Joint Committee on Health debate -
Thursday, 19 Jan 2017

National Maternity Strategy: Discussion

Chairman

The purpose of the meeting is to meet in the first session the Irish Nurses and Midwives Organisations, INMO, and the Institute of Obstetricians and Gynaecologists and in the second the Health Service Executive, HSE, to discuss the national maternity strategy, 2016 to 2026, which was prepared by the maternity strategy steering group. On behalf of the joint committee, from the INMO I welcome to the first session Ms Mary Leahy, vice president, and Ms Mary Gorman, executive council member. I also welcome from the Institute of Obstetricians and Gynaecologists Dr. Peter Boylan, chairperson, and Professor Louise Kenny who will provide us with their perspective on this key strategy document.

By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by it to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable. I advise that any opening statement or other material submitted to the committee may be published on its website after the meeting.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable.

I ask Ms Leahy to make her opening statement.

Ms Mary Leahy

I thank the Chairman and members of the committee. The Irish Nurses and Midwives Organisation, INMO, has welcomed the launch of the country’s first national maternity strategy, Creating a Better Future Together for the period 2016 to 2026. Our midwives section has particularly welcomed the recognition within the strategy of the need to give pregnant women appropriate and informed choices supported by access to the correct level of care and support for their individual needs. Our midwife membership also welcomes the recognition within the strategy of the role of midwives in the natural childbirth experience. In particular, we welcome the recognition of midwives leading and delivering care within the multidisciplinary framework for delivering the care pathway intended for normal-risk mothers and babies. In that regard, we advise the committee that all audits of existing midwifery-led units, MLUs, confirm high-quality performance and high levels of satisfaction felt by mothers. My colleague, Mary Gorman, has experience of such a midwifery-led unit as she works in Our Lady of Lourdes Hospital, Drogheda. Ms Gorman can provide further details with regard to the effectiveness and potential of this service model.

In this regard, the publication of the strategy and, more importantly, its implementation should herald a move away from the current overly-medicalised models of care in existence across the country. It has long been the view of the INMO that current maternity services underutilise the potential of the registered midwife, thus minimising the choices for the woman. It is imperative, through the implementation of this strategy, that our maternity services utilise the expertise and autonomous practice of all health care professionals within the service in the interests of optimising the quality of the service and the supports to the mother and newborn baby. In that context, the organisation also fully endorses the recommendations within the strategy for the development of a community midwifery service. This development, which will see hospital midwives coming out into the community to provide ante and postnatal care, will represent a hugely positive development for mothers and babies, bringing the service to them rather than requiring them to come into a hospital for care and support. The INMO has also noted the intention to establish a national women and infants health programme to drive forward the implementation of the strategy over the coming years. Our organisation is on record as looking forward to working with this programme to implement, in the shortest possible timeframe, all of the recommendations itemised, leading to a positive transformation of this country’s maternity services. However, we are aware of difficulties in recruiting key personnel to lead this programme, which has delayed the pace of progress to date. This leadership issue is pivotal and must be addressed without delay. The INMO has sought a meeting with the Department of Health for the purpose of agreeing the necessary measures - particularly with regard to workforce planning and including an analysis of training needs - to ensure we will have the additional midwives required to facilitate the full implementation of the strategy. This meeting has yet to take place but we expect it shortly. It is now almost one year since this strategy was published and notwithstanding its excellent potential and the positive response the strategy has received from all stakeholders, the INMO is becoming increasingly concerned at the slow pace of implementation. A key example, which goes to the heart of all maternity care, is the midwife-to-birth staffing ratio that continues to exist in this country. The accepted midwife-to-birth ratio, which arises from evidenced-based practice, is one midwife to 29.5 births. In fairness, the strategy commits to the introduction of this ratio, over a number of years, as maternity services evolve through the implementation of the recommendations. However, in the short term, it has proved extremely difficult to secure the additional midwifery posts necessary to improve the current ratio that in some units continues to be in excess of one midwife to 40 births, with one midwife to 36 births being the average across the country. The latest HSE service plan refers to the recruitment of 100 additional midwives. However, we have yet to see this happen and, in particular, there is absolutely no certainty that even advertising these posts will secure the additional midwifery expertise required in hospitals and maternity units across the country. In addition, the strategy will require increasing the number of midwifery posts by 100 in each of the next four years but again, nothing has been done to recruit or to retain midwives in the health service despite the current shortage and we have no sense of proactive planning.

The reality is that our current services are severely understaffed and the experience of the INMO is that there is a complete absence of workforce and manpower planning to address this critical staffing shortfall and to ensure a supply of midwives wishing to work within the Irish public health service into the future. This committee must understand that the implementation of the strategy, which everyone supports, is dependent upon an acceptance that as we remodel pathways of care and provide choice for mothers, there will be staffing resource implications, particularly in midwifery, which must be planned for, addressed and supplied.

A fundamental requirement with regard to workforce planning to realise and maintain the best-practice ratio is to increase the number of direct-entry undergraduate midwifery places by at least 25% or 125 midwives and, in addition, to expand the number of postgraduate midwifery places available across the country. The INMO believes this is self-evident but we are not aware of any plans to provide for this increase in supply. However, it must be noted that in recent years, a number of these postgraduate places have not been filled due to lack of applicants. This is yet another example of the service-wide issue of recruitment and retention which must be addressed if we are to establish and maintain safe practice levels.

On the more positive side, the committee should note that arising from a recommendation in the report on maternity services in the Midland Regional Hospital in Portlaoise, directors of midwifery have been, or are being, appointed to all maternity units and hospitals, numbering 19 in total. One important point to note about these appointments is that the post of director of midwifery will, in the context of implementing the maternity strategy, have a remit which spans both the maternity hospital and the adjoining community services. This is most welcome and is indicative of what should happen as the strategy is implemented and will provide governance to the enhanced community midwifery services referred to earlier. We believe this strategy, which was formulated after detailed discussion and debate involving all partners in maternity care, represents a step change in our approach to pregnancy and childbirth. The recommendations place the mother and child at the centre of all services and will require all members of the multidisciplinary team to alter existing approaches to facilitate new models of care totally sympathetic to the mother and her newborn baby. Implementation of the strategy is also essential in recognition of the changing demographics with regard to the age with which women chose to have children. Maternity services will have to be capable of addressing the modern-day realities of pregnancy, including increasing levels of obesity, management of other chronic illnesses and the many issues which flow from modern work-life balance. This requires our maternity services to be resourced, responsive and flexible which, in fairness, will result from the implementation of the strategy.

We wish to acknowledge the dedicated work of the steering group leading to this forward-looking strategy. The INMO, and particularly our midwives section, commits itself to working with all concerned to deliver upon the strategy’s recommendations. The collective goal must be to ensure excellent standards of care in the environment chosen by the mother based upon her needs and preferences. The recognition of the role of midwives within the proposed new pathways of care is very welcome and our midwife members look forward to embracing this change and providing these new models of care and choices for women nationwide.

Chairman

I thank Ms Leahy. I now invite Dr. Peter Boylan to make his presentation.

Dr. Peter Boylan

I thank the Chairman and members of the committee. The Institute of Obstetricians and Gynaecologists fully endorses everything Ms Leahy has said in respect of the role of midwives. We are fully supportive of what she has said. The institute also welcomes the national maternity strategy and hopes it will be implemented. There are three areas which the institute is particularly keen to see implemented without further delay. First, we wish to see the mastership model of governance applied nationwide, with each unit having its own separate budget and governance structure. This model has been in operation in the three Dublin maternity hospitals for more than 200 years. It is a tried and tested model that works. A clinician is effectively the chief executive officer, CEO, and is assisted by a director of midwifery and a general manager who has the appropriate financial and clerical support. The master is ultimately responsible for the quality and safety of the service and is therefore accountable. With that accountability goes authority to operate the service in the best interests of patients, that is, women and children. There is an identifiable person who is answerable for the quality of the service. Experience in the UK has shown that the further away from the patient the governance structure is, the more there is emphasis on financial outcomes and less on clinical outcomes. The current governance model, whereby maternity units around the country are integrated into the general hospitals, is a failure and recent problems in Cork and Portlaoise are good examples of this. This failure has been demonstrated repeatedly over the past several years by well-documented tragedies. There is no budgetary protection for maternity services, including gynaecology, and so they are the first to suffer cutbacks in our hospitals.

Second, we wish to see all units have access to expert ultrasonography services for all pregnant women. At the moment there is a huge variation in availability of ultrasound for pregnant women around the country. This has serious implications for the quality of care which can be given to women in pregnancy.

Third, we wish to see an increase in consultant numbers to bring us up to internationally accepted norms.

It is well recognised and accepted that the number of specialist obstetrician-gynaecologists in Ireland is the lowest in the developed world. There is a need for an additional 100 consultants to bring us to an acceptable level.

There are other elements of the strategy which the institute would like to see developed, such as more community-delivered antenatal care closer to women’s homes. Learning from experience in the UK, it is essential that obstetricians and midwives work together as a team and not separately. Finally, there is no mention of gynaecological services in the national maternity strategy. This is a serious deficiency. A national gynaecology strategy needs to be developed.

Chairman

I thank Dr. Boylan. I ask Professor Louise Kenny, professor of obstetrics at University College Cork and consultant obstetrician-gynaecologist at Cork University Maternity Hospital, CUMH, to make her opening statement.

Professor Louise Kenny

I thank the Chairman and committee for this opportunity. I echo what my colleagues have said. We must accept the fact that the woman is at the heart of everything we are addressing today. We must not lose sight of that. Notwithstanding that, my colleagues and I at the Institute of Obstetricians and Gynaecologists welcome the national maternity strategy and sincerely hope it will be adequately resourced and fully implemented without further delay.

There are fundamental inequities in the provision of women’s health care in Ireland in 2017. First, Ireland has the lowest number of obstetricians and gynaecologists among the OECD countries, at a rate of just 3.95 per 1,000 live births. This is just over half the comparative number in the UK for the same number of births. Despite this, clinical outcomes for mothers and infants are comparable with the best internationally. We urgently need to recruit a minimum of 100 extra consultants. This will require remedial steps to retain our senior trainee specialists who are currently discouraged from remaining in Ireland by poor working conditions, the perception of a hostile media and gross inequality of remuneration and contracted hours that has been brought about by the introduction of the divisive 2012 consultant contract.

Second, we reiterate the need for equal access for all women to standardised ultrasound services. Neither specialist ultrasound nor foetal medicine services are available to all pregnant women in the Republic of Ireland. Even in CUMH, where I work, a tertiary level referral unit where more than 8,000 infants are born every year, we cannot provide second-trimester foetal anomaly scanning for the majority of pregnant women attending for antenatal care. This issue remains unresolved in 2017 and exposes pregnant women attending CUMH, and their health care providers, to an unacceptable level of risk.

Finally, the single most important step to safeguard the success of the national maternity strategy is to ensure the governance of women’s health services is robust, independent and secure. International experience demonstrates that women’s health services are always the first to be cut when they are not protected by independent governance and a ring-fenced budget. Closer to home, the well-documented issues with the provision of gynaecology services in CUMH, which have led to unprecedented and dangerously long waiting times for outpatient and surgical treatment, further illustrate this point. We believe that in keeping with the national maternity strategy, maternity services within the Irish hospital system need to be led by a single accountable individual with both clinical and executive authority.

I thank the committee again for the opportunity to be here today.

Chairman

We will now open the discussion to members and will take questions in groups of three. The first group is Deputy Louise O'Reilly, Senator Colm Burke and Deputy Kate O'Connell, in that order. Deputy Louise O'Reilly is first.

Deputy Louise O'Reilly

I thank the witnesses for their attendance and their comprehensive presentations. I have a number of questions. The first is for Ms Leahy. She mentioned community midwifery services in her presentation. I am specifically interested in knowing how geared up are the primary care centres at present. I suspect I know the answer to this question but will ask it anyway. How geared up are they to lead on those community-based maternity services? Second, what will we need to do to ensure they are geared up and can meet those demands? Ms Leahy also mentioned the issues of recruitment and retention and the need for, at a minimum, an additional 100 midwifery posts. Will Ms Leahy elaborate for the committee on what will be needed? Recruitment is important but is no use without retention. Ms Leahy should address those two elements.

Dr. Boylan spoke about the need to have a master in the maternity units. Some of those units are much bigger than others. Does Dr. Boylan envisage any scenario whereby they would be amalgamated to get the critical mass that would necessitate a master or is he specifically talking about the need to ring-fence budgets with some person who has ultimate financial responsibility and ultimately the capacity to hold on to that money? As Professor Kenny said, when things get a little bit rough, it is very often the first place that gets cut.

Dr. Boylan and Professor Kenny spoke about the need for ultrasound services and scans. I asked the HSE about the availability of the 20-week scan and it advised me initially that 20-week to 22-week scans are available to patients and it listed a number of hospitals. It initially advised me they were routinely offered and provided. This is not the case. I know it is not the case because the HSE revised its response to me and told me then that they are available. I would like to hear from both Dr. Boylan and Professor Kenny on what exactly is meant by "available". I do not believe they are available. I certainly do not believe they are offered as a matter of routine but perhaps the witnesses could enlighten the committee as to how women can access these services. A person in my family was told that if a woman is medically indicated for it, she will get it. That is anecdotal but I thought that one would need it to know. The witnesses' expertise on this is vital.

There are no gynaecological services mentioned in the maternity strategy. I speak as a lay person, albeit one who has availed of the maternity services. I would have thought the two must be connected and that if they are not, somehow we are missing a big chunk of the picture. Are the witnesses aware of plans to develop a similar strategy? Perhaps they might be able to tell us why the HSE or the Department of Health left out this very vital service.

Ms Leahy spoke about the need for ratios. It is in the strategy and that is to be welcomed but perhaps we are far from having the personnel to populate the ratios. Does Ms Leahy see a need for those ratios to have some sort of legislative underpinning? Does she believe a guideline would be enough? Can we trust the workforce planners, the HSE and the Department of Health to put in place the necessary numbers or do we need something stronger in terms of legislation?

Senator Colm Burke

I thank the witnesses for their detailed presentations. I will touch on a number of issues. The witnesses have referred to an additional number of midwives and I am not sure whether that takes into account the number of people who retire every year. One major concern I have is lack of support for nursing staff, consultants and junior doctors when there is an adverse event. It is not clear whether in all of the 19 units there is adequate support for the nursing staff when that occurs. The witnesses might be able to give us some information on the level of nursing staff who are dropping out of the system because of the pressures and stress they are under in trying to do their job. Professor Kenny referred to the adverse media reporting on some incidents, which is not helpful to staff.

Can the witnesses give us some indication of the number of people who are moving away from the service into other areas of nursing? What recruitment numbers should we be targeting every year, taking into account retirements and the reasons people are leaving? Is there adequate support for nursing staff where adverse events occur?

The report into Midland Regional Hospital, Portlaoise recommended the appointment of directors of midwifery. My understanding is that eight positions remained unfilled. That may have changed in the past two or three months, but I understand eight out of 19 positions have not been fully filled or people are only in place in a temporary capacity. The bar may have been set extremely high. It might be difficult to get candidates in some of the units because the qualifying criteria have been set so high. I am keen to hear the views of the witnesses.

Professor Boylan discussed the recruitment of consultants. A report was published in 2003 - I keep referring to it - setting out how by 2012 we should have 180 consultants. At the time we had approximately 100 consultants. I understand that at the moment we have a whole time equivalent of 130 staff. I may be wrong about the figure but that is the most recent information I have. When I raised the question with the HSE recently, I got the impression the executive was only planning to recruit an extra six or eight consultants in the coming 12 months. Should we set a clear timeframe for the recruitment of the additional consultants? In 2003, we set a timeframe such that by 2012 we would have 180 recruited. We are nowhere near the 180 figure. I am unsure what the birth rate was in 2003 but it had gone up dramatically by 2008 without a significant increase in staffing levels of nursing and medical people. Yet, they were required to provide the same level of service. In fairness, they did a good job despite all the pressures. Let us suppose we were to set a timeline for 100 new consultants. What timeframe should be set to get the candidates in place and to ensure the necessary back-up support for them? These are relevant issues in the development of maternity services.

Deputy Kate O'Connell

I thank all the witnesses for their presentations. It is worth noting that despite a ratio of live births to consultants of 1,000:3.95 our outcomes are comparable with the best in the world. I am mindful, however, that there is always the straw that breaks the camel's back. A large number of people have put a great deal of work into this strategy and it is excellent. One could possibly be excited by this strategy. I am possibly as excited as I will ever be about a strategy having spending a good deal of time in the maternity services in recent years.

All of us are born at some stage so we all have skin in the game. When we refer to good outcomes in births, we want a 100% success rate because a catastrophic event at a birth can change the course of the lives of those affected forever. It is probably the most tragic thing that can happen in the life of any family.

I will repeat Deputy O'Reilly's question. I cannot understand how gynaecology was not included in this report. Can someone identify why that is the case? Is there any historical reason for leaving gynaecology out of the strategy? I cannot see how the two could be separated.

The master model seems to be a no-brainer. It seems to have worked for the past 200 years, as one of the witnesses has said already.

One commendable point from the strategy is the lean team structure. This is something other areas of the health service could examine. The key is to have an identifiable accountable clinician at the top and there should be a clear chain of command. The master model is something we have to develop. It is great that we have the appointment of 19 midwives in train, but it seems the master model is the only way forward.

It was interesting to hear that the first maternity services to be cut are those not protected by independent governance. We all need to work to ensure that they are ring-fenced or protected.

Without going too much into the detail, will whoever is best placed outline for the committee the impacts of poor gynaecological services on the every day lives of women? One example relates to having to wait for two years for a procedure. What effect can that have on quality of life of those affected? Perhaps it is something people are not comfortable talking about. My experience is that this would have a serious impact on the day-to-day life of any woman who has to wait for a long time for such a procedure.

Professor Kenny referred to fundamental inequity within our service. Can she offer a personal view on why it exists? Why have we ended up in a situation whereby our maternity services or the associated plans are simply not up to scratch, notwithstanding the outcomes?

Can the deputation outline the position on sonography? Reference was made to an unacceptable level of risk because of deficiencies in sonography services. Can the deputation provide some detail on this to the committee not only regarding the unborn child, but the issues that might materialise if there is no 22 week scan? What effect does this risk have on the outcomes? I assume that following a 22 week scan those involved know what they are dealing with and can plan to mitigate any adverse event. Let us take this to its natural conclusion. If there is no 20, 21 or 22 week scan, what is the domino effect? At the end point, the birth, could we end up with outcomes that are not ideal? Does it put the clinician in a position that is far from ideal if she does not know what she is dealing with at birth? Is there any barrier other than resources? Is it a question of buying machines and getting people to operate them?

Is there any ethical or political barrier to the roll out of detailed scans at 20 weeks? I am simply putting the question out there. Is there any such reason? Perhaps there might be some historical reason that the maximum amount of information might not be made available to the mother of an unborn child. Is there anecdotal evidence on this point? What is the proportion of women who are pregnant and who do not get the 22 week scan as a matter of routine? How many of these people go and pay for a scan? What I am getting at is whether this is a class issue. If people cannot afford to pay, is there a reason? The cost was €160 the last time I had a scan, but perhaps it is €200 now. Are poorer people not getting a 22 week scan? Let us take this to its natural conclusion. Are such women disadvantaged because of their social circumstances? Will the deputation give me some indication of their experience in practice?

Chairman

Four themes have arisen in the questions. They relate to recruitment and retention, ultrasound deficits, the mastership model and leaving gynaecological services out of the strategy. They are the four common themes of the questions. Professor Boylan, will you comment on those first, please?

Dr. Peter Boylan

Yes. I can offer two anecdotes with regard to recruitment. Two jobs came up recently. One was a consultant job between the Rotunda Hospital and the hospital in Drogheda. It would normally be seen as a rather attractive job, but no one applied for it. Another job came up between the National Maternity Hospital and the hospital in Mullingar. There was one applicant, who was from Lithuania. She withdrew her application before the interview and that post was not filled either.

I have just retired from clinical practice in the National Maternity Hospital. My job was exclusively in the National Maternity Hospital and there was no trouble recruiting an excellent candidate to replace me. She started recently. This brings us back to the governance issue and it ties in with what we have said about the mastership model.

I will give the committee an idea of the role of the master. The master is a senior clinician who is responsible for the outcome of all pregnancies in the hospital in a corporate sense. They are assisted by a manager who runs the administration and financial side of things but who reports to the master. The director of midwifery runs the midwifery side of things and works together with the master. It is one identifiable person who is responsible, accountable and has authority. When there is any budgetary leeway then one person can make a decision, obviously in consultation with colleagues and so on. The master is, if you like, a team captain. On a daily basis, for example, the master goes into the hospital in the morning, meets with all the junior staff who have been in on call the night before and the staff who are coming on duty that day. The master then knows exactly what has happened since he or she left the hospital the previous day if they have not been in during the middle of the night. The master has a very tight handle on what is happening at a clinical level, on the ground, which is very important in identifying risk or deficiencies and knowing who is really sick or who might need transfer to a general hospital. The master has a lot of administrative duties obviously, including meetings with the Department of Health, the HSE, in-hospital meetings, the risk committees and maintaining clinical standards. The master has a clinical practice also. He or she does ward rounds at the hospital and knows exactly what is going on.

Deputy O'Reilly raised the question as to what would happen in smaller units. The group structure is a way of dealing with that. For example, the Portlaoise hospital has come under the governance of the Coombe hospital. They are part of the group that the Coombe and Portlaoise hospitals are in. In Cork or in the National Maternity Hospital, which is part of the Ireland east hospital group, there is a master responsible primarily for the National Maternity Hospital but one would also have directors of obstetrics and maternity services, including gynaecology in the smaller units but reporting in to the main unit. In Cork it would include Tralee and Clonmel and so on. That is the way it works. The term master can sometimes get up peoples' noses but we think of it as the master mariner, the master of a ship as the captain of the ship, the team captain and so on. That is the way to look at it. Part of the whole mastership model, the really important element, is that the master has control of the budget and that there is a protected budget for maternity services and for women's health services. Cork is a prime example of what goes wrong when they do not have a separate budget that they control. Professor Kenny will address that issue in a bit more detail. I believe she has personal knowledge of it.

With regard to ultrasound services being available, the service availability is very sketchy around the State. The three Dublin maternity hospitals offer 20 week scans to everybody. They get them as a matter of routine. The advantage of knowing if there is a problem is that we can alert the parents to it and we can involve the paediatricians in planning for the outcome. For example, if a congenital heart defect is detected then the paediatric cardiologist will come to the hospital to meet with the parents. This would also happen if there are neurological problems such as spina bifida. A neurosurgeon would come to the meetings and discuss the management of the case, meet with the parents and plan for the outcome.

Deputy O'Connell asked about ethical issues. It is interesting that in the past when amniocentesis was a way of diagnosing problems that the Catholic Church had no problem with amniocentesis and knowledge; it is what is done with that knowledge that causes difficulties for the church. I imagine that the same holds with the fact of diagnosing problems that a baby might have in the womb. What the parents do with that information is a matter for them, involving their own doctor and their own backgrounds, belief systems and so on. Professor Kenny will address the ultrasound issue in a little more detail on what are the implications of the follow on from making the diagnosis and foetal medicine services. It is also important to realise that problems can arise later on in pregnancy. For example, where a baby is not growing correctly it needs intensive monitoring with ultrasound also. Those services are very deficient around the State.

The last issue related to gynaecology services. I have no idea why gynaecology was left out of the maternity strategy. I was not involved in its development in any way. From the point of view of maternity services it is a very good strategy and we support almost everything in it. Gynaecology is complementary. A woman does not stop having an involvement with the services that obstetricians, gynaecologists and midwives provide when she stops having children, or if she is trying to have children. The services are very closely interlinked and it makes no sense for us not to have the gynaecological service. Gynaecological services are effectively the Cinderella of our health services and are the first to get cut when there is any type of problem with bed allocation and so on. The question was asked on how many women pay for a scan. For us it is hard to say but the member is absolutely correct in saying that the poor are disadvantaged, right across the board and do not have access to the same sort of ultrasound services outside of Dublin that they do have access to in the three Dublin maternity hospitals. There is no distinction with regard to ability to pay.

Deputy O'Reilly raised the issue of community midwifery services and there is a very good model of the whole range of services out of the National Maternity Hospital with the home birth service, run by midwives from the hospital, community midwifery services where midwives deliver care in the community close to mothers' homes. There is also what is known as a domino system where a mother will have her antenatal care at home. She will come to the hospital for scans, etc., has her care at home, has her baby in the hospital and then goes home within a few hours. She is visited by the midwives afterwards. This is whole range of opportunities for care and that model should be implemented across the State. This is all I have to say in response to those issues.

Professor Louise Kenny

Taking those issues in turn I will address first the issue of consultant attraction and retention. Notwithstanding the fact that we need to attract another 100 consultants to bring us up to international norms, even that will still be at the lower number of comparable consultants per 1,000 live births in the OECD countries. It is going to be a challenge. In Cork we do not even have the jobs to recruit two, but even if we did it would be a challenge because of the issues I outlined in my statement. It takes 12 to 14 years to train a subspecialist in obstetrics and gynaecology. That is not a quick process. What is perceived as a very hostile media, allied to a very unattractive consultant contract, means that at every stage of training our trainee specialists are now leaving the State in significant numbers. Ireland is failing to attract trainees in at an early stage upon leaving medical school. At every stage they are leaving for other countries, for better working conditions, greater parity of pay and better working hours. That is a significant issue for us. We know - because we have a very transparent and robust reporting system - that our clinical outcomes for mothers and babies are comparable with the best internationally. There is some variation in figures and population differences can sometimes mask inequalities of caseloading, but that is despite the fact that our clinical resources are inadequate. That is reflective of the very high standard of midwifery care and consultant care in this State. It is not, however, sustainable for much longer. Senator Burke spoke about the straw that broke the camel's back and we are approaching that point.

On the ultrasound issue, in Cork less than half the women are able to access the 20 week scan. A few years ago that figure was slightly better but loss of staff and the fact that we have not been able to replace those specialist staff has led to the provision of the 20-22 week scan only being available to that half - or less - of the women attending our unit. I can give the committee some anecdotal evidence of the impact of this situation. Women in Cork are two and a half hours by road from Dublin and if a baby is born with hypoplastic left heart syndrome it needs to be assessed immediately after birth and transferred to specialist services. If that baby has not been identified prior to birth due to lack of the 20-22 week scan that whole process has to take place ex-utero with a very critically ill baby in an ambulance.

This is the most disadvantaged start that child can have and it will absolutely have an impact on its chances of survival. It is a devastating event for a family. Other anecdotes involve significant foetal abnormalities such as anencephaly, a very severe form of spina bifida. If it is not diagnosed antenatally, the effect it can have on health care providers and the women in question is unacceptable in 2017.

There is no way we can triage or screen for risks in the case of the 22 week scan. Because we cannot offer a scan to everybody in Cork, we triage on the basis of age and previous history. It is a screening test but for it to work, it must be applied across the entire population. Clinicians who make the decisions about who should and should not have a scan are haunted. It is both extremely frustrating and unacceptable.

There are time issues with the 20 to 22 week scan. The staff in our unit are highly skilled midwives. It take many years to be trained in midwifery and ultrasound provision. The staff are involved in post-diagnosis management and counselling. If we were to roll out the service tomorrow, we would not be able to match it with adequate foetal medicine services because we would detect a significant increase in the number of abnormalities which would require specialist input. Nothing can be done in isolation. Our big concern is that if we were to address any one of these inadequacies, it would have to be done in tandem with the rest of the strategy.

The budget for women's health services is still the first to be cut in 2017. That is both self-evident and a fact. Historically, there are a few reasons there are unacceptable waiting lists, which are national disgrace, but it is mainly down to governance. In obstetrics we often say we fire fight. We cannot say "No." We cannot let a waiting list build. Babies will come at 2 a.m. and 2 p.m. and the obstetric service manages in this fashion.

Most women who are significantly ill with gynaecological diseases do not lie on hospital trolleys. Generally, they are young or middle-aged women who do not present at emergency departments. They do not lie on trolleys and are not part of the trolley initiative. They are not on anyone's radar.

With regard to the impact of gynaecological conditions on women's lives, more than 4,000 women are waiting to be seen in outpatient services at Cork University Maternity Hospital. Many of them are incubating a malignancy, which is an unacceptable level of risk. Those who present with urogynaecological issues or heavy menstrual bleeding are young women who are trying to raise a family and-or hold down a job, have a haemoglobin level of five and bleed two or three weeks every month. They cannot leave the house. They are housebound for the want of an outpatients service treatment investigation and effective management. From a urogynaecological perspective, we have women who suffer from urinary incontinence. It has been well demonstrated in a lot of international research that this has the most devastating psychological impact on a woman's health and well-being. It has a significant impact on the household's economy as women cannot work and are on long-term sick leave. It has an impact on their children and partners. It is a devastating conveyor belt towards significant problems. Frustratingly, many of these issues can be addressed adequately. We are not speaking about very complex open-heart surgery but about access to relatively low intensity procedures. If we were resourced adequately, we could offer them. I come back to the fact that many women who are referred to the outpatients service with what are perceived to be minor problems, because we can only triage on the basis of a referral letter, are incubating a malignancy, which is an unacceptable level of risk.

I will be happy to answer supplementary questions or go into any of these issues in further detail.

Chairman

I ask Ms Leahy or Ms Gorman to address the ratio of nursing staff to births.

Ms Mary Leahy

In 2014 we surveyed the number of midwives and the information was provided by employers. There were 1,849 midwives, which gave a ratio of one midwife to 38 births, based on a total of 70,879 births. At the time 554 midwives were needed, but two things have happened since. The birth rate has decreased slightly and a strategy has evolved which recommends a ratio of 1: 29.5. We have a long way to go to reach that ratio.

The issue of recruitment and retention has been mentioned. We have significant problems in that regard. In our opening statement we mentioned that we had a problem with the undergraduate programme. There is a high attrition rate from the direct entry midwifery programme. Committee members may not be aware that traditionally people became general nurses first and then went into midwifery; therefore, they got a good introduction to health care in general. They worked in a hospital and then sought midwifery placements. As a result, they knew going into it what was ahead of them. Direct entry to midwifery is somewhat more difficult for students in that they do not necessarily have knowledge of what they are going into. It is highly pressurised, an area which has been under the microscope in recent years, with many negative reports, including the report on services in Portlaoise. It involves a high level of litigation and high risk. The pressure on students is extreme. This is coupled with the fact that there is a deficit in the number of qualified midwives, with the result that they are not freed to educate or mentor students. There is an attrition rate of 25% from the direct entry programme, which is extremely worrying. In some pockets the attrition rate is as high as 40%. Students are leaving the four-year degree programme in the third or fourth year because the pressure is too much.

Another problem I must highlight in this area affects clinical placement co-ordinators - clinicians who are working with student midwives to educate them in clinical skills. The recommended ratio is one clinical placement co-ordinator to 15 students, but we are nowhere near this figure in the Irish health care setting. Student midwives do not receive support and are not being mentored; as a result, they find the area pressurised. We also have anecdotal information that direct entry students are working in part-time jobs to support their education and are being harvested into areas such as retail, which is worrying. They are qualifying or coming near to it, but they do not practise. They are being offered salaries in the retail sector or other non-midwifery areas which exceed that which a midwife earns. They may also have company cars. Midwives ask why they should take a position where they would be at risk of litigation on a daily basis, with their licence exposed, in a pressurised and stressful role when they can take something much easier.

In our opening statement we alluded to the difficulty in seeking postgraduate placements. We have called for an increase in the number, but we must acknowledge that many such placements are not taken up by students. There are a number of reasons for this, one of which is we are very short of nurses. To reply to Senator Colm Burke, there is a distinction between nursing and midwifery; they are two separate professions. Many nurses who wish to move into midwifery are not released to pursue education in midwifery because we are short of nurses and employers will not fund such education because of budgetary constraints. A postgraduate midwife will qualify after undertaking a four-year undergraduate nursing degree programme and an 18-month postgraduate midwifery programme. Those who ordinarily undertake this programme have identified that when they complete it, they will not gain experience and will not be recruited. If they have a lack of experience, they have poor job prospects. They are asking what is the point of undertaking the midwifery programme when they will not be recruited at the end of it. Many of those who have come through the postgraduate system have returned to general nursing and do not use their midwifery qualification, which is huge concern.

The answer is we must produce our own midwives. We have to increase the number of undergraduate and postgraduate placements. The midwives who complete the undergraduate programme perform very well in the workplace. They are possibly in pockets in which they receive support and mentoring, but there are also pockets in which there is no support or mentoring.

Deputy O'Reilly asked what is needed. We have to grow the strength of our own midwives and we need to attain a critical mass of them in this country. She asked whether we need legislation to underpin this, but we must grow midwifery and reach a critical mass first. Legislation will be warranted further down the line, but we have much work to do. We are greatly concerned that we are a year into the strategy and we do not see any evidence of recruitment. We would welcome the rolling out of the provision of directors of midwifery in the 19 units. Heretofore, many units did not have directors of midwifery, and if they did, they were often directors from a nursing background, not a midwifery background. We have a lot of work to do in recruiting. We cannot recruit midwives from abroad for a number of reasons. They are often not there, and if they are, we have a very high standard of education in Ireland so there is often a deficit or a difference in educational standard.

Deputy O'Reilly also mentioned community midwifery and primary care. I am a registered midwife but I work as a public health nurse so I am in community and primary care. I am fortunate enough to be in a world-class purpose-built primary care unit. The problem with it is that it is so busy that it has only been open for three years and we actually find it hard to get a room within our own building because the level of turnover is massive, although the turnover is great to see. The antenatal programmes have reached that primary care centre, so mums - this is all about mums - now have their antenatal care in a primary care centre. Then, as public health nurses, we provide the postnatal care in the exact same centre, which is very close to the mums' residential areas, so the care is delivered in the community, which is to be welcomed.

What is to be done? Deputy O'Reilly almost answered the question herself. We need far more primary care centres and they need to be rolled out very quickly. Some of my colleagues work in single inappropriate facilities with a lack of IT and care-taking facilities. This is not appropriate as a clinic for antenatal women. If we had the infrastructure rolled out in the community - we have been talking about this for far too long - it would help a lot in bringing more antenatal care into the community. We also have the domino scheme, to which Dr. Boylan alluded. We had a domino scheme in Galway and it was taken away because of lack of funding. However, we have an early discharge programme in Galway whereby the midwives take on an average of four to five mums who have delivered their babies home to the community within perhaps 24 hours or at most 48 hours. The midwives care for them in the community perhaps for the first five days and then hand care over to the public health nurse. In this regard, it was a very retrograde step that midwifery was taken away as a necessity for public health nursing education because if midwifery were brought back for public health and community midwives came out for the early postnatal period, this would help us to reach our critical mass.

Deputy Burke, or Senator Burke, rather - I apologise, I have elevated him - mentioned support. I have gone some way towards answering his question with the points I made about the lack of a clinical co-ordinator for the student. The supports are not there for the students coming through the system, but they are not there for the midwives on the ground either. The nature of midwifery practice is that it is quite challenging. There are many unforeseen and emergency situations. It is underestimated by our management system, and the staff are not on the ground to take time to process some of the harrowing events being dealt with in the workplace. The Senator mentioned the 19 directors of midwifery and that eight posts were not filled. I am not clear on the numbers, so perhaps my colleague will take that question.

Deputy O'Connell made a comment on why gynaecology was not included in the strategy. My colleague, Mary Gorman, was a member of the strategy so, again, she might take those questions. If there are questions I have not answered, I ask members to feel free to come back to me again.

Ms Mary Gorman

I will add to Ms Leahy's comments on community midwifery services. There are quite a number of pockets in different places all over the country - Dublin, Cork, Galway and midwifery-led units, MLUs, in Drogheda and Cavan - where there are quite good services. However, it was recognised in the strategy that they were only in pockets, and it is a matter of getting the driver to roll them out across the country. This can be done in an incremental phase, but we need to get a driver or task force to implement and roll out community midwifery services.

The provision of directors of midwifery is certainly very welcome as previous to this, at our highest level, we had an assistant director of midwifery who did not have autonomy. We now have directors of midwifery who have autonomy and can lead the service. The jobs were advertised and have now been filled. However, because these positions were not available, the bar was set high, as it should be, but experience should also be taken into account and these people should be allowed to attain the qualifications along with the experience.

The gynaecology element of the maternity strategy was looked into, and we as a group tried to push for its inclusion in the strategy, but it was excluded from the terms of reference. The Department of Health said it would certainly look at this when preparing the maternity strategy and that there needed to be a gynaecology strategy and that it should be to the fore.

Chairman

I will now bring in the next group of speakers, Deputy Alan Kelly and Deputy Billy Kelleher.

Deputy Alan Kelly

I welcome all our guests to this session. In the next session, representatives of the HSE will be before us, so if the witnesses want to prompt anything to me and my colleagues, I am sure we will be able to facilitate that for the second session. I apologise for being late; I also had to attend a meeting of the Committee of Public Accounts. A number of us have two committees on at the same time.

I am very supportive of the strategy and I was one of the people who asked that the witnesses be brought before the committee. I accept the criticism regarding gynaecological services but, in principle, the strategy is a very good one. My issue is not with the strategy, rather to get the witnesses' realistic views as to whether it can be implemented. I am giving them an opportunity to give us their considered views because they are the experts in this area and because we will hear the alternative views of Mr. Liam Woods after the break.

There is a huge capital requirement regarding this strategy and I want to see it happen. It needs to happen and it needs to be a priority for this and future Governments because it will take that amount of time. I am open to the suggestion of alternative funding models to ensure we bring this about as quickly as possible. Do the witnesses support that view? I note the commentary regarding funding and women's health being first to be cut from a capital point of view with all the competing priorities. Realistically, given all that is going on, I cannot say with certainty that it will be guaranteed that the capital requirements will be put forward to ensure that the strategy is implemented as swiftly as possible. We will therefore need to consider alternative models. Would the witnesses support that? For instance, in the past few years, my wife and I have used the services in Limerick under the excellent service provided by Dr. Gerry Burke. The building is falling down but the service is excellent. I want to see the design phase of the new unit in Limerick happen, but €3 million is envisaged this year just to design it. I have seen neither sight nor sound of this. I ask the witnesses' opinions in this regard.

The second issue is one which is sometimes underestimated, namely, mental health issues. While recognised in the strategy, I am concerned about how much progress is being made in appointing consultant psychiatrists and teams with a particular interest in perinatal mental health. What funding is being provided in this regard? Have the witnesses seen any changes? Is it improving? Is it disimproving? From evidence I have heard and seen, and which has been brought to my attention, unfortunately, I understand it is the latter. I ask the witnesses for their views in this regard.

Ultrasound was mentioned.

I do not want to go over previous questions because they have been comprehensive in their answers. I have huge concerns about equal access to ultrasound across the country. In their reply this time round, they might outline why, and where geographically, there are differentials in the availability of ultrasound for women in the hospital groups.

I am very much taken by Dr. Boylan's comment on the mastership governance model. I fully agree it has worked for a couple of hundred years. More have an issue with the term than with the ideology behind it which is correct. The master is the captain of the team and the person leading. Given Dr. Boylan placed such emphasis on it, has he a concern that there will be a different model put in place? If so, Dr. Boylan might express his concern so that we can tease it out with others coming in later.

I am very much taken by the contributions of both Marys, in particular, Ms Leahy, on the midwife-to-staff ratios. It is clear that where there is good guidance, for want of a better word, there is a greater chance that more students will come through. Why is this the case? Are there geographical issues or issues in relation to certain hospital groups which Ms Leahy might outline to us, and is this down to personal good management or are there other issues? Is it down to the fact that in some areas there is contagion because of the issues in a specific hospital or hospital group? I want to tease that out more because it is an important issue for us.

The strategy envisages a doubling of consultant obstetricians over the next ten years. Have any of the witnesses, in the past year or so, because the strategy is now a year in place, seen locally of any extra funding being provided to implement this? I presume the answer is, "No". It points to the fact that this strategy is all very well on paper but it is not being implemented.

I am sorry for all the questions. My final one relates to community midwifery and funding in this area. I have seen evidence in some areas where it is working well and in others where there are gaps in funding which means the service available differentiates. Could we have a little more information on the areas where the latter is the case where there may be problems rather than where there is a certain standard? Those are my questions.

Deputy Billy Kelleher

I welcome the witnesses and thank them for their presentations. I must be repetitive because all our questions are of equal importance. I will re-emphasise and maybe get more detail, particularly from Professor Kenny, on the issue of the 20th week scan not available to everybody. Is it purely a clinical decision as to who gets the scan? At what stage is the clinical decision primarily based on whether or not there is funding available? In other words, if an obstetrician decides that every case is clinically required, will every scan be provided? Professor Kenny can answer that in the overall context but it is an important issue. Professor Kenny stated quite clearly that this is putting the lives of both mother and child at risk and I am trying to work out the ethical side of that in terms of making a decision primarily based on the fact that they ration because they are told there is no funding available. I wonder where that falls in the issue of the efficacy of the decision-making process, not only of the doctors but, primarily, of management.

At what stage is the optimum time for a scan to identify most challenges that could come about in terms of both the fetal development or implications for the woman's health? Is 20 weeks critically important or could it be at 15 weeks or 14 weeks? At what stage is it best to do the scan? The reason I ask is Deputy O'Connell raised issues about whether or not there is resistance to scans and the sharing of that information based on religious ethos. I ask whether or not that is the case in any of the maternity services.

Recruitment and retention is an issue, both in midwifery services and also in obstetrics and gynaecology. Let us be honest, we talk about career pathways and the work environment, but I assume the remunerative package is a big issue. There is no point in us beating about the bush here. The remunerative package is clearly an issue as well. There is plenty of evidence that consultants are not even looking at contracts in this country anymore because, although there are other issues, of the remunerative package. They might elaborate on that as well.

The strategy states that all pregnant women need a certain level of support, but some need more specialised care, and it proposes an integrated care model that encompasses all the necessary safety nets in line with patient safety principles, which delivers care at the lowest level of complexity, yet has the capacity and the ability to provide specialised and complex care, quickly, as required. It also recommends that dedicated emergency obstetric teams be provided in each maternity unit, and that a maternal retrieval service should be available alongside the existing neonatal retrieval service. I assume that is an aspiration and it is not happening in practice in every one of the 19 maternity centres. It goes back to what Dr. Boylan stated about governance and a master-led governance structure. Dr. Boylan stated in his presentation that he wished to see the mastership model of governance applied in every unit but I assume he means in every hospital group as opposed to every unit. At what stage are we in terms of assessing whether or not all the maternity units will be able to deliver safe maternity services according to the strategy outlined or are we merely pretending and trying to avoid difficult political decisions about maternity services in the time ahead in some of the maternity units?

The issue of the capital programme follows on from the previous point. If we are to talk about recruitment and retention and expanding the services, we need a lot of capital investment, merely to stand still. I note there are some amalgamations here in Dublin but across the country many of the facilities are poor.

Women's health and home birthing is an issue that was prevalent and campaigned about for a number of years. The campaigning element of home birthing has dissipated to a certain extent. Do we have the capacity to deliver a safe home birthing service for those who want it? Is there an issue about stating that service is available when deep down we know that we do not have the capacity to deliver it? There is an ethical question there, and a patient safety question as well.

With regard to the issue of women's health and well-being, a key component of the strategy recommends the health and well-being approach to give babies the best start and improve women's health. I presume it is referring to women's health in advance of pregnancy, during pregnancy and post-natal. How far down the road have we got on that because the statistics show us that obesity, diabetes, smoking and poor diet lead to poor health outcomes? How far down the road have we got in providing proper services and educational programmes for women of conception age?

Professor Louise Kenny

Perinatal mental health services are patchy at best. I have not seen any improvement in perinatal mental health provision in recent years. It is a very specialist area. All best practice recognises that a woman and a family's best chance of full recovery from an acute perinatal mental crisis is through the provision of specialist services in dedicated mother and baby units, to which we do not have adequate access nationwide. On a more worrying level, we do not have individual specialists in perinatal mental health at anywhere near what would be regarded as international norms. This is a fundamental problem and a matter of grave concern in an area that is woefully under-resourced. I have not seen any improvement in recent years in the provision of perinatal mental health services, a point with which my colleague would agree.

The accepted international norm for care pathways of ultrasound provision in pregnancy is a minimum of two scans, the first of which takes place at the end of the first trimester and the beginning of the second. The primary function of this scan is to confirm pregnancy, the location of the pregnancy and the number of babies involved. That is of clinical importance in dating the pregnancy, defining multiple pregnancy, which is a high-risk pregnancy, and also an extra-uterine pregnancy, which can be a life-threatening condition.

Following the first trimester scan, the next recommended minimal scan is a 20-week to 22-week scan, best performed at that time. That is a scan to screen for foetal development and foetal abnormality. As it is a screening scan, it cannot, by definition, be given to just selected proportions of the population, yet that is what we are doing. We are doing it specifically because we cannot give this scan to every one of the 8,000 women who present at Cork University Maternity Hospital, CUMH, for antenatal care every year. At present, we have adequate resources to provide that scan for approximately half of all women. Those who are not triaged to receive this scan can, if they are in a position to afford it, pay for a private scan. Accordingly, we have a two-tier health provision in terms of access to ultrasound and the poor are disadvantaged.

Clinically, we make the decision on the basis of those who are perceived to be at higher risk of having a baby or a pregnancy affected by a complication. Currently, we screen out those women who are of an older maternal age, those who have had a previous bad obstetric outcome and those who have a significant family history that would delineate them as being at risk. The majority of babies born with complex foetal abnormalities or significant neonatal conditions resulting from, for example, foetal growth restriction, are not born to women with any risk factors. In that kind of situation, we will miss the majority of babies born with problems.

If, for example, early foetal onset growth restriction or grave foetal abnormalities, such as hypoplastic left heart syndrome, which would be amenable to surgery, potentially ex-utero, are not picked up, it will increase the mortality from those conditions. Babies will and do die as a direct result of a lack of access to ultrasounds.

Deputy Billy Kelleher

If every woman was given a 20-week to 22-week scan, then these would all be definitely picked up.

Professor Louise Kenny

It is a screening test and, like any such test, it is not perfect.

Deputy Alan Kelly

It would be highly more likely, though.

Professor Louise Kenny

Absolutely. The more significant the abnormality or clinical finding, the greater the probability it is that it would be picked up. At present, we are simply not providing these scans to more than half the women in our hospital. It is equally patchy across the country.

Deputy Alan Kelly

Does the lack of full provision of 20-week to 22-week scans mean many cases are missed?

Professor Louise Kenny

Absolutely. We triage because we have to, not because we want to or not because we should. In a situation where we can only provide ultrasounds in respect of half of all pregnancies, we have to make a decision as to who will get that scan. We make very difficult clinical decisions, based on previous history and perceived risk. It is woefully inadequate and sets us apart from our international neighbours.

I have been in Ireland for ten years, having trained in the UK. I cannot speak to whether the provision of that scan has been curtailed by a perceived influence of religion versus State or patient choice based on the findings of the scan. That is not my impression. At various times in recent years we came close to providing the scan for 70% to 80% of the population. However, loss of staff, the fact staff are not replaced and increasingly curtailed resources are driving the availability of this scan.

If we are in a position to roll out that scan to every single woman, it will have a knock-on effect on foetal medicine services. We cannot provide a scan and make a diagnosis but not be in position to follow up with foetal medicine services. That will certainly have an impact on the care we provide in CUMH. We will need more foetal medicine sessions to provide ongoing care pathways to those women identified with complex pregnancies.

Dr. Peter Boylan

A private scanning system was developed at the National Maternity Hospital. Private patients are sent to that unit for scans. That has allowed us in the hospital to free up areas for giving every public patient a scan. There is no lack of availability of ultrasound. This comes back to the governance issue in that in a hospital with a master, one can do that. In a maternity unit integrated in a general hospital, it is well-nigh impossible to have that entrepreneurial approach to matters. One will just get slapped down and will not be able to do it.

It is well recognised that we need an extra 100 consultants but, clearly, they cannot be appointed at the one time. That would not be good practice in fact. We need to get ten a year over the next ten years, plus replacements for those who retire. Those numbers are absolutely predictable. So far, there has been very little movement on that. The committee could ask the Health Service Executive, HSE, as to what movement there is to replace consultants and how it will make it more attractive for them.

As to the question on the governance model and whether smaller units would be closed, it ties in a little bit with the question of home births and risk stratification. Most obstetricians have grave concerns about home birth because a birth is only safe once it is over. The nature of obstetric practice is that things can happen very fast and unpredictably. Having said that, I would be personally comfortable with women having their second or subsequent children at home if they are in a low-risk category and if their first baby was a normal birth. The majority of problems in obstetric care arise in women having their first baby. That is well documented. Obviously, there are some women who will try and have their first baby at home. A home birth service is run out of the National Maternity Hospital. A substantial proportion of those women are referred into the hospital during the course of their birth, mainly for pain relief because they want an epidural, which can only be given in hospital, or the labour is too slow. If done within the proper governance structure, home births can work.

Over time, the smaller units will probably deliver women who are very low risk. This means they will deal with very few women having their first baby and more women having their second and subsequent children, where the first one was normal and the anticipation is that there will be no adverse outcome, although one cannot be sure until the whole thing is over.

It is something that will probably evolve over time and my impression is that this is how the smaller units will evolve. It is not a recommendation. It is just an impression and I think that is probably what is going to happen.

Deputy Kelly asked about funding models. The cancer strategy is a good model. In this case, one had a protected budget run by a clinician who was able to implement a strategy for the development of cancer services. The same sort of model could be implemented to develop and implement the maternity strategy in future years. There has been an appointment to the national women and infants' health programme office. I am not sure whether that has been made public yet but a very highly qualified person has been appointed who will be superb at doing this job. The hope for us is that this office, the HSE and the Department will work together to implement the strategy in a phased way because it cannot all be done overnight. That is not the way things work. In response to Deputy's Kelly's question about whether it will happen, not all of it will happen. Nothing ever does but we would hope that some of the things will happen. The three issues I listed that were elaborated upon by Professor Kenny are things we certainly feel are essential. The more one talks about maternity services and the maternity strategy, it all comes back to governance, budget and governance models. The reason there are so many problems in Cork, which is a classic example of a hospital which is the same size as the Dublin maternity hospitals, is because of governance. It is integrated into the main hospital so it has no control over its budget, staff appointments, midwifery numbers and so on. It cannot open the operating theatres and has lost millions from its budget from the years because it is integrated into the general hospital. It is a failure. It is not working and women are suffering as a consequence with some women developing cancer in the community as we speak because of the failure of that governance model. That needs to be changed and is the single most important thing. If we have that governance model with doctors and midwives working together to implement the really important bits of this strategy first, it will allow all the other midwifery elements to be developed. The critical issues are governance, a protected budget and no integration with the general hospitals because it does not work and women and babies suffer as a consequence.

Professor Louise Kenny

The issue in Cork is both topical and very pertinent to the discussion and illustrates at a fundamental level the disparity of care in women's health provision. When CMH opened in the 2006 to 2007 period, I was a newly appointed consultant. My colleagues had argued successfully for a budget that was adequate to run the hospital. Had we had control over that budget - no increases and no particular incentives - we would not be where we are now. We are where we are now with 4,000 plus women on our outpatient waiting list and 2,000 plus women waiting for surgery because pregnant women and women with gynaecological issues are on not trolleys, not in the headlines and not on the radar. They are the first to be cut all the time. Year on year, we have lost our budget to the main campus. I am not pretending or suggesting that the money has been misspent in any way. It has been reallocated to vital clinical care but the past ten years have been ones of fiscal constraint. It has been very difficult in every hospital and in every form of health care provision across the entire country. That money has been spent in other areas of clinical care and not on gynaecology or maternity services and, consequently, we are where we are now with waiting lists that are worrying beyond belief.

We were asked directly whether we are advocating a different model from the mastership model because we do not have the mastership model outside Dublin. I am agnostic as to what we call it - a master or mistress. All our colleagues nationally agree fundamentally on the need for one single accountable individual with clinical and executive management and oversight. I can assure the committee that if we had that in the past ten years, we would have no waiting lists and our hospital would be the flagship it was designed to be and could be if we were adequately resourced. We are not talking about an increased budget. We are talking about the budget we argued for back in 2006. If we had that and governance, our waiting lists would not be making headlines nationally.

Deputy Billy Kelleher

In respect of women's health-----

Dr. Peter Boylan

Health promotion?

Deputy Billy Kelleher

Yes.

Deputy Alan Kelly

I also have a few questions.

Deputy Billy Kelleher

In respect of women's health, the witnesses talk about scans not being available to everybody in terms of different cohorts, socioeconomic backgrounds and educational programmes. Are we risking a lot by not having proper integrated health and well-being programmes for women in advance of, during and after pregnancy?

Deputy Sean Sherlock

Can I ask the Chairman for some guidance? I am not a member of this committee but there has been specific reference to Cork, about which I have a few questions. Begging the indulgence of the members, while we are on the theme of Cork and the governance issue, I ask for some forbearance to ask one or two questions while it is the hot topic. Obviously, I will be guided by the members and the Chairman on that matter.

Chairman

I understand Deputy Sherlock's position. Four more members wish to speak so I ask them to be brief. We will undoubtedly come back to the issue of governance. I have one or two questions myself. I will take Deputies Durkan, Murphy O'Mahony and Sherlock and Senator Alice-Mary Higgins and ask them to be brief.

Deputy Alan Kelly

Perhaps in the next round of answers, the two Marys, for want of a better phrase, might be given the chance to answer the questions Deputy Kelleher and I asked.

Ms Mary Gorman

In respect of the 20-week scan, there are huge problems outside Dublin in recruiting staff to carry out the scans. They can be recruited within Dublin but it is very difficult outside Dublin to recruit staff to carry out those scans. Nobody is interested in going outside Dublin. I am talking about midwives and sonographers. They are not interested.

Deputy Bernard J. Durkan

I am always brief, as the Chairman knows. I thank our guests for coming before us this morning and offering their advice and responses. In respect of midwifery and nursing in general, obesity in women's health has already been referred to. I presume the witnesses have a programme in mind to alert young women and young people in general to warnings about their health and obesity, which is an increasing problem. What is in hand? Is it being done through the schools, particularly secondary schools?

The issue of recruitment has come up on several occasions. Sadly, I have put down thousands of questions over the past ten years. Nobody has adequately answered the question about why we have such a problem with recruitment in the health services at nursing and consultant level and even at GP level. Is there any advice the witnesses would give us and the Department about the problem because they deal with it at first hand? What is the problem here? Does it apply in other jurisdictions. Does it affect them in the same way and if not, why not? It is not that I wish to in any way encourage some of the difficulties they have here. We take the point about gynaecology services and inclusion in the strategy. Presumably, we will take this up with the Minister to ensure that we have the most comprehensive report possible. Recruitment comes up again and again. It has been said that the positions are not attractive. Why are they not attractive? Again, it applies to all levels. An interesting point was made by Dr. Boylan to the effect that only one person applied for a position and subsequently withdrew.

That has been happening in regard to the appointment of general practitioners to fill spaces at local level.

I do not want to labour my next point but it is very important. There is a certain amount of stress in the health services arising from litigation and various other circumstances. It appears the general public has concluded that if things had been done in a different fashion, some litigation might not have occurred. Altogether apart from litigation, there is the question of the health of the victims, be they women or children. Could the delegates give us some indication as to what could or should have been done in this regard bearing in mind the number of cases with which they are very familiar? What procedures and fail-safe measures could have been put in place to try to prevent some of the events that occurred? I will not go into individual cases. I have dealt with a number of them and I am sure every other member of the committee has done so also. To respect people's privacy, I would not dream of mentioning the cases. I am concerned, however, about some of the matters that have been brought to my attention that should not have arisen. I refer in particular to the matter of early diagnosis for newborn babies. As Professor Boylan has already said, things can and do happen very quickly. Do the delegates have any advice or information that might be helpful to us in our discussions with the Minister to try to lift the burden of pressure on the health services? Fear of litigation arises where things do not happen as they should and when they should, with obvious consequences.

Deputy Margaret Murphy O'Mahony

In the interest of moving things on, I will be very brief. I thank the witnesses for attending and giving up their precious time to be here with us today. Most of my questions have been asked by my colleagues.

Pre-conception care seems to be very much missing in the whole strategy. Would it be a good idea to include it? As Deputy Kelleher was saying, perhaps there should be more advice on weight and the dangers of smoking.

Should there be a fertility section in the strategy? To me, the concept of maternity covers the time from when one tries to get pregnant to when the baby is born. Personally, I would like to see more emphasis on that. What are the delegates' opinions on it?

All the delegates mentioned the lack of workforce planning, recruitment and the lack of staff. Could these problems prevent the whole plan being implemented? It could be a major stumbling block.

Senator Alice-Mary Higgins

I am replacing Senator John Dolan today. I thank the speakers very much for their very interesting and comprehensive answers to the questions. I will not ask again many of the questions, including that on fertility asked by Deputy Murphy O'Mahony.

I wish to highlight a couple of key points and ask the delegates for their thoughts. In a previous role, I worked with the National Women's Council of Ireland, which was deeply involved in consultation on the maternity strategy and would have welcomed it. One of the key elements was the question of choice for mothers. It is strong that there are options on supported care, assisted care, specialised care and the various strands. There is a vision of parallel facilities that allow dedication in one area but swift movement to another service, if necessary. Are the practical facilities beginning to be put into place to ensure the choice is practicable and that the movement between the strands, where necessary, is being managed? I would really appreciate an answer.

One of the key points the National Women's Council of Ireland found women were making was on having the option of midwife-led services, where possible. There is strong demand for greater midwifery resources.

I thank Ms Leahy. She outlined some obstacles resulting in people getting lost in the system. Potential midwives, at postgraduate or undergraduate level, are getting lost.

Could the delegates comment on another aspect in addition to the questions of recruitment, redirection and retention, namely the question of progression? There seem to be many concerns over how people can progress. What is the position on incremental recognition and remuneration? What are the ladders of progression for people entering midwifery, particularly if we want to encourage people to provide services such as out-of-hours care and clinical care? I refer also to progression separate from management. It is very strong that there will now be directors of midwifery but it seems that, in many cases, the only progression is into management. How is progression as a clinician or medical expert in practice in the field being supported? How could it be? What difference might it make?

Could the delegates comment on neonatal nursing and neonatal nursing care? There are concerns over this area. Postnatal care has been touched on. Perinatal psychology is very important. I understand that in the west, there is no perinatal psychologist. There are three part-time perinatal psychologists available in the country. My figures may be wrong. The number available represents a considerable concern and vulnerability. Could I hear comments on how the gaps in this area and areas such as lactation support put pressure on general nursing if the necessary specialised postnatal services are not available?

Let me cover the question of obstetricians and gynaecologists. I really welcome the debate we have had on the gynaecological supports. That has been key. I imagine a gynaecological strategy will be taken up with the HSE. Even in advance of that, it would seem there needs to some very clear measure in respect of the support services currently associated with the maternity strategy. What should be happening in the interim as we move towards having a gynaecological strategy? What kinds of demands should we be making to the health services in this regard?

On consultants, we are talking about very low numbers so it seems very ambitious to refer to in-house consultants. We know that when there are complications in pregnancy, they can be very sudden and catastrophic. As we have said in regard to 24/7 care, having a senior consultant available is the ideal. What are the delegates' thoughts on having in-house consultancy capacity? How far are we from that? Could it be achieved? Would it be valuable?

We have talked about the idea of dedicated resources, people being in parallel acute adult care in a general hospital and the need for dedicated ring-fenced resource and dedicated accountable management. If there is dedicated accountable management that is not just minding and guarding the budget but also responsible for ensuring that all the resources in a hospital, such as that in Cork, are made available on a practical level, would this in itself prove an incentive in respect of recruitment?

The fear of litigation has been highlighted. If there were an accountability structure and resources such as sonography, which allows for better diagnosis and a better-prepared birth experience, would they incentivise higher rates of recruitment and retention?

There are gaps in terms of choice and consent in our national consent policy, and the question of legal uncertainty has been highlighted. There are circumstances in which, even at birth or during pregnancy, legal advice should be sought. I wanted to mention this and am not necessarily asking the delegates to comment on it. I refer to legal advice in respect of the eighth amendment, for example. That is not necessarily what we are discussing here but this is still an area over which there may be a question mark in the delicate decisions around birth.

Deputy Sean Sherlock

I thank the Chairman for his indulgence and the committee for allowing me, as a non-member, to pose some questions. I will endeavour to be very brief.

I refer specifically to the issue of governance, particularly as it relates to Cork University Maternity Hospital which the Minister visited last week. Following the visit I asked a parliamentary question about the engagement with clinicians at the hospital. I am particularly delighted that Professor Louise Kenny is here. I acknowledge publicly the work she has done, particularly as a principal investigator and a Science Foundation Ireland funding awardee. I also acknowledge the work being done at the infant centre at Cork University Maternity Hospital where the research conducted is world class.

To get down to brass tacks, my parliamentary question was related specifically to the issue of waiting lists for gynecological services. We have had an articulation of the pressures and the potential for the presentation of cancer cases in the absence of proper and timely interventions. When I asked the Minister what his intentions were on waiting lists, he replied:

I am assured that the 2017 NTPF waiting list initiative will help to alleviate some of the difficulties in Cork. In 2017, the NTPF will have an allocation of €20 million and, in the first instance, in the region of €5 million will be targeted at day case procedures. The NTPF anticipate that 2,500 of the longest waiting day case patients, including patients on the CUMH waiting list, will be treated under this initiative.

My question is very simple. Is the National Treatment Purchase Fund the proper mechanism under which women waiting to be seen at Cork University Maternity Hospital should be dealt with? I have my doubts about whether the National Treatment Purchase Fund is the correct mechanism or the most appropriate solution to this problem and I ask Professor Kenny and her colleagues for their views in that regard. There are two theatres in Cork University Maternity Hospital, but I understand only one is open and four days a week. As such, it is operating at a sub-optimal level. I ask for the perspective of Professor Kenny of how this is impacting on services and whether, if the two theatres were operating at the optimum level, that would be the best use of resources.

Chairman

This is really a matter for discussion in a debate on the maternity strategy. While there are elements that relate to gynaecological services, the Deputy is discussing local issues.

Deputy Sean Sherlock

In that case let me couch it in the language of the national maternity strategy. If we are to have a fully operational national maternity strategy, there is a governance issue, to which the delegates have referred. It is evident by any objective analysis of the operation of Cork University Maternity Hospital under the umbrella of Cork University Hospital has been to the detriment of health services for women. There is a very clear, linear connection. I am trying to ascertain something on the governance issue that has been referred to and relate it to the south/south west hospital group. We are being told that the HSE's national women and infants health programme and maternity networks will be established across hospital groups, if it has not already been done. My question is whether, if Cork University Maternity Hospital is part of the south/south west hospital group, it is being represented adequately within the group such that there are transfers of funding and resources from the parent hospital in a manner which ensures services are delivered for women.

Ms Mary Leahy

I will start from the beginning with the questions from Deputy Alan Kelly. He asked if the strategy was implementable. It is a ten year strategy and we have grave concerns at this stage, given that a year has passed in which there has been very little progress. While the strategy can be implemented, the important aspects must be identified, as Dr. Boylan said, and driven first. A task force has to be established. It cannot be a shiny strategy which is on a shelf, as other strategies have been. We need an annual report as each year unfolds because two or three years can pass quite easily and then there is a crisis. While the strategy can be implemented, doing so will require great dedication and investment. We have to get the staff in place.

Deputy Alan Kelly mentioned budgeting. It has been a problem, on which the INMO has made a presentation to the joint committee. We have made a proposal on multi-annual budgets because when new services are established, funding must be front-loaded. There is a lot of investment in setting up a service not to have adequate funding to drive it forward. As such, we need multi-annual budgets. A ring-fenced budget is needed for implementation of the strategy. The current HSE service plan refers to the recruitment this year of 100 midwives, but no moves have been made in that regard. Again, it needs to be driven and pushed by the politicians.

Deputy Alan Kelly referred to mental health service. I think that question was answered. The issue of ultrasound services has also been addressed. The Deputy mentioned students and asked if there were geographical issues. I am not clear on what was meant.

Deputy Alan Kelly

Ms Leahy made the point very clearly that where there was good management or leadership, it was much more likely that trainees would stay within the system. I was wondering if there were other reasons for this.

Ms Mary Leahy

The moratorium of a few years ago was the most destructive instrument ever waved at the health service. It was unmanaged and crude in that it was financially driven. Posts were simply eradicated to meet budgetary constraints and no regard was had to the expertise being lost to the health service. As a result, there are pockets of deficits. There is no universal service nationally. Services in one area will excel in a particular way, while in others there will be deficits. Students may be mentored well in some areas, but in others it will be to their detriment. There is no uniform approach. I have mentioned that there is a huge deficit in clinical-educator ratios. The ratio should be 1:15 for clinical educators in the workplace, but that is not happening. We are possibly at half of that ratio, with the result that students are not receiving the support they need. I have also mentioned that staff deficits mean that staff are not freed up. Staff involved in midwifery care are under pressure from the point of view of the fact that one has direct entry undergraduate midwives entering the workforce and looking for placements and to gain clinical skills, while there are also postgraduate midwives, general nurses who have undertake a maternity service placement and student public health nurses who undertake a maternal and child module. As such, staff are under a great deal of pressure to provide mentoring, but the numbers are just not available to provide it.

In relation to the strategy, Deputy Alan Kelly asked if there was evidence of money being provided locally. I can speak for the community and say there is no such evidence. There has been a move where I work to provide antenatal care in the community, but that was happening pre-strategy and I cannot credit the strategy with it. My colleague, Ms Gorman, might be able to answer the Deputy's question in greater depth.

I was asked about community midwifery service differentials. I think I answered that question. There is no uniform approach; everything is based on the availability of resources.

If there is any question I have not answered, the Deputy should feel free to say it.

Deputy Billy Kelleher is not here, but I will address his questions. He mentioned the issues of recruitment, retention and career pathways, in particular. Career pathways constitute one of the major issues in recruiting and retaining nurses. There are no career pathways. Senator Alice-Mary Higgins mentioned the pathway leading to management. I agree with what she said.

There is a grade in nursing and midwifery, the advanced nurse practitioner and the advanced midwifery practitioner, and we have suggested a certain number of those be recruited but we do not have near the number we have recommended. There is no satisfactory pathway, therefore, unless one goes into management and many practitioners do not wish to take that route. The HSE will tell the committee later that it is recruiting but we are 350 nurses and midwives down on the end of last year, not the end of 2016 but the end of 2015. Although there might be recruitment there is also a huge attrition rate, because staff are not staying. The career pathway is definitely an issue and it must be developed.

On the question about when we will be able to provide a safe maternity programme, I have a simplistic answer to that. It depends on the resources in staffing. There is a strategy that recommends a ratio of one midwife to 29.5 births, but we are nowhere near that. We cannot say we have a safe practice until we reach that level. There is also a problem with staff midwives not being released for continuing professional development or education, which is vital in a profession such as nursing and midwifery where things are changing all the time. One must keep abreast of that. It will be when midwives are released for education and career development, when we reach the ratios required and when we have really good governance, which we are moving towards. We welcome the directors of midwifery in the 19 units.

There was reference to women's health and home birthing. That has been addressed, although Mary Gorman might wish to comment further.

On education programmes provided for women from the conception stage, that could improve significantly. It must be brought into the schools. Many women will encounter unplanned pregnancies and at that stage, without wishing to be crude about it, the horse has bolted. There is huge room for health promotion. In fact, health promotion suffered hugely in the last number of years because the service has become reactive rather than proactive in many areas of practice.

Senator Higgins mentioned concerns about recruitment and retention. I believe I have responded to that.

Senator Alice-Mary Higgins

I also referred to the neonatal and postnatal services, including lactation and psychologists. Does it put pressure on nursing services when those specialist services are not available?

Ms Mary Leahy

I will give the example of what happened during the moratorium. In Galway, most of the neonatal intensive care midwives were incentivised to retire. Once they had left, the HSE realised that their expertise was lost to retirement. I had to re-recruit them as retirees, which is not ideal. Mary Gorman can correct me if I am wrong but I believe there are very few places on the neonatal intensive care course. One might even have to go abroad to study for that course. It is something that must be harvested. We have an older maternal population and an increased incidence of early births of low birth weight babies. An increasing number of babies are going into the neonatal intensive care unit, NICU, so that must be addressed as well. I do not wish to over-beat up the HSE, but it was dreadful how it let that expertise go. It was uncontrolled and unmanaged.

There is a huge emphasis on lactation support, in midwifery initially and then in the community from the point of view of the early discharges, the midwives who are coming out and the public health nurse. Unfortunately, our rates have improved but they are still quite low. We have an initiation rate in breastfeeding of approximately 48% to 50%. We carry out a three month development assessment of all neonates and when we bring the mothers back it has dropped to approximately 38% at that stage. We have examined this and there is a great deal of research on it, but our most recent anecdotal information from speaking to many colleagues and midwives is that it is due to the pressure on mothers to return to work. A cultural sea change is needed in that area as well. There are many Polish women in our communities and Polish and eastern European women will automatically breastfeed. Their rate is approximately 98% and our indigenous population levels are being pushed up because of the eastern European women and women of other nationalities who are now living among us.

Deputy Sherlock mentioned governance. I will not respond to that question as it is not in my area. Have I dealt with everything?

Chairman

I believe so. I call Professor Kenny.

Professor Louise Kenny

I am conscious of the time so I will be brief. Returning to the governance issue and the national maternity strategy, which is the basis of the discussion today, the hospital groups were designed so that there is a major hospital within every group and, within that situation, a single accountable individual. It can be a clinical director, a master or whatever one wishes to call them. That governance system will work well. It is fundamentally important that they must have both clinical and executive authority with a ring-fenced budget. It is what the maternity strategy calls for and it is what best evidence, both nationally and internationally, proves works. Sadly, it has been lacking from CMH.

There is a final matter I wish to flag. We have not mentioned it today, but I am a clinical academic and the general move towards an academic health science model would be welcome. It will increase innovation in both clinical care and care provision. International best practice demonstrates that. Ireland has been slow and very much behind the curve to adopt an academic health science model. In the South/South-West Hospital Group we like to think we are ahead of the curve in delivering on that vision. We should welcome it.

I will let Dr. Boylan conclude in the limited time left.

Deputy Sean Sherlock

Can the witness respond on the NTPF issue? It is important with regard to the waiting lists.

Professor Louise Kenny

On the NTPF, whatever is left over from the very small amount of NTPF funding that the Minister mentioned in the response to the supplementary question Deputy Sherlock asked would be woefully inadequate to tackle our waiting lists. I do not believe it is the right model. The NTPF does not build long-term sustainability. We have outlined clearly in three specific areas what is required both to address the waiting lists and prevent them from building up again, and it is not the use of the NTPF.

Dr. Peter Boylan

Money is short but one thing that would not cost money, or if it did cost it would be a small amount, would be a change in the governance structure and the implementation of a protected budget for women's and infants' health care. Take away the integrated model which has failed our women and children over the years.

There was a question about litigation and so forth. One of the problems with litigation in this country is that there are many locum and agency staff who staff our hospitals over weekends, bank holidays and so forth, and a disproportionate number of cases arise from that unsatisfactory arrangement. Mediation would be a way of dealing with some of the cases. What often happens is that the plaintiff's solicitor intervenes and that breaks off all possibility of contact with the treating clinicians where things have gone wrong. That is not helpful either for the grieving parent or couple or for the system. It is not healthy for society to have that type of adversarial arrangement in place.

The NTPF is a bad idea. That money should be invested in the health services immediately. What happens is that somebody who is on a waiting list for years is sent to a doctor they have never seen before for a pre-planned procedure that might not be appropriate. They get the procedure and never see the person again. It is grossly unsatisfactory. It is just bad clinical practice and it should be abandoned. That money should be put into the health service. If €5 million was given to Cork, it would be a start.

Professor Louise Kenny

If we had €5 million, we would open our theatres and highly qualified internationally trained experts and sub-specialists in that area would operate on those women, as opposed to sending them to another hospital where they will meet a clinician who has never met them before, does not know their history, might do the wrong procedure and there is no aftercare. It is beyond poor in terms of clinical practice.

Deputy Sean Sherlock

There is an element of risk.

Professor Louise Kenny

We made this case vociferously to the Minister last week. The NTPF in its current format is not a solution to addressing waiting lists across the board.

Chairman

Thank you. I wish to raise a final point with Dr. Boylan. With regard to litigation, in the past few months we have had meetings dealing with open disclosure. What are your views on open disclosure regarding maternity litigation?

Dr. Peter Boylan

All of the international evidence is that it reduces litigation. If something goes wrong, one puts one's hand up and says: "I am terribly sorry. We made a mistake." The outcome might well be disastrous and tragic and will affect that family for the rest of their lives, but at least one gets on with it. The current system is bad. If something goes wrong, it will be two or three years down the line when the parents might initiate a legal action. Then it takes another three or four years. One is facing five, ten or 15 years for a case to reach either settlement or a court. If there was a system of open disclosure and a proper system of audit, which again comes back to governance, it would be possible to spot and fix problems early.

For example, if a particular clinician has many cases against him or her and they are all in a particular area, it may take five, ten or 15 years for the cases to come through. With a proper system of open disclosure and audit, they can be spotted early and the problems can be addressed and fixed, which is what patients need in the future.

The current adversarial litigation system is not helpful to anybody. It is incredibly stressful for the parents going through this. Very often parents of a child with a severe disability, which they feel may be associated with the birth, sue because they do not get State support and are left on their own. There have been tragic and very moving descriptions in newspapers of carers, including one in The Irish Times a few months before Christmas. It can have a devastating effect on a couple's life looking after a child who may be in his or her 20s and who needs constant 24-hour care in terms of changing nappies, feeding, etc.

The State needs to step in. Sometimes parents sue because they do not get State support. State support should be the first thing and then if there is a problem, it should be analysed by an independent expert who will make recommendations about changing practice, which would help other parents and hopefully reduce the risk of the same thing happening. We can never eliminate risk; it will happen. People make mistakes; that is the nature of us as humans. We can minimise these things, but the current system is not working in anybody's interest.

Ms Mary Gorman

I would like to reply to Senator Higgins's point on the choice and options for MLU care. Coming from a unit that has that care programme, the supported care pathway has been recognised as being as safe as consultant-led care. Research indicates that there is no statistical difference between the seven outcomes and there are fewer interventions. It is a clear pathway that women are looking for. It can be delivered quite easily within our current system. It is under the governance system to which Dr. Boylan referred. It could be rolled out relatively quickly with the proper governance structure.

Senator Alice-Mary Higgins

Is there a sense that it is moving now that it has been included in the strategy?

Ms Mary Gorman

There is not a sense. As it was on the strategy, the feeling was that it could be easily implemented within a year, even with an alongside birth centre within the current delivery suite, but it does not appear to have rolled out across the country. That might be an area in which we could have an easy win in the interim.

Chairman

I thank the representatives of the INMO, Ms Mary Leahy and Ms Mary Gorman, and those from the Institute of Obstetricians and Gynaecologists, Dr. Peter Boylan and Professor Louise Kenny, for giving of their time and expertise.

Sitting suspended at 12.05 p.m. and resumed at 12.10 p.m.

Chairman

During this second session, we are meeting representatives of the Health Service Executive on the National Maternity Strategy 2016-2026 prepared by the maternity strategy steering group. On behalf of the committee, I welcome Mr. Liam Woods, national director, acute hospitals division, Ms Angela Fitzgerald, deputy national director, acute hospitals division, Mr. Kilian McGrane, national programme director for women and infants' health and Mr. Ray Mitchell.

By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by it to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable. I advise that any opening statement or other material submitted to the committee may be published on its website after the meeting.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable. As Mr. Woods's opening statement has been read, I now invite questions from members.

Deputy Alan Kelly

I thank the witnesses for attending to discuss this critical topic. We heard some very good presentations earlier from the Irish Nurses and Midwives Organisation, INMO, and the Institute of Obstetricians and Gynaecologists. I would go as far as to say they were some of the best I have heard during my time in public office. I hope that our current witnesses were listening in or that they will at least have a copy of them. I accept that there are variations of views on stories etc. but I took an awful lot from our earlier session and I would encourage the witnesses to reflect on the transcript of it.

My questions for the witnesses are based on similar questions I put earlier to the representatives of the INMO and the Institute of Obstetricians and Gynaecologists, because I think it is good to hear both sets of views, and a few additional questions. While there are questions around a gynaecology strategy etc., I am a huge supporter of this strategy. By and large, it is a very good strategy but I do not believe it will be implemented because I do not think the necessary funding is available. I am also not convinced the will to implement it exists. It is a ten year strategy and we are now one year into it. What has happened, aside from the few jobs which I understand were advertised in the not too distant past? There are four politicians here today. We know the areas that have to be prioritised in terms of the funding streams. Has there been any thinking outside of the box in regard to funding this strategy? I am not convinced that it will be funded directly from the Exchequer over the next nine years. Is there an alternative strategy in place in regard to funding? For example, has consideration been given to how funding could be raised through other mechanisms? I am concerned that this strategy will not be implemented within ten years.

I was born in the maternity hospital in Limerick, as were my children. The service there, under the guidance of Dr. Gerry Burke, who has since moved on, was and is still the best I have ever seen but the building on the Ennis Road in Limerick is falling down. I understand that service is to be moved on campus at University Hospital Limerick, in respect of which €3 million is required for the design phase, but that this project is already behind schedule. That is just one example. In terms of capital funding of the strategy, from where will that funding come? Are alternative mechanisms of funding being sought because we cannot wait for it? What progress is being made on the strategy? For example, is it being positively received by consultants, psychiatrists and teams with special interest in peri-natal mental health? The evidence we heard earlier in terms of the statistics in regard to these areas was shocking.

We also had a discussion earlier on the services being provided to women, including ultrasound services and the requirement for a clinical decision to be made in regard to the provision of a second scan. Worryingly, we heard from Professor Louise Kenny that this is not safe and that because second scans are only carried out at 20 to 22 weeks in a low percentage of cases critical issues are missed. What is being done to address this issue and, more important, are sufficient numbers of people being trained in this area to ensure an increase in that percentage? We also heard from Ms Mary Leahy of the INMO that a number of years ago the percentage in this regard was 70% but that it is 50% now. In regard to governance plans, Dr. Peter Boylan made a comprehensive case for the mastership governance model, with which I agree. Unfortunately, this does not apply across the country. Why can it not be standardised? Will it be standardised? We heard earlier from Professor Louise Kenny that the budget for the maternity unit at CUH is being transferred to other clinical areas. Why can this budget not be ring-fenced? What is the plan in terms of governance going forward?

In regard to obstetricians and gynaecologists, it is proposed in the strategy to double the number of consultant obstetricians over the next ten years. Is this possible?

Obviously, this cannot be done in one go and must be planned. One year into the plan, I presume funding is in place for the recruitment of these staff. I ask the witnesses to set out for each budgetary area what is being done and provide evidence of same.

On the recruitment of midwifery personnel, the committee heard clear evidence on staff to patient ratios. The safe ratio is 29.5:1. Are plans in place to reach this ratio and, if so, when will it be achieved? The current figures are causing grave concerns, as we heard from previous witnesses.

On the implementation of the maternity plan, while I am aware that people are working on the plan, I have not seen its impact or any evidence to suggest a dedicated funding model is in place or a dedicated task force has been set up to oversee its implementation by the Health Service Executive and Department. Will the witnesses alleviate my concerns in this regard because all the evidence suggests none of this is happening? In many cases, the ratios are moving in the wrong direction.

Deputy Louise O'Reilly

I thank the witnesses for their attendance. We have been given a comprehensive overview of the reality as it is experienced by those working in the maternity services. There are probably people present who could give the perspective of those who have availed of the maternity services. The only conclusion I can draw from this is that the HSE is not in any way, shape or form serious about implementing the maternity strategy or prioritising women's health. It gives me no pleasure to say that.

My first question relates to the provision of an anomaly scan at between 20 and 22 weeks of pregnancy. When I asked the Minister about this issue in October 2016, he referred my question to the HSE which subsequently advised me that this scan is routinely offered and available to patients. In December, it revised the reply it provided in October, which is relatively quick for the HSE, and informed me that the scan is available. The truth is that a postcode lottery applies. If a woman is lucky enough to live in Dublin and is attending one of the three maternity hospitals in the capital, she will be offered the scan as a matter of routine.

The need for this scan was brought home to me when I met a young mother from County Kerry. While I will not mention the woman's name, I have no doubt the HSE witnesses will be familiar with her case. She gave birth to a beautiful baby girl suffering from hypoplastic left heart syndrome. I hope I pronounced the condition correctly. If the mother had undergone the scan, she would have known what was coming, could have made plans and would have been able to travel to Dublin and have her family around her. Instead, her child travelled to Dublin in an a ambulance while she stayed in hospital in Kerry. I spoke to her and it is clear that her suffering was made immeasurably worse by the fact she was not prepared for what happened.

According to Professor Kenny, women are exposed to an unacceptable level of risk by not having these scans available. The woman to whom I referred wrote to the Minister in September 2016 seeking a meeting. She received an acknowledgement of her letter and when I followed up the matter, I was advised that the Minister was open to meeting individuals but was very busy and had asked the newly appointed director of the HSE's national women and infants health programme to meet the woman to discuss the issue. When I contacted her this morning, she informed me she had not had any communication from the HSE. While I understand the director's appointment is recent, it cannot be beyond the HSE to arrange a meeting with a woman who has suffered greatly and is seeking a meeting. I expect it to do so as a matter of priority.

This case highlights the issue of the anomaly scan at 20 weeks. Does the HSE have plans to roll out this scan throughout the country for all pregnant women, including those who may be watching proceedings or may read the transcript of the meeting? Women want to know whether they will be able to access the types of services that would be considered basic in many other jurisdictions. In this jurisdiction, this service appears to be something of a luxury and the subject of a postcode lottery, which is not right. If the HSE has a strategy, will its representatives set out how the staff who will carry out these scans will be recruited and retained?

Recruitment is one thing, and we all know the HSE has a problem in this area, but it also has a problem with retention, one which is caused by working conditions, wages and poor access to educational opportunities. As we heard from Mary Leahy of the INMO and Professor Boylan and Professor Kenny, there is a shortage of trained health care professionals in the system. Midwives are graduating and entering private sector industries that have nothing to do with health care.

This brings me to the issue of clinical placement co-ordinators, CPCs. During the moratorium, which was introduced in the health service two years earlier than everywhere else in the public service, as I know only too well, many CPCs were redeployed in the system or back on to their tools, as one might say. This has left us with an unacceptable ratio of student midwives to clinical placement co-ordinators. Does Mr. Woods have a plan for recruiting more clinical placement co-ordinators? Has the HSE set a target for their recruitment? It must be remembered that midwives are central to the implementation of the maternity strategy because one cannot have a maternity strategy without the trained personnel to implement it. Without staff, a strategy is nothing more than words on a page, which is all the strategy is at the moment. We discussed recruitment and retention at length with those working at the coalface before the HSE representatives arrived. Does the HSE have a comprehensive plan in this area? We are short of midwives and we have problems with recruitment and retention. I would like the HSE witnesses to comment on those issues.

The National Treatment Purchase Fund was referred to. Professor Kenny, who we all agree knows what she is talking about, described the NTPF as not building long-term stability. We have experience with the NTPF and we know it will not work in the long term, even if it may have a short-term impact. I appreciate, however, that this will not prevent the HSE from utilising the fund again. Professor Kenny was asked about the €5 million being spent on the NTPF. She estimated that if the public health service had this money, it could open up theatres and operate on patients in public hospitals, which is where this work should be done. Does the HSE have a strategy to wean itself off the NTPF and begin the process of investing in hospitals and working towards implementing the maternity strategy?

Chairman

I remind members to switch off their telephones as they interfere with broadcasting.

Senator Colm Burke

I thank the witnesses for their presentation, which was circulated to members before the meeting.

I welcome the report on the national maternity strategy. My problem with reports is that in 2003, when there were between 90 and 100 consultants in obstetrics and gynaecology, the plan was that to have 180 by 2012. The report published last year showed that in 2014 there were 121 consultants. My understanding is that is that there are now approximately 130. The report states that over 100 additional consultants should be recruited. Can we make a time frame for the implementation of that recommendation? I know there is a difficulty in recruiting and retaining people but of the 130 some will retire in the next five years. Apart from additional recruitment, are we forward planning for these retirements? How many consultants will be recruited per annum during the next five years to implement that?

I understand that 13 director of midwifery positions were filled. Are those permanent appointments? I understood that there were to be 19 directors of midwifery appointed.

Has the bar been set too high for small units, thus making it difficult to get candidates? Has that been reviewed? The candidate has to have a certain level of experience and have worked in that area. People with a lot of maternity experience may have gone into other parts of a hospital for a period and now do not fit those criteria.

Deputy Sherlock mentioned the unit in Cork. When it opened, there were two theatres - one has never been opened and the other is open only 3.5 days a week. In order to open it for longer, more nurses would have to be recruited and that would take time. To open the second theatre would also require more nurses and beds. It has been proposed that the HSE rent space in another location, rather than using the National Treatment Purchase Fund, NTPF. The consultants are willing to go off site to carry out procedures - many of them are day procedures - where there is another location available. This might be a far cheaper way to deal with the problem. The patient would remain under the care of her own consultant who knows her history. Is that being considered?

In some units there is a lack of support for staff where there is an adverse outcome. While there is a huge trauma for a family there is also a trauma for staff which we sometimes forget. When there is an inquest or court case there is a lack of support for them. What new procedures will be put in place to ensure that? Where an adverse outcome arises there should be an independent review. I know of two cases where everyone agreed that there should be independent reviews. There was a decision about who should carry out the review but someone in administration decided that the person was not suitable - although the individual in question was very competent and had done previous reviews - and, 18 months later, that review has not been completed. Therefore, the people who have suffered as a result of the adverse outcome suspect that something is being hidden. When it is decided to hold an independent review, why can a timescale not be set down? That would help greatly in reducing concerns.

Senator Alice-Mary Higgins

Overall, we welcome the strategy and our questions concern its implementation. The National Women's Council worked with the HSE around some of the consultation on this. One of the strong desires among women was for choice and options. That is set out to an extent in respect of the supported care options as well as assisted and specialised care. The strategy seems to envisage side-by-side facilities, such as birthing centres, which would allow people access their preferred option but also to move smoothly to another option. Are those birthing centres in place? Has there been progress in the 19 centres towards having those side by side facilities? What is the witnesses' estimated timeline for those options being available? Other resources might be put in place to support how people make those choices and how decisions are made on people moving between them. It is a different approach but it is not enough that it be theoretical. It needs resources. What is happening to ensure that is happening and working smoothly?

One of the key points that came from the witnesses' consultations for the strategy was that one of the key desires was for midwife-led procedures where there was a low risk. We have heard in great detail about the problems in midwife recruitment. The witnesses spoke - with regard to the strategy and its implementation - about some of the problems they have encountered in recruiting people at the highest level. It is clear, however, that those problems exist throughout the system, although their impact around the country is uneven in nature. The moratorium has been mentioned. Has anything been learned from that because it seemed to create pockets of great deficiency in certain areas of care? Have the gaps in care that came about been analysed?

Recruitment and retention of midwives has been mentioned but there is also a concern about those involved in midwifery or who want to move into the area being released to pursue professional development opportunities. There is also a question of mentorship and progression. Directors of midwifery are now being recruited and there are student and entry levels but there is a large gap in the middle. There is also a problem of reward. The wages are very low. The only option for progression is to move into management. What is being done to ensure a pathway for progression for practising midwives to allow them to become advanced midwifery professionals? Will such a pathway be put in place? If it is, that might help resolve the problem relating to mentorship. There is a great shortage of mentors. There need to be increments and incentives for people to climb the ladder and remain involved in midwifery.

I imagine what we would like to hear is what the timelines on recruitment are in terms of the medium-term timeline. We do not want to simply hear that each year, depending on what comes through in the budget, the recruitment list will be drawn up. We want to know about the five and ten year plans for recruitment, in particular in terms of replacement. We have heard that 350 nurses and midwives are leaving the system annually and if we are looking to recruit approximately 100 nurses per year then we will not even be standing still. I know the question has been asked so I will not elaborate further about how it will be done.

Another area of key concern is neonatal care. I understand we do not have adequate training facilities and courses in this country and that in many cases people are going abroad to study neonatal care. There is a question of the gap in neonatal care, which is one that suffered from the moratorium. Could the witnesses discuss what is happening in that particular area which is important? That relates to the wider area of postnatal care. In the plan we discuss a lot about women's health and well-being but currently there are only three part-time perinatal psychologists in the country. Reference is made in the plan to the Coombe hospital but I understand there is a huge shortfall in the west, despite this being an extremely high-risk time in terms of mental health.

In terms of breastfeeding within the strategy, it was mentioned that all 19 units participated in the World Health Organization's baby friendly health initiative but only nine units were designated, which meant less than half of the units met the standards for the WHO.

The main point that came across in the earlier discussion was the lack of gynaecology. Why was that area left out of the terms of reference? What is happening in terms of a gynaecology strategy, and what will happen in the interim, in particular in postnatal care to ensure gynaecological services are provided? That is a crucial point which has come through. I agree with those who said the National Treatment Purchase Fund is not an adequate response to what is a predictable and should be a manageable issue.

We have heard about the mastership model in terms of governance structures but the key thing we have consistently heard is the importance of dedicated specific resources. It is important, for example, that we are not seeing it merged with acute adult care but that dedicated resources, dedicated theatre access and dedicated budgets are provided, including the capacity to strategise and think for the long term. We would like to see what models are being considered in terms of leadership and dedicated, separate resources. One of the key things in that regard is sonography and scanning. That is something on which we really need to see action this year. It is noticeable that where there is a different governance structure such as the mastership structure it has been prioritised. I would appreciate the thoughts of witnesses on the following: if we do intensify and improve governance structures, have clearer structures and resources, do they believe it would assist in dealing with the gaps and problems that have been experienced with recruitment?

This is a ten-year strategy. Care, consent and choice were crucial points in the strategy. Over the course of the ten-year strategy, however, we are likely to see legislative change on areas such as the eight amendment. I know that is key, and that it has been highlighted by groups such as AIMS Ireland, which has worked on and welcomed the strategy, while accepting there are gaps in terms of choice and consent. Do the witnesses consider the strategy is capable of responding to such changes as may arise because if there is legislative change that would require different resourcing and measures which means it will have to be flexible in that regard?

Deputy Kate O'Connell

I am sorry for missing the presentation as I was in the Chamber. I do not wish to repeat anything that has been said already. I will follow on from Deputy Louise O'Reilly's point about the scanning rate in Cork University Hospital and the incorrect data she received originally. To my mind that signifies something a lot more serious in that if one does not know what the rate of scanning is, that shows it is not high on the HSE's list of priorities. As was made very clear to us earlier by Professor Kenny, the knock-on effect of increasing sonography services has an effect on pre-natal care and neonatal care because the more one finds the more one has to fix. I find it exceptionally concerning that those responsible were not sure what was going on and therefore they could not say that it was on their radar if the facts and figures were not known and they had not anticipated what might be the knock-on effects of increasing the services. Perhaps I am wrong.

I do not wish to misquote Professor Kenny but I was shocked to hear that babies will die due to a lack of sonography in Ireland. I wrote it down as she said it so I think I am correct about what she said. In a civilised society and what is essentially a first world country it is difficult to believe that the lack of non-invasive procedures could have an impact on the live birth rate. How does she feel about that as an employee of the HSE? Does she think the women of this country have been failed?

It was stated that there was a failure of the governance structure at Cork University Hospital. Does Professor Kenny accept that? The year 2006 was mentioned. We cannot blame history for the problem as the structure is recent. The obstetrics and gynaecological services did not have a ring-fenced budget and, therefore, as we heard in great detail, the money was relocated to different areas. Does Professor Kenny accept that the governance structure in Cork University Hospital is a failure and that the mastership model is the way forward?

When it comes to the strategy itself, could the witnesses explain why nothing has been done for almost a year and could they outline the HSE's key priorities when it comes to the strategy? What I am trying to get at is whether they align with the clinicians and midwives we spoke to earlier on? With regard to the 13 of the 19 directors of midwifery who have been appointed, while that is a good thing I am a little concerned about a little bit being done in several places but nothing being done completely right. I am more of the opinion that one would fix A and then move on to B as opposed to doing a little bit here and there as I feel the value is lost. Perhaps I am wrong. Is that just the way it has ended up or is that what the HSE set out to do?

I cannot remember which of my colleagues referred to the appointment of a person to lead the national women and infants health programme. Is it the case that a lead has been appointed? If that has happened, have there been discussions on how the strategy will be implemented? We constantly hear about the success of the cancer strategy under Professor Keane and the late Professor Donal Hollywood. Is the HSE going about the maternity strategy in the same way or is it reinventing the wheel?

Other speakers have raised the issue, but I do not understand why the gynaecological strategy was omitted from the terms of reference. Even though we cannot turn back time it is really important that the committee is enlightened as to how that came about so perhaps if something arose in the future we might be able to mitigate against such omissions.

Chairman

That was a huge number of questions and interrogation. Perhaps Mr. Woods would lead the response by speaking about how the plan can and will be implemented and the funding that will be directed towards it.

Mr. Liam Woods

Mr. Kilian McGrane, who is sitting on my left, is the recently appointed - since 3 January - lead for this programme. It is following a model that is analogous to the national cancer control programme, NCCP, approach, which I will speak more about in due course. We are in the process of appointing an obstetric clinical lead and we are also recruiting a director of midwifery. They will be the three key posts. That is rather similar to the kind of collection of skills one would have had at the core of the delivery of the cancer programme.

I will address some of the common themes and then I will go back through the individual points. Gynaecology came up a couple of times and perhaps I should deal with that. From our perspective it seems a natural fit to have the gynaecology service within the deliberations of the overall strategy, so it is our intention to do that.

We see it as part of the overall dialogue with women in the service. The plan is to progress is on the same basis as the overall strategy.

Deputy Louise O'Reilly

I appreciate that it will be included, but why was it left out? Would it not have been better to include it in the first place?

Mr. Liam Woods

It is a national strategy, to which the HSE contributes, with many other parties. We did not reach a conclusion that it should be excluded; it is not for the HSE to decide to include or exclude things from national strategies.

Deputy Alan Kelly

It is for the Department of Health to decide.

Mr. Liam Woods

The strategy was published by the Minister and is a Government-wide, national strategy.

Deputy Alan Kelly

Therefore, Mr. Woods was in favour of it being included, but it did not make it in.

Mr. Liam Woods

I cannot say that. I was not sitting at the table when it was being discussed.

Deputy Alan Kelly

Did Mr. Woods ask for it to be included?

Mr. Liam Woods

I do not think I could even go so far as to say that.

Deputy Alan Kelly

We are here to get answers. Either Mr. Woods did or he did not.

Mr. Liam Woods

I am not seeking to avoid the question, but I was not a party to the deliberations.

Deputy Alan Kelly

Will Mr. Woods ask the person in the HSE who was a party to them and write back to the committee with a "yes" or a "no" answer?

Mr. Liam Woods

Of course, I can.

A number of issues related to staffing were raised. I will address them by making reference to the actions already taken and intended actions, both in respect of recruitment, training, support and retention strategies. Prior to the creation of the office, the HSE had undertaken the Birthrate Plus study which was a review of the number of midwives in each of the 19 facilities across the country. It has invested in 100 midwives to deal with identified deficiencies by site. That was done in the past 12 months and if it is helpful, we can provide lists indicating where they were allocated. It was done with a view to having the total numbers of midwives required for the safe delivery of clinical services. The latest information I have is that 88 of the 100 midwives are in place.

There was a wider point about recruitment and the approach of the HSE to dealing with the impact of the moratorium, retirements and replacements. There is no moratorium or set rules operating within the HSE. I take the point about the effect of the moratorium and removing posts during the time of austerity which had an unbalancing effect within the overall system. The Birthrate Plus midwife numbers reviews sought to address it. A midwife who leaves service can now be replaced within the current complement.

Senator Alice-Mary Higgins

Will that bring us to the ratio of 29.5? When does Mr. Woods see us arriving at the recommended ratio?

Mr. Liam Woods

The ratios set out in Birthrate Plus can determine that question and we can share the information with the Senator. It will bring us to a ratio of 29.5. Staff can be recruited as there is replacement capacity within the system which was not available at the time of the moratorium.

A number of questions were put about directors of midwifery. Thirteen of the 19 are in place. Senator Colm Burke asked whether there was an issue with the particular requirements to be a director of midwifery. The answer is "Yes". We have reviewed them and slightly amended them, while staying faithful to the overall needs. We are trying to recognise experience, as well as qualifications. We are working with our partners to address the matter in the units where they have been a difficulty. They are key leadership posts across the 19 units. It was our deliberate intention to have the posts filled within a close timeframe because they are key building blocks in the maternity networks. I will discuss these under the governance heading which was referred to by a number of members.

Deputy Louise O'Reilly

Mr. Woods was asked very specific questions about recruitment and retention. I have said many times that there are too many chiefs and not enough Indians. We have heard about the comprehensive plan for the recruitment of chiefs, which is to be welcomed, but what about the Indians? Not only can the HSE not recruit them, it cannot keep them. Does it have a plan? Does it have a target, as I cannot see one?

Mr. Liam Woods

The answers are "Yes" and "Yes". The overall number of midwives in the system is growing and while there is a challenge presented by the flow of retirements-----

Deputy Louise O'Reilly

I understand the total is down by 350. The figures do not add up.

Mr. Liam Woods

In the current year the overall number of nurses in the HSE acute division is up by about 200.

Deputy Louise O'Reilly

We are talking specifically about midwives.

Mr. Liam Woods

We are within 12 of the intended number in Birthrate Plus.

Deputy Louise O'Reilly

Therefore, when the INMO states the number is down by 350, it is wrong. It is not usually wrong.

Mr. Liam Woods

I would have to see its numbers.

Deputy Alan Kelly

Mr. Woods said he listened to the INMO. Does he agree or disagree with it?

Mr. Liam Woods

I am sorry, but I do not understand.

Deputy Alan Kelly

Mr. Woods said he had listened to the INMO's presentation; therefore, he is aware of what it stated. Does he agree with it?

Mr. Liam Woods

We frequently both agree and disagree with the INMO.

Deputy Alan Kelly

There is a big difference between 12 and 350. Perhaps Mr. Woods and his team might confer a little more on this issue.

Deputy Kate O'Connell

Perhaps the figure of 12 refers to the ratio.

Ms Angela Fitzgerald

No.

Deputy Alan Kelly

This is incredible.

Ms Angela Fitzgerald

The exercise undertaken by the INMO and in the Birthrate Plus report was endorsed by Mr. Liam Doran of the INMO before the information was released. It was set to make sure we would have a ratio of one in 29 at the very minimum. Some units were already operating at or above that level, while some were well below it. With the moneys we had received in 2016, the priority was to bring the numbers in the sites operating at below the required ratio up to it. The report we have shows that 88 of the 100 posts have been filled. The wider issue is the ability to retain, which is a challenge. If we put the matter in context and move away from midwifery-----

Deputy Alan Kelly

What is the answer?

Ms Angela Fitzgerald

Midwife numbers have increased. There is no evidence that we are losing them as quickly as we were. We can provide a report by site. In his former role Mr. McGrane exercised the requirement in Wexford and Kilkenny to bring staff numbers up to minimum levels. Each site is required to operate within a ratio of 1:29. There is no impediment in replacing somebody when they leave. I am not sure what reference point was used by the INMO for the gap, whether there is a vacancy factor or whether it relates to the ratio of 1:29, but we are happy to share the detail with members. The intent is to recruit. The gap is 200. We received funding in 2016 to recuit 100, of whom 88 have now been recruited. A further 100 are to be recruited and the expectation is we will move to do this. The question of whether we are just running to stand still is fair, but it is a challenge we are meeting.

Deputy Alan Kelly

Therefore, what is the answer?

Ms Angela Fitzgerald

We are recruiting the balance of 12 staff, but we recognise that a further 100 are to be recruited. The number agreed with the INMO was 200. We do not know what the figure of 350 refers to.

Deputy Alan Kelly

I refer to the number lost through the system versus the numbers of staff who have come in.

Ms Angela Fitzgerald

I do not have that information, but I will be happy to give it to the Deputy. The number we agreed with the INMO was 200.

Deputy Alan Kelly

This is a serious issue because the statistics are completely at odds.

Ms Angela Fitzgerald

No. The statistics are agreed with-----

Deputy Louise O'Reilly

Ms Fitzgerald has said she will provide the figures. The recruitment of 88 midwives is a good news story and I appreciate that she wants to keep telling us about it. If the HSE is running to stand still, it is doing well because I think the numbers leaving, for various reasons, are not being matched by the numbers being recruited.

Deputy Alan Kelly

That is why I keep asking for the net figures.

Deputy Louise O'Reilly

Will Ms Fitzgerald let us have the actual figures? I am not referring to the 88 who have been recruited because we have heard about them.

Ms Angela Fitzgerald

We understand the question.

Deputy Louise O'Reilly

How close is the number to the ratio?

Senator Colm Burke

The simple solution is to give us the figures for what was in place in 2014 and what is in place now. That would allow us to see the comparisons.

Ms Angela Fitzgerald

That is not a problem.

Deputy Kate O'Connell

And on the birth rate as well.

Ms Angela Fitzgerald

I think we can provide both.

Senator Colm Burke

I ask that we be given the figures for 2014 as well because that is the year we are talking about and-----

Ms Angela Fitzgerald

The reference period, yes.

Senator Colm Burke

The reference period. If it is possible, Ms Fitzgerald might also give us the figures as of January 2017-----

Ms Angela Fitzgerald

Yes.

Senator Colm Burke

-----for each of the units, and the birth rate for each of those units for the year ended 31 December 2016.

Ms Angela Fitzgerald

We would have all of that.

Senator Colm Burke

That would allow us see the comparisons and sort out the problem in terms of determining whether the figures are accurate.

Senator Alice-Mary Higgins

The key point is the ratio. Can we get an up-to-date figure on the ratio so that we can get a sense of that?

Ms Angela Fitzgerald

Absolutely.

Senator Alice-Mary Higgins

With regard to some of the specific issues mentioned such as the release for professional development and the question of progression, what does Ms Fitzgerald see are the gaps in terms of retention and progression?

Mr. Liam Woods

In terms of the data from 2014 to date and the benchmark in terms of numbers of births, we have that and can make it available to the committee. It is not a difficulty. In terms of the numbers of births, the ratios are in the Birthrate Plus report. They are based on a slightly higher number of births than we have now but we have not used that to alter the numbers, if the members know what I mean. The birth rate is falling slightly.

I want to touch on a couple of major themes and then come back to-----

Deputy Alan Kelly

I am sorry to interrupt but at the outset the Chairman asked how this would be funded. I would appreciate it if Mr. Woods outlined that.

Mr. Liam Woods

The next themes I intended to come to were around-----

Chairman

My initial question was how the Health Service Executive saw the plan progressing in its implementation. Is there sufficient funding for it and is there the will to complete the plan?

Mr. Liam Woods

I will come to that as part of both the funding and the governance issue, which arise within that. We are putting an office in place specifically for the purpose of implementing a plan that has been set out nationally that we have both a duty to implement and which we are mindful to see fully implemented. Issues will arise with that, and I will come back to some of the issues referred to by the Deputy, particularly in the capital area that may be worth speaking about. From our point of view, set out nationally there is already an indicative funding level on an annual basis in revenue, not capital, funding terms for the development of this programme. I believe the figure is-----

Mr. Kilian McGrane

It is €52 million over the lifetime spread, front-loaded, with approximately €12 million a year for the first three years and a lower rate of investment thereafter.

Mr. Liam Woods

One of the early tasks of the new office was to set out a detailed plan to implement the strategy as it is currently expressed. That intention is a multi-annual expression and it is subject to the Estimates process annually through which the HSE is funded.

On the revenue side, there is a funding intention behind this plan that recognises there is a real cost. The other staff category referred to in terms of the queries was numbers of obstetricians. The need to recruit obstetricians was referenced by previous presenters. The clinical programme in obstetrics within the HSE has identified the need to, in effect, approximately double the number of obstetricians. Our obstetric colleagues advise us that will not happen all at one time; it is a phased recruitment process. It has commenced with some approvals for obstetric appointments in both 2015 and 2016. The numbers are relatively low. From memory there were about six posts nationally in each of those years. Clearly, the requirement is much higher than that but it is a start.

On the further question of capital funding, the Deputy will be aware of a number of projects. There was a reference to the need to move Limerick maternity hospital onto a single site in Dooradoyle and the National Maternity Hospital moving onto the site at St. Vincent's Hospital. In terms of maintaining existing facilities and either improving or developing new facilities, both those projects, and others in the maternity service, and a question was raised about adjacent facilities, are all subject to the capital plan of the HSE, which is currently in a mid-term review as part of the national mid-term review of the capital programme. In terms of what is in the capital plan of the HSE currently, there is provision relating to the movement of Holles Street hospital to the site at St. Vincent's Hospital. I will not say at what level as it is subject to tender, but there will be a provision for that.

Deputy Alan Kelly

Is it about €250 million?

Mr. Liam Woods

Too high, Deputy.

Deputy Alan Kelly

Go on.

Mr. Liam Woods

It would be injudicious of me to say based on the need for us to go to tender, but there is provision for that. Provision will need to be made for other similar moves, and Limerick would be one of those. There is also a need for significant investment. In its capital plans the HSE has flagged the need for equipment and obstetrics-----

Deputy Alan Kelly

I understand Mr. Woods cannot-----

Chairman

Could Mr. Woods give a timeframe for the transfer of Limerick maternity hospital from its present site to Dooradoyle?

Mr. Liam Woods

It will be dependent-----

Deputy Kate O'Connell

Chairman, a vote has been called in the Dáil.

Deputy Louise O'Reilly

We have six and ten.

Deputy Alan Kelly

We have a few minutes.

Chairman

We have two Senators, and I will be remaining so we will continue.

Deputy Alan Kelly

The Government does not need the Chairman's vote. I will have to leave soon but on the capital plan, it is a huge budget. What Mr. Woods referred to earlier will be a huge outlay, whatever it will be. I was chancing my arm on that but it will be huge. I am not convinced. We are from the mid-west and we are thinking about Limerick. A total of €3 million is required just for the design. I have not seen sight nor sound of it. If they are struggling with providing €3 million, where will they get the volume of funding required in the next eight and a half years to finish it, with the openings done and so on?

Mr. Liam Woods

I will be brief as I am conscious the Deputy has to leave. His suggestion, which I believe he made at the Committee on the Future of Healthcare, to examine other streams of funding becomes relevant here. While, traditionally, the HSE has been funded for capital purposes through a capital allocation in the Vote, it is open to examining other delivery models, if we can move in that direction, which would, in effect, have the impact of moving from capital funding to a revenue stream over the lifetime of an asset. We are open to that. We would have to explore it in detail. We have done that in some----

Deputy Alan Kelly

Is anybody currently exploring it?

Mr. Liam Woods

We have already done that in some other areas of capital provision.

Deputy Alan Kelly

I understand that. That is the reason I suggested it.

Deputy Louise O'Reilly

I have to leave but before I do, Mr. Woods might confirm that that meeting will be arranged as I took another call from a very distressed women this morning.

Mr. Liam Woods

Yes. We will come back on that. If I could get the details-----

Deputy Louise O'Reilly

Yes. I will provide those but I hope Mr. Woods will still be here when I return.

Deputy Alan Kelly

On the capital side, regardless of who is in government I do not believe we will have this completed in eight and a half years. We will have to step outside the box, make some recommendations as a committee and examine alternative funding mechanisms to deliver the scale of the budget required, whether through a national bond or some other mechanism, because we cannot wait any longer. This is a very good strategy, which has received broad political support, but we must make sure we can deliver it. On the current side, it will be difficult to deliver but, on the capital side, it will be virtually impossible. I believe the four people sitting across from me believe that also. This is an issue we should come back to and on which this committee should make a recommendation.

Senator Colm Burke

The problem for the past 25 years is that very little has been set aside in the capital budget. In real terms it is a case of developing services in a piecemeal way because not enough moneys have been put into capital funding. To take the example of the three maternity units in Dublin, they are all more than 150 years old and we are now talking about dealing with those over a short timeframe. It is not only a matter of maternity services when we talk about capital budgets; it is the entire area across the HSE. The director general referred to a figure of €9 billion. I would probably agree with him. It has not been an issue for the past five years but over a period of 25 years.

Mr. Liam Woods

To respond to the points made by the Deputy and the Senator, there is a significant issue for the HSE in terms of its global capital provision post-austerity to make sure we have infrastructure that is fit for purpose and does the job. The service plan and the capital programme for the HSE, which are the amounts determined by the Oireachtas, are expended. We are in dialogue with colleagues in the Department of Health and in other Departments relating to future needs, which would include maternity services but also the wider agenda to which the Senator referred. In the planning of the implementation of this strategy there is a strong capital element that has to become visible. There is a significant challenge with that, and we understand that. Mr. McGrane and his colleagues will be working with our finance units around the country, and centrally, on that.

The idea will have to come on the table in terms of looking at that. It has already because if one looks at the funding of primary care centres, it is done through a third-party support with private capital partners. Therefore, we will have to examine creative ways of ensuring that we get access to the right capital resource as quickly as we can to proceed with the policy. There is no question about that. Some resources are already available, which are helpful. The moving of Holles Street is a significant one. There are already planning deliberations under way around other parts of the Rotunda going to Connolly, which is under discussion right now and in phase 2 of planning. These projects will need to continue through to a point of funding and there will be a big challenge with that. The Exchequer will have to examine that when the plan is complete, looking at what the feasible timings are and the implications. The Senator is right to say that it is a wider reality for the HSE's capital programme.

Senator Alice-Mary Higgins

Before we move on from the capital funding, I am a little concerned. Mr. Woods was mentioning the side-by-side services and it seems that they are now going through capital funding, even though they are described in some cases as new units. However, the low-risk birthing centres are potentially relatively low-cost and I am concerned that they may well fall by the wayside if we are talking about these major projects that are under way. I wonder what Mr. Woods' vision is on that. What is the timeline for the 19 centres we are talking about? Does Mr. Woods see all of them being included and developed with side-by-side facilities coming in in the next three years? Where does that fit in? When one has grand-scale projects a core change happens. One of the core demands was for these parallel services and options. I would like to hear a lot more about where they are coming from and fitting in, rather than just being on an application list for capital funding.

This is a question on funding from our colleague, Deputy O'Connell, who had to leave but she hopes to come back later. The question concerns the sum of €52 million and the front-loading of €12 million a year over the next three years. From what we are hearing it does not seem to be adequate. Mr. Woods is talking about improving a service, yet he is also talking about a great deficit. Does Mr. McGrane think the funding is adequate? Let us signal early on if we feel it may not be adequate so that we can identify it. Perhaps the witnesses could deal with those points before we move on from funding and the question of capital.

Mr. Liam Woods

I will ask my colleague, Mr. McGrane, to address that.

Mr. Kilian McGrane

Regarding the Senator's question on alongside birthing centres, I do not foresee a huge capital investment requirement there. The strategy refers to the fact that for some of the existing units, where there are small centres with a relatively low number of births, some of the existing facilities can be modified to facilitate that. In larger units it is about looking creatively at what physical space is there. Obviously we do not have enough people in the office yet to have a robust discussion about it, which we need to do, but we plan to look at taking one or two sites - maybe one of the larger ones and one of the smaller ones - and putting something in place on a trial basis to see what works best.

Putting the three care pathways in place is of critical importance. We need to ensure that the model for those is well described, and that takes a little bit of time, but there is no reason we cannot use the existing facilities in a more creative way. As the Senator has seen, the alongside birthing centres are about taking the complexity away and normalising the birth, which is central to the approach.

On the funding issue we have to develop an implementation plan which we have committed to do by mid-year. At that stage we would be better able to answer the question about funding. Clearly there is always a big funding component to it.

Deputy O'Connell asked about the priorities for the programme. We see them as two-fold at this stage, although that is not to eliminate anything else. One is the managed clinical networks and the second component, which is related to it, is the quality and patient safety agenda. There are costs associated with implementing both of those and we would see that as being the No. 1 priority for us. If we can do that, then all the other things that are so important in the strategy can flow from it.

We definitely intend to make progress on the alongside birthing centres this year, but will probably do it in a phased way so we can make sure the model works. It will be different depending on the nature of a tertiary or secondary centre.

Chairman

To guide the meeting through a thematic approach, perhaps Mr. Woods can discuss the mastership model of governorship. From the Cork experience we have seen that being part of a hospital group, and not having autonomous structures in place, is leading to a less than optimal service. Perhaps Mr. Woods could comment on that.

Mr. Liam Woods

The present governance arrangement is that there are hospital groups within which the 19 units are spread across the country. The intention in the strategy, which has just commenced in the south-south west group, is to put in place networks with clinical leadership that are specifically focused on services for women and infants, in accordance with the strategy. The first appointment in that area has been in the south-south west region where an obstetrician has been appointed to such a role. It is intended that there will be similar networks in the other six adult services and that work is currently under way.

I will come to the mastership piece in a moment. The governance within the HSE moving forward, based on the strategy, is that there are groups and specific networks within groups. There is also a national office, which Mr. McGrane is leading, that is doing both planning and resourcing, as well as evaluation and standard setting, to support those four networks.

There was a further point concerning the role of hospitals and the place of obstetrics and gynaecology services within hospitals. There is nothing in the strategy which intends to put in place a different governance arrangement for those services outside that which is group and hospital-based. Strong leadership is being invested within those. It is akin to taking the clinical leadership dimensions of the mastership role and embedding that in a network leadership role within the groups.

The mastership structure has a history dating back as far as 1720 in Dublin and has served both the city and the country well. I do not intend any critique of the mastership system, but the governance arrangement that is in place here is about having strong clinical and managerial leadership. On the point about ring-fencing and identifying resources, I agree entirely that the programme needs to be able to ring-fence the resource that is within the service at the widest level, support investment from there and avoid any risk of resource seepage into other services. That issue works across a number of specialties. All specialties want to have a ring-fenced resource.

The HSE has already invested in the identification of resource, and activity associated with resource, under the activity-based funding process. It helps us to identify what the resource is in each of those sites and the associated activity in each of those sites that is subject to that dialogue. We would see a leadership model where one has a group, a clinical network within a group, and that network is supporting all the sites. All, bar one group, have multiple sites.

Chairman

So Mr. Woods does not see the mastership model being extended to maternity units that do not have a mastership model at the moment?

Mr. Liam Woods

At the moment, the three Dublin maternity hospitals have a master. We do not see the appointment of a person titled "master" in the other 16 units. We do see the appointment of strong clinical leadership with a managerial input in the networks and in the individual hospitals to support what they are doing. We see it as a strategy.

Senator Colm Burke

Can I ask a question on that, Chairman? Mr. Woods talks about the appointment of strong clinical leadership. Where all the clinicians in a particular facility agree there should be an independent review, however, someone in administration - who has neither hand, act nor part in the facility - can overrule their decision and 18 months later no review report has been completed. If that is the structure Mr. Woods is talking about, it is not going to work.

Mr. Liam Woods

No. The experience heretofore will be different from what will come in future with the strategy being implemented. I am sorry but what was the point concerning a review related to case reviews on obstetrics?

Senator Colm Burke

It was an adverse outcome. A decision was taken that a clinical review would be carried out by an independent person outside the particular facility. All the clinicians agreed on who should be appointed. They were overruled, however, by someone in administration who had no physical contact with the unit, but who just drew a line across the person who was appointed. Some 18 months later, there is still no review completed.

Mr. Liam Woods

Apologies for that.

Senator Colm Burke

That is causing problems within the maternity services, which leads to litigation as a result.

Mr. Liam Woods

I would like to hear more about the matter from the Senator at the side of this meeting. My apologies but I thought that he was talking about a governance review but instead they are individual cases. What he has said sounds unusual to me and I would like to hear more.

In the model that is emerging, which is based on the strategy, the authority around decisions relating to obstetric services will reside within the network reporting to the group, and individual hospital sites within that network.

Chairman

This morning Dr. Boylan told us that the present structures in Cork do not work and will not work unless there is an adoption of a mastership type structure where there is immediate accountability both clinically and otherwise. Such a structure works in the major maternity hospitals in Dublin. Why would that not be adopted rather than be set aside?

Mr. Liam Woods

What we have done, under the strategy, is appoint a strong clinical leader in the south-south west group that includes Cork and other hospitals. We did so with the very intention of providing direct clinical leadership and support to all of the hospitals within the group.

In terms of the individual hospital, when the reports were in the media some days ago I looked at what happened the head count for the services in CUH over the past number of years and discovered that the figures have grown. Since 2013 there has been an increase of 40 in the number of midwives and about an increase of 14 in the number of medical staff. There were reports that showed reductions in finances. The overall position showed me a growth in resource based on the human factor, which is the main cost in the system.

In terms of the question of governance, the strategy clearly shows that there will be networks. We have taken a first step in Cork to support the south-south west network by appointing a lead for that. It is not called a master. The post is a clinical lead for obstetrics and gynaecology services in that group.

Senator Alice-Mary Higgins

It might be useful to get a sense of how the model works. A concern has been expressed about accountability in the networks. Is there an accountability structure? Is somebody responsible for the structure? It is important to know this information both in terms of recruitment and giving confidence to people down the line. How does the delegation see this matter impact on accountability? Is there a danger in the model outlined? Can responsive clinical expertise be called on rather than the strategic leadership, response to trends and setting of a vision that we have seen?

It is clear to people that the structure did not need to be called a master model. People have called for a structure that would operate in parallel with the strategic structure that has been outlined. I mean a three pronged approach of a captain or leader of some form, a director of midwifery and an administrative need that exists at the core of each of the 19 units within the section. How does the delegation see the three strands reflected? Where is the accountability? Where is the input for a strategic vision? Is there a danger of the vision becoming so diffused in the network structure that it is lost or mixed up in something like acute adult services? While there may be a network, in terms of a key hospital, which is part of that network, a whole separate set of decisions are being made and the network does not have a strong grip on the service. I had another question but that is all for now.

Mr. Liam Woods

The national office will have a strong connection with the networks. It is through that connection that we would look for the strategy to be implemented. The network sits at a group level and reaches into each of the sites. Reference was made earlier to the cancer control programme. Part of this model is analogous to the cancer control programme. One has a central office that is influential in the hospital environment in terms of decisions about resources and the direction of travel in terms of clinical service provision and safe standards of care. The office will play a key role nationally and will have a direct link with the network. It will also work with the groups within which each network sits.

I shall come back to the Senator's question on clinical placement co-ordinators, CPCs. A director of midwifery is being recruited into each unit and they will work as part of the network. We see the recruitment as part of the network in terms of delivery. The wider points made by the Senator about training, support and placement are relevant to the role. Perhaps my colleague, Mr. McGrane, wishes to comment.

Mr. Kilian McGrane

The cancer control programme did not have a mastership type model or equivalent but protected invested resources. It had cancer networks and protected at network level both the existing resource and all new development money. The latter was held by the cancer control programme and then allocated to resources.

The model that we seek to establish at group level is equivalent to a clinical directorate in a hospital. Most hospitals have clinical directorate models. Ms Fitzgerald, from her days working in St. James's Hospital, and myself from my days working in St. Vincent's Hospital, have experienced how the model operates. One has a dedicated individual who is the clinical director and he or she is accountable for everything that happens within that service. He or she is supported exactly as has been said usually in a hospital context by an assistant director of nursing and a business manager. We are replicating this process at group level. One will have a named clinician who becomes the clinical director or clinical lead; I am not sure if we have clear titles yet. One would also have a director of midwifery, somebody at administrative level who can provide business intelligence and support and, also, a quality and patient safety person because that is central to how this model works. All of that will ensure there is clear governance and accountability. It does not mean that there will not be robust discussions on whether obstetrics and gynaecology get investment over general surgery, cancer services or anything else. Robust discussion will still happen but the voice of the obstetrics and gynaecology will be clearly heard, well identified and supported at national level by the programme office and, indeed, by the political commitment that has been given in the Department and by the Minister. We see this model as taking something that works well in the acute hospital sector at the moment. I appreciate that the strategy goes much beyond the acute hospital. This model will allow us to put a governance structure in place at group level that supports the direction of travel for the acute hospitals system.

Chairman

This morning we heard evidence that funding for gynaecology services, but perhaps for obstetrics as well, gets lost in the reduction in services and funding. As spoken about this morning, there is a necessity for funding to be ring-fenced to protect obstetrics and gynaecology services. If funding is not ring-fenced then the obstetrics and gynaecology sector will lose out as it is the first area to lose funding.

Mr. Liam Woods

Yes. The processes in place allow us, in terms of financial and services analysis, to identify current activity and the associated resources. Part of the role of the office will be to become aware of that and to protect that within the national network. It will consider the relative resourcing, which is what the national cancer control programme or NCCP does. Normally, it would be known through service provision.

I should have touched on the references to the NTPF and, maybe more fundamentally, they dealt with providing adequate volumes of service to meet the service need. Clearly, we understand the point that says to build sufficient services to deliver over time in a structured way. That is where we want to be. The NTPF can help in the short-term to deliver services if there is a difficulty in doing so within the public space. The NTPF is not the HSE and I ask members to be aware that I do not speak for the NTPF.

Reference has been made to the possible use of other facilities. During the past two years, specifically last year, we have considered optimising investment within the HSE in whatever facilities are available to undertake or work off the waiting lists and put that resource into public hospitals. My brief would be to optimise that because one has the continuity of care, which was the point that was made, and it also tends to be good value and a good use of public funds.

Senator Colm Burke

If one operated the theatre in Cork University Hospital for five days a week one would have a problem with beds and other problems caused by a lack of staff. The consultants have suggested that they could get space in another facility, and get the beds, and backup support staff thus taking many people off the list in a faster time. Let us remember that it will take time to recruit people. A six-bed day unit has been sought.

They will also need to have access to a theatre to deal with people who are using the six-bed day care unit. That will take some time. It might take anything up to six months. They are saying that in the meantime, they are prepared to move to other facilities outside Cork University Hospital where there is space available to carry out the procedures and get people off the list. There are over 4,000 people on the waiting list at present. Dr. John Coulter, who is one of the consultants, is concerned because it is not known how many of the 4,000 people on the waiting list might have early-stage cancer. That is why there is so much concern about the delays in seeing people and why this issue needs to be prioritised.

Mr. Liam Woods

We are looking at options. Ms Fitzgerald has told me that we have adopted this approach in the orthopaedic sector since mid-2016. Orthopaedic services have been provided in one of the Dublin hospitals where such an opportunity arose. We would be very open to the south-south west group bringing such proposals to us. I understand such a proposal is being prepared and we will get to look at it. I expect that there will be a strong clinical input into that and that it will cover Kerry, Clonmel and Waterford. I am looking for the group to give us a group response to what it can do. We would be well disposed to ideas that make the best use of the resources we currently have and provide continuity of care and a safe service, subject to contractual conditions we may have to work our way through. The only remaining question would relate to what resources are available to do what this year.

Senator Alice-Mary Higgins

Is there any danger regarding the allocation of moneys to the NTPF? Is it possible that similar, parallel resources will be allocated to increase capacity? There is a concern that when money is put into the NTPF, we are told that funding has been allocated to deal with a health crisis or problem and the issue is taken off the agenda. I suggest that when allocations are made to the NTPF, matching funding should also come through in support of core resources.

I would also like to ask Mr. Woods about the gynaecological strategy. He does not have to answer this question now. I know our time is short. He will be sending a response to the committee about another issue at a later stage. Could he also send us a timeline in this regard? It would be good to get written information.

Mr. Liam Woods

Sure. We recognise that there is a need for ongoing investment in the provision of an increased level of service to deliver on the demands that exist at the moment and the demands that may exist as demographics change. I am sure the Oireachtas committee that is looking at this matter will make helpful observations. It has certainly received some strong submissions. We understand and accept that permanent investment is needed. I think NTPF-type funding can be of strong support in providing additional capacity in the short term. As members have mentioned, significant portions of our total waiting lists are day work. Such work can account for up to 60% of waiting lists, depending on the specialty in question. That can also lend itself to proposals like those we were discussing a few moments ago, or indeed to NTPF-type proposals. I ask members to bear in mind that the NTPF can fund services within the HSE. Our challenges tend to relate to capacity and the compensatory effects of dealing with admissions through emergency departments and other areas. We have identified a need for a medium-term approach. I have not responded to a couple of issues that were raised.

Chairman

I was about to ask Mr. Woods to move on to the deficits in ultrasound availability.

Mr. Liam Woods

A number of members referred to the availability of ultrasound scans. I would like to provide clarity in response to the questions that were asked. Scans are available to all patients at 20 to 22 weeks at six sites: Holles Street, the Coombe, the Rotunda, University Hospital Galway, Cork University Hospital and - with a slight variation - University Hospital Limerick. In the latter case, a clinical decision is required before a second scan is carried out. I think that is the point Deputy Kelly was making.

Senator Alice-Mary Higgins

We were told that the figure for Cork University Hospital is 50%. Half of people are able to access this service. The figure had reached 70% at one point, but it has decreased to 50%.

Mr. Liam Woods

We can get back to the committee with precise current data if that is helpful. As part of our overall strategy, we will have to look at the need to invest in this and all other areas of the service. I would expect that the plan will set out our journey from here with regard to the requirement to invest in equipment and personnel. Deputy O'Connell referred to the need to manage the implications of undertaking this work when she said that clinical and diagnostic supports will be required. I expect that the plan to be drawn up by Mr. McGrane and his colleague will seek to address that. We understand that it is a deficiency. It is something we will have to address in the plan.

Chairman

What does Mr. Woods think is inhibiting the provision of this basic obstetric service? It seems that some people are unable to routine scans and screening scans as a matter of course. One would imagine that such scans are an essential part of obstetric care. How could the service be so deficient?

Mr. Liam Woods

The adequate availability of appropriate personnel and equipment is one of our key challenges. As we heard earlier, there is a need to provide training and to ensure the workforce plan that is in effect is a subset of the overall plan here. Deputy O'Reilly spoke strongly on the need to reflect on how we can attract and retain appropriate personnel. That will have to be set out in a strategy. We are doing wider work on workforce planning within the HSE. We are engaging with our colleagues in the INMO in that regard. As far as we are concerned, the key deficiencies relate to access to appropriate clinical and diagnostic personnel within the system and, to a lesser extent, equipping. I do not think equipping is a huge issue in this area.

Chairman

Is it accepted in the HSE that investing in ultrasound would lead to significant savings in the future? It would help identify illnesses in unborn babies before they are delivered and could prevent litigation.

Mr. Liam Woods

There has been investment in effective diagnostics, including ultrasound. The Chairman will probably be aware that the primary care service has invested in a range of externally provided ultrasound services along the west coast from Letterkenny to Tralee. This is giving GPs direct access to ultrasound and is supporting hospitals that are already struggling to deliver in terms of total volume demand. We see the provision of more ultrasound as a critical component of our wider interaction with the primary care service and as part of this strategy. I want to make sure I pick up on the thematic point that was made about scans and the NTPF. I am not sure whether I missed anything specific. I can look back through my notes if that is helpful.

Chairman

On the questions of recruitment and consultant numbers, there is a belief that we are 100 consultants short. We were advised to have 180 consultants. We have 130. Our number is low by comparison with other EU countries.

Mr. Liam Woods

Yes, I agree. I am sure the Chairman is aware that it is clearly identified in the Health at a Glance data and in the submissions that were made to the Committee on the Future of Healthcare that the number of doctors in this jurisdiction, by comparison with other jurisdictions, is very low. The data for obstetrics are visible and available as part of our own background work and the work of the programme on obstetrics. We can see the data clearly. We are aware that there is a need to increase the number of obstetricians, as we heard again earlier. The challenge for us in that regard is to ensure the resources are there to provide for an increase. There is a timescale issue as well. I am sure the committee is aware that the timescale for the recruitment of a consultant is approximately 12 months. It is important that we start as soon as we can after the funding is made available to us. Having spoken to clinical colleagues in obstetrics, I am aware that we will need a phased programme of recruitment over a number of years to build those numbers up. There is no doubt that it is one of the key tenets of the strategy.

Senator Alice-Mary Higgins

Two issues were raised that relate to policy rather than to resources. There has been a policy change to ensure people can be released to pursue professional development within nursing and midwifery. Do the progression scales and increments ensure that people are rewarded and have a progression model-----

Mr. Liam Woods

A clear path-----

Senator Alice-Mary Higgins

-----into clinical practice as well as into management? That relates to midwifery. It is a policy thing.

Mr. Liam Woods

We currently release people. It is vital for us to overcome any difficulties that exist in that regard as part of the work on workforce planning and retention. Deputy O'Reilly made the point that there is a need for people to enjoy good training and development opportunities. This is one of the retention strategies we can adopt.

With regard to the career path discussion, public sector pay levels are a matter for the Minister for Public Expenditure and Reform. The idea that there would be a career path that provides an attractive career journey at increasingly senior levels of care provision and management is something that the workforce plan within the overall strategy would help.

Senator Alice-Mary Higgins

It would be training and management.

Ms Angela Fitzgerald

A member raised the matter of the rationale for the director of midwifery post in every unit. There are a couple of reasons. One concerns clinical leadership, with part of that ensuring that people are constantly supported around training and development. The other concerns clout and being able to sit shoulder to shoulder in the management team with the director of nursing, making sure the voice of midwifery is heard. HIQA identified that as one of the strengths of the actions taken in the aftermath of the Portlaoise issue. The intention would be to ensure the voices of nursing and midwifery are equally represented at the management table. That would address some of the concerns articulated earlier.

There is a separation of midwifery. We had much discussion with the Irish Nurses and Midwives Organisation, INMO, in developing the post, and the role is to ensure we recognise a separate professional pathway. It is early days but those steps are very important in having a voice and somebody with the expertise to drive out the points that were raised around professional development.

Senator Alice-Mary Higgins

I know we are finishing but there was a point that was not addressed. Perhaps I could follow up on that. It was the question of neonatal nursing and that there may be inadequate training in that. Parallel with that is postnatal care. I know there is a question of perinatal psychological resources, which are crucial within the picture.

Mr. Liam Woods

We have a significant piece of workforce planning to do and it is not just about directly provided midwifery and consulting. There is also a requirement in the bereavement area and members have touched on that in some of the mental health observations. We understand that. There is a very significant piece of work to be done as a subset of this strategy that needs to include the entire workforce requirement and be clear about it. We have reasonable clarity in terms of the requirement relating to midwifery and consultants but we must also develop plans for other areas of service. We understand that.

Chairman

Another point raised was the attrition rate in midwifery nursing schools, which is 25%. That means that in the third and fourth years of nursing training, we are losing 25% of potential graduates. Not only are we failing to recruit and retain but we are failing to educate those who have entered but found the working conditions far too onerous. How could this be approached?

Mr. Liam Woods

Our human resources function is working on strategies relating to retention and seeking to address that. To change tack slightly, the provision of a strategy and clear direction for the service at a national, group and hospital level will assist people in understanding precisely where the service is heading and a clearer view of the future. The investment in physical infrastructure will also be important and the nature of some of our physical infrastructure is challenging. That investment will also be important.

With regard to retention at the training level, we will need very direct interactions within our overall workforce approach as part of our obstetric workforce plan to seek to address issues of loss of students. There was also reference to loss of qualified midwives to the commercial sector or other environments. We are fully aware we have a job to do in that regard. We are looking to the workforce plan to deliver that.

Chairman

Is there a deficiency in the way student midwives are selected? Should there be an interview process or some other form of interaction allowing nurses to realise what they are getting into while giving support to continue the education?

Mr. Liam Woods

I would have to take advice from the senior director of midwifery on that and revert to the Chairman. I could not yet respond "Yes" or "No".

Chairman

If there are no other contributions, I thank Ms Fitzgerald, Mr. Woods and Mr. McGrane for attending the committee. I apologise for going over on time because our previous visitors were so interesting and engaging. I also apologise for the structures of how the Oireachtas functions but when a vote is called, one must go.

Ms Angela Fitzgerald

That is okay.

Chairman

We will discuss overcrowding in accident and emergency departments at our next meeting.

The joint committee adjourned at 1.45 p.m. until 1.30 p.m. on Wednesday, 25 January 2017.