I thank Dr. Fitzpatrick. That was a fantastic, passionate presentation. I have seldom been as impressed by or as proud of a professional colleague sitting in that chair as I am of him right now, calling it as it is. However, I am not overly confident that all the things he has said will actually percolate through to the decision-making process, such is my level of cynicism about that process since I became a Senator.
With respect, everything Dr. Fitzpatrick said about the multitude of usually ignored reports rings true. When I came back to the country 22 years ago I set out to point out the incredible deficiencies not just in cancer services but in the health services in general. In particular, since I became a Senator, I have repeatedly beaten the drum to the point of appearing very tedious to my colleagues. I would have prepared the report for free – it would not have been necessary to pay HIQA or any external person. The quality of obstetrical services in Ireland is mediocre. We have great doctors and very well trained nurses who work in unbelievably under-resourced, underfinanced, understaffed, irrationally led systems, and as a result the output is not all that good. It is not awful, but it is mediocre.
Dr. Fitzpatrick is right. People have wrapped themselves in the cloak of relatively favourable outcome statistics, not realising that obstetrics is different. If a country’s cancer survival rate is 3% lower than in other countries, that might indicate room for improvement. If we have two unnecessary maternal deaths here, that is a tragedy. We should have zero tolerance for any maternal deaths and for any unnecessary paediatric long-term brain injuries, etc. It is not good enough for us to wrap ourselves in the cloak of being in the top 15 of 29 of the most economically developed countries in the world.
While I hate to personalise it, I must mention the tragedy in Galway a few years ago. People kept missing the point, which I kept repeating here. This is the region in Ireland that has the lowest number of obstetricians per head of population. Ireland has the smallest number of obstetricians per head of population in the world. One can join the dots and come to the right conclusion about the care of individual patients that is delivered by a number of rotating junior doctors over a three- to four-day period. The palliative mix there was pretty obvious to me and it did not relate to improving the management structures or anything like that – it was about bringing in more doctors.
This brings me back to the cancer programme. If the entire bureaucracy of the National Cancer Control Programme were dismantled tomorrow, it would not have a major negative impact on cancer outcomes. Cancer survival improved about 15 years ago as a result of one intervention that was made by the then Minister for Health, Deputy Noonan. I jokingly tell him that he gently plagiarised a speech I had made stating that there are hospitals in the country that I would not let any relative of mine with cancer go into. On his first day as Minister for Health he said the same thing and said he was going to appoint more cancer specialists. I was the fourth oncologist in the country when I came back. I was often in the elevator in the Memorial Sloan Kettering Cancer Center with more Irish oncologists than there were in Ireland at the time I came back. The Minister, Deputy Noonan, just set about appointing a larger number of oncologists, and suddenly multidisciplinary care became available to people before there was any bureaucracy. I believe that is what made the big difference.
While I have sympathy with Dr. Fitzpatrick’s view that there should be an obstetrics tsar, the absolute first priority is not more reports, but an attempt to double or treble the number of consultant obstetricians so that everyone in the country who is going through any phase of obstetrical care is not being looked after by a trainee, which is what junior doctors are.
They are trainees. Take out the words “senior house officer”, SHO, “registrar” and “specialist registrar”, insert the word “trainee” and see how rational many of the things we say on a day to day basis in Irish hospitals would sound, for example, “My precious young daughter went into the hospital and the trainee surgeon saw her and conferred with the trainee anaesthetist who said the trainee in intensive care hd said this was their opinion.” We would never accept this in any trade, never mind medicine.
I have a few specific questions for Dr. Fitzpatrick. This is a hard one: in Portlaoise hospital there are 2,000 births a year. If we were flush with money and had an adequately resourced health service and were not operating under economic constraints, would 2,000 births a year be enough to justify keeping open a modern obstetric unit? My suspicion is that it would and that our decisions about Portlaoise hospital are based on the fact that we are not prepared to resource it the way it needs to be resourced in order that it will be more cost-efficient. Perhaps there are professional reasons to roll it in to something else.
How critical are these numbers as one of the metrics on which the relative failure of our obstetric services is based: in Ireland there are 4.8 obstetricians per 100,000 of the population; in the Netherlands which has a lower birth rate there are 7.6, while in Switzerland there are 17? I had this argument with somebody last week about cancer outcomes. We saw figures last year which showed that Ireland had pretty dismal cancer outcomes, despite all the tosh we heard about the national cancer control programme. There is an emerging story that if as a society we deny people cancer drugs, we will have inferior cancer survival rates. I have a beautiful five month old baby. My lovely wife Orla presented me with a gorgeous child and she was beautifully looked after in difficult circumstances in Holles Street. In my heart I believe, in respect of many of the tragedies about which we read every couple of years and the awful pictures of children in wheelchairs outside the High Court, that if there had been a real senior person making all of the decisions all the way through those pregnancies and deliveries, those tragedies would not have happened. I would like Dr. Fitzpatrick’s input and thank him for a very inspiring presentation.
I am at this stage officially despondent about any attempts to reform the health system or about meaningful practical actions to improve the service for patients taking place on foot of administrative reports. Forgive me if I sound browbeaten at this stage. I have been harping for 22 years since I came back to this country about the absolutely mediocre health system. People talk about it being a Third World service, but anybody who has worked in a Third World hospital will know it is not. However, we have a strictly mediocre health system and obstetrics is the tip of the spear. This is all to do with the way the service is run and the absolute treacle-like ability of the bureaucracy to thwart any attempt to fix things.
In Ireland, the number of obstetricians per 100,000 people is 4.8; the next lowest in Europe is the Netherlands, which has a lower birth rate, at 7.6.; Turkey, 9.1; Poland 13.5; and Switzerland, 17. It is a question of cause and effect. Appalling cancer survival figures came out last week, and for all the guff we have heard about our brilliant attempt to tackle the cancer problem, we are just one notch ahead of the British, who are by far the worst of the western countries. We set our bar low and compare ourselves to a British yardstick. The British health system is also strictly mediocre and, in quality terms, pales in comparison to the other good socialised medical systems of Europe, the German, Scandinavian, Belgian and French. It is bad on all the metrics. However, we insist on bringing over British administrators to do our inspections.
I do not know why I am even bothering to speak. At the time of the Savita Halappanavar tragedy, I pointed out that the region with the fewest obstetricians, in the country with the fewest obstetricians in the OECD, could expect disasters related to insufficient senior, on-site presence, 24 hours with continuity of care of senior specialists, and too much delegation to trainees. I said it then, I say it now, and I see no evidence that it will change.
Ireland has no excellent obstetric centres. I say it very advisedly. Some five months ago, my beautiful wife gave me a beautiful son, who was delivered with wonderful skill by the obstetric staff of the National Maternity Hospital, Holles Street, and the great backup of the midwifery and other staff. However, given the hospital’s facilities, we cannot call it a centre of excellence. It does not have a full ICU. There is limited surgical backup for other surgical emergencies that occur. It does not have the full range of medical specialties on site, such that very sick adult patients have to be sent to other institutions. This is not the way to do modern obstetrics. While we can delude ourselves all we want about being the best in the world, we are not. We set the bar very low. I mean no disrespect to my obstetric colleagues, who do a heroic job and are incredibly well trained. We probably have the best trained cohort of obstetricians of any country in the western world, most of whom have trained in international centres of excellence. Dr. Peter McParland, who delivered my baby, James, is a wonderful, internationally reputed obstetrician, but look at the circumstances in which he is forced to work and the backup he has. Maybe the Department is prepared to fix it, maybe there is going to be a road to Damascus moment for the health service. I do not see it coming.
