Dr. Peter Boylan:

Several points have been raised, some of which are overlapping. With regard to the complexity of pregnancies, Dr. McKenna is absolutely correct. Women are getting older when they are having their children, particularly their first baby. Many of the complex problems associated with assisted reproduction are the result of donor egg pregnancies. One finds women in their late 40s and perhaps into their 50s presenting with pregnancies, sometimes with twins. They also have hypertension or diabetes so their pregnancies are far more complex than would have been the case a decade ago. This presents particular challenges for management. It places extra demands on those consultants working in the system.

Women are also coming through who have survived as a consequence of excellent neonatal care. For example, women who had surgery as newborn children for complex cardiac conditions are now coming through and reaching the time when they are having children. This is obviously another area, so there are a lot of complex medical problems among women at the moment and things are becoming more complex. Of course, obesity is a major issue in Irish society.

Regarding the litigious nature of the job, pregnancy is generally expected to be a happy event where everything goes very well normally and one gets a healthy baby at the end of it. Consequently, when things do not work out, the consequences - the disappointment, anxiety and grief - are much more accentuated than if somebody goes into hospital with a long-term illness and maybe dies after surgery or after being in hospital for a prolonged period. The expectations are different from the rest of medical practice. When things do not work out as expected, the natural inclination of people is to wonder what went wrong, why it went wrong, whether anyone is to blame for this or whether it was a mistake or a negligent mistake where people did not take due care. That places an extra strain on people working in the system. When something goes wrong, such as when a baby dies or is damaged as a consequence of a human error, the people working on the ground need to be regarded as the second victims in this scenario. They feel it deeply, particularly the midwives, because in crises they are of tremendous assistance but they are not the ones making the decisions. They may sometimes see things happening with which they disagree and they are right, so for them to see something go wrong and to know that the doctor has done something wrong but has ignored their advice is particularly hard on them. Young trainee midwives go into it and see many happy births - it is a tremendously rewarding profession - then something goes wrong and they are in the midst of this maelstrom of grief, anger and blame.

One of the problems we have, which relates to the retention of staff, is the fact, as mentioned by Dr. McKenna, that sometimes there may be three or four consultants staffing a smaller unit. With holidays, study leave and so on, that works out at each consultant being on call every third 24-hour period and every third weekend from Friday morning until Monday morning when they carry the entire responsibility for what is going on. What frequently happens is that a locum or an agency doctor consultant will be brought into a smaller unit over the weekend. In a bank holiday scenario, the agency consultant will have come on duty on the Friday. In the event of a catastrophe at 9 p.m on that Friday, the consultant who had been attending to the patient will have been away and will come back on the Tuesday morning after the bank holiday. There may well have been agency midwives as well. The woman will have gone home but nobody will have informed the consultant or the midwives working on the ward and they are all very busy running around. The woman will go home and effectively is almost abandoned. When the consultant meets her - possibly because the general practitioner will have contacted the consultant - he or she does not really know an awful lot about the case and is taken unawares. That is one area where the network development is very important. It is in its infancy and it will take time. If one has a network, one will have audit of all of the outcomes - all of the births, caesarean sections, adverse outcomes and so on - as is the model in the larger units, particularly in the Dublin hospitals on a weekly, monthly and annual basis. It is like running any good business. People running a hotel need to know how many guests they have, how many were happy, how many were disappointed, bed occupancy and revenue per room etc. In the same way, from a clinical perspective one needs to know what is happening to the women coming through the door with regard to their outcomes, how many of them got infected, how many had blood transfusions, how many had caesarean sections, how many babies went to the neonatal unit etc. All of that needs to be done continuously. This is where the network audit system that is being instituted by the office is extremely valuable and will make a huge contribution to improving safety and quality in the future.

The other thing about working in a smaller unit is that by virtue of the on-call commitment these consultants have, they will run out of their pay for being on call to such an extent about halfway through the year or maybe earlier. After that, they are working for the State on call for free. That is a problem. I do not think any other person working in the health service would work for free. We would not find the porters, laboratory people or anybody else saying it was fine and that they had earned their cache of overtime for this year and would work for free overtime for the rest of the year. I do not think that would happen but consultants have been doing that for years. That is a problem that needs to be addressed.

I have spoken about the recruitment and retention of consultants. It may well be that if a new contract is negotiated with the Irish Hospital Consultants Association and all the consultant groups, it may evolve into something along the lines of the Australian model where doctors get paid for their public commitment and have a choice as to how much public commitment they give. They have a choice as to how much public commitment they give but they must give a minimum. So one may find a doctor who says they want to give four sessions a week to the public service and spend the rest of their time in the private sector. They only get paid for their four sessions in the public service with a relevant contribution to a pension fund which they can manage themselves. That is a huge advantage to the State. It works for the doctors because they can do what they want in terms of commitment to public or private practice and it works for the hospital because it knows exactly what the doctor is due to be doing. It is a system that works very well in Australia so it is something that might be worth looking at.