Dr. John Murphy:

I thank the committee for the opportunity to speak this morning. This is a fact-finding mission to inform the committee about a group of patients that one may not come across in one's everyday work, although at the far side of Merrion Square there is a large unit in the National Maternity Hospital. Newborn babies are defined as those in the first month of life. Believe it or not, often this is when the greatest problems occur for small babies. It is a difficult hurdle for children to get through the first month.

As the Chairman noted, we marked World Prematurity Day on 22 November. The idea of World Prematurity Day is to highlight the issue of prematurity for the stakeholders, including doctors, nurses, paramedics and health care professionals who look after these babies. However, it is also a matter for the public because most members of the public have been touched either directly or indirectly by prematurity, whether in the case of a brother, a sister, a father or a grandchild who was born prematurely. I will discuss the issues that affect a large number of babies.

One year ago I was appointed as the national clinical lead in neonatology. Clinical lead programmes are a collaboration between the HSE and the Royal College of Physicians of Ireland. The purpose of a clinical lead is to set standards and then to implement strategies to allow these standards to be brought into being throughout the country. On my left is Ms Hilda Wall, a nursing manager in the hospital in Holles Street and a clinical lead for neonatal nursing. Ms Wall will discuss some aspects of neonatal nursing later on, including the complexity of the speciality. On my right is Ms Mandy Daly, who represents the Irish Premature Babies association and who is doing a great deal of work to help families who have had pre-term babies and to highlight the issues for pre-term infants.

The first slide on prematurity will give the committee a flavour of the speciality. Our speciality is different from others in that it is rather visual with small babies and the things that are done. One can see in the top panel the remarkable amount of intensive care provided to these babies, who are either pre-term or term babies who are very sick. The lower panel shows the more human side. There is a picture of a mother who is giving a baby skin-to-skin kangaroo care, which is an effective way of interacting with the infant and keeping him or her warm. There is also a picture of a baby with a mother and father. That is probably the smallest baby I have ever brought out of hospital, born at 23 weeks' gestation. There is also a picture of pre-term twins and slightly older children. There is a complexity to the intensive care involved but these children emerge as normal children.

The next picture shows a map of Ireland. I decided to use it as a challenge for the committee. There are approximately 75,000 births annually in the country. There are 4,800 premature babies born, a total of 19 neonatal units used to look after these babies and 300 neonatal cots. These are the figures for the country. In the North of Ireland there are approximately 25,000 births and, therefore, on the island of Ireland there are approximately 100,000 births. This is equivalent to the number of births in Sweden, which has a population of 9 million. Therefore, clearly we have a large number of children born, thankfully so, because they will grow up and be part of a young population in the country.

The Chairman referred to the definition of prematurity as being less than 37 weeks' gestation as well as the associated issues. A term baby is one of 40 weeks' gestation.

The more pre-term the baby, the more troublesome the case. Members will note from slide 5 that the incidence of prematurity in Ireland is 7%. The percentage in other countries is much higher. For example, in the United States it is 12%, which is a big problem. During World Prematurity Day, an international speaker pointed to the real problem in the United States in terms of prematurity. We are fortunate in that the percentage in Ireland is a little lower, although overall it is rising. Members will see from the slide that some babies, although pre-term, are relatively big in size and others are relatively small and vulnerable. As such, the care required varies.

Slide No. 6 deals with one of the most important issues we would like to discuss this morning. Not all units in the country are the same size. As shown on the slide, there have been more than 8,000 births in four particular units, which is a large number of births by international standards, a smaller number in four others and 2,000 births between the remainder of the units. This is important in the context of the delivery of care. Level 1 care involves basic care of babies, including resuscitation on a needs basis. Level 2 care, which takes place in more regional centres, involves the provision of supportive or intensive care. Level 3 is intensive care for infants. It is important to be able to interact these three levels, using them quickly and effectively. This is where the term "network" comes in. In this regard it means professional connectivity. We have been working on how to make connectivity happen and on getting all of the units in the country to work together, in terms of the management of premature babies, in a cohesive fashion.

In trying to determine best practise, we visited all the units in the country and met with all the doctors in all the hospitals. We learned about what is being done on a daily basis and of the main problems being experienced. It is important all these hospitals, in terms of the provision of care of infants, work effectively and cohesively. I will comment further on that issue later.

Slide 8 shows how successful the speciality has been. The reduction in mortality rates has been divided according to birth weight panels. In some cases, there has been a drop in mortality of up to 28% or 36% over ten years. It would be a challenge to any group in society to achieve a reduction in mortality of patients of 30% over ten years. It has been a great success. Members will note that the diagram contains information in regard to babies weighing 500 and 750 grammes, which is 1lb to 1.25lbs in weight. These babies are the new challenge for us. These are very much wanted babies of mothers who have undergone IVF treatment and have difficulties around getting pregnant. The challenge over the next five to ten years will be trying to get a better outcome for this group of infants.

Slide 9 relates to the benchmarking report of last year, which was mentioned at the first World Prematurity Day event last year. While many medical services in Ireland have in the past developed in an ad hoc fashion what is needed now is a much more planned approach to neonatal services. The structure of these services needs to planned and implemented. When there is a structured system in place new developments can be applied rapidly. Where there is not a structured system in place and new developments occur they are not quickly implemented countrywide. This is important for the future.

The second last sentence of slide 10 states the philosophy of the lead programme, namely, bringing expertise to the baby or bringing the baby to the experts. In other words, we want these babies to be cared for as locally as possible, by their local doctors with their families as close by as possible. They should only be moved to a bigger centre where necessary and as soon as possible after they have received that care they should be returned to the local hospital. The next slide highlights the importance to neonatal care of a seamless transfer across the system from level 1 to level 3 care and back to the local hospital as soon as possible. We are trying to eradicate post code disadvantage and want every baby in the country to get the service they need in the time they need it.

Slide 12 deals with my final point, which is on one of the most important issues in this area, namely, transport. We are lucky to have a neonatal transport system in Ireland. It operates from 9 a.m. to 5 p.m. However, no service is available after 5 p.m. The service includes a dedicated ambulance and specially trained doctors and nurses, who collect babies from any unit in the country and take them to whatever facility is selected for the treatment they require. This service needs to be developed further. We would like to have a 24/7 service. Babies are regularly born outside of office hours, with some born in the middle of the night and requiring transfer by a dedicated team of staff. During our visit to hospitals around the country the need for a 24/7 service was highlighted. My main priority is to make this happen. A 24/7 transport service would be life saving.