Dr. Chris Fitzpatrick:

I thank Deputy Ó Caoláin for some very insightful questions. In response to his questions, 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.