Dr. Peter Boylan:

A private scanning system was developed at the National Maternity Hospital. Private patients are sent to that unit for scans. That has allowed us in the hospital to free up areas for giving every public patient a scan. There is no lack of availability of ultrasound. This comes back to the governance issue in that in a hospital with a master, one can do that. In a maternity unit integrated in a general hospital, it is well-nigh impossible to have that entrepreneurial approach to matters. One will just get slapped down and will not be able to do it.

It is well recognised that we need an extra 100 consultants but, clearly, they cannot be appointed at the one time. That would not be good practice in fact. We need to get ten a year over the next ten years, plus replacements for those who retire. Those numbers are absolutely predictable. So far, there has been very little movement on that. The committee could ask the Health Service Executive, HSE, as to what movement there is to replace consultants and how it will make it more attractive for them.

As to the question on the governance model and whether smaller units would be closed, it ties in a little bit with the question of home births and risk stratification. Most obstetricians have grave concerns about home birth because a birth is only safe once it is over. The nature of obstetric practice is that things can happen very fast and unpredictably. Having said that, I would be personally comfortable with women having their second or subsequent children at home if they are in a low-risk category and if their first baby was a normal birth. The majority of problems in obstetric care arise in women having their first baby. That is well documented. Obviously, there are some women who will try and have their first baby at home. A home birth service is run out of the National Maternity Hospital. A substantial proportion of those women are referred into the hospital during the course of their birth, mainly for pain relief because they want an epidural, which can only be given in hospital, or the labour is too slow. If done within the proper governance structure, home births can work.

Over time, the smaller units will probably deliver women who are very low risk. This means they will deal with very few women having their first baby and more women having their second and subsequent children, where the first one was normal and the anticipation is that there will be no adverse outcome, although one cannot be sure until the whole thing is over.

It is something that will probably evolve over time and my impression is that this is how the smaller units will evolve. It is not a recommendation. It is just an impression and I think that is probably what is going to happen.

Deputy Kelly asked about funding models. The cancer strategy is a good model. In this case, one had a protected budget run by a clinician who was able to implement a strategy for the development of cancer services. The same sort of model could be implemented to develop and implement the maternity strategy in future years. There has been an appointment to the national women and infants' health programme office. I am not sure whether that has been made public yet but a very highly qualified person has been appointed who will be superb at doing this job. The hope for us is that this office, the HSE and the Department will work together to implement the strategy in a phased way because it cannot all be done overnight. That is not the way things work. In response to Deputy's Kelly's question about whether it will happen, not all of it will happen. Nothing ever does but we would hope that some of the things will happen. The three issues I listed that were elaborated upon by Professor Kenny are things we certainly feel are essential. The more one talks about maternity services and the maternity strategy, it all comes back to governance, budget and governance models. The reason there are so many problems in Cork, which is a classic example of a hospital which is the same size as the Dublin maternity hospitals, is because of governance. It is integrated into the main hospital so it has no control over its budget, staff appointments, midwifery numbers and so on. It cannot open the operating theatres and has lost millions from its budget from the years because it is integrated into the general hospital. It is a failure. It is not working and women are suffering as a consequence with some women developing cancer in the community as we speak because of the failure of that governance model. That needs to be changed and is the single most important thing. If we have that governance model with doctors and midwives working together to implement the really important bits of this strategy first, it will allow all the other midwifery elements to be developed. The critical issues are governance, a protected budget and no integration with the general hospitals because it does not work and women and babies suffer as a consequence.