Dr. Tony O'Connell:

I wonder if I might add something to the question about outpatient departments, which the director general partially answered. I merely want to reassure Deputy Kelleher that last year we sent out 15,000 patients who were waiting too long on the public waiting list to the private sector to be serviced. A small percentage of those returned because they were not seen for whatever reason. If that was the case, they rejoined the list at the place they were previously; in other words, there was no disadvantage to them. At least they had the opportunity to see someone in the private sector. If they came back because they had been seen in that private clinic and required a procedure which was not part of what we had contracted with the private sector to provide, they came back to the public sector. Then, the doctors who were to perform the procedure often wanted to see the patients, which is quite reasonable from a clinical quality point of view. When that occurs, the patients are treated as review patients because they have already had an outpatient clinic visit and they are given priority above others. In the end, we had a system which, although it could have been improved, resulted in thousands of patients being seen sooner than they might have otherwise, with no disadvantage to themselves if they came back to the public sector.

With regard to the maternity strategy, I thank the Minister for those clarifications about how it is running. I merely want to add some details there. We will visit all 19 units, each of which is quite different. They have different caseloads and levels of complexity. It is important to have a sense of what is going on in both the small and big units. As the Minister stated, the Department has already done a literature review, which has only just been sent over to my office and which I have not yet had a chance to read. It arrived only in the past 48 hours. I will certainly look at that.

In the acute hospitals division, we have surveyed all 19 units for high-level information about the number of obstetricians, midwives, deliveries, procedures, etc., and all of that information is back and is being collated. Clearly, the next step is to drill down and look much more closely at the quality of service in each of these 19 units and whether there are other ways in which the service can be provided which represent a more efficient use of the mix of skills among midwives, midwife assistants and obstetricians. That work will be done as we visit the 19 units. We are, as was stated, setting up a guiding group which will steer this piece of work and which will also participate in the visits to the 19 institutions.

With regard to the tragic event that occurred in Cavan, as was mentioned, the High Court has insisted that the report not be released. I want to reassure the committee that those eight actions at Cavan and Monaghan hospital that Deputy Ó Caoláin referred to in the written answer to his question have been initiated and enhanced subsequent to any adverse events which have occurred, and they are a response to the desire of the management, the obstetricians and midwives in the hospital to continue to improve the services available. There will be a new investigation because of the quashing of the previous one. Yesterday the college nominated two independent doctors to be involved in that investigation, which will start in November. We are keen, for the sake of the family, to ensure the investigation is completed as soon as possible without in any way compromising thoroughness.

With regard to the question about Caesarian section rates, as the Minister stated, these vary across countries, but Ireland is broadly in line with other OECD countries. There is variation within Ireland: for example, Sligo has a 19% Caesarian section rate, whereas Kilkenny has a 38% Caesarian section rate. It is for that reason that we are pleased the Health Research Board has given a grant to Professor Richard Layte from the ESRI and Professor Michael Turner from UCD, who works at the Coombe hospital and who is also the chair of the obstetric clinical programme, to look at national databases to study the issue of variance in Caesarian section rates. Clearly, we need to put all of that together with the improving data collection that we are doing on the standard of quality in the hospitals.

As was stated, the unfortunate events surrounding the death of Ms Savita Halappanavar in Galway have resulted in numerous recommendations. We are implementing all of those recommendations, some of which take longer than overnight. We have been surveying all 19 units to ensure they are implementing the recommendations and we are in the process of reviewing progress on those implementations. Some of what we are doing is described in the answer we have given to the question, and I will not go into it in detail - for example, the implementation of the Irish maternity early warning score, which detects patients in a similar condition to the late Ms Halappanavar, who previously may not have been detected early enough. There is excellent penetration of use of that particular tool in the maternity hospitals. In our regular performance management process with the almost 50 hospitals in the country, we are utilising the Safer Better Healthcare standards and the recommendations that emerge from the various reports, especially the HIQA reports, to inform our conversations with the hospitals, and we are using national standards for safety and health care to ensure that hospitals are continuing to dynamically review the output of their self-assessments. We are also establishing a quality and patient safety profile, QPSP. This is a comprehensive, timely and reliable report which will be used by the senior and most accountable manager in each of the services, which describes the quality and safety of the health care provided within the service and the actions taken to improve those services where required. This is being overseen by a cross-divisional HSE steering committee which is developing that framework and supporting the services to implement that QPSP.

With regard to the question on foetal monitoring, this technique is not used in a blanket way across the system. The use of foetal monitoring is guided based on guidelines which have been developed by clinical experts in the Irish system, and it is only used when indicated. Overseas experience shows that electronic foetal monitoring can increase Caesarian section rates, but that is only in countries that do not concomitantly use foetal blood sampling. That is not the case in Ireland, because foetal blood sampling is available in all maternity units here.