Joint Committee on Health and Children díospóireacht -
Thursday, 1 Oct 2015

National Maternity Services and Infrastructure: Discussion (Resumed)

Chairman

I welcome from the Health Service Executive, HSE, Mr. Liam Woods, national director, acute hospitals division, Ms Angela Fitzgerald, deputy national director, acute hospitals division, Mr. Patrick Lynch, national director, quality assurance and verification; from the Dublin Midlands Hospitals Group, Dr. Susan O'Reilly, chief executive; from the Royal College of Surgeons in Ireland, RCSI, Hospitals Group, Dr. Alan Finan, consultant paediatrician, Cavan General Hospital, and clinical director for women and children services. I thank Mr. Ray Mitchell, HSE parliamentary affairs, for his ongoing assistance with the committee.

I draw the attention of witnesses to the fact that 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 the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a 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 they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

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 House or an official either by name or in such a way as to make him or her identifiable.

I invite Mr. Liam Woods to make his opening statement.

Mr. Liam Woods

Maternity services are delivered in 19 hospitals, of which five are stand-alone maternity hospitals. There were 67,347 births in 2014 and it is projected there will be 65,473 for 2015. Since 2012, there have been several reports on maternity services and lessons have been learned, informing how maternity services are now delivered. In line with the HSE accountability framework 2015, the acute hospital division has established governance and management arrangements to support the ongoing monitoring and measuring of the implementation of recommendations from all reports.

The imminent maternity strategy will provide the platform for how maternity services are delivered to have a world class maternity service. Since 2014, a number of maternity staff have been recruited who will improve maternity care, including additional midwives to Portiuncula Hospital, Midland Regional Hospital, Portlaoise, Midland Regional Hospital, Mullingar and Wexford General Hospital. A maternity anti-microbial pharmacist has been put in place in each hospitals group. Funding for six additional obstetricians in 2015 for Midland Regional Hospital, Mullingar, Midland Regional Hospital, Portlaoise, Wexford Hospital, Waterford University Hospital, Letterkenny General Hospital and Sligo General Hospital has been made available and these posts are currently being progressed. The requirement for additional midwifery staffing nationally will be informed by the outcome of the HSE commissioned national midwifery workforce planning review, Birthrate Plus, and the 2016 Estimates has made provision for additional midwifery staff as an immediate requirement.

Clinical networks are an important element of our strategy for increasing evidence-based practice and improving models of care. Hospitals groups provide better opportunities for building effective networks to provide direct support which goes beyond oversight and planning and into direct hands of responsibility for solving problems. Planning commenced at the beginning of 2015 for the integration of the Coombe Women and Infants University Hospital and the women and infant service in Midland Regional Hospital, Portlaoise. The process of establishing the first clinical network is a model which will provide a framework for all groups. This hub-and-spoke model of obstetrics is intended to deliver the Coombe services on two sites according to agreed pathways and policies. In March 2015, the Coombe board and the HSE Dublin Midlands Hospitals Group signed a memorandum of understanding to achieve this goal, contingent on well-planned integration. A senior obstetrician from the Coombe was appointed as the director of integration and is on site in Portlaoise. The Coombe-Portlaoise implementation planning is proceeding well. There have been joint multidisciplinary workshops defining the pathways according to HSE national policies and the Health Information and Quality Authority, HIQA, better health care standards. Recommendations from the ongoing maternity strategy will be integrated. My colleague, Dr. Susan O’Reilly, can provide further detail and answer any questions.

In addition, Wexford General Hospital and Midland Regional Hospital, Mullingar are developing closer links with the National Maternity Hospital, Holles Street, as part of the Ireland East Hospitals Group. These links will strengthen clinical governance arrangements and will involve the review of maternity services medical manpower needs. The RCSI Hospitals Group has appointed a clinical director for women’s and children services who is leading on the development of the maternity clinical network to include Cavan General Hospital and Our Lady of Lourdes Hospital. My colleague, Dr. Alan Finan, can answer any questions on this. In the South-South West Hospitals Group, a review of maternity services is under way which includes the establishment of a maternity clinical network with Cork University Maternity Hospital as the hub.

The Saolta University Health Care Group has in place a clinical director and group director of midwifery for women and children’s directorate across the group and the clinical network is being established. To support the networks, the national neonatal transport programme is now a 24-7 service for the retrieval, stabilisation and transfer of critically ill neonates up to the age of six weeks from maternity units outside of Dublin to one of the neonatal intensive care or paediatric intensive care units in one of the children hospitals.

The establishment of managed clinical networks will promote consistency and quality of service throughout the care pathway. The HSE considers more needs to be done at a national level to ensure appropriate oversight and clinical leadership and to drive necessary reform and reconfiguration in maternity services. Looking to the system for precedents of successful organisational reform, the national cancer control programme stands as a model which has significantly improved cancer services and patient outcomes.

A programmatic approach to maternity services will underpin the provision of quality and safe, patient-centred, sustainable maternity care. The programme will provide the necessary governance, integration and leadership to drive reform and standardise care across all units. Such a dedicated structure will also ensure learning from adverse incidents is applied in a comprehensive and consistent manner and promote a national approach to consistent, evidenced-based practice in maternity care. This approach will support staff and enhance the opportunity for optimal clinical outcomes for mother and baby through the integration of the best research evidence, clinical expertise and patient values into the decision-making process for patient care.

A charter for maternity care is being developed in partnership with the clinical programme for obstetrics and gynaecology. The charter will outline a set of principles which describe what matters to women and their partners when engaging with and using maternity services. It aims to inform and empower women to actively look after their own health and the health of the unborn baby, while influencing the quality of maternity care. The work will be completed once the maternity strategy is finalised as the key components of the strategy need to be reflected in the charter.

The MN-CMS is an electronic health record, EHR, for all women and babies who access the maternity services in Ireland. This system will provide accurate and up-to-date information to all those involved in the care of mothers and babies in maternity units. The vision is to continue to develop the system to meet the ongoing changes within maternity services and to work closely with other national systems and initiatives to capture and provide key information. This system, when implemented, will provide a seamless, complete and reliable source of all the information clinicians require to quickly and accurately make care decisions for the health and well-being of mothers and babies within Ireland. Phase 1 of this project is focused on the initial roll-out to the following four hospitals in 2016: Cork University Hospital; the Rotunda Hospital; Kerry General Hospital; and the National Maternity Hospital. This system will then be deployed to the remaining 15 maternity hospitals from 2016 onwards.

Moving on to the Irish maternity patient safety statement, a key concern for patients is that they receive safe and appropriate care. The CMO Portlaoise report sets out the requirement for a maternity patient safety statement. The maternity patient safety statement will provide up-to-date information for management and clinicians in maternity units on key patient safety issues. It will have the advantage of creating a source of information that is much more accessible and transparent for the purposes of external scrutiny, including by the public. The information within the statement will support local and hospital group management to identify trends, to target quality improvement measures and support ongoing risk assessment. It is expected these statements will be published online on a monthly basis commencing with August 2015 data published in early October 2015.

As you may be aware, Chair, yesterday the HSE published on its website two reports that were undertaken as part of our internal review of maternity services by David Flory. We can also address those, if required by the committee, or refer to them at a future date. That concludes my opening statement and I look forward to taking members' questions.

Chairman

I thank Mr. Woods. Does anyone wish to add anything to his comments? The witnesses are happy enough. That is very good.

Deputy Caoimhghín Ó Caoláin

I join you, a Chathaoirligh, in welcoming Mr. Liam Woods and his co-panellists. I thank him for his opening statement. I am going to address the issues, largely from a more parochial point of view, and I give notice to Dr. Finan that I will concentrate more on the Flory report, as published yesterday, and on how it reflects on Cavan General Hospital. I ask his indulgence in that respect because it is of considerable importance to the people who have entrusted me with the responsibility to represent them here. It gives me great comfort and assurance to reflect on the positive report that has been published by David Flory. It is most welcome that we had sight of the report in advance of today's engagement with our guests.

I wish to reflect on a number of points from the report. Mr. Flory makes some general statements, not just in respect of Cavan or Clonmel - that will be of interest to my colleague, Deputy Seamus Healy - but he also makes a number of very important points. He refers, for example, to cuts and the fact that they are still having a significant impact on day-to-day service delivery. We are all - people who work at the coalface and those of us who are in roles of political responsibility - very conscious of that.

Mr. Flory also reflects, very correctly, on the fact that the absence of a clear and understood strategy for maternity services has given rise to speculation and suspicion and creates a negative environment that absorbs the energy which, in his words, "can be better used focussing on day to day service delivery. I recognise that to be the case and I welcome that it is spelt out in clear and unequivocal terms.

In the context of other matters, there is a perception about smaller units. I suppose Clonmel would fall into that category and Cavan, at which there were approximately 1,800 births last year, would also come into that general sense of scale. There is a shared perception that they are at the back of the queue when it comes to access to funding for capital works. We have had that suspicion reflected before the committee previously. We have known it with regard to other situations, namely, that someone, somewhere is planning to downgrade the sites or, even worse, to recommend closure. There is no such recommendation in this report. If anything, this is a report that substantively supports the retention and development of these sites. I hope that message would come clearly from today’s meeting. There needs to be a scotching of that fear. People should not be concerned about group relationships, as in any way undermining or impacting deleteriously in relation to existing provision.

In terms of Cavan in particular, and knowing many of the personalities involved, it is only right to reflect what Mr. Flory speaks of, namely, that it is a much greater number but, in terms of the core management of the hospital, he speaks of a small number of key individuals working beyond their contractual commitments and carrying a much broader range of responsibilities than their job titles entail. There has been a change of personnel at the hospital and the general manager with whom Mr. Flory engaged has moved on to other responsibilities. It is only fair that it would be reflected here this morning Mr. Flory's statement to the effect that Bridget Clarke sets a tone by her example of leadership, which is based on care and compassion. Ms Clarke deserves to have that highlighted in the public arena because it is absolutely the case.

The other post to which Mr. Flory refers is the clinical director with responsibility for women and children’s services. I understand that is Dr. Finan. Mr. Flory says of Ms Clarke and Dr. Finan that they are both highly capable and that senior colleagues in the hospital have great confidence in them. As a service user in the Cavan and Monaghan area, as father of five children and as someone who has had the occasion to present before Dr. Finan - in his capacity as a paediatrician - I acknowledge that is absolutely the case and I would even add much more to it. I thank him for the professionalism and courtesy he always displays. I know that to be the shared experience of those who have presented for his professional advice and intervention through the years. I wish Dr. Finan well. Staff going beyond the call of duty is something which Mr. Flory reports. Again, that comment is deserved because it is absolutely and unquestionably the case.

There is much more in this report to which I could refer. However, I wish to get to a couple of critical points because the backdrop to all of this is the series of very unfortunate, adverse outcomes in respect of births which date back to November 2012. The reports on those cases have not yet been presented. That has in its own way given rise to increased upset and concern in the absence of clarity. I hope that where reports are available for publication, the greater number would be so published. I understand, however, that parents in any given situation may be reticent about such a course. A number of the parents concerned wish that the reports would be published and I support them in that. It would be a critical part of the journey to the restoration of full confidence across the board and the scotching of any concerns that may obtain.

I note that a number of initiatives have been taken at Cavan General Hospital to address what were perceived as areas that required further attention. I would like to ask a number of questions of Dr. Finan, if I may. Do we have strict compliance now with the national obstetric programme of clinical guidelines?

We had a practice development officer appointed last month, as of 21 September. Is that appointment RCSI Hospital Group-based or is it dedicated to Cavan hospital?

I also note that, in the preparation of the budgetary requirements for 2016, Cavan General Hospital has sought a number of additional posts, including an increase in the number of consultant obstetricians at the hospital. We currently have four approved, of which there are only three filled. In fact, only one is permanently filled. I understand two are locums. Perhaps the officials can clarify that. However, we have three, where we should have four, trying to provide cover 24 hours a day, seven days a week. It is not tenable. What is the position with regard to the filling of the fourth vacancy? I note that the hospital is seeking approval for the appointment of a fifth consultant obstetrician in 2016, which the birth numbers would justify and which is most important. I also note that there is an application for an increased number of midwifery posts included in the proposals for the Estimate for 2016.

There was much public concern - I will conclude on this, and I appreciate the Chair's indulgence - that the first report on the tragic outcome in November 2012 was suppressed by a decision of the High Court. Of course there were recommendations, but the entirety of the report, by the decision of the courts, was suppressed. It is important that there is public realisation that whatever may have been entailed in the recommendations would have been picked up in any event from a number of other reports and from the general exercise in the preparation of that report, and would have been acted upon. Could the officials comment? Have the published reports - including HIQA's Galway report and HIQA's Portlaoise report, which are in the public domain - informed improvements in Cavan General Hospital? Will the witnesses avail of the opportunity to outline some of the improvements and the additional steps that have been taken in order to ensure that, where it is at all humanly possible, we will not see a further tragic adverse outcome in the maternity services at Cavan General Hospital?

I will conclude with this one remark. My youngest was born in Cavan General Hospital. At my age, I am not in the business of intending to return with my wife to Cavan General Hospital, but I would say to those whom I know so well across the dependent population that I would have no hesitation in using its services in the future.

Deputy Seamus Healy

I welcome our visitors and thank Mr. Woods for his presentation.

I will deal almost exclusively with the report on South Tipperary General Hospital. Obviously, I have a particular interest in it as I am elected in Tipperary South, but I am also a former employee of the South Eastern Health Board and I was manager of the hospital for quite a number of years.

First, I welcome the report. I believe it is a positive report. It gives the unit a clean bill of health. It paints a picture of good staff working well together, good facilities and good outcomes. There is a paragraph in the report which is worth repeating because it gives a sense of the unit at the hospital, and probably gives a sense of the strength of units such as this throughout the country. It states:

The sense of strong team working is palpable in the unit. The broader Midwifery leadership team is energetic and positive and just gets on with things. This too adds to the resilience. A large proportion of the staff are local people who have a huge personal commitment to the hospital which means that they frequently turn up to work outside their contracted hours when things are busy. This is such a strength and should not be underestimated or taken for granted.

That final sentence is important, "This is such a strength and should not be underestimated or taken for granted." That has always been a feature of South Tipperary General Hospital, and, indeed, its maternity unit, and, to a large extent, general hospitals right throughout the country. I compliment and thank the staff, generally in the hospital, and particularly in the maternity unit, for the work, service and commitment to the unit that they have shown down the years.

I welcome also that Mr. Flory identified issues that need to be dealt with within the unit in the future. To some extent, Mr. Flory is confirming the policy of grouping the hospitals, which has been accepted and which, as we speak, is being implemented in the south-west grouping. The report simply confirms that position.

There are issues that Mr. Flory raises in the report, and it is important that we get some clarification from the HSE, because there is a fear out there among all smaller units and general hospitals that the view behind all such reports is that downgrading or closure is only a step away. Of course, that fear has been strengthened by the conduct of the HSE over the past number of years. I refer, in our case, to a strong and determined approach by the HSE to transferring services from the hospitals to other areas in the south east a few years ago. Indeed, it took 15,000 people on the streets of Clonmel to stop that development. The HSE has a particular responsibility to make it very clear that it supports units such as the South Tipperary General Hospital unit and wants to see such units continue in existence in the future, providing a good-quality service for the people of south Tipperary.

Specifically, in the report, Mr. Flory speaks about staffing deficiencies. With regard to consultant staff, he makes it clear that at least a fourth consultant is required for the unit. I want to know what the situation is in that regard. Mr. Flory also highlights the issues of governance and management, and the lack of a significant number of management staff within the hospital and the unit. I also want to know what proposal the HSE has for dealing with that situation. I accept that to some extent the whole governance area is in transition because of the hospital group situation. We have a situation in which the structures may not be fully in place, but there are strong professionals with leadership qualities who to some extent at this stage would be compensating for the lack of formed structures.

Will the HSE representatives outline their proposals for strengthening the management system within South Tipperary General Hospital? While Mr. Flory indicates that midwifery numbers are at a ratio of 1:32 deliveries, he goes on to say that this level does not provide enough staff to provide leadership on a 24-hour basis. He states:

The midwife to births ratio is a healthy 1:32 following the addition of five new posts in the last few months. Whilst this is positive the unit still cannot operate 24/7 shift leaders.

What proposals does the HSE have for dealing with that situation?

Another issue is the question of the development of the group. It seems to be developing very slowly. Mr. Flory refers to that in the report. My understanding is that the boards of the groups have not been appointed as yet. Again there are gaps in the filling of posts within the groups. That whole area needs to be developed.

In the case of South Tipperary General Hospital, Mr. Flory refers to a number of specific areas which he feels must be upgraded. We have been asking for that for quite some time. The Minister visited the hospital in July of this year and I, as chairperson of the hospital action committee, put this point to him. The phase 2 development plan, which has been in existence for quite some time, effectively means the upgrading of the old hospital building. This is the former workhouse dating from 1846 and that part needs to be urgently upgraded. Has funding for this development been put in place and when will we see work on this second phase?

Senator Colm Burke

I am a bit sceptical about the report because report after report has been issued over the past 15 years. One can go back to the Hanly report of 2003, which I raised at last week's meeting, which sets out that we would have 170 consultants by 2012. We currently have whole-time equivalents of 114 consultants. The proposal in this report is for another six consultants for the various hospitals. What about the ratios of deliveries to the number of consultants in the bigger hospitals in Dublin and Cork? We have not even started to look at that issue. At present, quite a number of staff in maternity units are agency staff. We have done nothing to try to deal with the challenge of junior doctors not finding it attractive to work in maternity units. That has not been dealt with in the report.

On the issue of adverse events, the idea is that, in such instances, parents would get answers in the fastest possible time. I know a review group has been set up to look at adverse events, but 18 months later no final report is available. In some cases a team has been set up to examine adverse events which seems to be under significant pressure and does not always get the necessary backup to ensure all the issues related to adverse events are dealt with. I am not clear whether there are proper structures set up in each unit to deal with adverse events. I would like some explanation as there is nothing in the report as to how we are dealing with this issue. This is the major issue leading to litigation. When people still do not have answers after 12 months, they consider the litigation route. That is when things seem to close up. The impression is being created that when adverse cases arise, all the information will be given out as soon as possible, but that is not what is happening.

Last week, I raised the issue of stress levels for staff arising from adverse events. Have we sufficient support for staff when an adverse event occurs? I also raised the issue of the level of support for staff when a matter goes to litigation. I have heard of cases where staff were told about an event a week before the case relating to it came for hearing, and no real support was provided to them. I know of staff who have left the service because they felt they did not get that support when they needed it. What are we doing about that? We have some great staff in all units but they are at the coalface. It is fine for management to say this is how we will deal with adverse events but they do not have to deal with it in the core system or in the public domain afterwards. We are not doing enough for the staff who have to deal with these issues. We need answers on the issues I have raised.

Deputy Catherine Byrne

I thank Mr. Woods for his opening statement. I compliment all the people who work in hospitals, particularly the doctors, midwives and general staff who have aided the delivery of more than 67,000 babies. I echo Senator Burke's comments that when something goes wrong, staff should step up and be open about what has happened because it affects the family when the child who is born does not live.

I heard a discussion on the radio this morning about the report on maternity services in Cavan General Hospital. I was surprised to learn that one midwife looks after more than 37 patients. Is that the usual ratio? It is a substantial workload.

The employment of agency nurses is a real issue that must be dealt with immediately. From discussing the issues, people believe that agency nurses pick and chose what they will do. This is what gives rise to the inability to recruit staff to do certain jobs in hospitals. On the 2016 Estimates and the provision for additional midwifery staff, does the HSE have figures from the midwifery planning review of the number of staff required?

The integration of the Coombe hospital into the St. James's campus is to be supported. It is welcome that the new national children's hospital will be built on the campus and that funding will be allocated for the relocation of the Coombe hospital, as announced in the recent capital programme. As I live not far from the Coombe hospital, I notice the work of the staff and the conditions in which they have to work because that building is not world class.

Senator John Crown

I am at this stage officially despondent about any attempts to reform the health system or about meaningful practical actions to improve the service for patients taking place on foot of administrative reports. Forgive me if I sound browbeaten at this stage. I have been harping for 22 years since I came back to this country about the absolutely mediocre health system. People talk about it being a Third World service, but anybody who has worked in a Third World hospital will know it is not. However, we have a strictly mediocre health system and obstetrics is the tip of the spear. This is all to do with the way the service is run and the absolute treacle-like ability of the bureaucracy to thwart any attempt to fix things.

In Ireland, the number of obstetricians per 100,000 people is 4.8; the next lowest in Europe is the Netherlands, which has a lower birth rate, at 7.6.; Turkey, 9.1; Poland 13.5; and Switzerland, 17. It is a question of cause and effect. Appalling cancer survival figures came out last week, and for all the guff we have heard about our brilliant attempt to tackle the cancer problem, we are just one notch ahead of the British, who are by far the worst of the western countries. We set our bar low and compare ourselves to a British yardstick. The British health system is also strictly mediocre and, in quality terms, pales in comparison to the other good socialised medical systems of Europe, the German, Scandinavian, Belgian and French. It is bad on all the metrics. However, we insist on bringing over British administrators to do our inspections.

I do not know why I am even bothering to speak. At the time of the Savita Halappanavar tragedy, I pointed out that the region with the fewest obstetricians, in the country with the fewest obstetricians in the OECD, could expect disasters related to insufficient senior, on-site presence, 24 hours with continuity of care of senior specialists, and too much delegation to trainees. I said it then, I say it now, and I see no evidence that it will change.

Ireland has no excellent obstetric centres. I say it very advisedly. Some five months ago, my beautiful wife gave me a beautiful son, who was delivered with wonderful skill by the obstetric staff of the National Maternity Hospital, Holles Street, and the great backup of the midwifery and other staff. However, given the hospital's facilities, we cannot call it a centre of excellence. It does not have a full ICU. There is limited surgical backup for other surgical emergencies that occur. It does not have the full range of medical specialties on site, such that very sick adult patients have to be sent to other institutions. This is not the way to do modern obstetrics. While we can delude ourselves all we want about being the best in the world, we are not. We set the bar very low. I mean no disrespect to my obstetric colleagues, who do a heroic job and are incredibly well trained. We probably have the best trained cohort of obstetricians of any country in the western world, most of whom have trained in international centres of excellence. Dr. Peter McParland, who delivered my baby, James, is a wonderful, internationally reputed obstetrician, but look at the circumstances in which he is forced to work and the backup he has. Maybe the Department is prepared to fix it, maybe there is going to be a road to Damascus moment for the health service. I do not see it coming.

Deputy Mary Mitchell O'Connor

I apologise, but I have read the report and I am glad there was a meeting last night about the National Maternity Hospital moving from Holles Street to St. Vincent’s hospital. It is antiquated and I am worried. The last time we had a meeting about the maternity hospitals here, I asked whether we could tell mothers and mothers-to-be that our hospitals were safe. On reading the repots, I am still worried. Yesterday, I was at a committee meeting here with the Ombudsman, who said a protocol had been worked out with the hospitals around complaints and procedures. The last time we had a meeting about it, we did not hear there was a procedure. We heard that in the hospitals there was some kind of complaints procedure and a management board. While there seemed to be many boards, complaints up the line were not dealt with. This is what is worrying.

Years ago, I lived in Navan and we, as young mothers and pregnant women, knew something was going on in Drogheda. It was known among mother groups, although we did not have much choice. We know there are problems in the smaller provincial hospitals. Somebody asked me whether, in 20 or 30 years' time, we will be saying we knew all this, but covered it up and failed to solve it. Why was the fact that the Ombudsman had worked out a protocol not mentioned here?

Mr. Liam Woods

With regard to the overall commentary on staff numbers, we have referred to Birthrate Plus, which is a review that, when complete, will make observations on the numbers of midwives required in Irish maternity units. The initial findings are that we will require more, and we have bid for it in the Estimates. A standardised approach is being used. Regarding Senator Crown's point, any review of the OECD data on health would indicate that our obstetrician numbers are relatively low, and the clinical programme has identified a need to at least double the numbers. There are, at most, 120 obstetricians in the country and there is a recognised need to grow the number very substantially, and potentially to double it.

Chairman

Are we recruiting?

Mr. Liam Woods

There are two components to it: funding and recruiting. We are already recruiting for posts that were approved this year. We will not recruit 120 obstetricians overnight. It will be a gradual process and it must also be considered in terms of our Estimates for 2016.

Chairman

This morning, in a different forum, Mr. Woods's chief executive, the Director General, said there was a difficulty in recruiting staff in the HSE. Does this apply to obstetrics?

Mr. Liam Woods

Yes, it reflects in recruitment generally. We are having difficulty recruiting and retaining staff. Some of Senator Colm Burke's points on staff experience come to bear there, both in recruitment and retention. We face significant challenges in these areas.

The implementation of the recommendations of these and previous reports was raised. It is my responsibility to report to the Department of Health and the chief medical officer on the recommendations of the Portlaoise report. I have a process under way to do it, we are working on it and the recommendations are being implemented on the ground across the country. We can discuss it in more detail another time if it is helpful. We also have recommendations on the back of the two reports we have just been discussing that need to be implemented locally. Those reports are being used by all the hospitals and groups to review what may be required across the 19 units. This assessment will come back to me. We have a process in place for it. We have examined all previous HIQA recommendations - there are more than 270 - to be sure we are implementing them effectively, where required. The HSE has a process under way at a detailed level to cover it.

Touching on Deputy Ó Caoláin's point, we also have requests directly from parents to publish reports in certain instances and we are seeking ways to do it. We will be happy to report further on it. The timing of reports is an issue for us. As the number of inquiries, investigations or reviews we have to undertake grows, there is a challenge in the system regarding capacity to provide speedy reports. While it is a requirement and is part of what we must do, it is also a concern for us. We are seeking ways to accelerate it and Mr. Lynch may talk about it later. We recognise that faster access to senior clinical review may help in certain circumstances without any lengthy delays, and we are evaluating it.

Regarding stress on staff, I am aware of cases in which midwives who have attended a coroner's court have struggled to return to work. There have been cases in the High Court. Obstetrics is an area of high litigation. The committee is aware from previous dialogue that more than 50% of claims dealt with by the State Claims Agency are related to obstetrics. It is very litigious and very demanding and stressful on staff. Our staff surveys indicate that there is a high degree of stress. Actions that have been taken previously in that regard would relate to use of employee assistance programmes at a local level. There is a wider challenge to us to say how we support people and what revised national policies we might need to put in place for it, given that there are issues, both before and after incidents, with which we need to support our staff.

Practice in this regard varies across the country. There are good examples of this support being in place but there are also deficits.

I referred to the obstetrician numbers. I will ask Mr. Lynch to address the Ombudsman report and complaints to that office. I will then ask Dr. Finan to answer the specific questions on Cavan.

Chairman

There were questions on the hospital groups and on appointments to the boards.

Mr. Liam Woods

The group chief executives are in place and have been in place since the start of the year. They have legal delegation under the Health Act from the director general, through myself, for their roles. Boards are coming into place, and boards are in place, in some of the groups while chairs are in place in all of the groups. The Minister may be able to give more information on this when he appears before the committee in the near future but I understand the board members will be in place in the next few weeks. The one exception will be the national paediatric hospital, which will go through the legislative process to create a board late this year and early next year.

Dr. Alan Finan

I thank Deputy Caoimhghín Ó Caoláin for his kind comments towards myself and the previous general manager of Cavan General Hospital. They are much appreciated. We are two people in clinical-management positions who have the support of a very strong but, as indicated by Mr. Flory, very small management team without whom we could not do the work we do. We also have a very committed team of midwives and doctors in the maternity service who work very hard and who produce very positive outcomes, a fact also commented on by Mr. Flory. Mr. Flory's report specifically states that the outcomes in the maternity service in Cavan Monaghan Hospital are positive and the key performance indicators for Cavan Monaghan Hospital maternity service are good, both by Irish standards and by international standards.

Deputy Ó Caoláin raised the issue of the publication of reports and I agree with him that the delay in the publication of reports is a significant problem for families. While this report is positive, we are very mindful of that fact that a number of families who have attended our maternity service did not have a positive experience. I wish to reassure those families who have received reports relating to their care or that of their infant, or are expecting to receive reports, that we will pursue the recommendations in those reports with the energy that is required to make sure they are implemented. There are five outstanding reports on infant deaths over the past number of years in Cavan. Two of them have been completed and have been provided to the families concerned. Two are at final draft stage and are being circulated to the staff involved for feedback and commentary and one of the five is still at a fairly early stage.

We were asked about the speed with which reports or reviews of adverse incidents are dealt. A very robust system is in place to identify and manage adverse events in the maternity service in Cavan Monaghan Hospital, when they occur. I am confident that the process recognises adverse events at an early stage and examines and identifies what needs to be done about them. In many cases, reviews are required and I believe the internal system is sufficiently robust for many such reports and that an internal review is the quickest way to achieve a report on adverse incidents. However, in a number of incidents, the complexity will require a level of external expertise, so a review will ideally be conducted externally in these cases. In a number of cases, families themselves request that reports are conducted externally to achieve the level of objectivity that they perceive to be necessary. When an external review is requested, however, it takes a significant length of time and that is a problem the system needs to address and improve on.

Chairman

What is the reason for these reviews taking an extended length of time?

Dr. Alan Finan

As Mr. Woods said, it is largely because we need to get the clinical expertise on board. As already identified, the system is understaffed with senior and expert clinicians as all of them are very busy and it can be very difficult for them to free up time to conduct these reviews, which take an enormous length of time and energy.

Deputy Ó Caoláin also made inquiries about compliance with our obstetrics and gynaecology programme guidelines. To date, the programme has issued approximately 40 clinical guidelines and in Cavan Monaghan Hospital, there is a clinical governance committee. Part of its role is to examine each of the guidelines as they issue and as they come off the production line to identify where we may have difficulty in achieving compliance with the guidelines. That system works very well and we are largely - in fact, in the majority of cases - compliant with all the national guidelines.

There are some areas with which we are struggling, namely, those relating to the necessity for networked care, an issue to which the Flory report also refers. Mr. Flory talks about networked care being particularly important in the case of high-risk pregnancies and foetal anomaly scanning. Hospitals the size of and, indeed, bigger than Cavan will always have difficulty with those areas and the only solution is networked care. I was very pleased that Mr. Flory emphasised that. The RCSI hospital group, whose three maternity units are Cavan Monaghan, Drogheda and the Rotunda, has done significant work in the past five or six years to progress networked care. We have developed a Dublin north east neonatal network which ensures that prematurely-born babies are delivered in the best location and at the right time. We have also made significant progress in developing a regional perinatal pathology service so that when babies unfortunately die, they get the expert perinatal post mortem that is required for their parents to be given clear, unambiguous and open information on the cause of the baby's death.

Foetal medicine is an area we have not adequately networked to date. However, a proposal is in place for this and there is a plan for staff recruitment in order to deliver it. We have had significant difficulty with that recruitment over the past 12 months and we have not been able to progress the plan for that reason. Deputy Ó Caoláin also asked about the practice development officer who has been appointed. A part-time practice development officer has been in place for a significant number of years and she has made an enormous contribution to the service and the quality of care provided. Recently, we appointed a full-time practice officer and she is a dedicated practice development officer for Cavan Monaghan Hospital who does not hold sessions in any other hospital.

Deputy Ó Caoláin also inquired about staff expansion. We have approval for four full-time consultant obstetricians in Cavan Monaghan Hospital. The only factual inaccuracy in Mr. Flory's report was to state that there was only one full-time person in place. Three full-time people are currently in post but we are having difficulty recruiting a locum for the fourth post, which is currently vacant. The Deputy is correct that three people are currently doing the work of four at consultant level. While we are doing our best to address that, there is a national difficulty in the recruitment of consultant obstetricians - it is not something unique to Cavan.

Mr. Woods spoke about midwifery staffing. The Birthrate Plus recommendation of 1:37 is based on a UK model published a number of years ago. A number of years ago, HSE north east, comprising Cavan and Drogheda maternity services, set a target ratio of one midwife for every 37 deliveries.

We reached that for a brief period a number of years ago, but it slipped as the financial climate deteriorated. In the Cavan-Monaghan situation, the staffing ratio slipped to 1:44 or perhaps 1:45. We are currently at 1:40, so the situation has improved over the last couple of years. Our target remains 1:37. As we have said, submissions have been made as part of the 2016 Estimates process to make sure we get to 1:37.

Deputy Ó Caoláin also asked about certain recommendations that are specific to reports that were completed previously. All of the recommendations coming from any reports are entered into a system with which maternity departments and clinical governance structures work constantly - week in, week out. There is a constant review of the report recommendations that are outstanding. Machinery is in place to make sure we are constantly aiming to implement all of the recommendations that are outstanding. That includes all reviews that have been done over the years.

I would say the same thing regarding the HIQA reports on Portlaoise and Galway. All HIQA recommendations are dealt with through the same internal departmental machinery. Anything that is not manageable internally is escalated to local management and, if necessary, to regional or national management. I believe we are making very significant progress in addressing all of the HIQA recommendations on maternity services.

Mr. Liam Woods

I might ask my colleague Mr. Lynch to address the follow-on question about the Ombudsman that was asked.

Mr. Patrick Lynch

A couple of things arise in this context. As I am conscious that there are often many new faces from the HSE around the table, I might help the committee by briefly explaining my role. As part of its service plan for this year, the HSE has introduced a new accountability framework, part of which involves a restructuring of our quality and patient safety function at a national level. My role has been established this year with a slightly more independent input in the organisation in terms of looking at quality and safety and seeking to provide assurance through audit. That is one of the reasons the Flory reports were commissioned. When people come to our health services, they expect at the very minimum that they will be safe, that they will be treated with compassion and that we will care for them when they cross our doors.

I know that the committee had a considerable discussion on adverse events at a recent meeting. I suppose it is something we really need to have a greater focus on. It has been our experience, and certainly my experience, that when people experience something going wrong in the health service, they look for a few things. First, they want to ensure the services are as safe as possible so that what happened does not happen again. They certainly do not want it to happen to somebody else. Second, they want answers for themselves. This year, we have introduced a new system whereby we record what we call serious reportable events. There is a mandatory requirement to report on all of these events when they occur, with a requirement now across the organisation that they be investigated within 120 days. From the August performance report, we will now be reporting on the number of serious reportable events for each month and we will be tracking the progress being made with the implementation of that target for investigation and review timeframes. I have to say we are nowhere near that yet, but that is the intention.

Following on from what Dr. Finan said, there is a struggle at times with professional staff, particularly busy clinicians, being made available. We work closely with the forum of postgraduate training bodies to identify clinicians. The forum is enormously helpful in that regard. Part of the 2016 programme will involve determining how we can do this more effectively, particularly in certain areas. We know there are groupings of events at certain hospitals, including Portiuncula Hospital. We need to do that more efficiently, so that is a programme of work.

Reference has been made to complaints. The Ombudsman has met the committee. Members will be aware that a report on the complaints management system in the acute hospitals sector was produced and threw up a number of issues. My office is working very closely with the Ombudsman. The report in question is now, in effect, the implementation plan for the development of our complaints management system, which will now be led from my office. The system in question will apply across hospital and community services. For the first time, we now have people at national level in each of the service divisions within the hospital groups and the community health care organisations who are responsible for complaints management in their service areas. We recently published on our website a full list of complaints officers across all our services across the country. There is a significant amount of additional work to be done there. In any industry, complaints are the lifeblood of understanding what is going on in the service. If we are not in a position to invite, hear and respond to concerns as they arise, we will never develop a greater focus on quality.

I am aware that at the last meeting there was some discussion about the sharing of data with the State Claims Agency. As a result of the way the legislation was set up, State claims relate to individual hospitals. We now have agreement from most of the hospitals that the relevant data will be released. This means we will soon be in a position, for the first time, to have intelligence at national level and hospital group level around what is actually going wrong, where it is going wrong and what needs to be done to address it.

Chairman

If our staffing levels are inadequate, for whatever reason, the issue of adverse incidents could arise again, perhaps more regularly than we would like.

Mr. Liam Woods

The staffing of the complaints process is an environment that we are rationalising in system terms. I understand that the Chairman's question is a wider one. We are rationalising a number of systems into a single system that will give us immediate oversight of all issues arising nationally. That information will be available locally. The Chairman is absolutely right when he says that the two reports are pointing out very clearly that clinical staffing levels - I refer to doctors, nurses and other clinicians - are critical to the delivery of service. The underlying point relating to the recruitment and retention of appropriate staff is critical.

Chairman

Senators Crown and Burke spoke about obstetrics. I met a midwife recently in the maternity department of Cork University Hospital. She is a long-term member of staff. She complained to me that she is working harder than she ever did with less staff in a changed environment.

Mr. Liam Woods

One of the points that came up regarding agency staff has been mentioned on a number of occasions. If one looks at the two hospitals that are referred to in the reports, one will see that their actual staff numbers are growing slightly. The hospitals in question are under a financial requirement to reduce their agency costs. While there is staff growth, the underlying number of hours may or may not be changing, depending on what is happening and on the actual agency spend. It is correct to say that increases in the pressure on and demand for the service are leading to staff pressures. There is another thing to watch when talking about midwives and midwife numbers at Cork University Hospital. It is important to understand that midwives do things that are not necessarily obstetrics. When we count these numbers, one of the challenges we face is to be clear about what midwives are actually doing. If we do not count appropriately, we could get a false base. I take the Chairman's point. The number of midwives in Cork is actually pretty good, based on national comparison. They would stand up pretty well in Birthrate Plus analysis.

Chairman

Dr. Chris Fitzpatrick, who will be in attendance at the second part of this meeting, has commented that there was no investment during the boom years. This goes back to the point made by Senator Crown. It is clear from the Senator's hypothesis about the obstetrician ratio that we are talking about nearly having to double the current staffing level. Even though we are playing catch-up, we will probably never get to where Senator Crown wants to be.

Senator John Crown

That would leave us way below the average.

Mr. Liam Woods

The clinical planning process within the HSE has identified that. We are looking for resources in the Estimates to go down that road.

Senator Colm Burke

I would like to make two points in regard to staff retention. I recently came across a case of a GP who was employed in a hospital to provide a particular service but because six months into the job he had not been paid he resigned. That is not the way to go about trying to retain staff. The second issue relates to agency staff and the reason some hospitals are experiencing difficulty getting staff on other than the normal HSE contract. Has there been any analysis of what would make this more attractive? While issues such as pay and so on, as per the guidelines, are being adhered to, courses for junior doctors have been cut back. It is important these issues are addressed if we are to retain junior doctors. Many of our interns are emigrating to Australia, New Zealand and Canada because we are doing nothing in terms of making it attractive for them to remain here, particularly in the area of maternity services.

I would like to make a point in regard to maternity services in another country. The level of litigation in that country has increased substantially and most of the people providing maternity services are non-nationals. We are moving down that road. We need to recruit consultants and retain junior doctors. We do not appear to be making it attractive for them to remain in the service, particularly maternity services. We need to review this situation.

Deputy Caoimhghín Ó Caoláin

I have an ancillary question for Dr. Finan. The RCSI Hospital Group has appointed an assistant director of nursing for sepsis management, which position is to be taken up this month. For clarity, is that a group appointment rather than specific to Cavan Monaghan Hospital?

The Chairman made the point that in the absence of the critical staffing needed, we run the risk of returning to the starting point that gave rise to these reports. Cavan Monaghan Hospital has identified that its cover is inadequate, which is confirmed in the Flory report and has been previously confirmed. I appeal today to Mr. Woods to please note, in the context of the hospital's presentation for the 2016 Estimate, it is imperative that approval be granted for the fifth consultant obstetrician and that the additional midwifery posts that are also included in the Estimate for 2016 are approved at HSE national level. It is essential this happens otherwise the whole exercise is without point. Otherwise, we will again be faced with some unfortunate event that might have been avoided. I make that special appeal today. The case being put is based on very sound analysis.

Mr. Liam Woods

The points made in relation to recruitment and retention are well made. While pay levels are an issue they are far from the only issue. Working conditions and training opportunities can be incentives or disincentives in terms of people's likelihood to remain in-post. The location of training posts is also an issue. When we move away from large areas there are relatively few training posts and that is a big factor in where our junior doctors choose to work. We have seen evidence of this. We have also seen some good progress in that area. I was recently in Letterkenny hospital where a great deal of progress in terms of training has been made. The staff being trained have very much enjoyed their time there. There has been very strong focus from the consultants in Letterkenny General Hospital.

In terms of nursing, there have been some very astute interventions with graduates in recent times to offer them contracts in our environment. There is, of course, strong international competition in this area, of which members will be aware. The private market has been a significant incentive in terms of sign-on to particular grades, including nursing. We have had some success in this area recently, which we need to build on. My own dialogue with nursing organisations would indicate strongly that training is a key driver. In terms of where we go, it is right to say that while we still spend significantly on training, most of that is now what is required by regulation and law rather than additional training. That is a point of focus.

The other point that is relevant is that the creation of groups affords opportunities to deploy clinical staff across multiple care environments. This gives staff opportunities to work in different types of environment and conditions, which would not have been possible in stand-alone units be they large or small. That is an opportunity that has to be grasped by the groups. It is a way of securing the role of all units. It is already visible through some of the interaction of the groups that this is going to bring benefit, and has to some extent already.

On the point on the Estimates, we have already approved the posts mentioned into our Estimates. I understand the Deputy's point around them coming back out of the Estimates. His point is well made and I get it. The points on the availability of staff and our capacity to continue to provide safe services and to expand that capacity as we face increasing demographic pressure, which we do, are also points well made. The underlying point about recruiting and retaining staff is probably, in my own experience of interacting with the acute environment, one of our top priorities. We have to find ways to do that. Members will be aware that we are engaged internationally to support staff recruitment. We need to do the same on an ongoing basis locally. I will ask Dr. O'Reilly to now make a brief comment from a group perspective.

Dr. Susan O'Reilly

I am the recently appointed group CEO of the Dublin Midlands Hospitals Group having previously been the lead for the cancer control programme in the country. It has been my observation since taking up this role that the major benefit that the groups can deliver will be clinical networks where we can strengthen services in smaller services and integrate a number of services with the larger ones. This is the way of the future.

I have had a lot of learning as a consequence of having Portlaoise and The Coombe as our two maternity centres within our network. Portlaoise has been, of course, in the eye of the storm. One of the challenges for all of us, including the staff there, is to ensure the provision of safe and compassionate care to patients. We are endeavouring to plan for the future. We also have to deal with the review of the past and be fair to people who have had either serious adverse events or concerns or deaths that need to be evaluated. All of these things are going on simultaneously.

Although I do not always agree with Senator Crown, I agree with him in this circumstance. One of my biggest concerns is recruitment and retention of high quality permanent staff, whether it be in consultant posts, junior hospital doctor posts, which preferentially should be training posts, midwifery, nursing, quasi-safety manager posts or a whole panoply of allied health staff. We have to get there incrementally, coming out of one of the worst possible recessions and a blunt instrument of a moratorium that has constrained management in terms of planning for the future. We are now in a position whereby resources will begin to improve but getting the staff back is going to be the biggest challenge.

From my observation, it has been very helpful to be able to recruit nurses and midwives on permanent posts or term contracts rather than agency staff. I could not agree more that this is better than having a revolving door of people from agencies, whom, even if good people, because they are new to the site and the patients, make hand-overs very difficult. That is not an ideal solution, rather it is a very expensive and somewhat disjointed band-aid for the circumstances that arise in clinical care. From my observation, it has been reasonably straightforward to recruit a good cohort of midwives into Portlaoise hospital.

It is somewhat attractive, the cost of living is lower once one gets outside the big cities and people have been very willing to come. It is harder to recruit obstetricians, so although the component-----

Chairman

Is there a recruitment difficulty?

Dr. Susan O'Reilly

Yes.

Chairman

Tony O'Reilly was speaking about that at another forum, while both Dr. O'Reilly and Mr. Woods have said it here. Is that down to pay or is it a variety of reasons?

Dr. Susan O'Reilly

It is multi-factorial. One of the issues for midwifery is having the positions ready at the times people are coming out of the programmes and not making the role so unattractive because of all the difficulties and emotional experience for staff in dealing with tragic events for patients and some of the fallout from that. There is a huge morale issue around recruitment into midwifery. However, we have been very successful in Portlaoise in this regard.

Obstetricians and junior hospital doctors are looking for a career path that will sustain them and there are multiple elements involved. They have to be working in a collegial environment in a good location, so facilities matter. They have to be well supported, with access to the resources they need to do the job well. They need to feel that they will be compensated at a rate comparative to some of the other circumstances, and often to have opportunities for research teaching and other elements of care. Therefore, it is very much multi-factorial.

In terms of where we have gone since the HIQA report on Portlaoise - and, in fact, well before that - there is a clinical network between Portlaoise and the Coombe, which had already begun to evolve some time ago. This network operates well. Women with complex medical problems will be referred to the Coombe from Portlaoise. Women who are in premature labour or at risk of premature labour are referred for an opinion. They may or may not choose to deliver them there. We have infant transportation for children who need intensive care and that works extremely well on a 24-7 basis throughout the country. That network certainly works well.

As regards the journey we are on now with the Coombe, we are in the process of doing a legal integration of governance and management where the hospital will run its services on two sites. To that end, there has been a huge amount of work done. First of all, we have been approved for more recruitment of obstetricians and neonatologists. However, we have been very careful to plan to advertise these as joint appointments next January. The next cohort of trainees will become available 180 days later. The sense was that if we advertised as Portlaoise posts on their own, they would not be as attractive as joint posts. We also planned the timing to match the output of people coming along. There are two obstetrical posts which will be joint and two neonatal posts which will be joint. These will be advertised in January as a result of both the timing issue and the likelihood of success.

There is a director of clinical integration on site - Dr. Michael O'Connell from the Coombe - who has worked out all of the clinical pathways through a series of workshops with both hospitals across the entire spectrum of maternity, delivery, outpatients, neonatology and dealing with grief and bereavement. These will now go out to patients as well as staff to say "Was my journey like that in these hospitals and has it worked for me? Can I give input?". That work is ongoing.

We have been examining how we build an integrated information technology between the two hospitals. The Coombe has an old one, Portlaoise has none. We need that for clinical audit, to see how we are doing every step along the way. There is clinical audit but it should be automated to make sure we know what is going on. The direction of travel is that I anticipate that at some point in 2016 we will have formal governance and management from the Coombe. Building success, however, must be based on these steps along the way. Management is critical: there is a need for clinical leadership, a lead obstetrician, a strong general manager for the service and there must be quality and safety. There must also be complaints management within the system. Joint reviews of adverse events that are noted and integration with Mr. Patrick Lynch's programme to ensure we are very careful to evaluate why, for example, a baby died. Sometimes a death is not preventable, while on other occasions it might be.

It is really important that we engage with patients. I know that Mr. Woods is setting up a programme of patient engagement for the groups that we can roll out across the country and Portlaoise will be one of the lead groups there.

I would be happy to take any further questions on any of those elements.

Chairman

Okay, thank you. Are we happy enough?

Deputy Caoimhghín Ó Caoláin

Yes.

Dr. Alan Finan

I wish to comment on that final question from Deputy Ó Caoláin about the assistant director of nursing for sepsis. That appointment is an RCSI group appointment. It happens to be an individual who has been working in Cavan for quite a few years and she will do a powerful job, I have no doubt. However, there is a strong sepsis management team in Cavan. The idea of the hospital group appointment is to try to standardise sepsis management protocols and SOPs around the group, and raise all boats in that way.

Chairman

I thank all the witnesses for their participation. I remind members that the committee has written to the Committee on Procedure and Privileges about marking pregnancy and infant loss remembrance day, which is on 15 October. We will have an event here in the committee room area on that date. We will suspend proceedings for ten minutes.

Sitting suspended at 11.25 a.m. and resumed at 11.35 a.m.

Chairman

We will resume. I thank Deputy Ó Caoláin and Senator Burke. I welcome Dr. Chris Fitzpatrick, consultant at the Coombe Women & Infants University Hospital and its former master, to our second meeting this morning. We are looking forward to hearing from him. We have already had two interesting meetings on the future national maternity strategy.

I remind Dr. Fitzpatrick that, by virtue of section 17(2)(l) of the Defamation Act 2009, he is protected by absolute privilege in respect of his evidence to the committee. However, if he is directed by it to cease giving evidence on a particular matter and he continues to do so, he is entitled thereafter only to a qualified privilege in respect of his evidence. He is directed that only evidence connected with the subject matter of these proceedings is to be given and is asked to respect the parliamentary practice that, where possible, he should not comment on, criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the ruling of the Chair to the effect that they should not comment on, criticise or make charges against any person outside the Houses or an official by name or in such a way as to make him or her identifiable.

I apologise to everyone for my raspy throat. I have a touch of something.

Dr. Chris Fitzpatrick

I wish to preface my opening statement by saying that it is opportune and important that we are meeting on a day when The Irish Times once again highlights on its front page the serious problems in our maternity services with the publication of yet another report that appears to tell us what we already knew about our problems, including the slow pace of change over a considerable period and the need to act decisively now. Mr. Paul Cullen quotes the HSE's response to Mr. David Flory's report, in that it provides "important insights" into quality standards in safety. With the greatest respect, we have the accumulated wisdom of more than ten years of reports and reviews, but a paralysis in terms of meaningful action.

I wish to offer my sympathies to all who have suffered loss or serious injury in our maternity services. As a doctor, I am only too well aware of the harrowing consequences that adverse outcomes have on mothers, fathers, babies and families. I thank the committee for giving me the opportunity to share with it some of my experiences of working in the Irish maternity service over many years.

As a clinician who has worked as a consultant in a busy tertiary referral women and infants university hospital for almost 20 years, seven of which were as master, I cannot overemphasise the importance of the responsibility that politicians, most particularly those in government, have for the planning, resourcing, provision and regulation of effective health services on a national basis. In the context and ethos of open disclosure, clinicians have a responsibility to explain and apologise to patients and their families honestly and transparently when their care falls short of appropriate clinical standards. Although health service managers are now being investigated in respect of their individual and corporate performances, even the most rudimentary root cause analysis will reveal, in the context of the Irish maternity service, that critical strategic decisions made on prioritisation and funding at the highest levels of political authority have had a significant impact on clinical outcomes in hospitals. Often, hospitals have been run into the ground by chronic underinvestment over many years.

It is important that what I have stated should not in any way be interpreted or misconstrued to excuse poor individual professional performance or negligent clinical care. If we are to gain a full understanding of what went wrong, however, it is important to scrutinise why a service that is designated to look after our most precious and vulnerable resource - mothers and babies - never became a political priority until such time as a series of adverse clinical outcomes hit the headlines of our newspapers and news bulletins on successive occasions in the recent past. During the boom years, there was little, if any, investment directed into maternity services and when the bust happened, they were exposed to systematic cutbacks while absorbing unprecedented levels of clinical activity, complexity and demographic change. The fact that the overall clinical outcomes for mothers and babies in this country still indicate, by international comparison, a high level of clinical performance is a testament to the dedication and professionalism of clinical and support staff, local managers and other health care officials, who often felt, and were at many times, abandoned by the political system over successive Administrations. Despite the overall reassurance of our national clinical results, there were outcomes that undoubtedly should not have happened and near misses that turned out better than expected.

The succession of problems that has come to the attention of the public in recent years and that has been the subject of simultaneous and sequential investigations has arisen in a particular context. The warning signs were there for a long time and were raised by many within the system. Unfortunately, they were mainly ignored and, when acknowledged, merely became the subject of reviews and reports, which often cost considerable amounts of money and, when completed, were mostly not implemented in any meaningful sense.

In 2011, as master of the Coombe Women & Infants University Hospital, I established and chaired a multidisciplinary team of clinicians and health care managers from the Coombe, Portlaoise and Mullingar hospitals. Having highlighted a number of significant clinical risks across this network of hospitals, we identified a number of important posts that were required to manage these risks.

Conscious of budgetary constraints, we developed a comprehensively funded innovative strategy that involved piloting these posts with strict performance indicators as well as a long-term savings potential. Despite several modifications of the proposal and presentations at the highest levels of authority and at a national forum, there was no response. These risks were also highlighted in the risk register of the hospital that was submitted to the HSE on numerous occasions over this period. It is noteworthy that this model of tertiary and secondary hospitals, working in close co-operation, emerged some years later as the appropriate strategic response to certain clinical incidents that occurred in Portlaoise hospital and also as the model for the alignment of maternity services within hospital groups. It is the model that have been endorsed by the Flory report. It is also of concern that many of the risks highlighted in the 2011 tri-hospital submission are still present throughout the country.

If the current maternity strategy is to have any credibility, and if it is to bring about a sea-change in the way that maternity services are funded, organised and run in this country, then it must be more than a cut and paste exercise of generalisations, as many previous reports have been. It must have specifics in regard to models of care, staffing levels and infrastructural development. To do this it must have a methodology of implementation and a ring-fenced budget. Most importantly, it must be a political priority with a life expectancy beyond the next election.

The national cancer control programme is an example of how political prioritisation improves clinical outcomes. Accordingly, I believe that the Minister for Health should establish a national women and infants programme in order to drive change and clinical excellence. He must act decisively to restore confidence in this service otherwise there will be more critical incidents, more traumatised mothers, fathers, babies and families, while ever fewer school leavers and graduates will choose to become midwives or obstetricians in this country.

Deputy Caoimhghín Ó Caoláin

I wish to especially welcome Dr. Fitzpatrick and apologise to him for the poor attendance at this point in time. We have been in session since 9.30 a.m. and unfortunately we have lost some colleagues for this later session. However, it is important that Dr. Fitzpatrick knows that the content of his contribution and the engagement that we will have will be recorded and noted by all of the members. His contribution does matter and I wanted to reassure him about that.

I thank Dr. Fitzpatrick for his opening remarks. They reflect on some of what we have already discussed here this morning. He said that decisions made on prioritisation and funding at the highest levels of political authority have had a significant impact on clinical outcomes in hospitals. He also briefly referred to the Flory report which is very much a focus of this morning's newspaper reports. I note that he referred to Mr. Paul Cullen, who wrote a front page report on the Flory report for this morning's edition of The Irish Times, a newspaper that I am happy to purchase every day. I would like to say for Mr. Cullen's benefit that if I were a Dublin Deputy speaking about maternity services in Dublin, the matter would never be referred to as a parochial issue. As I am a Cavan-Monaghan Deputy referring to Cavan-Monaghan maternity issues, it is no more a parochial issue. From Mr. Cullen's tweets, I am sure that he will note my comment.

Dr. Fitzpatrick said that during the boom years, there was little, if any, investment directed into maternity services. That is absolutely the case. This is an historic problem that dates back a critical number of years. It is not only reflective of the cuts that have only added even deeper to the problems that existed historically. The maternity services were exposed to systematic cutbacks. That is a fact of life that has been borne out again in the Flory report and other reports and it concerns the underprovision of staffing. The Portlaoise report very definitely exposed the fact that there was serious and significant underprovision of staffing for maternity services at Portlaoise where Dr. Fitzpatrick has a particular interest because of the connection now between the Coombe and Portlaoise.

Dr. Fitzpatrick spoke about the current maternity strategy. We do not have one and that is the nub of the problem. We need a new maternity strategy to be fast-tracked. The absence of same is giving rise to a significant lack of confidence and certainty. It has also impacted on the staff at many of the smaller entities rather than at the major Dublin based maternity units. Many of the staff at the other smaller entities, which are spread across the 19 maternity settings located across the country, are fearful for their futures because there is no certainty. We have encouraged and urged the Minister and his Department to move towards the delivery of a national maternity strategy that will give us certainty going forward.

I ask Dr. Fitzpatrick to elaborate on what he meant when he said that he believes the Minister for Health should establish a national women and infants programme in order to drive change and clinical excellence. Where would a national women and infants programme fit into the jigsaw of the overall governance of health care delivery in this country? How does Dr. Fitzpatrick envisage its make-up in terms of personnel and accountability? To whom would it report? I ask him to give us a sense of his vision for such a structure and to outline where it would fit into the overall circumstance today.

I have a few questions for Dr. Fitzpatrick that relate to his time as master of the Coombe. Had there been, traditionally, a relationship between the Coombe and any of the other maternity settings across the country? Did he feel, in his role as master, that he was listened to when he brought forward particular proposals and points of relevance? Did he feel that his expertise and knowledge was properly acknowledged and respected? In terms of the system - I refer not only to the political system but also to the permanent government in terms of the Civil Service - was he given an ear? Was there follow-through in terms of actions on the recommendations made by him during his years of service in that post?

I thank Dr. Fitzpatrick again for his contribution and I look forward to his responses.

Senator Colm Burke

I thank Dr. Fitzpatrick for his presentation. I also thank him for his long years of service in the obstetrics and gynaecological area and as master of the Coombe. I know that the hospital was run very efficiently and in a good manner.

Dr. Fitzpatrick has raised a few issues, in particular an issue that I have raised at all of the presentations we have had here and I refer to the Hanly report of 2003. In terms of the recommendation, at the time we had 93 consultants. I understand we now have 114 whole-time equivalents while there are 133 consultants on the books. What happened between 2003 and 2010 because no progress was made? Where did things stall during that period in terms of the change that has been clearly identified? I ask Dr. Fitzpatrick to outline how the birth rate changed in 2003. The figure rose to 75,000 births but I am not sure in what we year we reached that figure. Why did the health care system not respond to growing demand?

We have focused on maternity services here. It was highlighted by one of the people who made a presentation here last week that the issue is not just maternity services but also gynaecological services. In the overall discussion we seem to have lost sight of the fact that a range of services are provided.

We have not been given the numbers being dealt with in the gynaecologist services where the same people are working in both areas. It would be interesting to know the figures Dr. Fitzpatrick is talking about in regard to surgical procedures and all the rest of what is being done in that area.

On the employment of consultants, Dr. Fitzpatrick might advise the current ratio of the number of deliveries per consultant in the Coombe hospital. I am referring to whole-time equivalents. How does that compare to the ratio that would be the normal requirement in, say, an equivalent health service in the UK?

The second issue I wish to raise relates to agency staff and the availability of junior doctors and nurses. Does Dr. Fitzpatrick have figures for the number of doctors employed on an agency basis in the Dublin hospitals? How would he address that issue to make it attractive for people to work within the HSE contract system?

I understand the issues are not related to salary but to the conditions and issues such as training and funding for training. Dr. Fitzpatrick might touch on a number of the issues that make that system unattractive. I recently spoke to a UCC graduate who did an intern year in Ireland and is now working in Perth in Australia. I understand a core of students from UCC who graduated in 2014 are now all working in Perth. What do we need to do to reverse that trend in the context of the hospital systems in Ireland and, in particular, in regard to maternity services? If Dr. Fitzpatrick was in charge of that area in the morning what three or four elements would he change to make that difference? People want to go abroad to get experience, and rightly so, but people seem to be leaving. I conducted my own survey in 2012 of those who graduated that year and it clearly identified that more than 60% of them had decided, even before they had graduated, that they would leave the country once they had completed their intern year. What changes would Dr. Fitzpatrick bring about in that respect?

In fairness to all the Dublin hospitals, they are not confined to looking after patients in the Dublin or the Portlaoise areas but take in patients from other parts of the country where necessary. Dr. Fitzpatrick might indicate the numbers who are referred to those hospitals from throughout the country. What percentages do they make up? Are they a very small percentage? The three Dublin hospitals and Cork University Hospital provide very specialised services where genuine problems arise. What number of patients are referred to those hospitals from outside their immediate catchment areas? I thank Dr. Fitzpatrick again for his contribution.

Dr. Chris Fitzpatrick

I thank Deputy Ó Caoláin for some very insightful questions. In response, I would point out that maternity services suffered during what was a period of reckless spending in that they were ignored. Ghost estates were built and hospitals were not built and during the austerity years a blind eye was turned to the requirements of the maternity services despite consistent advocacy, as I said, at the very highest level with authorities in both the HSE and the Department.

With regard to the strategy, we do not know what is in it and we expect it will be delivered this year but there are a number of things that can happen now in advance of the strategy being published. The current and I think the previous session addressed issues in terms of the networking of secondary and tertiary hospitals. In our context, the Coombe hospital is being networked with Portlaoise hospital and there will be a transfer of governance of Portlaoise maternity services to the Coombe hospital and it will come under the auspices of both the clinical and corporate governance of the Coombe hospital. That is a dramatic change. A hospital that was run by the HSE in terms of its maternity services is now being transferred into the governance of a voluntary hospital, not a HSE-run hospital. There are issues that can be addressed in regard to making that more effectively completed.

Number one, there are deficits and that does not just pertain to the Coombe hospital. I was master of the hospital up to 2012 but I am not involved in the current negotiations on the transfer of governance. That issue relates to the Coombe hospital, Holles Street hospital and the Rotunda hospital. These are voluntary hospitals and they are now expected to assume corporate and clinical responsibility for maternity services that were run by the HSE. These hospitals are currently all running big deficits and I would imagine those deficits need to be cleared. These hospitals all made submissions for increasing staffing numbers and they need to be addressed. Although the Minister has announced, and it is very welcome, that maternity hospitals will be located - and I sit on the project team for the relocation of Holles Street to the St. Vincent's campus, of which I have been highly supportive - this will take a while to happen.

There are current deficits within the infrastructure of our hospitals that need to be addressed as a matter of priority. It may not be attractive, in the run up to an election, to say that we will clear the deficits of maternity hospitals that are now assuming responsibility for erstwhile HSE-run hospitals, that we will deal with the critical staffing issues in these hospitals in terms of patient safety and that we will deal with equipment and infrastructural issues as a trade-off for these hospitals assuming responsibility for hospitals that were previously run by the HSE. A maternity strategy is not required to do that. That could be done very quickly at the stroke of a pen because we are led to believe there is money within the system. That would put the networking of hospitals on a really secure footing. My concern is that big hospitals that are cash-strapped are now being asked to take responsibility for smaller hospitals that have in fact been run into the ground over a period. The maternity strategy is welcome. There is an accumulation of reviews and reports going back to 2005 and one can cut and paste comments that were made in 2005 about the organisation of maternity services in Dublin. John Higgins wrote an excellent report, which was commissioned by the Institute of Obstetricians and Gynaecologists and funded by the Department of Health, on the networking of big and small hospitals. That was in 2006. The Flory report endorses that type of arrangement. We went to the Department in 2011 with regard to the issue of big and small hospitals working together on cross-institutional appointments, training and audit. Nothing was done about it.

We do not need a strategy to address the critical issue of perinatal pathology services within the country and within our networks. One of the big motivations to undertake the recent series of reviews, and also to undertake the recent maternity strategy, has been a critical number of instances involving mainly perinatal deaths but also maternal death with regard to maternity services. Currently, we are undertaking a significant number of historic reviews of cases, and that needs to be done in respect of bereaved parents, but we do not have a system in the country to appropriately investigate the deaths of babies. There are up to 300 stillbirths in the country every year. There are up to 140 early neonatal deaths. If there are risk management issues or patterns of clinical activity or professionalism that need to be addressed, this is the most rigorous way of doing that. We do not need a maternity strategy to do that; we could do that in advance.

The maternity strategy is welcome. My concern is that it would be a broad brush stroke and that it would not address some of the critical issues. The Minister could address the networking of hospitals by clearing deficits and dealing with infrastructural and critical staffing issues. There are bigger issues in terms of the building of hospitals. That is important. We recognise that this needs to be done, and we also support co-location. There are issues regarding the rebalancing of community and hospital services so that mothers at lower risk in terms of obstetric care can access that care closer to home in community settings.

The rebalancing of hospitals and communities, which we all support, takes a much longer period of time. However, there are things that have been consistently addressed since 2005-06 but which have not happened. Others have happened. Cancer and cardiac services were prioritised. In the case of maternity services, the fact is that globally our figures stack up in terms of perinatal morbidity, perinatal mortality, serious maternal morbidity and maternal mortality. Our figures are comparable in an international sense to those for good performing countries in the OECD. However, they could be better. The Taoiseach's ambition is that this should be the best small country in which to do business. My ambition is that it should be the best country, big or small, in the OECD in which to have a baby, both for the mother and the baby.

Dublin is the home of obstetrics. Obstetric practice developed historically in Dublin. It is the home of audit services, clinical research and so forth; therefore, we have the capacity. We have, however, lost a phenomenal amount of intellectual property in terms of our graduates. In my generation people went away, worked in the best centres abroad and then returned. Now, they either do not take up obstetric posts or when they go away, they do not return.

Regarding our relationship with Portlaoise hospital, we were within a funding group with it. Dublin-mid-Leinster was a financial arrangement of hospitals when I was master. Portlaoise, Mullingar and the Coombe hospitals were all within the same funding matrix. We were aware of the fact that the Government was moving towards hospital groups. As a group of clinicians across three hospitals where we were aware of the fact that there were ongoing risks, proactively we decided - midwives, doctors, anaesthetists and health care managers - to sit down together to identify where the risks were and put together a package to deal with them. The tragic irony is that the package we put together in terms of the jobs we critically required was the model that emerged in 2014 regarding certain critical instances that happened in Portlaoise. In 2006 there was an opportunity to do it. In 2011 there was also an opportunity to do it. Now we have the Flory report of 2014 saying the same thing. There has been paralysis of action in respect of maternity services.

I have consistently advocated for the women and infants programme. Dr. Susan O'Reilly has appeared before the committee. She headed up the cancer programme. Professor Tom Keane headed it prior to that. A political decision was made at the highest levels of authority that we would focus on it, not other things, and it worked. Professor John Crown is an expert on this. Having breast cancer in this country, difficult and problematic as the experience is, in this day and age is a very different prospect from what it was ten years ago. One hears of patients who have access to rapid diagnostics; they have multidisciplinary team, MDT, meetings and the best quality of care is provided by a team. We do not have that in a maternity hospital. What we require is one person in charge of maternity services. One can access the HSE in many offices through many personnel to find out what is happening in maternity services, but there is no single person whom one can call on the telephone to ask what is happening in maternity services because nobody has control. This should not be a bureaucratic monster. It requires one person at the top whom I believe should have significant administrative and management experience, as well as clinical experience. There are issues that must be dealt with that have a significant clinical resonance that have been ignored by those with little or no clinical experience. It should have a small cabinet; one could draw up the list of people in this country with the expertise to do it. Most importantly, it should have a ring-fenced budget. The danger of hospital groups, as has been the experience in Cork, is that if women and infant services are not independently budgeted, the budget will drift into being used to support general services. In the stand-alone maternity hospitals we can at least protect beds and our budget. We know what our budget is and it is not lost in the amorphous mass of a budget that must support general surgical and medical services and so forth. There must be a ring-fenced budget which must protect women and infants. The person in charge of it should report directly to the Minister. This must be a constant political agenda.

Chairman

Does that not happen already in the allocation of resources to the HSE by the Minister? Surely there is accountability in that respect.

Dr. Chris Fitzpatrick

There is accountability, but there is no single person whom one can telephone to say one wishes to do or know something about maternity services. In terms of what has happened and the diffusion of responsibility throughout the HSE and the Department in respect of policy makers, where people are looking after midwifery services and so forth, there must be one person in charge. That person should have a budget and the authority to enact what we have known for the past ten years must be done. It is a tragic irony that we are here this morning following the publication of yet another report. With the greatest of respect to the people who are undertaking reports, we have a type of post-colonial inferiority complex. We have commissioned hugely expensive reports. I am not referring to the Flory report, but we have used KPMG. We had experts in 2011 which cost a fortune and much of what emerged from KPMG is now superfluous in terms of the way forward. The intellectual property to run the service is within the country. As I said previously, we know what the problem is. There are shelves of reviews and reports in my office on critical instances and with analysis of maternity services, but there has been precious little action.

Chairman

Would it not be fair to say that, arising from what happened in Portlaoise, the Minister has acted? We have seen that report implemented and used as a roadmap for implementation following what happened in Portlaoise.

Dr. Chris Fitzpatrick

That had already been brought to the attention of the Department of Health. The issues pertaining to Portlaoise hospital and the solution were brought to the attention of the highest level of authority in the Department and the HSE in one week in September 2011. Three years later the model that was ignored and sidelined was, in fact, the one that suddenly was magicked up at a time when critical incidents were publicised in the newspapers.

Bereaved parents need to know that there is a different narrative regarding clinicians and health care managers over a consistent period of time. I have the greatest of respect for the many managers I worked with in the HSE, as well as officials in the Department, who came to the assistance of hospitals and did their best to squeeze out what resources were available. Knowledge of what to do was there in advance, but it was not a political priority. It frustrated many when they came forward with an idea. We went with a creative idea. We also know that investing in women and infant services is not only the right thing to do, but it is also the correct medical thing to do. Investment will improve outcomes, quality of care, experience and save money not just in terms of the €60 million we pay out every year in obstetric litigation but also in terms of the care of children who, unfortunately, sustain serious adverse cerebral events in pregnancy or labour. It saves money and makes sense to make that type of investment, but it did not happen.

I would take a leaf out of the Minister's book. He went on the airwaves after incidents had been reported in the media regarding Portlaoise hospital and said he felt ashamed, as a Minister and a doctor, that patients had not been treated with compassion and respect. As a health care clinician who advocated consistently at the highest level of authority in the HSE and the Department, I felt ashamed of how politicians and the political system had treated maternity services. Women and infants are our most valuable and precious resource, but they were treated with a lack of compassion, respect and care.

We are not slow learners but are slow in action, and I hope that at this stage of our experience we will do something now. Action speaks louder than words. Announcing new hospitals is fantastic; it is futuristic at present. I spent two years of my time building an imaginary hospital in Tallaght that never actually happened. I would like the Minister to do a number of things. First, he should clear the deficits of hospitals that are taking responsibility for the HSE services that are now being transferred into them. Across those hospitals, we need to deal with critical staff requirements, equipment requirements and capital developments that need to be done now. If the Coombe Women and Infants University Hospital is to be relocated on to the St. James's campus in five or ten years, certain things need to be done now. If the Rotunda Hospital is moving to Connolly Hospital Blanchardstown, certain things need to be done now. However, that does not sound as appealing in the run-up to an election as a promise to spend €150 million building a new hospital.

Senator Burke asked what happened between 2003 and 2010. In consultant appointments, we fell far behind other specialties. That happened because decisions were made. It was not as though jobs were not going into the equivalent of the consultant appointments unit there, but other jobs were being prioritised. I know from my involvement that in 2005, the old Eastern Regional Health Authority published a report on the three Dublin hospitals and addressed critical manpower issues in terms of consultant appointments, midwifery-neonatal appointments, etc., but none of those were addressed. From 2005 up to the present, submissions were made for posts. Maternity services were not being prioritised. In addition, our morbidity and mortality figures stacked up in international terms. So at a very superficial level we seemed to be doing all right, but in fact we were not.

On top of that, we had the tsunami of deliveries. In Dublin the hospitals are up to 9,000 or 10,000 deliveries while being resourced to deliver about 3,500 fewer babies. We were skating on thin ice. We were constantly appealing for additional resources. We had the chaos of voluntary redundancy schemes and early retirement schemes. Our revenue was cut back every year. We had the collapse of the private sector and patients coming in from private hospitals with no insurance accessing care, as they are entitled to do and as we wanted to provide. We had huge issues in terms of interpretation services. The hospitals were providing interpretation services that they found themselves, rather than doing it centrally.

A member mentioned gynaecology, which is very important. The cancer programme has had a significant impact on gynaecology services. The hospitals have importantly prioritised women's cancer, and the results and services are better. The patients with benign disease, among whom will be some patients with cancer, are coming into the maternity hospitals. So the Coombe Women and Infants University Hospital would inherit a very significant cohort of benign gynaecology from St. James's Hospital, and we are not resourced to do that. In addition, the emergency rooms we provide in the standalone maternity hospitals are not resourced as emergency departments. So we do not form part of the audit of trolleys - and there are no trolleys. However, we are not resourced. We are providing emergency gynaecology services and elective gynaecology services out of a budget that is stretched beyond belief in terms of obstetric services.

The use of agency staff is not an issue in Dublin, in that all the consultants and non-consultant hospital doctors in the Coombe Women and Infants University Hospital are non-agency people. They all have standard HSE appointments. Outside Dublin, it is a major issue. It is also an issue in regard to training and networking. In terms of consistency of care, it is not possible to run a hospital on agency staff where the people dropping into and out of the hospital do not necessarily have loyalty to it. There is no continuity of care, and a patient sees whomever is in carrying the bleeper at the time. The way to address that is through networking of hospitals, cross-hospital appointments, and also the provision by the universities that are part of the groups of academic leadership and an academic context, as has been the case recently, so that someone working in a small hospital will get valuable training and will also get exposure to an appropriate academic context.

I believe that about 15% to 20% of women and babies in hospital at any one time have come through referral from other units. The money does not follow the patient at present. In one sense, the HSE managers who are responsible for the income and expenditure of hospitals might be asking why the hospitals are overspending. It may be because we have taken four babies from another hospital, including babies weighing less than 1,500g, which cost a phenomenal amount of money because of the resources they require.

I addressed this issue at the highest level of authority in the HSE and the Department of Health and asked for more support in this regard. That transfer of funding needs to happen. There are issues the Minister can address that would give a major impetus and really drive the momentum for change in the maternity services.

Senator John Crown

I thank Dr. Fitzpatrick. That was a fantastic, passionate presentation. I have seldom been as impressed by or as proud of a professional colleague sitting in that chair as I am of him right now, calling it as it is. However, I am not overly confident that all the things he has said will actually percolate through to the decision-making process, such is my level of cynicism about that process since I became a Senator.

With respect, everything Dr. Fitzpatrick said about the multitude of usually ignored reports rings true. When I came back to the country 22 years ago I set out to point out the incredible deficiencies not just in cancer services but in the health services in general. In particular, since I became a Senator, I have repeatedly beaten the drum to the point of appearing very tedious to my colleagues. I would have prepared the report for free - it would not have been necessary to pay HIQA or any external person. The quality of obstetrical services in Ireland is mediocre. We have great doctors and very well trained nurses who work in unbelievably under-resourced, underfinanced, understaffed, irrationally led systems, and as a result the output is not all that good. It is not awful, but it is mediocre.

Dr. Fitzpatrick is right. People have wrapped themselves in the cloak of relatively favourable outcome statistics, not realising that obstetrics is different. If a country's cancer survival rate is 3% lower than in other countries, that might indicate room for improvement. If we have two unnecessary maternal deaths here, that is a tragedy. We should have zero tolerance for any maternal deaths and for any unnecessary paediatric long-term brain injuries, etc. It is not good enough for us to wrap ourselves in the cloak of being in the top 15 of 29 of the most economically developed countries in the world.

While I hate to personalise it, I must mention the tragedy in Galway a few years ago. People kept missing the point, which I kept repeating here. This is the region in Ireland that has the lowest number of obstetricians per head of population. Ireland has the smallest number of obstetricians per head of population in the world. One can join the dots and come to the right conclusion about the care of individual patients that is delivered by a number of rotating junior doctors over a three- to four-day period. The palliative mix there was pretty obvious to me and it did not relate to improving the management structures or anything like that - it was about bringing in more doctors.

This brings me back to the cancer programme. If the entire bureaucracy of the national cancer control programme were dismantled tomorrow, it would not have a major negative impact on cancer outcomes. Cancer survival improved about 15 years ago as a result of one intervention that was made by the then Minister for Health, Deputy Noonan. I jokingly tell him that he gently plagiarised a speech I had made stating that there were hospitals in the country that I would not let any relative of mine with cancer go into. On his first day as Minister for Health he said the same thing and said he was going to appoint more cancer specialists. I was the fourth oncologist in the country when I came back. I was often in the elevator in the Memorial Sloan Kettering Cancer Center with more Irish oncologists than there were in Ireland at the time I came back. The Minister, Deputy Noonan, just set about appointing a larger number of oncologists, and suddenly multidisciplinary care became available to people before there was any bureaucracy. I believe that is what made the big difference.

While I have sympathy with Dr. Fitzpatrick's view that there should be an obstetrics tsar, the absolute first priority is not more reports, but an attempt to double or treble the number of consultant obstetricians so that everyone in the country who is going through any phase of obstetrical care is not being looked after by a trainee, which is what junior doctors are.

They are trainees. Take out the words "senior house officer", "registrar" and "specialist registrar", insert the word "trainee" and see how rational many of the things we say on a day to day basis in Irish hospitals would sound, for example, “My precious young daughter went into the hospital and the trainee surgeon saw her and conferred with the trainee anaesthetist who said the trainee in intensive care had said this was their opinion.” We would never accept this in any trade, never mind medicine.

I have a few specific questions for Dr. Fitzpatrick. This is a hard one: in Portlaoise hospital there are 2,000 births a year. If we were flush with money and had an adequately resourced health service and were not operating under economic constraints, would 2,000 births a year be enough to justify keeping open a modern obstetric unit? My suspicion is that it would and that our decisions about Portlaoise hospital are based on the fact that we are not prepared to resource it the way it needs to be resourced in order that it will be more cost efficient. Perhaps there are professional reasons to roll it in to something else.

How critical are these numbers as one of the metrics on which the relative failure of our obstetric services is based: in Ireland there are 4.8 obstetricians per 100,000 of the population; in the Netherlands which has a lower birth rate there are 7.6, while in Switzerland there are 17? I had this argument with somebody last week about cancer outcomes. We saw figures last year which showed that Ireland had pretty dismal cancer outcomes, despite all the tosh we heard about the national cancer control programme. There is an emerging story that if as a society we deny people cancer drugs, we will have inferior cancer survival rates. I have a beautiful five month old baby. My lovely wife Orla presented me with a gorgeous child and she was beautifully looked after in difficult circumstances in Holles Street. In my heart I believe, in respect of many of the tragedies about which we read every couple of years and the awful pictures of children in wheelchairs outside the High Court, that if there had been a real senior person making all of the decisions all the way through those pregnancies and deliveries, those tragedies would not have happened. I would like Dr. Fitzpatrick’s input and thank him for a very inspiring presentation.

Deputy Catherine Byrne

I thank Dr. Fitzpatrick for his presentation. What are his feelings and views about the development of the new national children’s hospital on the St. James’s Hospital campus? Senator John Crown said Dr. Fitzpatrick had made some very passionate remarks, but I saw only frustration and anger at some stages. In hindsight, if funding was the only problem in the health service, perhaps we could fix it in the long run. As somebody who served on the Eastern Regional Health Authority, ERHA, and the south western area health board, I believe that after the ERHA was broken up, there were too many chiefs and not enough Indians. Management was overcrowded and while people were making decisions, there was nobody doing the work. There were more managers after the break-up of the ERHA than in the English football league at one stage.

I agree 100% about people who lose their children and those whose children are brain damaged because of things that went wrong when they gave birth. One of my biggest hang-ups is the lack of transparency and why it takes between ten and 16 years for people to go to court to be heard and compensated for having to live with a child who will never be able feed himself or herself, walk or do anything else. That is partly due to a system in which there is a lack of compassion.

I was interested in what Dr. Fitzpatrick said about going away when he was younger and doing what he had to do when he came back. I believe the new generation does not feel the same way about coming back to their homeland because those going away are better educated and they want a little more, perhaps not for all the right reasons. I have talked to several people who have left, who were in the medical business, doctors and nurses, and they go not only for education but also to upskill and see how emergency services are managed in other countries. Money and quality of life issues are also involved. A doctor friend of mine recently went to Australia because he wanted to become a consultant. If he had stayed here, he probably would not have been made a consultant before he was well into his 60s. Taxation is another issue which explains why some people will not come back.

I welcome the announcement through the capital funding plan that the Coombe hospital will be relocated to St. James’s Hospital. That is a step in the right direction. Having been many times in the Coombe Hospital as a parent and a grandparent, I believe it has moved well past its sell-by date. I do not refer to the staff but to the building. We can keep on adding to places, but that does not make for better practice in the long run.

Dr. Chris Fitzpatrick

I thank Senator John Crown for his comments. I absolutely agree with him that there is no acceptable level of maternal or perinatal morbidity or mortality. My ambition for the country is that rather than being “the best little country in which to do business”, it should be the best country in the world in which to have a baby, both in terms of maternal safety and paediatric outcomes. There is the capacity to achieve this.

I hope the Minister for Health, Deputy Leo Varadkar, is in the same mould as the Minister for Finance, Deputy Michael Noonan, and a person who is able to make up his mind about what needs to be done. I agree absolutely that there is a critical need to appoint more consultants. The problem is that in my day when one went for a consultant interview, there were 20 people being interviewed but now there might be only one. We have lost a generation of graduates who competed, who wanted and were inspired to work in obstetrics, went away and got the best jobs and pursued fellowships in North America, Australia and Britain and came back here to work. Some of them have not taken up the speciality and some of them do not want to come back for a variety of reasons. There is demoralisation about what they see here.

There are things that can be done immediately: we should clear deficits in order that voluntary hospitals would not be under a financial burden. Most of the creativity in the health service has happened in the voluntary sector. With the greatest of respect, if the three Dublin hospitals had been run by the HSE during the years of austerity, they would not be standing today because having people give of their expertise in a voluntary capacity to try to make a hospital work was hugely advantageous to us. The deficits need to be cleared. We need to appoint consultants in Portlaoise, the Coombe hospital and the Rotunda hopsital and all other units. That will take time because there are not necessarily the people available and we need to appoint the best people. We do not only need obstetricians. Neonatologists are run off their feet looking after babies with the highest risk in the country of dying, serious morbidity and mortality. They are grossly understaffed. On top of this, we need perinatal psychiatrists. We passed legislation on the protection of life in pregnancy and emphasised the importance of dealing with the issue of suicide. We do not have enough perinatal psychiatrists to deal with the referrals we are seeing. A sign of the disconnectedness in one person being in charge is that we do not have a mother and baby home in the State to look after mothers with a serious mental illness in pregnancy or afterwards. We cannot accommodate them appropriately.

In respect of the cancer programme, we do not want to create a bureaucracy. The appointment of critical staff is far more important. I agree with Deputy Catherine Byrne that it is possible to have a system that is overburdened with management. It needs to be at a level of priority that perhaps only comes with that type of designated programme.

On the sustainability of Portlaoise hospital, by international standards, there are many units in the developed world which deliver 2,000 babies very effectively. It cannot be a stand-alone facility, it needs to be networked into a tertiary hospital. Cross-institutional appointments, cross-institutional training, cross-institutional audit, cross-institutional research and dedicated transfer pathways would work extremely well.

Approximately 15% of cerebral palsy is due to intrapartum events. In the other 85% of cases, we are not certain in the context of the aetiology. Obviously, there is a strong obstetric factor to it but 15% of instances of cerebral palsy occur during pregnancy. The unfortunate scenarios that we see at present - the Kafkaesque scenarios - where parents and children are dragged through the courts in order that they might obtain adequate compensation is something most of us find absolutely reprehensible. In terms of open disclosure, if something goes wrong then this could be clearly identified. There are opportunities to mediate and to try to deal with the issue very early on at source. Parents are often forced to go to court in order to secure the long-term well-being of their children because there is nothing else. In terms of children who have a long-term disability from neurological injury or other conditions, one need only to speak to people at the Jack and Jill Foundation to find out what level of care is available in the community. These families need to have the security of long-term care for their children. That will not necessarily remove from them their right to go to court in relation to litigation if something happened that should not have happened. I agree with Senator Crown that the more consultants and the better-trained individuals one has looking after mothers and babies, particularly at critical periods, the better will be the outcomes.

Deputy Catherine Byrne asked about locating the new national children's hospital at St. James's Hospital. We are fully supportive of this proposal. My only regret is that it did not submit an application for a maternity hospital at the time. Given the delays relating to the last decision, there would have been plenty of opportunity to submit such an application. The nightmare scenario would be that planning permission to build a children's hospital will be granted and then for some reason there will be a problem with having the tri-located entity. I hope the project proceeds. In terms of the Coombe, I hope we will relocate on to the St. James's campus. I think there was a once-in-a-lifetime opportunity, given the delays, to actually put the whole package together. The Deputy is correct - the Coombe hospital needs to be redeveloped. We need a new hospital. The Rotunda needs a new hospital. This is a reflection of how non-partisan are obstetricians. I am doing my best, working on the project team to relocate the National Maternity Hospital to St. Vincent's hospital. Our loyalty is to patients, not to institutions. Those days of trying to promote one's institution, at the expense of another institution, are gone. The three Dublin hospitals work very well together as a network in terms of a joint committee. We also work with the hospitals with which we are networked, in our case, Portlaoise hospital.

The Coombe, the Rotunda and Limerick need a national maternity hospital. We need interim development. The things that need to be fixed must be fixed now, namely, in the context that the hospitals will be rebuilt. That is why I am appealing to the Minister. If there is one message to come out of this, it is to appoint the consultants, the obstetricians, the midwives, the neonatologists, the perinatal psychiatrists, the perinatal pathologists and deal with the equipment and the infrastructural issues that need to be dealt with in the short term, build the hospitals and then look at community care. There is a way of doing it and we do not need to wait for a programme to tell us what we all know.

Deputy Catherine Byrne

Dr. Fitzpatrick mentioned appointing all these specialists. Have we got them in this country?

Dr. Chris Fitzpatrick

Some are here and we have to make it more attractive for others to come back here

Deputy Catherine Byrne

Yes.

Dr. Chris Fitzpatrick

It is an international market. We can attract people but not necessarily Irish graduates. What we want are top-class graduates coming back to work as doctors, midwives, neonatologists, etc., in our country but we also need to plan. I teach medical students. What I sense is a disillusionment regarding the medical area. There are really bright people that one would want to be working in one's hospital ten years from now but they say to me that they will work in North America, Canada and so on. We need to inspire them. There is an opportunity to do so now. We have a Minister who speaks his mind and I would like him to do so in respect of this issue. In coming forward, I have taken a leaf out of his book because I have been ashamed at the way the political system has actually turned its back on what should be our most precious resource. In that context, next year we are celebrating 100 years since the founding Proclamation of the State. We have done many things in terms of our independence but there is a legacy of not looking after mothers and babies. Whether it was in the context of the mother and baby homes, the Magdalen laundries, the industrial schools or whatever, there is a legacy of not looking after our most precious resource - our mothers and babies. Let us hope that we can actually make the decision but quick action and long-term planning are required.

Chairman

I thank Dr. Fitzpatrick for attending, for the contribution he made and for his ongoing commitment.

Deputy Caoimhghín Ó Caoláin

I thank him for his forthrightness.

The joint committee adjourned at 4.15 p.m. until 4.30 p.m. on Tuesday, 6 October 2015.