Oireachtas Joint and Select Committees
Wednesday, 25 February 2026
Joint Oireachtas Committee on Health
National Maternity Strategy 2016-2026: Discussion (Resumed)
2:00 am
An Leas-Chathaoirleach:
I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit members to participate if they are not adhering to this constitutional requirement. Therefore, members who attempt to participate from outside the Parliament will be asked to leave the meeting. In this regard, I also ask members participating via MS Teams that, prior to making their contribution to the meeting, they confirm they are on the grounds of the Leinster House complex.
Today, the committee will resume consideration of the National Maternity Strategy 2016-2026. The consideration builds on last week's meeting on the same matter when the committee met the Pregnancy Loss Research Group, Féileacáin and the INMO.
I welcome from the Health Service Executive: Dr. Colm Henry, chief clinical officer; Ms Roseann Killeen, integrated healthcare area manager, HSE Dublin south east; Mr. Kilian McGrane, national programme director, national women and infants health programme; Dr. Clíona Murphy, clinical director; Ms Angela Dunne, national lead midwife; and Professor Richard Greene, director, national perinatal epidemiology centre and chief clinical information officer; and from the Department of Health: Ms Tracey Conroy, assistant secretary; Ms Rachel Kenna, chief nursing officer; Ms Mary McGeown, principal officer; and Ms Linda O'Connor, principal officer. I welcome them and thank them for the work they are doing in the positions they occupy.
Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that may be regarded as damaging to the good name of a person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative they comply with any such direction.
Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable.
I invite Dr. Henry to make his opening remarks on behalf of the HSE.
Dr. Colm Henry:
I am grateful for the invitation to join the committee this morning. I am joined by my colleagues, Roseanne Killeen, IHA manager in the Dublin south east region; Killian McGrane, director of NWIHP; Dr. Cliona Murphy, clinical director of NWIHP and consultant obstetrician-gynaecologist; Ms Angela Dunne, lead midwife; and Professor Richard Greene, chief clinical information officer and director of the national perinatal epidemiology centre.
The national maternity strategy, Creating a Better Future Together, was published in early 2016. The strategy was developed in the context of the very significant issues that had emerged in maternity care in Ireland over the previous decade and, in particular, high profile tragic cases in Galway University Hospital and the Midlands Regional Hospital Portlaoise. The publication of the strategy in 2016 and the establishment of the national women and infants health programme in 2017 were important developments in improving maternity care in Ireland, as well as in women’s health. The strategy has 77 recommendations and the implementation plan has 236 actions to address the recommendations. As of today, 98% of the actions are either complete or ongoing, and only a small number of actions remain to be implemented.
I acknowledge the HIQA recommendation that has resulted in the appointment of directors of midwifery in all 19 maternity services. This has been a very important development in enhancing maternity services.
The purpose of the strategy was to transform and configure maternity care around four pillars: improving health and well-being for mother and baby; ensuring quality and safety of the services we provide; expanding choice for the mother regarding the birth; and strengthening governance and leadership. The strategy has led to significant improvements across all four pillars in maternity services.
It is also important to note that the HSE has worked closely with a wide variety of stakeholders on improving maternity care over the past decade. This collaboration has been essential to effective implementation. In the interests of time, I will not go through the implementation plan in detail but there are a few areas I would like to highlight. Improving the health and well-being for mother and baby is a fundamental element of good maternity care. At the heart of this pillar is empowering mothers and families to improve their own health. Initiatives such as the Making Every Contact Count support reductions in smoking, alcohol consumption and substance abuse. Training has been provided to support staff to identify women at risk of domestic violence, alongside a new accessible online domestic sexual and gender-based violence training programme. National health literacy supports have also been strengthened through the My Pregnancy and My Child books, which provide consistent, evidence-based guidance from early pregnancy through early childhood, enabling informed decision-making and promoting healthy behaviours.
Colleagues in the mental health division developed a new perinatal mental health model of care, which has been implemented. The model is based on a hub and spoke structure, with consultant psychiatrists and their teams based in the tertiary sites and supporting the regional hub site. A programme of work is under way to refresh the model and ensure greater resources for the hub sites.
Ensuring consistent, high quality, safe care across our maternity services is an ongoing commitment. The maternity networks, a recommendation from the strategy, ensure that smaller units are supported and connected with tertiary centres, supported by clinical leadership and regional oversight. In addition to the regional processes, NWIHP has a national oversight and assurance role. Since 2022, 27 national clinical guidelines have been published, with a further 19 guidelines in development.
The continued rollout of the maternal and newborn clinical management system, a shared electronic health record for mothers and babies, supports improved clinical decision-making, reduces duplication and enhances communication between care settings, while also strengthening audit and safety surveillance. One area of particular focus has been babies who suffer a brain injury at birth, requiring treatment with therapeutic hypothermia. NWIHP established the obstetric event support team in 2021 as a mechanism to promote shared learning from these adverse events and, where possible, reduce the occurrence.
Choice has expanded through the new model of care for maternity service with the three care pathways of supported, assisted and specialist. The new model of care is about ensuring that women, working with their clinical team, can determine the most appropriate pathway for themselves, guided by the clinical advice. For the supported care pathway, care is provided by a midwife and is suitable for normal risk women. The objective in the implementation plan was that 30% of women would be offered access to the supported care pathway. By 2022, 33% of women had been offered access.
Investment in governance and workforce has underpinned maternity reforms. Since 2016, funding of €80 million been invested into women’s health, transforming maternity services for women and babies. Investment has funded over 567 additional whole-time equivalent, WTE, healthcare professionals, including 44 consultants and 382 additional nurses and midwives. This investment in front-line staff has been a critical element of the implementation of the national maternity strategy. There are some workforce challenges, particularly for some of the regional maternity services but increasing the workforce by more than 550 in ten years is a very significant development.
While acknowledging the progress made over the past decade, there is still much work to be done. There remain inconsistencies in service provision in some parts of the country, particularly regarding access to the supported care pathway and home births. As outlined to the committee last week, we have more work to do to sustain the changes in bereavement care and early pregnancy loss. This involves working with our regional executive officer, REO, colleagues to ensure critical services, like bereavement care, are prioritised even when hospital services are under pressure.
A number of maternity services have challenges in recruiting and retaining key staff, particularly midwives. As referred to earlier, we have implemented the perinatal mental health model of care but significant additional mental health supports are required to meet an ever increasing demand for services.
Our maternity infrastructure remains challenging. The move of the National Maternity Hospital to St. Vincent's University Hospital, SVUH, campus is progressing but there are challenges in other maternity hospitals, including the Rotunda Hospital, the University Maternity Hospital Limerick, the University Hospital Galway, the University Hospital Kerry and South Tipperary University Hospital.
Colleagues in NWIHP have commenced a review of the implementation of the strategy. This is a systematic piece of work designed to assess the impact by the implementation of the strategy. In addition, this work will highlight areas that require attention in the next maternity strategy.
It is important to recognise that Ireland’s maternity population has changed significantly over the past decade. Families are starting later, clinical complexity has increased and services now support a more diverse population. Rising maternal age, a higher body mass index, BMI, underlying health conditions and the introduction of a public fertility service may further increase complexity and demand.
While the current strategy has delivered meaningful change, moving maternity services toward safer, more consistent and woman-centred care, the aforementioned challenges will be important considerations for next strategy. The next phase provides an opportunity to consolidate progress, address any remaining inconsistencies and respond to the evolving needs of the maternity population. We look forward to continued collaboration with our colleagues in the Department and other key stakeholders as this important work progresses. This concludes my opening statement.
Ms Tracey Conroy:
I thank the Leas-Chathaoirleach and committee members for the invitation to speak about the national maternity strategy and the progress made so far in its implementation. I am joined by my colleagues, Rachel McKenna, chief nursing officer, Mary McGeown, principal officer, and Linda O’Connor, principal officer.
I want to say at the outset that we have listened very carefully to the voices of women and advocates for our maternity services. We very much appreciate their helpful interventions directed at improving services, including the evidence provided to this committee last week. We look forward to facing the challenges as we progress to the next phase of strategic planning for maternity services nationally.
The national maternity strategy, Creating a Better Future Together 2016-2026, is, as the committee members are aware, in its final year. When the strategy was launched in 2016 it set out a clear and ambitious vision to provide safe, high-quality, woman-centred maternity care where women and their families are at the heart of decision-making. It committed us to moving away from a one-size-fits-all model towards a system that recognises differing needs, clinical risk and personal choice.
Over the past decade, that vision has guided the reform of our maternity services across its four pillars. First, a health and well-being approach to ensure that babies get the best start in life. Second, that women have access to safe, high-quality, nationally consistent, woman-centred care and that mothers and families are supported and empowered to improve their own health and well-being. Third, that pregnancy and birth are recognised as a normal physiological process, and insofar as it is safe to do so, a woman’s choice is facilitated. Fourth, that maternity services are appropriately resourced, underpinned by strong and effective leadership, management and governance arrangements, and delivered by a skilled and competent workforce in partnership with women.
Over the lifetime of the strategy, as Dr. Henry has said, more than €80 million of revenue funding has been invested in new developments across maternity and gynaecology services, with more than €28 million of this directed specifically through maternity strategy funding. More than €100 million of capital funding has been directed to improving maternity unit infrastructure. This includes the progressive rollout of the maternal and newborn clinical management system, and providing improvements such as home-from-home birthing rooms, the refurbishment of wards and the provision of bereavement suites. Longer-term capital projects, such as the new national maternity hospital, continue our programme of modernisation.
Since 2016, over 567 additional WTE staff have been funded for maternity services through the national maternity strategy. This includes over 390 additional nurses and midwives, 44 additional consultants, and 53 additional health and social care professionals. Recruitment remains a challenge in some areas but staffing levels today are significantly higher than at the outset of the strategy. We have also expanded roles in bereavement support, perinatal mental health and specialist midwifery, recognising that maternity care is about more than the birth itself.
The national women and infants health programme was established, under the strategy, to lead the management, organisation and delivery of maternity, gynaecology and neonatal services. Our maternity services have been transformed through the progressive implementation of all 77 recommendations of the strategy. Now in its final year, as Dr. Henry has said, the programme is reporting that 98% of the 236 associated actions of the strategy are either implemented or in progress.
The voices of women were central to the design of the strategy. Therefore, service-user voices are embedded in our governance structures, reflecting our commitment to meaningful engagement. In December 2025, HIQA published the results of the second national maternity experience survey, following on from the inaugural survey in 2020. Over 3,300 women who recently gave birth responded, and their input has been worked into quality and improvement plans.
The feedback from the 2020 survey highlighted the need for improved postnatal care in the community. In response, we are developing a network of postnatal hubs. This week, the Minister announced and launched four new postnatal hub services, which provide midwife-led care for women and infants in the community following birth. This follows the successful pilot and independent evaluation of the first five postnatal hubs. The number will be increased by a further four postnatal hubs later this year. That will bring the national network of postnatal hubs to 13 out of 19 maternity units.
The cornerstone of the strategy is a new model of care. There are three pathways of care - supported, assisted and specialised - based on clinical risk and women’s choice. This has been supported by additional nurses and midwives, increasing availability of midwife-led care and expanding community-based care.
Through the strategy, we have strengthened the governance and safety of maternity services. NWIHP has driven a co-ordinated national approach to clinical standards, audit and quality improvement. This has been enabled by the establishment of six new maternity networks, each supported by a full-time quality and patient safety manager, funded through the strategy.
We have implemented a range of new measures to support the quality and safety of services. All units now provide all pregnant women with access to dating and anomaly scans. NWIHP has also enhanced training and supports for staff across a wide range of areas ensuring greater national consistency. In 2022, NWIHP established an obstetric events support team to provide objective oversight of adverse events in maternity units, with a focus on learning.
We have advanced both bereavement care, and perinatal mental health care, to ensure greater support for families who need it the most. NWIHP is implementing national standards for bereavement care, ensuring consistent and compassionate support for families experiencing pregnancy loss or neonatal death.
We have prioritised perinatal mental health through a new specialist perinatal mental health services model of care. Dedicated perinatal mental health services are now established across all 19 maternity units and hospitals nationwide, with specialist teams supporting women during pregnancy and in the postnatal period.
The context in which this care is being delivered has evolved over the lifetime of the strategy. Ireland’s birth rate has decreased but complexity of care has increased. Our strategy was deliberately ambitious, and unapologetically so, and our understanding of the challenges it sought to address has grown over the last ten years. The direction of travel has been consistent with a focus on the safety of our services, stronger governance, expanded community care, enhanced mental health supports and a more woman-centred model overall.
A full assessment of the delivery of the strategy will form the bedrock for its successor, as committed to in the programme for Government. This will include learnings from the National Maternity Experience Survey 2025 to ensure that women’s voices and experiences remain at the centre of maternity policy. We will continue to improve our maternity services in line with broader health reforms under Sláintecare. The establishment of HSE regional health areas provides opportunities to drive further improvements in maternity services within each region, with NWIHP overseeing and ensuring national consistency.
The national maternity strategy has driven an ambitious programme of reform across a complex and sensitive area of healthcare. The improvements in available services, national consistency, safety and standards and staffing are tangible but there is much more to do. We will build on the progress to date and listen to women and their families in planning for the successor to the strategy.
Martin Daly (Roscommon-Galway, Fianna Fail)
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I thank both the HSE and the Department for coming in and for their comprehensive statements, which I have read. Fortunately there has been a lot of progress in this area but there is a lot to do yet, I imagine, and the officials probably agree. The Department spoke of €100 million in capital funding in ten years. Am I correct that is the right figure?
Martin Daly (Roscommon-Galway, Fianna Fail)
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That is minuscule in the context of the overall budget. That would seem to be a very small amount of money to invest in our maternity and gynaecology infrastructure - the two go hand in hand - compared with the investment we are putting into the children's hospital, for example. There are deficits in obstetric unit infrastructure right around the country. Often they are the least pleasant places to be in the hospital. How does the Department feel about that?
Martin Daly (Roscommon-Galway, Fianna Fail)
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To me, €100 million buys ten primary care centres, approximately. I would not be lauding this as some sort of achievement. That is my only observation. I am not attacking the Department or anything but I certainly would not be lauding it. We were in the Rotunda last night. That is emblematic of what is going on. We are supposed to be getting a new maternity hospital at St. Vincent's in Elm Park. What is happening with that? How are we going to drive that forward? The women of Ireland deserve better.
Ms Tracey Conroy:
I have responsibility for acute hospitals policy nationally so I am very conscious of competing priorities and there are a whole range, obviously, of capital infrastructure projects we are very keen to move forward. Maternity services are an area very close to my heart. I have been involved in it since the outset and we are very deeply committed to this policy in the Department, as is the Minister. Maybe I will focus on what that €100 million has achieved in the first instance and then talk about where we want to go.
Martin Daly (Roscommon-Galway, Fianna Fail)
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In fairness, Ms Conroy has laid a statement and I have limited time but I accept-----
Ms Tracey Conroy:
Okay but €20 million of that funding has advanced our information-sharing infrastructure, so the maternal and neonatal clinical management system and capital investment, through successive capital plans and under the maternity strategy, has modernised facilities. Of course we always want to do more. We have made maximum use of that funding-----
Martin Daly (Roscommon-Galway, Fianna Fail)
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I understand that but-----
Martin Daly (Roscommon-Galway, Fianna Fail)
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We have come from a very low base with the digitalisation of maternity services. At least it is moving ahead compared with other services within the hospital sector.
Martin Daly (Roscommon-Galway, Fianna Fail)
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However, we have an awfully long way to go as we are so far behind. I thank Ms Conroy for her answers but I just have limited time.
What about access to services for people who are vulnerable, people in lower income groups and in particular parts of Ireland? I am speaking to Dr. Henry here. Are we making enough effort to get into those communities with outreach services and so on? We see a lot of centralisation. We have to have safe services but it cannot be all or nothing. We have got to have our safe centres for more complex births and pregnancies but we also need to be reaching out to communities to people in the new Irish community and the Traveller and Roma communities. People in areas of deprivation cannot get to an antenatal clinic. There is no point in having this castle in the sky somewhere in the city.
Dr. Colm Henry:
Obstetric care has changed. We have seen a falling birth rate and a more diverse population, as the Deputy pointed out. We are also seeing a greater proportion of deliveries from migrant women. It is about one in five or one in four and is probably going to rise further. That poses particular challenges. We are also seeing a rising age for women having their first pregnancy. In addition, we are also seeing higher rates of comorbitiy, which are perhaps higher among certain groups. A challenge looking forward, which we did not anticipate to the same degree back in 2016, is how we address the needs of a population which are fundamentally different from those we faced in 2016 and the issues we faced then. In specific answer to the Deputy's question, we have our system of quality in patient safety where we pick up on signals from the system, which point towards the need to tailor antenatal care more towards the migrant population, where individual units have provided translation facilities. We need to reach out more to avoid late bookings and all the other behavioural issues or access issues that may impinge on outcomes of care.
In gynaecology, which I can cover briefly, we have seen a doubling in referrals since 2019. It is a huge number of referrals, so we have greatly increased our capacity and we now have 19 ambulatory units. Our long stayers have greatly reduced but certainly there is a change in the profile of the population. Dr. Murphy might provide additional information on migrant populations.
Martin Daly (Roscommon-Galway, Fianna Fail)
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I will ask a question, which might fit into the answer, because I am down to two minutes. There are references to networking and joint governance, which are hugely important. We live in a small country but we have a dispersed population. We have had issues in some units. We want the highest-quality, safest care for women who are delivering their babies but we also need accessible care. For example, at Portiuncula Hospital there was a suggestion at the outset of the crisis this time last year that a very good diabetic service was going to be closed down. That made no sense to me. If you have a very good outlying diabetic service for gestational diabetes in a clinic you can do that there and you can still manage the complex delivery if it has to be in a centre. My concern is that with Portiuncula there was the Walker report in 2018 which described a one hospital two sites project, joint governance and then suddenly there was this abandonment of it. I still have not been given a reason it was not workable by anyone. Galway said it was not workable. Why was it not workable? Why was it not made workable? It is important because as we go further down we need the smaller units to be supported robustly, governance-, standard- and quality-wise in order to keep those units open because we need accessible units. We cannot just abandon everything.
Dr. Clíona Murphy:
Yes, absolutely. To talk about ethnicity and our underserved communities, there has been a lot of focus on that in the past few years and the HSE has collaborated with UCC on some research on that. What has been found is some of the barriers are not necessarily distanced but information and knowledge about our health service. Some of these women are coming from populations where they have not had the same access to healthcare. Some of the feedback was very positive but there are areas we can improve and our health service is very motivated to try to do that. One of the ways we have successfully improved is there was a project with the Roma community in Dublin where we linked with the Roma intermediaries, if you like, and they were able to explain to the Roma community what services were there and how they could access that. Similarly, with our Traveller community we know we can do better but it is about doing those interventions with members of the community so there is a better understanding on both sides. However, there can be things like systemic bias we all need to work against and we need to make our communication materials more accessible but there has been a lot of work in that regard.
The Deputy pointed to diabetic clinics and things like that. We recognise our diabetic population is increasing. From 2014 gestational diabetes might have been at a rate of 4% or 5% and some units now have up to 16% and it is true that it is not feasible for all those to be in a large urban centre. With Portiuncula there was no issue with clinics. There was a concern about intrapartum care, which is a different matter. I totally agree with Deputy Daly on making sure as many facilities that can be close to a woman's home should be open to her. The link with the intrapartum care is then where it should be.
David Cullinane (Waterford, Sinn Fein)
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I will start with Dr. Henry. Obviously, we all want to see safe maternity services. Reference was made to Portiuncula hospital. I understand that there were 12 reviews and that most of these have been completed. The last time I checked, five were ongoing. Have they been completed?
Dr. Colm Henry:
Not yet. We are expecting them to be completed in this first quarter, by the end of March. However, seven reviews have been completed by external reviewers, including by Dr. Sam Coulter Smith, the former master of the Rotunda. The recommendations in these pertain to multidisciplinary teamwork, communication, care after bereavement, clinical pathways, and communication within teams. The external team is working with the-----
David Cullinane (Waterford, Sinn Fein)
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I know all of that. Hopefully, the 12 reviews will be completed by the end of March or sometime in the first quarter.
David Cullinane (Waterford, Sinn Fein)
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What are the next steps at Portiuncula? Is a resumption of services on the table, subject to what emerges from the reviews? What is the current position of the HSE regarding Portiuncula?
Dr. Colm Henry:
In broad terms, the two approaches relating to the recommendations involved implementing the existing recommendations and addressing any concerns in regard to communication within teams, clinical pathways, care to mothers after birth and communication with families. This involves an active piece of work that has been led by the external team. The external team remains on site. We have two priorities, one of which is to address the immediate safety issues. There have been no new serious adverse events reported for some time at Portiuncula. The second priority is to ensure that we stabilise and enhance the existing services at Portiuncula hospital.
I remind the Deputy, considering that we are talking about the strategies and having regard to supporting a care pathway, our aim was for 30% of women to be covered by that pathway. The rate is now 33% nationally. It is exactly places like Portiuncula that are well placed to deliver the support and care pathway.
David Cullinane (Waterford, Sinn Fein)
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I have that. I thank Dr. Henry.
I have a policy question for Ms Conroy. We have all seen what happened at the Rotunda Hospital in the past couple of months. It was very unsatisfactory, to say the least. I am referring to the overturning of the planning application. There are also questions in relation to co-location with Connolly Hospital. In what year did it first become policy?
David Cullinane (Waterford, Sinn Fein)
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That is fine. It was 2015. I just need short answers. How much has been spent on it so far?
David Cullinane (Waterford, Sinn Fein)
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All costs. Some costs have been incurred, I take it.
David Cullinane (Waterford, Sinn Fein)
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No. All costs. Has any money been spent on this?
David Cullinane (Waterford, Sinn Fein)
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I am just trying to get some information.
David Cullinane (Waterford, Sinn Fein)
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In 2015, it was accepted as policy.
David Cullinane (Waterford, Sinn Fein)
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No money has been spent on it since. Where are we right now?
David Cullinane (Waterford, Sinn Fein)
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Yes. What is the plan?
David Cullinane (Waterford, Sinn Fein)
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We know it is Government policy. We have established that.
David Cullinane (Waterford, Sinn Fein)
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No. Ms Conroy should bear with me for a second, because I want straight answers. She told me the policy has been in place since 2015.
David Cullinane (Waterford, Sinn Fein)
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No money has been spent since, which means nine years.
David Cullinane (Waterford, Sinn Fein)
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Yes, but I am asking about the Rotunda.
David Cullinane (Waterford, Sinn Fein)
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I am sorry, but I am asking about the Rotunda Hospital. What is the plan right now? What is the timeframe Ms Conroy envisages for co-location, if it is to happen at all?
David Cullinane (Waterford, Sinn Fein)
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I am asking about the Rotunda.
David Cullinane (Waterford, Sinn Fein)
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The phrases "some distance into the future” and “down the line” do not answer the question. This is part of the problem in relation-----
David Cullinane (Waterford, Sinn Fein)
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Sorry, Ms Conroy, but it is my time.
David Cullinane (Waterford, Sinn Fein)
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I do not have two minutes. You need to answer the questions directly.
Ms Tracey Conroy:
May I talk about the Rotunda for the moment, if that is okay? The Minister has been really clear about her deep disappointment over the decision of An Coimisiún Pleanála to overturn the decision of Dublin City Council. Regarding the Rotunda, the priority is to deliver the critical care wing that is needed for babies. We are working with the master of the hospital. He is exploring all options in this regard. We are working with the master and colleagues in the HSE, including those in the HSE Dublin and north east to explore all options. That is the priority.
David Cullinane (Waterford, Sinn Fein)
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I have given Ms Conroy time now.
David Cullinane (Waterford, Sinn Fein)
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I am sorry but, with respect, I am asking a question about the future plans. I will come in a second to the proposal for the critical care wing, on which the decision was overturned. I am specifically asking questions about the co-location plan. What the master and others in the hospital are saying is that uncertainty over the policy has led to some of the problems. They want to stay where they are and do not believe co-location is ever going to happen. We can see from Ms Conroy’s answer that the policy dates from 2015 and that no money has been spent since. Nine years have elapsed-----
David Cullinane (Waterford, Sinn Fein)
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I am asking about-----
David Cullinane (Waterford, Sinn Fein)
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With respect – I am asking for the Chair’s indulgence here – I did not ask about Limerick or the Elm Park site.
David Cullinane (Waterford, Sinn Fein)
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I am asking about the Rotunda Hospital specifically. I know what is happening in Limerick and at Elm Park, so Ms Conroy should please answer the question in relation to the Rotunda Hospital.
David Cullinane (Waterford, Sinn Fein)
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Could I ask the question again?
David Cullinane (Waterford, Sinn Fein)
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Has the Department any timeframe or date?
David Cullinane (Waterford, Sinn Fein)
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It does not have any date.
Ms Tracey Conroy:
Obviously, we are restricted obviously by our capital funding. We have to prioritise within that envelope, as the Deputy will appreciate. We moved ahead with the NMH and we have Limerick at appraisal stage. It would have been envisaged that the Coombe would be next and then the Rotunda.
David Cullinane (Waterford, Sinn Fein)
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Does Ms Conroy accept that it is dead in the water? The plan is really good, and it is really disappointing that-----
David Cullinane (Waterford, Sinn Fein)
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If I could finish the question-----
Ms Tracey Conroy:
Could the Deputy just give me two seconds to answer, if that is okay? The move of the Rotunda was always going to be a project for the medium to longer term. That is why we are so keen on and supported the development of the critical care wing and why we are so deeply disappointed that the decision of Dublin City Council was overturned.
David Cullinane (Waterford, Sinn Fein)
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I have given you time to answer that.
David Cullinane (Waterford, Sinn Fein)
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You are not answering the question, so I am going to put it to you again. You are saying that the critical care wing is now a priority. I accept that it is needed. We have engaged with the master of the hospital. I have been there and I accept that it needs to be done. It will involve a significant investment of up to €100 million. It does not make sense, if there is investment at this level, to press ahead with a co-location plan, for which the Department has no date and on which no money has been spent. It is all wishy-washy and up in the air.
David Cullinane (Waterford, Sinn Fein)
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It is wishy-washy because you have not been able to tell me anything about dates. No money has been spent, and it is my-----
David Cullinane (Waterford, Sinn Fein)
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Sorry, but this is my opportunity to put questions to you. You do not have to like the questions to answer them.
David Cullinane (Waterford, Sinn Fein)
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I will finish up by making my point. It is wishy-washy. Anybody objective person listening to Ms Conroy’s answers and looking at what has happened would say that co-location is pie in the sky, that it is not going to happen, that everybody accepts it is not going to happen and that we should drive on with the development that needs to be proceeded with at the Rotunda rather than having this endless conversation about co-location that is clear to me is not going to happen any time soon, if at all.
Ms Tracey Conroy:
Co-location has underpinned the move of the NMH to St. Vincent’s. That was the first project to deliver on the co-location policy. Limerick is next. We were always mindful that it would take some time, given competing priorities, for the next hospitals, namely the Coombe and the Rotunda, to be moved. We were very mindful that there is an immediate requirement for the Rotunda now, and that is why the critical care wing was supported. It is still supported. We were really keen for it to be delivered now for the babies who need it now.
David Cullinane (Waterford, Sinn Fein)
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Babies will be 40 or 50 years of age before co-location, if we ever see it.
David Cullinane (Waterford, Sinn Fein)
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It is dead in the water.
Marie Sherlock (Dublin Central, Labour)
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I thank the officials from the Department and the HSE for attending. This is a very useful session. I am obviously going to be asking about the Rotunda. Am I correct that the Department still does not have clarity as to whether the Rotunda is moving to Connolly Hospital Blanchardstown?
Ms Tracey Conroy:
The current policy is co-location. There are very real patient safety reasons and rationales underpinning that policy and we can talk to those if necessary. The model of stand-alone maternity hospitals is not the norm internationally. That is why it was referenced in the maternity strategy a decade ago. That policy of co-location was agreed by the Government in 2015. The NMH is in line with that.
Marie Sherlock (Dublin Central, Labour)
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With respect, I am not asking about that. I want to hear about the Rotunda.
Ms Tracey Conroy:
On the Rotunda, the decision at the time in 2015 was that it would move to Connolly. Mindful that any move of the Rotunda was going to be some way in the distance, we were keen to ensure that the infrastructure would be developed appropriately in the interim to look after mothers and babies. That is why the decision was taken around the critical care wing. All options are on the table now in terms of ensuring this wing is built.
Marie Sherlock (Dublin Central, Labour)
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When the Rotunda approached the Department last year and asked it to make clear that the future of the Rotunda, whether in the short term or medium term, was in Parnell Square, why did the Department fail to do that? Did it ignore that request? Did it have good reason to decide not to do that? I do not know if Ms Conroy has read the An Coimisiún Pleanála decision-----
Marie Sherlock (Dublin Central, Labour)
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-----but it starts off by talking about co-location and it finishes off talking about co-location. As of June last year, the Department talks about the proposed relocation of the Rotunda hospital being at an early stage. If the Department wants to see the critical care wing developed, why did it not listen to the hospital and spend the €50 with An Coimisiún Pleanála, making clear that the short- and medium-term future was in Parnell Square?
Marie Sherlock (Dublin Central, Labour)
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But it did not make it clear-----
Marie Sherlock (Dublin Central, Labour)
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The Department was asked-----
Marie Sherlock (Dublin Central, Labour)
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I am not asking that. The Department was asked to write a simple letter and it failed to do so. It allowed an ambiguity as late as last July stating that the Rotunda was going to be moving. Does the Department accept any blame for the mess the Rotunda is currently in?
Marie Sherlock (Dublin Central, Labour)
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Okay. I just think that this has been a failure by the Department to make clear that the short- and medium-term future of the Rotunda was in Parnell Square and that is why we have this mess. An Coimisiún Pleanála looked at Government policy and at the parliamentary replies the Department was writing and decided accordingly.
What is the definition of "co-location"? The word gets bandied about but I am not crystal clear as to what it means.
Ms Tracey Conroy:
It is the co-location of stand-alone maternity hospitals on the grounds of acute hospitals. It provides mothers with access to the full range of medical and support services should the need arise, for example, cardiac and vascular surgery, diabetes services, intensive care facilities, haematology services, psychiatric services and many others. That was the basis of the policy in 2015.
Marie Sherlock (Dublin Central, Labour)
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What is the Department's assessment of the current arrangement between the Mater and the Rotunda? It is about 800 metres of a distance between them. It would take a slow walker about ten minutes and somebody running about two or three minutes. As I understand it, when there is a medical, emergency surgeons from the Mater come down to the Rotunda. Unlike what is being proposed with the new national maternity hospital where a woman will have to be put on a trolley and wheeled into St. Vincent's University Hospital, the surgeons actually come to the woman in the Rotunda. What is that? That is not co-location. That is something inferior, is it?
Marie Sherlock (Dublin Central, Labour)
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It is happening and the Department is saying-----
Ms Tracey Conroy:
The Rotunda works closely with the Mater. The Mater is a model 4 hospital. It is located nearby. It has what they would call a protected blue-light corridor to provide adult acute services should the need arise. What we are currently looking at is exploring the options of what can potentially be done in augmenting that. That is one of the options that is being looked at in the context of trying to ensure this critical care wing gets developed.
Marie Sherlock (Dublin Central, Labour)
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Does Ms Conroy accept that co-location with the Mater is happening in practice? If there is a medical emergency, clinicians from the Mater are coming to the Rotunda and assisting the Rotunda.
Marie Sherlock (Dublin Central, Labour)
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What is the physical distance between the theatres in St. Vincent's and the new national maternity hospital?
Marie Sherlock (Dublin Central, Labour)
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What is the physical distance?
Marie Sherlock (Dublin Central, Labour)
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There is a distance regardless of whether you are running down a public road or going through a corridor. The surgeons are coming to the woman in the Rotunda as opposed to the woman having to be wheeled along the corridor that is envisaged under the colocated national maternity hospital with St. Vincent's.
Ms Tracey Conroy:
Dr. Henry may have something to say about this but what we are talking about here and what underpins the policy is the immediate access to services when a woman is critically ill, for instance. It is about the speed of transfer. That is what underpins this. One of the things that the region would be looking at in relation to the Rotunda is pathways of care and how they can be improved. It is not just about the capital infrastructure.
Dr. Colm Henry:
The principle of co-location, a bit like the national cancer centres of which there are eight, plus one in Letterkenny University Hospital, is the physical situation of services beside one another, which in addition to the physical proximity of critical services also brings networking, joint clinical meetings and so on at a much closer level. It is true, as Deputy Sherlock says, that the Mater is very close. It is also true in the intervening period that the Rotunda has developed to a much higher degree. It is a high-dependency facility, so there are neonatal facilities. However, in any risk assessment, the infrastructure in the Rotunda is not fit for purpose. Clearly, the board of the Rotunda, the master of the Rotunda, the Minister for Health, the Department and ourselves accept that. It is not fit for purpose.
Marie Sherlock (Dublin Central, Labour)
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In the context of our declining birth rate over the next ten to 20 years, surely we should be developing services in the current existing maternity sites as opposed to looking to shut down a whole hospital and completely relocate it.
Dr. Colm Henry:
However, what is clear now is that the prospect of colocating the Rotunda with a model 4 hospital is greatly outweighed, in terms of its potential, by the exigent risk in clinical services in the Rotunda related to the infrastructure. Those risks can be addressed by the creation of the 80-bed critical care unit, which will address the needs of antiquated neonatal intensive care facilities and a high-dependency unit for women.
Ms Tracey Conroy:
There is. We need this critical care wing, and we need it for the babies now. That is why the wing was supported by the Department the whole way through the capital planning process, and it is why we are now exploring all options with the master and our HSE colleagues to try to ensure it gets delivered.
An Leas-Chathaoirleach:
I am going to move on to one or two other issues. I have raised the question of the digitalisation and computerisation of the maternity services previously. If we go back seven years, we started off with four hospitals that were fully computerised. Seven years later, it is my understanding that we are only at six hospitals. Once a system is developed, it should surely be easy to implement in the remaining hospitals. As I understand it, there are 13 maternity units where there is no computerisation. What is the programme for dealing with this?
Professor Richard Greene:
Where we are at the moment is that we are covering about 70% of the deliveries in the State and over 80% of the babies' neonatal beds are covered by the system. In fact, the plan is to expand to a further four units starting this year. That includes finishing out Dublin and the north east with Cavan and Drogheda and taking in Mullingar and Portlaoise. That planning is about to kick off any time soon.
The Leas-Chathaoirleach asked why it had taken so long. The reality is that a number of issues arose. One was related to the hosting. It is not all about just putting it into the hospitals. There is a whole hosting system in the background, and the hosting that was put in place for the first round of hospitals had to have an investment in it. It went through at a period when digital was changing from fixed posting in boxes to moving to the cloud and stuff like that. That was undertaken and it took about a year to 18 months to achieve. The planning for the subsequent units, which were Limerick and the Coombe, took place and they went live in 2025.
Professor Richard Greene:
Assuming the four units go ahead and get done in the next 12 months, which is the plan, there is a plan then to probably finish out the cohort in the south and south east and then go into the north and north west. Inevitably, there is also the whole national plan around the electronic health record.
An Leas-Chathaoirleach:
The new children's hospital will be fully computerised. Will the system in the maternity units be able to connect in? For example, if a baby is transferred from a maternity unit to the new children's hospital, will the computer systems be similar or will there be difficulties? Has that all been worked out?
An Leas-Chathaoirleach:
I want to touch on one other area relating to the smaller maternity units. A lot of them have gone from having two or three consultants to five or six consultants. The number of deliveries in lot of those units is under 1,500. Therefore, there is a question about the skill set of the people working in those units. What programme is in place to deal with that? They are not dealing the same volume as staff in CUMH, the Rotunda or the Coombe?
Dr. Clíona Murphy:
The Leas-Chathaoirleach makes a very good point. We have moved away in medical education from "see one, do one, teach one" and volume. The emphasis now is on things like systematic programmes. We have the practical obstetric multi-professional training, PROMPT, programme, which deals with obstetric emergencies. Those smaller units have those programmes, so they are ready for an emergency that occurs less frequently than it would in somewhere like the Coombe or the Rotunda. With regard to neonatal resuscitation, there has been recent work on rolling out systematic standardised neonatal resuscitation programmes across the country with trainers, and those are then embedded in the units. They have these skills and drills that are helpful in building up the confidence of newly on-boarded staff. It helps with multidisciplinary communication with teams, which is very important with the smaller units as well.
The other thing we have got involved in is simulation. That has been found to be really important because it brings the kind of real-world stress and time factors into those skills and drills, so you are much more prepared for something when it does happen.
Dr. Clíona Murphy:
Caesarian section rates are rising in many countries. There are a number of reasons for that. Some of those are demographic. We know our population has changed. For example, in the 1970s, the average age of first-time mothers was 25. Now, it is 33, so there is the older age of mothers. We now have 400 women a year over the age of 45. Age is an independent risk factor for caesarian section. Overweight and obesity are also independent risk factors for caesarian section. That is a societal problem with regard to obesity. Unfortunately, that will sometimes reduce the chances of having an unassisted delivery and will increase the chances of having a caesarian section.
Dr. Clíona Murphy:
It is hard to know. Quality improvement plans can be put in place, but I would caution that you need to balance that. In some countries where they have seen low rates of caesarian sections, they have actually seen slightly higher instances of cerebral palsy and other adverse incidences. To be honest, you have to look at it in the entirety.
Martin Daly (Roscommon-Galway, Fianna Fail)
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Senator Costello apologises to both groups, but she has had to go to the Seanad Chamber. She will return.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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I thank the witnesses for their attendance. I will focus on perinatal mental health and the assessments and interventions that are provided for women who are pregnant but also in the immediate aftermath of birth. It is not an area that is consistent with the level of care. It is not an area that is consistent with the level of care outside perinatal health. Are the Department or the HSE measuring the unmet need in perinatal mental health?
Dr. Colm Henry:
I will begin and then hand over to Mr. McGrane. We have a hub and spoke model of care with specialist teams in 19 hospitals. We have recruitment difficulties across all units. Each of these 19 units has a link to the service and the larger units have their own teams and services. Our new postnatal hubs will address some of the unmet need.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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Is it being measured currently?
Mr. Kilian McGrane:
A refresh of the model of care is being undertaken. We have a clinical lead for perinatal mental health, Dr. Colm Cooney, who is evaluating that unmet need. Unmet need mostly happens in spoke sites, so the hubs are well resourced. We put in clinical midwife specialists into each of the maternity units to act as that gatekeeper but we know that need has increased - I would not say exponentially - but significantly over-----
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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But multiples would be a fair statement to make.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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Is there an end date for the piece of work being undertaken by Mr. McGrane's colleague?
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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I am a fan of midwife-led care. We need more of it. We have postnatal hubs and the model of care that is there but could Mr. McGrane talk me through how this looks for women on the ground? A woman gives birth in hospital and avails of perinatal mental health services. Is she then referred to the community to start on a waiting list in our community services?
Mr. Kilian McGrane:
It very much depends. Some women will come in with an underlying mental health issue, in which case they are transferred from the psychiatric service they are in to the perinatal mental health service for the duration of their pregnancy and six weeks postpartum and then transferred back out. In the situation described by the Deputy, they will be transferred back out - usually to liaison psychiatry in the community. It is one of our areas of concern because any point of hand-off for a patient between two different services can always create risk so we are very conscious of the fact that particularly for some of the vulnerable groups, this transfer out back into the community can create risk and that is being looked as part of the refresh of the model.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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What does best practice at the handover look like?
Mr. Kilian McGrane:
I cannot really comment on that as it is not my area of expertise. In the refresh of the model, we will look at how that area is addressed because a lot of that will happen in the spokes, so that is where there is a risk of women coming back out into the community without adequate supports when they have been in quite a supportive environment during their pregnancy and immediately afterwards is.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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Has the HSE identified any areas where a best practice model exists and could be replicated?
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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What is the potential impact of the gaps in community mental health services for women accessing them in terms of staffing? Has that been evaluated or is it also part of that piece of work?
Mr. Kilian McGrane:
The focus will be on the maternity side because of the perinatal component but because our colleague is a consultant psychiatrist, they will also look at the community aspect and as they work as part of the mental health division, they will also look at where people are being discharged postpartum back into the community to be part of the mental health services in the community.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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How does Mr. McGrane see that piece of work when it is finalised sitting in with the new regions?
Mr. Kilian McGrane:
It should be very complementary because everything we have in maternity is completely aligned with the regions. We have six maternity networks that fit directly with the six regions. The idea is that any model that comes up now will be considered in the context of how it can be regionalised.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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There is a commitment in the programme for Government to a HIV action plan. How are women tested for HIV in our maternity services? Are they tested? What is the level of testing? Is it an opt-in or opt-out model? Does that model reflect the need?
Dr. Clíona Murphy:
For many years, women attending maternity services have been tested. It is very rare for anyone to decline. There are very good embedded clinics in some of the larger hospitals where they have a specialist infectious diseases multidisciplinary team. That has been reflected with very low mother-to-child transmission so that has been a great piece of work by colleagues working in the area. That is reported into figures to Europe. We are doing a bit more work with regard to hepatitis and prevalence going forward-----
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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That was going to be my next question.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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There is one human milk bank on the island of Ireland. Is that advertised to breastfeeding mothers in hospital who may be in a position to donate breast milk?
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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How is it advertised? It is a genuine question. I am a mother of four and nursed all four. I stumbled across the human milk bank.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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How often is it taken up with pre-term babies?
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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Usually for very specific cases of illness. Not every pre-term baby would need donated milk.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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Or those with a heart or stomach condition.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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Is there additional work we could do in this area? I am a proponent of pump breastfeeding. The milk bank is a wonderful addition to the island but as I said, I stumbled across it. I was not aware that it was there despite already having three children.
Sorca Clarke (Longford-Westmeath, Sinn Fein)
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I accept that. What is there is functional. We could do better at advertising it to both donors and those parents of babies who may need it.
Nicole Ryan (Sinn Fein)
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The Department stated that 98% of the 236 actions under the national maternity strategy have been implemented or are in progress. I will focus on pregnancy loss and bereavement care. We heard last week that the analysis of 12 years showed a high prevalence of stillbirth and neonatal death being reported. Only a minority of mothers had a body mass index greater than 30 or smoked. Mothers' average age was 31.7 years and 40% were first-time mothers. The demographic that was disproportionately disadvantaged consisted of black, Asian and Traveller women, which is quite scary. When we look at the national maternity strategy, pregnancy loss is mentioned in two little paragraphs, one of which talks about miscarriage - spontaneous miscarriage, which is the definition for pregnancy loss. However, it does not mention other types of loss.
It also states that all couples who experience pregnancy loss should be supported psychologically by hospital staff and have access to bereavement counselling either in hospital or at primary care settings. However, working in the cross-party group with women and listening to those on the ground, we know that is not happening and that they do not get offered these kinds of supports.
Why is the committee hearing two different things around pregnancy loss and bereavement care from people on the ground who have that lived experience, who are experiencing those services every day, and another thing from the Department?
Ms Tracey Conroy:
I will bring colleagues in from NWIHP regarding the detail, but there are 77 recommendations and 236 associated actions. The organisation has done a detailed review as part of the preparation for the development of the successor to the maternity strategy.
Things have evolved over the past ten years. We have made significant progress in the area the Senator mentioned but we are looking at that now in the context of the evaluation of that progress and what we do in the successor to the strategy. NWIHP put a huge amount of work into this area and is increasingly doing so. I might bring Mr. McGrane or Dr. Murphy in to talk about that.
It has been a significant and growing focus. We listened to the evidence presented to the committee in that regard and we accept there is more to do in this space.
Nicole Ryan (Sinn Fein)
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Absolutely, but it is also quite underfunded in terms of the impact it has on future pregnancies for women and the trauma they go through. We still hear cases today where a woman will go into a service in the maternity unit and will sit alongside a woman who has just delivered, while she has now been told she is having a miscarriage or an ectopic pregnancy; you name it.
We still do not have services, and equally we do not have the bereavement nurse specialists required to deal with this level of loss that happens to many women. The funding is only starting to happen now but it is only a fraction of that. When you think of maternity services, it is a continuum of care from the moment you find out you are pregnant, until you give birth, and so on and so forth after that. We are looking at early pregnancy loss as an occurrence that just seems to happen and women and their partners are expected to just get on with it.
There is very little care and while it is evolving, is it evolving at the pace we want it to be or is it just an afterthought in the current maternity strategy?
Nicole Ryan (Sinn Fein)
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But it looks like an afterthought in the current strategy.
Ms Tracey Conroy:
If you look at the current strategy, it recognises the importance of improving and standardising bereavement care and that was ten years ago. When you look at the progress we have made in that space, it includes implementing the national standards for bereavement care following pregnancy loss and perinatal death. We have put through the strategy, with dedicated funding for specialist bereavement teams in place in all maternity hospitals and units, and with clinical midwife specialists in bereavement funded in every service.
Nicole Ryan (Sinn Fein)
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We heard last week there are still vacant posts in those spaces-----
Nicole Ryan (Sinn Fein)
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I would say that too, but it is very slow. A woman does not have time - months or years - to wait for supports, if she suffers a loss today. She cannot wait months and weeks for somebody to be recruited to support her. That is not how it works.
What specific protections are currently in place to ensure bereavement care services are not deprioritised in a hospital, when the hospital is under pressure for other services?
Dr. Colm Henry:
There are challenges and I will clarify one thing to remove any anxiety. While recognising there is a tragedy at every individual level, our perinatal mortality rates in this country are falling, if you look at the past ten years. I spoke to the master of the Rotunda who said despite all their difficulties, foremost of which is their infrastructure, the perinatal mortality rate there is currently 0.8 per 1,000, which is a remarkable achievement.
There are challenges not just in the recruitment, as was alluded to there, but also in the infrastructure. The Senator referred to privacy and the fact people may be beside each other. While no healthcare team would want to see that happen or stand over that, it is an unfortunate consequence of some of the facilities we have to deliver healthcare through. We have to make them work as best we can.
I will ask Mr. McGrane to address the current service and the gaps the Senator identified in her question.
Mr. Kilian McGrane:
We fully recognise what the Senator is saying about the importance of bereavement care. It is fundamental to compassionate maternity.
The Senator saw last week that when it is not done right, the impact lasts forever. We know that and we work very hard at it. We hear stories all the time. The symbols used for a room where a baby has just died or is in the process of dying are there so people know not to speak loudly outside. These are all very small things, but the impact this has on the family lasts for a lifetime.
I do not see an inconsistency with the completion of the strategy or where it is at present. What was said last week highlights that we do get it wrong. Unfortunately, it is more often than we would like. The resourcing will always be an issue because if you have a very busy team, a baby loss will be one of five things they might deal with that day. If that individual who is looking after that family is having a bad day, that family will never forget that. They will also not forget when they are treated well.
Nicole Ryan (Sinn Fein)
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The question specifically relates to whether the HSE ensures the bereavement specialists are not deprioritised from a service.
Mr. Kilian McGrane:
We have to work with our colleagues in the region all the time on this, as well as every other issue. At present, there are two vacancies at CMS level for bereavement. We put in 19, there are two vacancies and that will happen in any environment. Can we ensure they will always be backfilled in a timely manner? No, but our colleagues work to do that.
The commitment in the maternity units to providing the support is extraordinarily strong and they will fight locally to try to get those resources protected because they know the impact it has. As the Senator said, it is not just for the pregnancy loss that has occurred; it is also for future pregnancies, and for the family and woman's ability to come back to that hospital and feel she is going to be cared for in the right way in the future.
They try to prioritise this, but we certainly do not always get it right.
Nicole Ryan (Sinn Fein)
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I have one final quick question for the Department.
When will the submissions be open for stakeholders to submit towards the new national maternity strategy?
Ms Tracey Conroy:
We are now in the final year of the strategy, and our priority is to make sure we close out the strategy and implement the recommendations. NWIHP is currently in the process of doing its own full evaluation of the strategy, and we are going to do an external evaluation this year which will feed in-----
Nicole Ryan (Sinn Fein)
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I am not asking about the evaluation. I am asking about when other groups and stakeholders can put their submissions into the new maternity strategy.
Nicole Ryan (Sinn Fein)
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Does the Department have a timeline? Is it a month?
Nicole Ryan (Sinn Fein)
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Quarter 3 is generally when people can submit.
Nicole Ryan (Sinn Fein)
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I totally get that but I am looking at all the other external groups that work in the space such as, for instance, the Irish Travellers, Pavee Point, MASI and the Pregnancy Loss Research Group.
Can they and when will they have that input?
Martin Daly (Roscommon-Galway, Fianna Fail)
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Without being contentious, I want to come back to the issue of the Rotunda Hospital, which is an emotive issue and rightly so. It is a facility that is clearly needed. Co-location to me means physical co-location on the same site with a level 4 hospital where there is access to emergency skills other than those of obstetricians and gynaecologists, for example vascular surgeons and general surgeons. In an ideal world, co-location would mean co-locating a site in north Dublin somewhere. The Rotunda is the terminus of a journey for most women. They do not go past the Rotunda, whereas with Connolly hospital is in north county Dublin and there would be two-way traffic. I know this might be contentious but, in an ideal world, is it desirable that we would have co-location for women's health and for outcomes for their babies?
Dr. Colm Henry:
In terms of co-location, we referred to the benefits of the cancer control programme where we centralised cancer services on eight sites. The benefits it brings are integration of teams, the proximity of critical services and the networking that, as the Deputy would understand from his other life, happens between clinical teams that are on one site. There is also the integration of quality structures and patient safety structures. These all bring huge benefits. In this case, as we discussed earlier, the benefits they bring, bearing in mind the timeline, do not justify the delay in addressing the safety issues the Rotunda has now. Those safety needs relate to the infrastructure and to the proximity of beds, the multi-occupancy wards and the shared use by many people of one bathroom facility in neonatal units. As I said earlier when I was quoting the perinatal mortality rates, it is a tribute to and acknowledgement of the extremely high level of care delivered in the Rotunda Hospital by all the healthcare staff, who have managed to keep up such a high-quality service in that infrastructure.
Martin Daly (Roscommon-Galway, Fianna Fail)
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I accept that. Chair, can I yield the rest of my time to Senator Costello because she wanted to come in with a question?
Teresa Costello (Fianna Fail)
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I thank Deputy Daly. Regarding the national maternity experience survey results, in 2025, 81% of women reported that they had always felt they were treated with respect and dignity while they were pregnant. A total of 71% said they had confidence and trust in healthcare professionals caring for them during their labour and birth and 75% said that while in hospital after the birth, they felt their questions were answered in a way they could understand. A total of 79.9% said their decisions about how they wanted to feed their baby were respected by healthcare professionals. Are those percentages satisfactory? Does Dr. Henry think that 29% of people do not have confidence in their healthcare professionals?
Dr. Colm Henry:
It is never good enough. I do not mean that in any glib way. Of course we want to do better. We want to ensure that women have a high degree of confidence in their healthcare professionals, in the service and in the outcomes they want, which is a normal delivery. Some of my colleagues may wish to contribute.
Mr. Kilian McGrane:
We always aspire to do better. The survey is a moment in time. We are also dependent on those who want to express their views. We generally get those who are very happy or those who are quite unhappy. As Ms Conroy said in the opening statement, the whole maternity strategy is built on the voice of women. We set up a public-private involvement committee last year to try to re-engage with women and make sure that their views are heard, including, as was referenced earlier, the views of the groups we do not serve as well as we should.
We take the maternity experience very seriously. My colleague Ms Dunne works with the directors of midwifery in all 19 units to look at the feedback and see if there are areas where we are perhaps underperforming as a system. Postnatal care in particular came up in the 2020 maternity experience survey. We used that to drive the development of postnatal hubs, of which, as Ms Conroy set out earlier, we now have nine up and running. We will have another four coming on stream this year to bring it to 13. They are an innovative and responsive way to meet some of the needs of women. We acknowledge that sometimes those surveys do not tell us what we want to hear, but that does not mean we will not listen to them or try to build on the experiences we have been getting.
Teresa Costello (Fianna Fail)
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It was said that 90% of the 236 actions in the national maternity strategy have been implemented or are in progress. What is the HSE having trouble implementing? What is taking a long time to implement? Are there any actions that are not realistic to implement?
Mr. Kilian McGrane:
I will answer the last one first. There is nothing in the strategy that we are not in a position to do. There are a couple of areas that are taking us longer than we would have hoped. One is the review of the maternity and infant care scheme. The process has started. There is a strategic review of GP care under way, so we have to try to align it with that. Realistically, it will be quarter 3 next year for that to be completed. In our original implementation plan, we foresaw that happening earlier but it has taken us longer.
The second area that is a disappointment is the perineal clinics. It is a recommendation in the strategy that each region have a clinic to deal with whatever serious postpartum conditions arise. Four out of six are in place. We have gone through an exercise to evaluate them and we will need additional resource to bring that on stream. Hopefully we will be able to do that in 2027.
The third strand is probably infrastructure. Without going into a discussion about the Rotunda, we are very fixed on ensuring that women have appropriate environments in which to give birth and care for their babies in our maternity units. We have put in about €3 million. We have put in a number of home-from-home rooms. We have changed gynaecology suites and delivery suites. There is a lot of investment required. We have talked about the National Maternity Hospital and the Rotunda. The Coombe requires investment, as do Galway and Limerick. Dr. Henry set that out at the start. They are probably the three big areas of the strategy where there is still work to be done. We would hope to get all of them advanced further this year.
Dr. Colm Henry:
I will differentiate what remains to be done in the strategy from the challenges that have emerged since the strategy was launched, and that includes recruitment. The POCC contract has certainly improved the attraction. Traditionally, we had huge difficulty recruiting consultants to model 3 hospitals - the smaller hospitals - but that has improved. The model we have now, where there are six consultants to a site, has made the posts more attractive, sustainable and certainly safer. We face recruitment and retention difficulties. We have much better numbers but they are not evenly spread across the country. We referenced earlier the challenge we face with more complicated deliveries, such as women having their first pregnancy at a later age and more comorbidities as well as the higher migrant population, which was not envisaged in 2016 when the strategy was written.
Teresa Costello (Fianna Fail)
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What existing Traveller and Roma commitments have not been followed through? Where is the biggest room for improvement with both these groups?
Mr. Kilian McGrane:
My colleague Dr Murphy referenced earlier a piece of research done in UCC with our colleagues in Cork University Maternity Hospital, CUMH, looking at the experience of ethnic and migrant minorities. The findings were quite stark. One of the most important things was about ensuring appropriate and timely access to antenatal care. For so many of our communities, we do not reach them in the right way. Somebody earlier referenced coming up with new and different ways to do it. We would see the new maternity strategy as looking at that. Our model at the moment is designed on the old 80:20 principle; we meet 80% quite well, but the other 20% not so well. I refer to things like interpreter services. Often it is left to mechanical devices to try to interpret, which is the wrong way to do it. Perhaps Dr. Murphy, who has a lived experience of this, can give some examples.
Dr. Clíona Murphy:
One of the major things for both the women and those looking after them is access to interpreter services. We now have such a huge range of people from various countries that sometimes it can be very difficult to find them. That is not to say that it should not be worked at. In some of the research done in other countries, people have complained about being given written English. They may have enough to get by with spoken English but cannot read English. It is really important that we use everything we can to reach out to women. Otherwise, they do not know such basic things like how, if you have a severe pain or bleeding during pregnancy, you are entitled to call an ambulance. In some countries, you would have to pay for that facility. Introducing them to the health service and even introducing people to wards and what the rules of engagement are - all of those things are really important to allow people to have their voice heard within hospitals. It is important that women from other countries are able to ask for help or say they are in discomfort because, culturally, there may have been a lot of differences, for example between somebody who is a survivor from Syria compared with a woman who has grown up and gone through the education system here. We have to adapt to the new community we are serving.
Teresa Costello (Fianna Fail)
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Do the witnesses get much feedback from the staff? Is their experience of dealing with patients a big part of the survey? How much of their experience is taken on board?
Dr. Clíona Murphy:
Yes, there is a learning there. People do learn about different cultures. We also have a very diverse staff in the health service and that has been a huge help. Sometimes we are able to facilitate interpretation in that way. It can make people feel safe when there is somebody of their culture looking after them. For example, in the hospital I work in, the Coombe, our theatre staff are multi-ethnic and that is really good and helps to promote the feeling that people are being looked after well.
Ms Roseanne Killeen:
It might just be an example of the Traveller community but in my region the maternity network has been working with the early childhood programme and it has established a forum called Brighter Beginnings, where they are working with the Traveller community on antenatal education for Traveller women and men. That is progressing within the region.
Martin Daly (Roscommon-Galway, Fianna Fail)
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I have a question that has to do with training. Dr. Murphy mentioned the PROM programmes earlier on the maintenance of skills and training. One of the issues that keep arising out of difficulties in maternity units - and probably not just maternity units - is the adherence or commitment to training, upskilling and reskilling of our profession, and the midwifery profession as well. It did arise in the Walker report, and again in the Coulter Smith report. It seems to me that it is sort of left to individual units. That is one of the issues that makes me really uncomfortable - that the joint governance structure that was supposed to happen was not robust enough. It was not monitored properly or enforced properly. Enforcement is the wrong word, but the impression I got is that people had not bought into it. It is so important when you think of the obstetrics environment in terms of operations and litigation-wise, and everything else but most importantly for outcomes, and then the cost if you do not get it right. Is there any way that we can have a much more robust, uniform system? We are a small country. We cannot have people working in all these individual silos.
Dr. Clíona Murphy:
The elements are to have a standardised programme and a standardised way of doing things, whether it is neonatal resuscitation or whatever it is, but then you need ownership at a local level. It does not work if somebody comes down from Dublin and says here is the way to do it.
People do not feel empowered. We need to have leadership at a local level. Where we have the model of somebody in the hospital designated with the role of bringing everybody through, whether it is with regard to advanced life support or PROMs, it really works. We have piloted attaching foetal monitoring midwives to a unit. They will help to roll out the continuous training that needs to happen. Another important element is that it is not only mid-level doctors, nurses and midwives who would do this training but that there is buy-in at leadership level. It sends a good statement if those who are experienced keep doing this training also. This is what needs to happen. Everybody needs to buy into it.
Martin Daly (Roscommon-Galway, Fianna Fail)
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I was glad that Mr. McGrane mentioned general practice and the strategy. Sometimes general practitioners feel they are at the periphery of this and they are not really included. Sometimes they feel they may even be considered a bit of a nuisance in antenatal care. With the shortage of GPs we will have to look at different ways of reaching out to women with regard to antenatal care. There just is not the capacity there.
If a GP refers someone to an obstetrics unit for an early pregnancy ultrasound assessment they are not wrapped around immediately and brought into an antenatal system. They are sent back to the GP and a second referral has to happen for them to access an antenatal service. These are things that drive the GPs and women mad on a day-to-day basis.
Mr. Kilian McGrane:
We recognise the most important aspect of GP care, which is that women always start their care journey with GPs and will be with them throughout. We have a GP lead in women's health who works with us and with the ICGP. This is very important because it provides us with a sounding board when we are not getting things right in the design. Unfortunately, it is not unique to ultrasound. I appreciate that GPs get hugely frustrated because when they send in a referral it gets bounced back to them. I will not ask Dr. Murphy because I am sure she will say it happens in the opposite direction also. We are very open. The new strategy will give us an opportunity to look at what comes next in how we do this. As Deputy Daly has said, there is a reducing number of GPs and not every GP will sign up to the maternity and infant scheme. A lot of them want to be part of it because it is part of the lifetime care for a woman and her family. Others say it is not an effective model from their perspective. There is a lot of work to be done. We have a very good collaborative approach with the ICGP in particular at present and we will continue to do this.
Martin Daly (Roscommon-Galway, Fianna Fail)
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I thank the witnesses and I appreciate the conversation.
An Leas-Chathaoirleach:
I have several questions on adverse outcomes in maternity care. In fairness, there has been a substantial reduction in adverse outcomes throughout the country. An issue I have heard about is with regard to support for the patient or the family of the patient when an adverse outcome arises. There seems to be a closing down of support. How can this support be developed further? It seems to be a problem that eventually leads to litigation.
Where there is an adverse outcome there is a lack of support for staff, whether nursing staff, junior doctors or consultants. I am not sure there is a robust system for supporting staff. Things can go wrong and it is not any one person's fault but it does happen. Staff find themselves very isolated. I have heard of staff turning up to inquests without any prior preparation. Is there a system in each of the maternity units to give support to staff? The most important element when there is an adverse outcome is support for the patient and the family of the patient.
Dr. Clíona Murphy:
The Leas-Chathaoirleach is correct that we strive all the time to reduce adverse outcomes. The NWIHP has the obstetric event support team, OEST, which looks at three events that are devastating, which are intrapartum foetal death, early neonatal death and babies requiring therapeutic hypothermia. In any of these events there is a visit to the site. Part of this is fact-finding and making sure the incident management process is followed. All of the documentation is looked at. Part of this also involves giving some support to the team. There has been a big recognition of the impact of these events on the multidisciplinary team, particularly on more junior members including midwives and junior doctors. It is about talking it through and making sure they have support. Some new initiatives regarding psychological supports have been rolled out. My colleague Professor Greene knows about one of these in Cork. We can do more on rolling these out around the country. There has definitely been a better understanding of the impact of these types of events on staff. We need to continually strive to do this. We have had a few conferences on this topic, where psychiatrists and psychologists have spoken about it.
With respect to families, nobody would want to go through one of these instances. There is the devastation of the incident, whether it is the loss of the baby or the baby suffering a disability, and there is also the issue of open disclosure which has become more legalistic lately. This has been difficult for staff to navigate. It is also potentially difficult for families. We are still trying to find the right balance between making sure there is full disclosure and having a compassionate approach to wrapping arms around the family. In some of the busier units there is also the issue of making sure there is an appropriate space for these families, which is very important. If a couple is brought into a room similar to one they were in previously, it can have a big impact. We are working very hard on the points that have been raised.
An Leas-Chathaoirleach:
When there is an adverse outcome with a death, the follow-on to the Coroner Service is a very slow process, which does not help the situation. Has there been any effort to look at this? The Coroner Service is totally independent from the hospital but there is a delay in dealing with it which prolongs the problem for the family which has suffered a loss.
Dr. Clíona Murphy:
We have engaged with the Coroner Service. Some of my colleagues have engaged separately on the bereavement and loss side. A coroner's inquest can be up to two years later and it is hanging over the family and staff members. People from the HSE may not have experience of a previous inquest and it is important that they are supported by more senior and experienced colleagues. We have seen coronial inquests becoming very adversarial in recent years. For those who work in the law, that is the work they do but it can be difficult to be in the arena when someone is not used to it.
An Leas-Chathaoirleach:
Perhaps the Department will give us an idea on whether it has any intention of looking at this issue. There is a substantial delay in many areas. The Coroner Service is independent from the Department but it is an area that perhaps we should look at. It would help the staff and the family that has suffered a loss. Something dragging on for two, three and, in some cases, even four years has no closure. I am not saying an inquest brings closure but it would certainly be helpful with regard to the sharing of information.
Ms Tracey Conroy:
Absolutely I do. The Department of justice is actively engaging with all relevant stakeholders. We are engaging with it, and have been very actively doing so, on supporting a sustainable solution for this. This includes engaging on operational issues when they arise and looking at longer term solutions.
An Leas-Chathaoirleach:
I thank everyone for their contributions this morning and also for the work they are doing in the Department and the HSE. I also thank all the medical people, nursing staff and support staff in our hospitals for the work they are doing. While we can be critical of the health services, there has been a huge improvement in this area over the past 20 years. One improvement is the employment of additional staff, which was referred to here this morning. This is a crucial factor. Even though the number of births has reduced, we have still employed additional staff. That is extremely important. We look forward to the next national maternity strategy. I hope we will see that in the not-too-distant future.