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24 September 2015

Opening Statement by the Master, Dr Sharon Sheehan to the Joint Committee on Health

Joint Committee on Health and Children, Meeting 24th September 2015

Opening Statement presented by Dr Sharon Sheehan MRCOG MRCPI PhD

Master/CEO, Coombe Women & Infants University Hospital

 

Chairperson, Members of the Committee, I would like to thank you for inviting me to appear before the Joint Committee on Health and Children to give evidence on the "Future of Maternity Services in Ireland".

I would like to start by introducing myself to the Committee. I am Master/CEO of the Coombe Women & Infants University Hospital, the largest provider of women and infants' healthcare in the State. As a tertiary-referral university-teaching hospital, we delivered almost 9,000 babies last year.

As well as being CEO, I am a Consultant Obstetrician and Gynaecologist and have trained in both Ireland and the UK. I am a member of the Executive Council of the Institute of Obstetricians and Gynaecologists, a member of the Royal College of Physicians of Ireland and a member of the Royal College of Obstetricians and Gynaecologists in the UK. I am also a member of the national Maternity Strategy steering group, representing the Joint Standing Committee of the Dublin Maternity Hospitals.

Introduction

Thankfully, the vast majority of pregnancies result in a healthy mother and baby.

We are on the verge of  producing the first ever Irish Maternity strategy and we must ensure that each child is given the best start in life, while endeavouring to make the experience the best possible for the mother.

Ireland demonstrates one of the highest fertility rates in Europe and despite a recent decline in the national birth rate, the maternity services are under increasing pressure. The complexity of mothers attending for antenatal care is steadily increasing. Significant increases in rates of obesity, Gestational Diabetes, assisted reproduction, and co-existing medical problems coupled with advancing maternal age continue to pose challenges for obstetricians, midwives and the allied health professionals. Poor social circumstances and more recently homelessness, are adding to the complexity of care. Advances in neonatal care, particularly at the threshold of viability, and therapeutic cooling of the full-term infant to prevent Cerebral Palsy, are great success stories, but the intensity and acuity of the workload must be recognised and resourced.

In recent years, maternity services have rarely been out of the media spotlight. Much work needs to be done to restore public confidence. We must acknowledge what is working well and what needs to be improved.

Gynaecology must also be considered as all of the maternity units in the country provide gynaecology services. Following the very succesful National Cancer Control Programme, the increase in benign referrals to the non-cancer centres spiralled without any transfer of resources. Waiting lists for gynaecology outpatients are unacceptable, often exceeding 18 months. We don't have the doctors to bring these waiting lists down.

Quality & Patient Safety

Perinatal death rates continue to decline and maternal death rates are among the lowest in the developed world. Despite low rates, we must not become complacent. A death is a tragedy and learning from it must drive improvement and change.

From the most recent confidential enquiry into maternal deaths across Ireland and the UK, published in December 2014, we know that the majority of women who died during or after pregnancy, died from indirect causes, that is, from an exacerbation of their pre-existing diseases. Three quarters of women who died  had medical or mental health problems before they became pregnant. We must plan for the care of women with known co-existing medical complications before and during pregnancy. Only one third of women died from direct complications of pregnancy such as bleeding.

(Saving Lives, Improving Mothers' Care: Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-2012)

A spotlight has been shone on severe maternal morbidity over the last decade as an important quality indicator of obstetric care and maternal well-being in high-resourced countries. Learning from morbidities is important; looking at what went wrong and what went well. One of our colleagues, Dr Michael Geary, refers to "Great Saves" rather than "Near Misses", recognising when patients do receive exceptional care and when adverse outcomes are avoided as a result of this care.

Review and oversight in relation to the provision of high quality maternity services are welcome. Each of the three Dublin Maternity Hospitals produces Annual Clinical Reports which are not only published but are peer-reviewed and externally assessed each year. In addition, each of the 19 maternity units submits data nationally relating to patient safety and quality of care to a number of agencies for review, including the State Claims Agency, the National Perinatal Epidemiology Centre and the Quality Assurance Programme of the HSE Clinical Care Programme in Obstetrics and Gynaecology. These allow assessment of performance over time and most importantly, benchmarking each individual hospital's performance against national rates.

Models of care

In designing models of maternity care for the future, the principles of access, equity, appropriateness, effectiveness and value should be considered. All women should expect and receive high quality, safe, care, delivered in the most appropriate setting, by the most appropriate care provider, based on the needs of the woman and her baby. Care must be patient-centred, evidence-based and allow the woman choice.

In Ireland, the majority of maternity care is hospital-based. Much of this antenatal and postnatal care however should be provided in the community. Community midwifery services are largely confined to the Dublin hospitals, allowing the woman to access care close to home and providing continuity of care, usually with a team of midwives. Demand for these services is increasing and a nationwide solution is required.

Collaboration and multi-disciplinary teamwork are essential for the delivery of a safe and high-quality service. Too often, we get lost in the debates of midwifery-led care versus consultant-led care, high risk versus low risk, hospital birth versus homebirth, consultant-led units versus stand-alone midwifery-led units. If we revert to the principle of providing the woman and her baby with the care they need, the path becomes a little clearer. Every woman, irrespective of her risk, should have trhe benefit of a midwife caring for her. Clinical care pathways facilitate the seamless transition of the woman across healthcare providers and services based on her needs at a particular time.

It is important to define standards of care. At present, the standards of care across the country are inequitable. By way of example, international best practice recommends that each mother has a scan early in pregnancy to determine her dates, and a subsequent anomaly scan to detect any fetal problems. These standards however are currently only being met in a handful of units. This is unacceptable.

The promotion of normality must be balanced with the need for escalation in the event of an obstetric emergency. It is important to define levels of care and to determine what level of care should be provided in each hospital. While it is inappropriate to expect every maternity unit to offer high-tech intensive care facilities, systems must be in place to facilitate streamlined access to critical care at the time it is needed. The Neonatal Transport Programme has been hugely successful and aims to provide all neonates who require critical care transport in Ireland, with access to a dedicated, highly trained and equipped professional team, available at all times of the day. A similar programme for in utero transfers is urgently required. Both programmes necessitate protected funding.

Staffing

An integrated approach to workforce planning in maternity services is required. In addition to midwives and obstetricians, a host of other specialists and specialties may interact with the mother or her baby, including neonatologists, anaesthetists, GPs, perinatal mental health specialists, perinatal pathologists and other allied health professionals. Investment in staff is essential.

We have a highly-skilled and talented workforce in Irish maternity services. Our doctors, nurses and midwives have always held the reputation of being the best educated and trained internationally. It is not surprising therefore that other countries look to our highly skilled doctors, midwives and nurses to staff their hospitals and maternity units. Staffing levels in maternity units in this country are of major concern. The lifting of the moratorium in HSE hospitals has resulted in movement of staff away from the voluntary hospitals and more recently, financially rewarding packages in the Middle East are attracting our highly trained skilled staff. Of greatest concern are the unfilled places on Bachelor of Midwifery university degree courses.

A recent study, Birthrate+, has been conducted reviewing appropriate staffing levels in Irish maternity units. I understand that funding requests for the additional posts deemed necessary to achieve minimum staffing levels have now been made to the Department of Public Expenditure and Reform. This funding must be approved and we must develop a robust national recruitment strategy to attract midwives to these posts.

Our hospitals continue to face ongoing challenges in relation to the European Working Time Directive (EWTD) for Non Consultant Hospital Doctors (NCHDs). There are insufficient numbers of NCHDs to achieve compliance and the 20% reduction in training time that will result from a 48-hour week has not been adequately addressed.

The findings of the recent supplementary report on Consultant Workforce Planning 2015, published in June of this year by the HSE National Clinical Programme in Obstetrics & Gynaecology, shows that Ireland has the lowest number of obstetricians and gynaecologists per 100,000 women and the lowest per 1,000 live births of all OECD countries. The report states that there are currently between 120 and 140 Consultant Obstetricians & Gynaecologists working in our maternity units and recommends that an additional 100 new Consultant posts are required to bring us in line with our UK counterparts.

Promotion and integration of education, training, research and innovation are essential components of high quality clinical care and should be included in all clinical strategic considerations and planning.

Governance

All women should have a clearly identifiable lead healthcare professional. Patient safety is a clinical and corporate responsibility. Any model of care proposed must be founded on the principles of good corprate and clinical governance, with strong leadership driving clinical excellence, quality, safety and clear accountability. I firmly believe that the Mastership model in the three Dublin maternity hospitals works extremely well and should be maintained and expanded to the Hospital groups.

Systems

While there is an acceptance that teamwork and good communication are essential, there is increasing evidence to demonstrate that systems can either support or obstruct collaboration. Organisational design must support effective collaboration.

Kofi Annan has said that "Knowledge is power. Information is liberating". Investment in Information Technology is essential. Many of the 19 maternity units in Ireland do not have any ICT system and thus basic data must be collected manually. Currently data is collected through the National Perinatal Reporting System and Hospital In-Patient Enquiry. More recently, the Irish Maternity Indicator System has begun to collect data, and has highlighted the lack of consistency across the different systems. I welcome the new Maternal and Newborn Clinical Management System, which has an expected roll-out of early 2016 to the first four maternity units.

Ireland has an international reputation for high quality research in maternity services and advances in medical research and technologies must be supported. Maternity care in the future is likely to involve early screening tests to detect biomarkers for potentially life-threatening conditions such as pre-eclampsia, and other pregnancies most at risk.

Funding

Our maternity units have suffered from chronic under-investment. Numerous reports and recommendations for improvements in quality and patient safety have been produced but never funded or implemented, and we cannot allow this cycle to be perpetuated.

Maternity is a demand-led specialty. There are no waiting lists. Clinics cannot be cancelled nor wards closed. Our emergency rooms are neither recognised nor resourced. There is a lack of transparency and I welcome the new funding models of activity based Funding and Money Follows the patient (MFTP). Historical underfunding and deficits accrued over the years however must be addressed if we are to move forward.

Location

Maternity facilities must be fit for purpose, with infrastructure appropriate to clinical needs. It is not appropriate to have bereaved mothers sharing a room or even  a ward with newborn babies. It is not appropriate to have mothers who are miscarrying waiting alongside mothers with buggies returning for hospital appointments. But this is happening to some mother as I speak. Funding for the business cases to re-develop our units must be made available in advance of the proposed re-locations so that we can deliver a humane service.

Summary

The national Maternity strategy must not be allowed to sit on bookshelves gathering dust with the many reports and reviews that have gone before it. It will only be as good as the plan designed to implement it. We have a poor track record of implementation and I would urge the Minister for Health, the Department of Health and the HSE to prioritise, fund and support its full implementation.

If I may leave you with one message, it is that investment in maternity services must be prioritised; investment in models of care, technologies equipment, facilities and most importantly, in our staff.

I am very appreciative of the opportunity to present my views to the Committee this morning and welcome any questions you may have.

 

Coombe Women & Infants University Hospital
Cork St.
Dublin 8.

Tel: +353-1-408 5200
Fax: +353-1-453 6033
email: info@coombe.ie

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