Dr. Sam Coulter-Smith:

I thank members for the opportunity to address them today on a subject which continues to be a source of significant public concern. As I approach the end of my term as Master of the Rotunda, I can look back over the last seven years with a unique perspective. This has been the busiest seven years in the 270-year history of the Rotunda. It has been a time when activity levels were extraordinary. The deficits in infrastructure became very evident and the strain and stress on staff was exacerbated by salary cuts. The hospital's ability to deal with these issues was curtailed by reductions in funding allocation and restrictions in head count. The combination of all of these issues has resulted in a significant inability to retain or recruit staff. These staff are a vital arm of our health service. All of these issues, and those I am going to identify today, have had a detrimental effect right across all elements of our health service.

Over the last two to three years, maternity services in Ireland have consistently been in the headlines for all the wrong reasons. There have been numerous high-profile cases reported in the news; multiple investigations with associated recommendations; high-profile Coroner’s inquests; and a variety of HIQA and independent reviews. It has now reached a point where the confidence of the public has been severely shaken and the quality of the services provided to our mothers and babies is questioned in the media on a daily basis. Much of the reporting has been sensationalist and some of it out of context. Such stories are understandably frightening for prospective mothers and families.

To put the situation in context, despite all of the negative publicity, we must recognise that maternity and neonatal outcomes in Ireland remain extremely good and benchmark well when compared to services in comparable countries. Having said that, our results could and should be improving.

There is a normal pregnancy loss rate of between four and seven per 1,000 births of babies greater than 500 grams. Most babies who do not survive suffer from fetal anomalies, extreme prematurity and infection, unpreventable cord accidents or placental dysfunction. Some deaths are unexplained, even after the most detailed post-mortem examination. Only a very small number of normally-formed babies in the latter stages of pregnancy do not survive. It is these preventable situations that we must do our utmost to avoid. It is in these cases that staffing levels, expertise and experience, funding and infrastructure, as well as good clinical governance are so important.

Obstetrics is demand led. Demand for antenatal care and delivery is significantly higher now than it was ten years ago. Some 70,000 babies are born annually in Ireland, which is up from 60,000 a decade ago. In some hospitals, delivery numbers are up between 25% and 30% over ten years. I know what that means, as will my colleagues here, but for the layperson they are just numbers. To put these figures into reality, as a hospital with nine delivery rooms and about 9,000 deliveries annually, we have between 25 and 45 births every day. That means that each delivery room is used between three and five times a day. Considering that the average duration of labour for a first-time mother is between eight and ten hours, those numbers just do not add up. This puts too much strain on our facilities and staff.

Ireland had the highest birth rate in Europe between 2004 and 2013, yet we have the third lowest number of consultant obstetricians per 100,000 women in the population, among 34 OECD countries. In order to reach accepted, recognised international norms, we need to increase our consultant numbers by 57% and we need an additional 600 midwives.

In 2003, the Hanly report recommended an increase in consultant numbers. Specifically for obstetrics and gynaecology, a target of 179 consultants was set for 2009, to go up to 191 by 2013. By the end of 2014 we only had 133, despite deliveries being up by 30%. In 2006 the Institute of Obstetricians and Gynaecologists recommended 24-hour on-site cover in the bigger units. A figure of one consultant for every 350 deliveries was recommended. This would require the current number of consultants to be increased by 57%. The KPMG report in 2008 recommended an expansion of consultant numbers. HIQA, in Galway in 2013, said there was a relatively low number of consultant obstetricians in Ireland.

That is more than ten years of reports saying exactly the same thing. I am not sure how many more investigations, reports, and recommendations are required - or how many more adverse events will be required - to get those who oversee and fund the health service to recognise the need to invest in the quality staff required to keep our mothers and babies safe.

The complexity of the patients we deal with has become a serious issue. Obesity now affects approximately 30% of our patients and, by extension, there is increased risk and cost. Unusual and resistant infections are now much more frequent and women with complex co-morbidity now conceive, requiring multidisciplinary care across several services. Population diversity has brought challenges, with new disease entities, greater social and communication issues. Despite all these challenges, results have remained good but our staff and infrastructure are strained by these extra demands. Crucially, no additional funding has been put in place to deal with these issues.

With regard to funding, we know that maternal and perinatal mortality rates when Government funding reduces, yet between 2009 and 2012, the busiest time in the history of modern Irish obstetrics, when activity levels were up by 25%, spending was cut by 3.5%. The recent recession has caused a reduction in fee income for our voluntary hospitals and these fees account for approximately 20% of our budget. This fall in income has worsened our funding deficit. We had opportunities to co-locate and, unfortunately, these opportunities were missed. None of our three major maternity hospitals has immediate access to intensive care facilities for adult patients and sick mothers are still transferred by ambulance to adult hospitals away from their newborn babies. Access to appropriate imaging, such as CT and MRI, has to be organised off site and access to joint services and multidisciplinary team care requires complex agreements between different hospitals on different sites and sometimes in different groups. All of these factors combined have resulted in all hospitals having difficulty retaining and recruiting quality staff. The exodus of our excellent trainees to more attractive packages abroad continues, resulting in an over-reliance on locum and agency staff. This drives cost up and quality down and is no way to run a health service.

In recent years the HSE set up clinical programmes in most specialties, which have assisted greatly with the provision of national clinical guidelines. This was a welcome development. Unfortunately, however, there was no provision of additional resources to allow some of these best practice guidelines to be put into action. Many hospitals do not have the infrastructure or the staff to implement such guidelines. Despite the availability of good, solid information on where staffing levels should be, no effort has been made to bring levels of staffing up to recommended ratios. Better incident reporting has assisted with improved knowledge of clinical incidents but without the factors identified above being addressed, it is difficult to see how we can improve the position. The new one-size-fits-all incident reporting form currently being trialled in conjunction with the State Claims Agency is not working very well or gathering the sort of vital information that we need to improve our services.

I will speak to inequality of access to services. Patients in different parts of the country do not have equity of access to subspecialist services and, for example, anatomy screening scans at 20 weeks' gestation are only available in bigger centres. In the tragic situation where a baby dies, only in the bigger hospitals will a dedicated bereavement team be called in and a dedicated perinatal pathologist be available to carry out a post mortem and get the best information as to what may have been the cause of death. This is really important information for the family and clinicians. Mental health issues in pregnancy affect approximately 10% of patients, yet services and staff for these patients are deficient. Endocrine services for diabetic and thyroid patients are stretched beyond coping point, and this should be addressed.

With respect to governance of services, historically, State-owned HSE hospitals report directly to HSE. Maternity units in HSE hospitals, therefore, have no direct governance relationship with the HSE, as it goes through the management system, and the performance indicators set for those hospitals by the HSE do not and never did relate to maternity services or their outcomes. This lack of direct oversight and a reporting relationship which was not designed to identify clinical risks has led to either failure to or delayed response to clinical issues. This lack of good governance in some hospitals has been pointed out in several recent reports. Even in voluntary hospitals such as ours, where clinical governance systems are tighter, we have still had great difficulty escalating some of our concerns. The theme is consistent, as clinicians raise concerns, governance systems are not good enough to ensure these issues are acted upon and nothing changes until something bad happens.

The oversight and running of our health service is currently undergoing another transition. The country has been divided into regions, with each one serviced by a hospital group based around an academic partner. The groups have been very slow to evolve. The appointment of chief executive officers has also been slow and these were meant to have boards to report to but they have not been appointed. The delay in driving this process carries the risk of leaving a vacuum at a governance level, particularly for the non-voluntary hospitals. This vacuum creates a dangerous lack of oversight and needs to be addressed urgently. How the voluntary hospitals fit into this new group model has not yet been worked out. The Minister has indicated that he sees voluntary hospitals, particularly the maternity hospitals, playing an important role in the new groups, and we welcome his reassurance, although it is unclear how this is going to work. There is a real fear that in the current proposed model, the voluntary sector, which has contributed so much to the development and improvement of our services, may be threatened by extinction. This, in our view would be a very retrograde, step for maternity services.

Ireland has a reputation for high levels of medico-legal claims and obstetrics is a high-risk specialty. Approximately 20% of claims arise from obstetrics and midwifery practice but this accounts for 60% of the monetary value of claims. This amounts to approximately €60 million annually, enough to run one of the Dublin maternity hospitals for that period. The State Claims Agency deals with this and shares information with individual hospitals but there is no national learning from this valuable information.

With regard to models of care, all women, regardless of their risk categorisation, should be entitled to the best possible facilities and one-to-one midwifery care, with access to medical information as required. There has been much discussion around models of care and some very vocal groups are suggesting that midwifery-led models are better. The delivery of maternity services requires co-ordination of both midwifery and medical obstetric services and it is impossible to separate these two functions because low-risk women can become high risk with little warning; therefore, in most developed countries, care of women in pregnancy is shared between these two professional groups. The important issue is that all mothers should have access to the best possible facilities in the most relaxed surroundings, with good continuity of care, and be looked after by midwives experienced in both normal and complex labour. Women who remain low risk can be delivered by those midwives and those who become more complicated can retain their continuity of care with that midwife but responsibility moves seamlessly to the medical team. There should be no need to move a patient in labour to a different location and continuity should be maintained.

If we genuinely want patient-centred care, we need to get away from the idea that one professional group has ownership over pregnant mothers. The terms "midwifery-led care" and "medically-led care" should be abandoned because they put the professional at the centre and not the patient. All patients, regardless of their risk category, should be able to access the best possible care and medical expertise required for delivery in comfortable surroundings. Care based on patient need is required. There is no doubt that antenatal care to low-risk women should be delivered in a community setting, as this would cut out long waits in hospital outpatient clinics and allow hospital services to be devoted to higher-risk patients. There needs to be significant investment in these community services to promote this model.

The current protection of life in pregnancy legislation is welcome. It puts some structure and guidance around what to do when a woman's life is at risk. However, that particular legislation does not assist us when faced with a woman carrying a baby with either a fatal foetal abnormality or one where the anomaly is life-limiting. Ideally, most obstetricians would like to see legislation that would allow us to support women and their families in whatever decision they make regarding their pregnancy in such a difficult position. Where a woman chooses to continue the pregnancy, we need to be in a position to support her choice with appropriate facilities and services for her unique situation.

Having identified some of the issues that need to be tackled, I will make some suggestions to the committee and the Minister to assist in improving the quality of services and help restore confidence in our services. I hope these suggestions will help to inform the work and output of the new national strategy group. First, we should set up a clinical governance system in each of our maternity units to oversee clinical activity, with appropriate clinical audit, clinical risk reporting and incident review to allow units to benchmark against each other. This system should mirror what currently exists in the Dublin maternity hospitals, where a clinician leads the service and is accountable for its provision. Second, each unit delivering maternity services should have a sufficient critical mass of activity to support the full range of services required to deliver that care to the population it serves. We believe this is approximately 4,000 to 5,000 births annually. This may require examining the models of care provided in some units or the provision of satellite clinics in some areas. These decisions can be made on a needs assessment of care. Third, each unit should have facilities to provide care for a full range services to deal with all levels of complexity, from the normal midwife model to the more complex medical model, with seamless transition between the two again based on patient needs.

I have already mentioned the terms "midwifery care" and "obstetric-led care" being abandoned and moving to a patient-centred care model.

Low-risk patients should be looked after by midwives based more in the community, where possible, and hospital clinics should be preserved for the more complex patients. The midwives delivering the community-based care should rotate through the hospital at intervals to maintain their skills, keep up to date with guidelines and stay familiar with current practice.

We need a well-organised and fully resourced national transport system to build on what currently exists to allow transport of mothers and babies to an appropriate setting when required. Our tertiary referral maternity centres should be co-located with acute adult hospitals which can support the requirements of the high-risk patient. With access to intensive care and radiology services, stand-alone maternity units should be a thing of the past.

Our maternity units should be staffed to a level commensurate with accepted international standards. This was recommended in the KPMG report in 2008 and a variety of reports stretching back to 2003 but has never been acted. Failure to provide appropriate working arrangements for highly-skilled and motivated staff will lead to further worsening of the current manpower crisis. The staff of the health service are its most valuable asset and need to be treated as such. Pay and conditions need to be restored to a level where we, as a country, can compete with services in other countries. We still have one of the lowest midwife and consultant ratios in the developed world.

In moving toward the hospital groups, any governance system we put in place should recognise the value that voluntary hospitals have given in the development of our service and foster the values and ethos of these institutions. The valuable work led by the national lead in the production of national guidelines needs to be accompanied by resources to allow their implementation. This issue has not been addressed adequately.

The maternity services need to have access to the State Claims Agency's information relating to adverse incidents and claims. This hugely valuable information would allow clinical issues and trends to be identifiable, benchmarked and highlighted and appropriate interventions to be made possible. This information would need to be monitored in an agreed way possibly through the national lead and clinical programmes. This data will be sensitive. It, therefore, needs to be anonymised and appropriate confidentiality measures put in place.

Dublin’s three maternity hospitals cover almost half the deliveries in the country. We believe we have a unique perspective and valuable experience to offer. While we accept that each of our hospitals has from time to time been involved in cases and issues where outcomes could and should have been better, we believe that through good governance and oversight, we have responded to those issues and put systems in place to improve the quality of our outcomes and the service to our patients. We not only benchmark against each other but also internationally. We believe our systems are robust and should be replicated across the country.

Above all, our health service is our staff. They are our most valuable asset and we urgently need to put measures in place to retain them. Failure to address the already acute staffing issue has started to affect the quality of services we provide and will ultimately lead to a worsening of outcomes, more adverse events and bigger medical, legal and litigation issues. Doing nothing or token gestures are not sufficient. We need a strategy to repair the damage that has been done in recent years.