SPECIAL REPORT: Wait for answers goes on as hospital lists lengthen and women's lives put at risk
THE figures are staggeringly high, and are rising.
In January 2016, 3,512 women were awaiting outpatient appointments for gynaecology services at Cork University Maternity Hospital (CUMH). Of these, 93 had been waiting 18 months or more. By June, the numbers had climbed to 3,859, with 371 having waited more than a year and a half.
Now, towards year-end, they have surpassed the 4,000 mark and the number waiting more than 18 months is just shy of 800 — an astounding 750% increase in the space of 10 months.
Which of these women will develop a malignancy while waiting to be seen is anyone’s guess. In addition, 557 women are awaiting inpatient procedures, of whom 51 have been waiting more than 18 months.
The overall waiting list figures are the largest of all gynaecology units nationally, and more than double those of the nearest comparable hospital, Dublin’s Rotunda.
It’s small wonder consultants staffing the hospital are at breaking point.
This newspaper obtained a series of documents, some under Freedom of Information legislation that show consultants have been raising concerns about the state of gynaecology services within the South/South West (SSW) Hospital group ad nauseam.
Letters directed to the CEO of Cork University Hospital Group, Tony McNamara; to Gerry O’Dwyer, CEO of the SSW hospital group, and to Liam Woods, HSE national director of the Acute Hospitals Division, highlight this.
In fact, Mr O’Dwyer made his own representation to Mr Woods last March, on behalf of the group he heads up, warning that there is “an acute need for greatly increased capacity in the gynaecology service in both the inpatient and outpatients services” at CUMH.
In a letter co-signed by Rob Landers, SSW group chief clinical director, Mr O’Dwyer wrote that while they had “outsourced” some of those on their waiting lists in 2015, they were “seeking a more sustainable, long-term solution to the unacceptable waiting times which present a significant risk due to the length of time to diagnosis and treatment”.
Mr O’Dwyer pointed out that CUMH had “long sought the opening of additional theatre capacity and day ward beds” and had produced a business case “to address the current sub- optimal service”.
“I strongly recommend the above for your favourable consideration in light of the clinical risks identified,” wrote Mr O’Dwyer.
However, when the chaotic state of the waiting lists was raised at the Joint Committee on Health on November 10, Mr Woods had little to say.
Fine Gael senator Colm Burke referred to the lists, saying: “My understanding is the HSE is aware of this: What do they intend doing?”
Mr Woods replied: “Yes, I’maware of the waiting list issues in the Cork area. We are seeking to remove all of the long waiters.”
He said their aim was to bring the waiting time “below 18 months”. However, he did not elaborate further.
The issue was also raised by Fine Gael TD Seán Sherlock in the Dáil in recent weeks. He said he had been told women left on waiting lists were arriving in emergency rooms at crisis point.
“I have been told there is a risk of delayed diagnosis of cancers in women who are forced to wait for years for their outpatient assessment,” he said. He referred to the reduced theatre capacity at the maternity hospital, which has two fully-commissioned gynaecology operating theatres.
One of those theatres has not been open for gynaecology surgery lists since the hospital opened almost a decade ago. Even the theatre that is open is only available some of the time — three to four days per week, functioning at 30%-40% of its originally intended capacity, according to the consultants who work there.
Mr Sherlock raised another important point in the context of this debate.
He said he believed the issue of under-resourcing the maternity hospital was “one of governance”.
“I do not believe for a minute that it is due to lack of funding. It is due to lack of will,” said Mr Sherlock.
His belief was that CUMH “must be recognised as a separate governance procedure, similar to other hospitals in the South South West group”.
The issue of governance of maternity hospitals is a hot topic. The mastership system is unique to the three large Dublin maternity hospitals, the Rotunda, Holles St, and the Coombe.
It effectively means that clinical and administrative responsibility lies at one individual’s door. The master is both CEO and lead consultant obstetrician/gynaecologist with overall corporate and clinical responsibility. It’s been around for the bones of 260 years and, according to the new National Maternity Strategy 2016-2026, it has “served the country well”.
IN fact, the strategy says there are “no plans” to change a mastership system that “demonstrates a sound governance model, operating with clear lines of accountability and responsibility”.
This belief in the mastership system is what moved Peter Boylan, chair of the Institute of Obstetricians and Gynaecologists and former master of the National Maternity Hospital, Holles St, to air his concerns in a national newspaper this year, about any moves that might compromise it.
Under plans to reorganise our maternity services, Holles St is penciled in to co-locate with St Vincent’s University Hospital in Elm Park at some point in the future.
However, in what can be a highly politicised environment — medical politics can be as cut-throat as anything you’ll see in the Dáil — talks between the hospitals broke down when it emerged that St Vincent’s Healthcare Group (SVHG) was refusing to allow Holles St to submit a planning application unless it dissolved its corporate structure and became a subdivision of SVHG.
The row was resolved just last week with agreement to set up a special company with each hospital equally represented and a guarantee no changes would be made without prior written consent of all company directors.
However while the row was ongoing, Dr Boylan wrote that attempts to dissolve the Holles St corporate structure ran “completely counter to Government policy”, as per the endorsement of the mastership system in the new strategy.
By way of illustrating the negatives of a maternity hospital not having its own governance framework, instead coming under the umbrella of a broader hospital group, Dr Boylan wrote in the Irish Times last April: “As we have seen with Cork University Hospital, integration can result in the cutting of maternity, neonatal, and gynaecology budgets to the detriment of patient services.”
His public letter did not please the executive management board (EMB) of Cork University Hospital Group where the mastership model is not in place and where one CEO — Mr McNamara — is in charge of both CUH and CUMH.
In May, Mr McNamara fired off a strongly worded letter to Dr Boylan on behalf of the EMB, saying he wished to register “our serious concerns at the observations made in your letter regarding funding of CUMH and the asserted detriment to patient services”.
Mr McNamara said the EMB considered Dr Boylan’s remarks “to be damaging to the reputation of the hospital and we will not tolerate a repeat of this assertion in a public forum”.
Moreover, a study had shown the quality of service offered by CUMH was “superior” to that of the three Dublin hospitals, he said. Finally, the EMB believed the governance model of obstetrics, gynaecology, and neonatal services at CUMH “works extremely well and provides a governance framework for our staff to deliver a high quality of service”.
The integrative governance model was “an exemplar as to how obstetric services might integrate with general services”.
One could deduce from this that Mr McNamara was keen to put to bed any suggestion that the maternity hospital might fare better if left to govern itself.
Alas, the consultants staffing CUMH did not agree with Mr McNamara’s emphatic claims, which were subsequently furnished to them, albeit not by Mr McNamara.
They wrote two letters in response — one to Dr Boylan, saying he had not said anything they would “regard as inaccurate” in relation to CUMH, and another to Mr McNamara in which they expressed “serious concerns” that the views outlined to Dr Boylan were those of the EMB, without input from the consultant obstetricians and neonatologists.
The consultants took particular issue with Mr McNamara’s claim that the group governance model was “an exemplar”.
Had they not told him “on innumerable occasions” of the negative impact on the maternity hospital of the failure of CUH to “ring-fence” their budget?
Indeed, the consultants say they have financial data to demonstrate that surpluses generated vis-à-vis resources allocated to CUMH from 2008 to 2012 amounted to €25.6m “which were not available to our service”.
Amid all the angst over governance and its impact on resources, there are issues of grave public concern.
There are women on waiting lists who are not being dealt with within acceptable timeframes.
Some will turn out to have malignancies, others won’t.
The 19 consultants — 15 obstetrician/gynaecologists and four neonatologists — who have joined forces to try and force change, have repeatedly warned of the danger of delayed diagnosis.
In May, they wrote to Mr McNamara saying their “inability to manage patients in an acceptable timeframe has resulted in diminished quality of life for patients on outpatient and surgical waiting lists over a prolonged timeframe”.
Lest there be any confusion, if you’re awaiting an outpatient appointment, you aren’t even in the system yet. If you are on a surgical waiting list, you have been seen and deemed in need of a procedure.
The doctors, all 19 signatories, representing almost the entire CUMH consultant obstetrician/gynaecologist and neonatal cohort, warned that “delayed diagnosis of cancer and other serious gynaecological conditions is an inevitable consequence of a service that has been under-resourced since CUMH opened in 2007”.
There is no doubt the gynaecological service is under pressure.
It serves a catchment population of over half a million and its consultants operate across six sites, at CUMH/CUH, South Infirmary/ Victoria Hospital; St Finbarr’s; Mallow; Bantry, and Mitchelstown Primary Healthcare Centre.
In 2015, more than 6,400 gynaecological outpatient consultations were provided and just under 2,000 gynaecological procedures carried out, even though the service has just 5.15 whole-time-equivalent gynaecologists.
The consultants say capacity to meet demand is “entirely inadequate and immediate action is required”.
They are infuriated that no new consultant gynaecologist posts have been created in Cork in the past decade, despite 26 such posts being advertised in a one-year period, 2015-2016.
This is costing the service “highly skilled senior trainees… to other hospitals nationally as a result of our inability to provide any prospect of upcoming consultant posts in Cork”, they warned.
How is it, they ask, that the hospital with the largest waiting list has received the least resources for its gynaecology service?
Aside from the human imperative to address the waiting lists, there is a financial imperative. The consultants say a quarter of patients on the general gynaecology waiting list have waiting times exceeding the 13-month target for review set down by the minister for health.
They say this “should result in the accrual of estimated fines in excess of €1m annually for the hospital”.
This is against a backdrop of the gynaecology waiting list increasing at a rate of more than 1,000 year-on-year over the past four years, with no net increase in consultant gynaecologist numbers since the hospital opened.
These warnings of the dire fallout for patients and finances if the deficits in the service are not addressed were repeated throughout 2015, as is clear from FOI documents.
In September, consultant obstetrician/gynaecologist Nóirín Russell, chair of the consultant committee, wrote to Mr O’Dwyer requesting a meeting “in your capacity as CEO of the SSW hospital group, to discuss the grave concerns about our service that we previously highlighted to you”.
Dr Russell wrote: “We are unclear regarding the management structure that would enable the release of funds to enable us to improve our gynaecological service… We are very anxious to work with you and your team to address this concerning situation.”
Also in September, Cathy Burke, consultant obstetrician and gynaecologist and director of gynaecology at CUMH, wrote to Mr McNamara highlighting her concerns at the effect of “recently introduced rolling theatre closures in the South Infirmary Victoria University Hospital on the waiting list for elective surgery in Cork”.
Dr Burke said that while she would prioritise the investigation of patients with postmenopausal bleeding (PMB) as the category most at risk of malignancy, additional surgical lists “will need to be offered up to the PMB service to investigate these patients in the appropriate timeframe”.
Dr Burke warned that the gynaecological theatre secretary “regularly fields calls from patients complaining about the waiting time for gynaecological surgery and requesting soon dates”.
In addition, consultants had been “receiving letters from TDs seeking to have patients within their constituencies operated on, sooner than we are able to facilitate”.
This “extremely unsatisfactory state of gynaecological services in Cork” was “well known” to Mr McNamara, she said, following “multiple communications” as well as through the attendance of the CUH executive management board at a meeting with consultants in June.
SO where to from here? Mr McNamara has been given a grim warning by consultants that if he fails to address the disastrous state of gynaecology services, they are no longer prepared to preside over a system they believe puts patients at risk, and have told him so in writing.
“As clinicians, we will not take responsibility for adverse health outcomes arising from a well-documented chronic lack of investment in the gynaecology service, which has resulted in longest waiting times for outpatient assessment and inpatient treatment nationally,” they wrote.
Over the past two years, they have requested that the in-use gynaecology theatre be extended to five days a week and the second theatre also be used five days.
They have called for development and staffing of a gynaecology day unit in CUMH, for which plans were drawn up and costed by the Capital Projects Team two and a a half years ago.
This, they say, would allow the enhanced throughput of day case surgeries.
The consultants are also looking for four additional consultant obstetrician/gynaecologists posts, each providing a majority of clinical sessions to the gynaecology service.
But perhaps what they most hope for is the introduction of a directorate structure for maternity and gynaecology series in the SSWHG, which would have “formal delegated responsibility for clinical governance and budgetary issues”, in keeping with the new maternity strategy which envisages that “all developmental funding for maternity services will be ringfenced and allocated through the [National Women and Infants Health] Programme”.
CUMH has no control over its budget; this was lost when three maternity hospitals amalgamated in 2007 to create one.
Prior to this, the budget of the Unified Maternity Services was held by that group to spend on obstetrics and gynaecology services in Cork.
Since CUMH opened, it has not had a ringfenced budget, and consultants say they have not been able to access the entirety of the budgetary resources allocated by the HSE to CUMH.
The future remains uncertain for many of the 4,193 women awaiting outpatient appointments.
Two-year wait to be seen at a gynaecology clinic
Excerpts from a patient letter to her GP and copied to a consultant in the gynaecology service Cork (dated November 2016).
Permission was given to her doctor to use excerpts to highlight the inefficiencies that exist in the provision of public gynaecological care in Cork.
The woman attended for a gynaecology ultrasound in March 2014.
A 3cm fibroid was found in her uterus at that time.
She was put on a waiting list to be seen at a gynaecology clinic.
She waited almost two years, until February 2016, for further investigations.
Her symptoms in the interim worsened.
Readers may find the following excerpts disturbing.
Questions we asked the HSE
- What actions have hospital management taken to tackle the waiting lists?
- Why is the second theatre at CUMH not open (nor has it ever been) to gynaecology surgery lists?
- Why has the SSW group not advertised for consultant obs/gynae posts in the past year, given the waiting lists?
- In light of the waiting lists and the concerns that were repeatedly raised by consultants about the risks to women of remaining on waiting lists for excessive periods, how does Tony McNamara justify saying that the integrated governance model vis-à-vis CUH/CUMH is an “exemplar” as to how obstetric services might integrate with general services?
- The consultants claim a total surplus of €25.6m was generated between 2008-2012 that should have been available to their service. Why does the maternity hospital not have a ring-fenced budget?
- What is the membership of the executive management board? (EMB)
The answer supplied to this question was to list the membership of the SSW hospital group leadership team, which is not the same as the EMB.
When I queried this, no clarification was provided. Heneghan PR handles press queries for the SSW hospital group.
The Irish Examiner made several attempts to acquire some of the documents referred to in this article from the hospital under FOI but neither original requests nor appeals were successful.
The SSW group did provide some documents under FOI, the bulk of it after an appeal.
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