Doing nothing is not an option when lives of mothers on the line
Published 12/05/2015 | 02:30
Maternity services in Ireland are under intense scrutiny as a result of widely reported adverse outcomes for mothers and their children.
The deaths of several babies at the Midland Regional Hospital, Portlaoise are the subject of the most recently published investigation report by the Health Information Quality Authority (Hiqa), commissioned by the Department of Health. One notable highlight is the report's criticism of the clinical governance at the hospital and oversight of services by the Health Service Executive (HSE).
The Department and the HSE have accepted the investigation report and its recommendations.
One of the solutions put in place in the Midland Regional Hospital was to ask The Coombe Women's Hospital to take on a leadership role and to take over governance of the maternity unit. Asking a Voluntary Hospital to take on responsibility for the service in an HSE-run hospital was a very significant and unprecedented move by the Department. It suggests that the existing governance system was not working and a different system that exists in all three of the Dublin maternity hospitals would be better suited to the maternity unit at the Midland Regional in Portlaoise.
The Voluntary Hospitals system has the hospital governed by a board that is responsible for all activities across clinical, financial and administrative departments. All activity, including clinical outcomes, is reported to the board on a monthly basis. This direct reporting system allows the board to understand what the issues are in a timely manner. Because decisions can be made without reference to the HSE, the hospital can respond more quickly to issues and deal with problems as they arise through a less cumbersome governance system.
The second governance system that exists in HSE-run hospitals such as the Midland Regional sees the executive management team report directly to the HSE, not the board.
Traditionally, the performance meetings held by the HSE with hospitals concentrate on financial management and headcount staffing levels, with possibly insufficient emphasis on clinical outcomes. And those clinical outcomes which were measured were not necessarily those which mattered most in maternity services. Trolley waiting times and numbers of long-stay patients are not issues for maternity units.
A recent report looked at numbers of medico-legal claims based on recently published data from the State Claims Agency. The bigger, higher-volume Dublin-based maternity hospitals are the referral units that deal with complex cases and would naturally expect to have greater numbers of problem cases. Despite this, the data indicates that HSE hospitals have a much higher rate of claims than Voluntary Hospitals. It would appear to support and provide further evidence that the tighter, clearer governance systems in the Rotunda, Coombe and Holles Street Hospitals are better suited to clinical oversight of our maternity services.
Health Minister Leo Varadkar and his Department clearly recognise the value of the Mastership system and the role that the voluntary hospital system can play in the health service. As we move to the new model of hospital regional groups, I would urge those in charge of groups to develop this regional model so that it retains what is good, as well as improves those areas that need revision.
However, clinical governance issues are not the only problem in our maternity units in Ireland. A lot of other things have changed in the last 10 years. These changes have led to a perfect storm for our health system, particularly in maternity services around poor infrastructure, reduced and inappropriate medical staff numbers, and increasing complexity in patient care.
The recession led to a reduction in salaries for those working in our health service, and at the same time expectations for patient safety have understandably risen. Staff have left our service for more attractive packages in other countries and we have been so far unable to attract new recruits or entice people back from abroad. Those staff that continue to work in our system here are being asked to do more with less, leading to an increasingly difficult and stressful working environment.
Our inability to attract both medical and nursing/midwifery staff has resulted in an increasing reliance on locum and agency staff. This not only costs more but can lead to lesser-quality staff who are not used to the environment in which they are working. The recent issue with radiology reporting in a number of hospitals around the country is evidence of this.
The continuing failure to invest in our hospitals' infrastructure during times of plenty means we now face the difficulty of asking people to return from abroad to work in facilities and buildings that are no longer fit for purpose.
Our population has increased and more babies are being born. The Dublin maternity hospitals have seen their delivery numbers increase by up to 30pc during a time of recession. At a time when headcount restrictions were in place and budgets were being cut.
The KPMG report on maternity and gynaecology services in the Greater Dublin Area, published in 2008, identified infrastructural and staffing issues and recommended that these be rectified. Ten years later, not much has happened to improve the situation. All three Dublin maternity hospitals need to be relocated and co-located with an acute adult hospital. All three need access to intensive care facilities, imaging, and interventional radiology facilities onsite.
The KPMG report also recognised the deficit in staffing in our maternity hospitals. The bigger hospitals have a midwife to patient ratio of about 1:45-50. International standards say it should be 1:25. Best practice standards promote a ratio of one consultant for every 350-500 patients in a tertiary maternity unit. The reality is we're closer to one for every 1,000 patients.
As well as infrastructural and staffing issues, the patients we deal with have ever increasing levels of complexity. Obesity has become a major factor in caring for pregnant mothers and increases risk for both mother and baby. Infectious complications with more atypical, unusual and resistant organisms are a more common complicating factor.
This was recognised in the most recent report into maternal deaths published in December 2014, which for the first time included Ireland in the report ('Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries 2009 - 2012').
Mr Varadkar has put in place a new Steering Group to report by the autumn of this year and to recommend how we should plan our maternity services into the future. There are already numerous reports with many recommendations sitting on shelves awaiting implementation. It is absolutely vital that this latest report being undertaken by this current group comes up with a strategy that is workable and recognises the current difficulties we face. Let's hope that this next report does not join the others on a shelf.
Our maternity services have reached a fork in the road. Doing nothing is not an option for us as a country. We must provide modern, well-staffed facilities, which are well governed, for our mothers and their babies.
These facilities need to be of a size and configuration suitable for a modern midwifery and obstetric service that supports all levels of patient complexity. It is vitally important we do not miss another opportunity. Lives literally do depend on it.
Sam Coulter-Smith is Master at the Rotunda Hospital