is considerable room for increased revenues from fee income even within the existing scale of fees and the annual administrative grant should take this into account. As dental students provide some benefit during their training this should be reflected in an adequate recovery from patients ineligible for free dental service and a satisfactory level and volume of public Dental Health Service in the hospital.
2.In light of the very substantial capital and running costs of Dental training and the acute shortage of public service dentists, the Dental Council should consider the feasibility of providing for a minimum of two years service with the Health Boards as an additional pre-condition for registration.
3.The Dental Council should consider as a matter of urgency whether and what forms of dental auxiliaries should be provided for, in Ireland; the Department of Health should consider whether and how they might be employed.
4.A comprehensive assessment of dental manpower needs, taking into account Health Policy, likely availability of funds and international trends should be undertaken before a final decision is taken.
5.A comprehensive survey of the buildings to be vacated by the Dental Hospital and school should be undertaken and a detailed plan for their adaptation to the most appropriate alternative uses should be costed and their realisable value established. This data should also be considered in the context of the new dental hospital proposal.
6.An alternative site to that proposed at St. James’s Hospital should be considered for the proposed Dental Hospital if it becomes a condition of site access that new offices are to be built for the Eastern Health Board. If no suitable alternative site is available and if, as the Committee has been informed, approval has been given for new offices, the full capital cost of that development should also be established and taken into account before a final decision is made on the proposed Dublin Dental Hospital.
7.In the present economic climate the provisions for fees and inflation in the estimates should be reduced with not more than 5% of the construction cost allowed for inflation and not more than 12% for fees.
8.Given the case made in 1972 by the Higher Education Authority for the establishment of one dental school and hospital in Dublin with the agreement of Cork and the Royal College of Surgeons the question should again be discussed by all the interests following completion of the necessary survey work to determine manpower needs and following consideration by the Dental Council and the Department of Health of the position of hygienists and other dental auxiliaries.
9.If the facts indicated, as they are most likely to, that
(a)the annual need for dentists will be less than 70
(b)the requirements for auxiliaries is likely to be small and
(c)there are considerable economies to be derived from one dental hospital, then the purpose of the discussions should be to devise a means of achieving that result in the interests of future dental students and present and future taxpayers.
10.If, however, no such means of rationalising dental training facilities can be found and the project were still to get approval, the Committee considers that reduced scale and student throughput should be matched to the future need for dentists and auxiliaries.
99.b) Recommendations in relation to project appraisal procedures
1.Despite the fact that this project has been under active consideration for so long as part of two major rationalisation programmes - for hospitals and for universities - the Committee recommends at this stage that it be drawn into compliance with the guidelines set out in Circular 1/83 advancing it through its final phase to include the following:
-A dental manpower needs survey.
-A review of progress on the Hospital and Universities rationalisation plans of which it was part.
-A review of the cost implications for the Exchequer on both the old and the new sites.
-A review of the adequacy of Public Dental Services which if they are to be improved will affect manpower needs and possibly the flow of patients to the dental hospital.
2.The guidelines of Circular 1/83 should be revised to tighten up the language to set out separately the requirements for Government Departments and State-sponsored bodies, as a first step in their further implementation.
3.The planning process should be shortened, sharpened and professionalised as a safeguard against repetition of the loss of time and effort which has gone into this project through committees, working parties, planning groups, planning officers, inter agency and interdepartmental consultations for up to twenty years and in a concentrated way over the past 11 years.
A second and even more important reason for this recommendation is to safeguard against the build up of ‘pet projects’ through the years of thought and consultation involved in the present process, with the result that it becomes practically impossible to stop them and the formal decision making is taken as a formality which considerations such as need, financial stringency or other priorities can at best delay.
4.To this end the Committee specifically recommends that, as part of the annual budget process, approval is required to undertake evaluation of capital projects for consideration and that normally the same project should not be approved in two consecutive years without a report being submitted and approval given for further investigations into specific aspects of it.
5.The obligation should be on project promoters to establish how they justify adding to Exchequer indebtedness and to the cost of debt servicing on taxpayers for the project they propose and in the case of projects involving over £10 million the project proposal document making this case should be placed before the Houses of the Oireachtas by the Minister responsible before approval in principle is given.
6.The procedure followed in offering a fixed sum grant to Trinity College might have much to commend itself given the pattern of over runs on public capital projects in the past. However, when the sum includes a £2.5 million provision for inflation in today’s economic climate the Committee recommends that, independent of the outcome of further consideration of the project, that this, the provision of £1.8m for fees and the provision of almost £5m for fittings and equipment should, in any event, be drastically revised These together account for more than half the budgeted expenditure and should, the Committee considers, be reducable in total by at least 50%.
100.The Committee’s primary concerns revolve around the fact that, despite the length of time and the cost of developing this project, the basic work as to Ireland’s need for more dentists has not been undertaken. This is compounded by the fact that inadequate allowance has been made in the planning process for the fact that the Cork Dental Hospital was established in the course of the planning and is now producing 36 graduates annually.
101.These deficiencies might not normally be of major concern given that any available third level places will be taken up and the Committee is not convinced that one school with a monopoly of resources is necessarily the best answer in any discipline. But they are very serious indeed when they apply to a dental school because of the present very poor availability of dental services through lack of funds rather than lack of dentists to Medical card holders and school children who are statutorily entitled to the service and the fact that the annual cost of dental training is over six times the average third level cost and is substantially in excess of the National average income. In these circumstances it is imperative that no more public funds, than is necessary, is provided to create dental student places since each graduating dentist who is not necessary, to an adequate dental service in Ireland represents 10 times young people denied a third level education.
102.The Dublin Dental Hospital was one of the first Public Expenditure proposals considered by this Committee before the main expenditure had actually begun. The Committee has in the past been mainly engaged in the business of making recommendations as to how the rules and procedures should be revised to avoid a recurrence of mistakes already made.
103.The Committee hopes that as a result of this examination no further mistakes will be made in relation to the Dublin Dental Hospital and that taxpayers will get value for money. Dublin will get an adequate dental hospital, both Dublin and Cork Dental Hospitals will be in a position to operate efficiently and effectively and dental training will be adequate and flexible enough to be well matched to Irish needs for the future.
104.The Committee cannot claim any special wisdom in these matters but it did consider conscientiously the evidence of the various expert groups and interest groups and of course the interests of present and future taxpayers in arriving at its conclusions.
105.The Committee wishes to thank all the expert witnesses who appeared before the Committee or submitted views, in particular:
Professor John Arbuthnott, Trinity College, Dublin
Professor Martin Hobdell, Trinity College, Dublin
M/s Murray & Cooper of Trinity College, Dublin
Dr. D. Shanley of the Dublin Dental Hospital
M/s P. Ó Maoldomhnaigh, S. Nolan and R. Sweeney of the Department of Education
M/s S. Trant, McCarthy, J. Clarkson of the Department of Health
Mr. Donal St. A. Atkins of the Irish Dental Association
Professor Barret & Professor O’Mullane of the Cork Dental Hospital
M/s O’Laidhin & Hayden of the Higher Education Authority
Mr. Frederick Donohoe, Programme Manager, Community Care, Eastern Health Board
Without their full co-operation the work of the Committee in considering this project on behalf of taxpayers could not have been undertaken.
Michael Keating T.D.
26th September, 1986.