Dr. Sharon Sheehan:

Yes. We need to be very careful because there is a fear among larger units as well that they will suddenly not be able to cope with having 12,000 to 13,000 deliveries in their units and the smaller units are obviously fearful of closure. It is not for me to say whether units should close as that is way beyond my level of expertise. We need to look at providing a nationwide service of maternity care and how that can best be provided across hospital groups and centres. The hub and spoke model, to which Dr. Sam Coulter-Smith, referred is very important.

As part of the strategy, we have had a number of invited speakers in to speak to the steering group. We have invited in Paul Fogarty, who is involved in the Northern Ireland maternity services strategy, and Polly Ferguson, who is involved in the Wales strategy. Wales would have similar demographics to ourselves in terms of the length of time it would take for some patients to travel to a maternity unit. Many of the women who come to our hospital, the Coombe, live in a catchment area where it would take anywhere between an hour to two hours to get to our hospital. When we consider Cork and Kerry, it could potentially take four and half hours for a woman to travel to the nearest maternity unit. Those women must be provided for. We must be able to offer a safe service to every woman in the country. As Dr. Sam Coulter-Smith said, we need to decide what levels of care can be provided, in which hospitals and at which point is it more appropriate to transfer a particular woman and-or her baby to another unit that can offer a different level of care. We already do that and that works very well.

It is in the context of the community model that we are able to expand our services in terms of antenatal and postnatal care. If one were to go into any of the Dublin hospitals, one would see that the antenatal clinics are burgeoning with patients who do not need to be there. That care can, and should, be provided in maternity and community settings. We offer community midwifery care, as does the Rotunda Hospital and Holles Street hospital. It is important for us to expand that. What works very well is where patients only come to the hospital to deliver their baby. We have many clinics running like that, where the women are seen and have all of their antenatal care in community. We have a clinic which runs from Naas hospital. It does not have a maternity service, but we run a full antenatal clinic there. Patients are booked to that clinic, have a scan done there, have all of their antenatal care there and only attend our hospital to have their baby. We need to replicate that model across all our communities, where we only bring the patients into hospital who really need to be there. We need to stop medicalising it where it does not need to happen. That is response to the question with regard to what happens in other countries.

I would echo Dr. Sam Coulter-Smith's point that we need to look at other jurisdictions. As I said, we have looked at Northern Ireland and Wales. Australia, Canada, the Netherlands and other countries in Europe also need to be looked at. I second the point that was made, that we cannot pick up a strategy and system in place in another country and simply prop it down in Ireland and expect it to work; that will not happen. We look at the UK, as our closest neighbour, but it has a very different health service from ours. Its funding mechanism for health is entirely different from ours but its community midwifery services are extremely well developed.

I return to other points that were raised in that context. The roles of the general practitioner and the public health nurse are very important. It is very useful to have general practitioners and representatives on the national steering committee. I am not sure if everybody knows but obstetrics is not a requirement of the general practitioner training scheme. One either does obstetrics or one does another model, so not all of our general practitioners are trained in obstetrics. That is an important aspect.

I would also add that public health nurses who look after mothers when they are discharged and after the babies when they go home are not employed by the hospitals but are HSE employees and midwifery is no longer a requirement to do public health nursing. It always was in the past. We always trained staff in midwifery and then they went on to become public health nurses. They are no longer required to train in midwifery and yet they are expected to look after mothers and babies when they go home to the community. We need to have an integrated structure and, as I said in my presentation, we need to have a integrated workforce planning strategy in place to match the kind of services that we expect and are able to deliver.

I will move on to Deputy Ó Caoláin's comments, although he is no longer here. He spoke about the deny and defend culture. I would like to deny that this culture exists in our hospital. Open Disclosure was launched by the HSE in conjunction with the State Claims Agency but I would argue that open disclosure exists in our hospital. One of our board members has raised concerns over the title, Open Disclosure, which implies that the disclosure we had heretofore was, in some way, potentially closed. I would echo those concerns. We have a very open culture with our patients. It is important to maintain that, to acknowledge and apologise when an adverse event has occurred and to establish, along with the patients and the staff involved, what went wrong and how we can improve the service.

Deputy Byrne and Senator Burke mentioned the effects on staff who are involved in an adverse outcome. There is emerging evidence of, and talk about, a second victim in an adverse event. The staff members are now being referred to as a second victim. An adverse event often has life-changing impacts. We are all traumatised when something goes wrong. We are traumatised by the loss for the family and share in the grief experienced by the family when something goes wrong. There is the trauma of an adverse event and then there is the trauma associated with potentially being in the coroner's court or potentially being in the legal system, which is a long-drawn out process. There is emerging evidence to suggest that there are suicide rates associated with staff who have been involved in adverse events and that they are increasing. We have a huge role to play in supporting our staff when these events occur, in addition to supporting our patients. We have advanced bereavement support in the Dublin hospitals but such support in the other hospitals leaves a lot to be desired because of a lack of resources around that.

We have a number of systems in place for our staff, certainly in our own hospital, in terms of employee assist programmes, to look after them when they are involved in such cases but such cases can go on for years. It may be ten or 15 years before a case appears in court, particularly a case involving a baby who has been born with cerebral palsy. That has hugely life-changing consequences for the family but also for the staff. Staff may never again work in medicine after an adverse event and we need to support staff. I would strongly echo what has been said in that respect.

I have addressed the questions Deputy Ó Caoláin asked about the models of care. He also asked about the moratorium and my reference to staff moving. Many of our staff had been commuting significant distances during the HSE embargo on recruitment. Following the lifting of the moratorium in the HSE hospitals and as posts opened in hospitals, such as Portlaoise, Kilkenny and in hospitals around the country, our staff who lived in those areas were able to obtain employment and moved back to those hospitals. We saw an exodus from the Dublin hospitals largely of staff moving to HSE hospitals where they could not heretofore get jobs.

The other questions put to me related to community care. As I mentioned, the main elements are in terms of antenatal and postnatal care. Who would not want to be cared for in one's community? Which one of us would not want a midwife to essentially come home with us when we go home with our baby and when we are learning to breast-feed and look after our baby? Women are given an enormous responsibility, that of being able to look after a baby, for which nobody has prepared them, and what woman would not want the midwife to visit her everyday at home? We need to develop, resource, staff and fund that service.

Senator Burke raised a question regarding the 114 whole-time equivalents. I would add that they are not even 114 whole-time equivalents dedicated to obstetric care. In respect of the number to which the Senator was referring, we are all qualified as consultant obstetricians and gynaecologists. There are not 114 whole-time equivalents in pure obstetrics as the number dedicated to that care is far fewer than that. Too often when we think of maternity services, we think only of the number of births. More than 8,000 surgical operations are performed in my hospital every year and those are taken out of and resourced from that complement of obstetricians and gynaecologists.

It is far more than simply the number of births delivering that defines our services.

Reference was made to staff going away. Deputy Byrne mentioned that she has spoken to staff who are leaving because there are no positions open here. That is a real concern. Like Dr. Coulter-Smith I trained abroad and I welcome people going abroad to train. What is unique, however, is that many of our staff who leave to train abroad have absolutely no intention of coming back to Ireland. That is new. We refer to ourselves as having a homing pigeon beacon, something inside our brains that makes us want to come home. This seems to have been switched off in the staff who are qualifying and training now. I sat amidst a group of UCD medical students last year who were embarking on their obstetrics and gynaecology programme. I asked for a show of hands for how many saw themselves with careers in Ireland eventually. Less than half of the class raised their hands. That is unique. In my class in UCD, everyone wanted to come back here. We all aspired to work in Ireland and put back into the system what the system had given us in our training. We are now training to export and we need to ask ourselves why that is. Why are our jobs and hospitals unattractive? They are not. We are delivering excellence in outcomes for mothers and babies, but we need to ensure that the resources and funding are put in place to recognise that and develop it. We must avoid being short-sighted or knee-jerk in our reactions by quickly changing one problem but ignoring what may be a far greater problem in the room.

Senator Henry discussed picking up rare diseases in pregnancy. Her case epitomised the care needed in maternity care. As a young healthy woman she developed a potentially life-threatening complication although she would probably have been considered a low risk. The low-risk mother can become high-risk at any point in her pregnancy and we need to be able to cater for the needs of all our patients. We need to recognise that simply because a woman is low-risk at the start of her pregnancy does not mean she will stay in that category throughout. This is why I urge collaboration across midwifery and obstetric care as well as the other medical specialists who we rely on heavily when patients develop complications. We need to be able to seamlessly transition our patients to the appropriate care when and as they need it. It should be possible for a woman to book in a hospital that may not have certain expertise but where the training is in place to recognise when she develops a problem. This should facilitate her being moved to the appropriate centre of excellence to ensure she receives all the care she needs. I urge us not to get lost in the debates of territorialism of maternity services, the idea that a woman must remain low-risk or high-risk or that she must be in midwifery care or consultant-led care. Let us forget about that. Let us move as the needs dictate. We must remember that we have two patients: the mother and the baby. A low-risk mother may carry a high-risk baby. Conversely, a high-risk mother may carry a low-risk baby. That is the key and that is why obstetrics is referred to as an art. We need to work seamlessly across health care professionals to deliver what patients need, not what I, as a consultant obstetrician, need or what a midwife needs. We should let our care be truly patient centred.