Dr. Peter Boylan:

Yes. I can offer two anecdotes with regard to recruitment. Two jobs came up recently. One was a consultant job between the Rotunda Hospital and the hospital in Drogheda. It would normally be seen as a rather attractive job, but no one applied for it. Another job came up between the National Maternity Hospital and the hospital in Mullingar. There was one applicant, who was from Lithuania. She withdrew her application before the interview and that post was not filled either.

I have just retired from clinical practice in the National Maternity Hospital. My job was exclusively in the National Maternity Hospital and there was no trouble recruiting an excellent candidate to replace me. She started recently. This brings us back to the governance issue and it ties in with what we have said about the mastership model.

I will give the committee an idea of the role of the master. The master is a senior clinician who is responsible for the outcome of all pregnancies in the hospital in a corporate sense. They are assisted by a manager who runs the administration and financial side of things but who reports to the master. The director of midwifery runs the midwifery side of things and works together with the master. It is one identifiable person who is responsible, accountable and has authority. When there is any budgetary leeway then one person can make a decision, obviously in consultation with colleagues and so on. The master is, if you like, a team captain. On a daily basis, for example, the master goes into the hospital in the morning, meets with all the junior staff who have been in on call the night before and the staff who are coming on duty that day. The master then knows exactly what has happened since he or she left the hospital the previous day if they have not been in during the middle of the night. The master has a very tight handle on what is happening at a clinical level, on the ground, which is very important in identifying risk or deficiencies and knowing who is really sick or who might need transfer to a general hospital. The master has a lot of administrative duties obviously, including meetings with the Department of Health, the HSE, in-hospital meetings, the risk committees and maintaining clinical standards. The master has a clinical practice also. He or she does ward rounds at the hospital and knows exactly what is going on.

Deputy O'Reilly raised the question as to what would happen in smaller units. The group structure is a way of dealing with that. For example, the Portlaoise hospital has come under the governance of the Coombe hospital. They are part of the group that the Coombe and Portlaoise hospitals are in. In Cork or in the National Maternity Hospital, which is part of the Ireland east hospital group, there is a master responsible primarily for the National Maternity Hospital but one would also have directors of obstetrics and maternity services, including gynaecology in the smaller units but reporting in to the main unit. In Cork it would include Tralee and Clonmel and so on. That is the way it works. The term master can sometimes get up peoples' noses but we think of it as the master mariner, the master of a ship as the captain of the ship, the team captain and so on. That is the way to look at it. Part of the whole mastership model, the really important element, is that the master has control of the budget and that there is a protected budget for maternity services and for women's health services. Cork is a prime example of what goes wrong when they do not have a separate budget that they control. Professor Kenny will address that issue in a bit more detail. I believe she has personal knowledge of it.

With regard to ultrasound services being available, the service availability is very sketchy around the State. The three Dublin maternity hospitals offer 20 week scans to everybody. They get them as a matter of routine. The advantage of knowing if there is a problem is that we can alert the parents to it and we can involve the paediatricians in planning for the outcome. For example, if a congenital heart defect is detected then the paediatric cardiologist will come to the hospital to meet with the parents. This would also happen if there are neurological problems such as spina bifida. A neurosurgeon would come to the meetings and discuss the management of the case, meet with the parents and plan for the outcome.

Deputy O'Connell asked about ethical issues. It is interesting that in the past when amniocentesis was a way of diagnosing problems that the Catholic Church had no problem with amniocentesis and knowledge; it is what is done with that knowledge that causes difficulties for the church. I imagine that the same holds with the fact of diagnosing problems that a baby might have in the womb. What the parents do with that information is a matter for them, involving their own doctor and their own backgrounds, belief systems and so on. Professor Kenny will address the ultrasound issue in a little more detail on what are the implications of the follow on from making the diagnosis and foetal medicine services. It is also important to realise that problems can arise later on in pregnancy. For example, where a baby is not growing correctly it needs intensive monitoring with ultrasound also. Those services are very deficient around the State.

The last issue related to gynaecology services. I have no idea why gynaecology was left out of the maternity strategy. I was not involved in its development in any way. From the point of view of maternity services it is a very good strategy and we support almost everything in it. Gynaecology is complementary. A woman does not stop having an involvement with the services that obstetricians, gynaecologists and midwives provide when she stops having children, or if she is trying to have children. The services are very closely interlinked and it makes no sense for us not to have the gynaecological service. Gynaecological services are effectively the Cinderella of our health services and are the first to get cut when there is any type of problem with bed allocation and so on. The question was asked on how many women pay for a scan. For us it is hard to say but the member is absolutely correct in saying that the poor are disadvantaged, right across the board and do not have access to the same sort of ultrasound services outside of Dublin that they do have access to in the three Dublin maternity hospitals. There is no distinction with regard to ability to pay.

Deputy O'Reilly raised the issue of community midwifery services and there is a very good model of the whole range of services out of the National Maternity Hospital with the home birth service, run by midwives from the hospital, community midwifery services where midwives deliver care in the community close to mothers' homes. There is also what is known as a domino system where a mother will have her antenatal care at home. She will come to the hospital for scans, etc., has her care at home, has her baby in the hospital and then goes home within a few hours. She is visited by the midwives afterwards. This is whole range of opportunities for care and that model should be implemented across the State. This is all I have to say in response to those issues.