A chilling diagnosis of the Irish health service

As he prepares to vacate his mastership of one of the world’s oldest maternity hospitals, Dr Sam Coulter Smith deliberates on the nation’s maternity services, says Catherine Shanahan     

DR SAM Coulter Smith, consultant in obstetrics and gynaecology, and master of the Rotunda Hospital since 2009, a position he will relinquish this year, says his tenure coincided with a perfect storm for medicine — recession, salary cuts, failure to invest, and rising numbers of births.

“We have probably had the biggest recession in living memory and that has affected the health budget, with a serious reduction in spending, he says. “We have had substantial salary cuts, inability to invest in infrastructure over the years. We have had moratoriums on head counts. It has been the perfect storm, and it has happened at a time when demand for maternity services was going up and we were getting a steady increase in activity levels right up to 2012.”

Rotunda master: Quality of doctors ‘dumbed-down’

On difficulties recruiting:

(i) At the Rotunda: “It has started to affect us. The number of trainees wanting to come into the specialty has fallen away. The number of midwives who want to come to work in the hospital has reduced. I think the reasons are multifactorial.

“I think litigation may be part of it, but also the stress and the strain that people suffer on a day-to-day basis, working in a demand-led service, which is really being stretched. I think you can only do that for so long without burning out.”

Dr Coulter Smith says ending the ban on recruiting did not have the desired effect. At the Rotunda, some of their midwives moved to hospitals closer to home, “because it was just easier and less strain”.

(ii) Nationally: “It would have been traditional for doctors and midwives who qualified here to have spent a little bit of time in Ireland, and then gone away and developed expertise and come back. But now we are in competition with other countries for those same people, and we don’t have the employment package that’s necessary to attract them back.

“It’s not just about the salary. It’s also about where they can come and work, what research possibilities are available, what service opportunities are available.”

On staffing ratios:

“If someone was to say to us , tomorrow: ‘Here’s the money, go out and employ another 10 obstetricians for each of the Dublin maternity hospitals, so that you can get close to providing a 24-hour service,’ we would not be able to get those people. They’re just not out there.

“The Irish health service, right now, is not a place where people are queuing to come back to, so we have to change that. We have to reverse some of the things, in recent years, to make the service more attractive. If you look at midwives, we have a ratio of about one midwife to every 45 deliveries. We should have between 1-25 or 1-30.”

On perinatal mortality rates:

Despite the challenges facing our maternity services, the number of babies who die late in pregnancy, or during labour, is very low, Dr Coulter-Smith says.

“Our perinatal mortality rates are very good and they should not be as good as they are,” he says. “It’s not so long ago since the maternity services were the flagship of the Irish health service. And we are putting that status at risk now, because we are not investing.”

On the development of a national maternity strategy:

The steering group set up to develop the strategy has 30 members.

“It’s a very big group,” he says. “I think reaching a consensus is going to be a huge challenge and I’m not sure how they are going to do that”.

A chilling diagnosis of the Irish health service

On the dumbing down of doctors:

Two years ago, Dr Coulter Smith commented on the poorer quality of doctors in the health service. His view hasn’t changed: “I think it is no different now. If anything, the situation has been exacerbated. There are less people coming back to jobs.” Hospitals want a range of people applying for a post, with relevant qualifications and experience.

“But what we are seeing, to some extent, has been a dumbing down of the levels. We are not seeing the same numbers and quality of people. I think we are getting some good people coming back, but there is not the same competition there might have been in years gone by. Generally speaking, the level has gone down a bit.” This is not just the case in obstetrics, but other specialities, as well. It is also the case that some smaller hospitals suffered more.

“People may come back to a job in the Rotunda, but not in Clonmel.

The incentive to return is not there, because people go abroad to do sub-specialty training, but when they come back here they are expected to be on call for a range of conditions.

“You have someone who has trained in cardiology or gastroenterology, and they are very good at that particular thing, someone that worked in America,” says Dr Coulter Smith.

“But if you come back to a hospital in Ireland, particularly one of the smaller hospitals, there may only be three or four physicians there. You are expected to be on call and take the cardiac, renal, and other stuff, but you may have gone off and trained to be quite specific in your expertise. Understandably, people are not going to come back to those posts. So US-style training, fast-tracking people to become expert in a small area, does not necessarily work here.”

An example: a joint appointment was required for a foetal-medicine specialist, who would work in the north-east and the Rotunda, as part of the Dublin North East Hospital Group. But there were no applications for the post. This was because the right applicant would have trained abroad in a department where they had time for study leave and research, and if such a person was to return to Ireland they would end up providing a service “as a single-handed specialist in a peripheral hospital”, where they would have little support or time to do anything other than run the service.

On governance:

The hospital group system is slow to evolve, Dr Coulter Smith says, and his group, Dublin North East, is already on its third CEO. The group boards have not been appointed, leaving a governance vacuum, he says. While the Rotunda will be expected to play a leading role in oversight within the group, Dr Coulter Smith says there is no mechanism in place to allow this to happen. Two of the other hospitals in his group have maternity services and he says the Rotunda’s board “is reluctant to take on responsibility for what happens in those hospitals.

“I have a busy job — do I need to be in Drogheda or Cavan two days a week trying to iron issues there? Not really,” he says. “There needs to be systems in place to ensure some reporting structure. And there needs to be funding to go along with that. That system has not been worked out and it is difficult to see how it will work out.”

The Rotunda would have to play a bigger role in the group setting, he says, and find ways of “sharing expertise”. For instance, women attending the Rotunda got a 20-week anatomy scan as part of their package of care, whereas that was not availble to women attending the maternity service in Cavan.

On top up payments:

Dr Coulter Smith says the voluntary sector “took a hit reputationally” during the controversy about top-up payments. However, he says that, in some cases, additional payments are justified.

“I think a lot of people don’t understand what a voluntary hospital is,” he says. “Take the Rotunda, for example. Yes, we provide maternity services, we have a service-level agreement with the HSE, but we also have a campus to look after and we also have facilities on site that need to be managed. There is the Gate theatre, the Ambassador cinema, the Pillar Room.

“There are other things that are involved, that take time and effort, that are not part of the service-level agreement we have with the HSE.

“There is a small number of people within the hospital whose job it is to look after some of those other things, and individuals did receive additional payment for those. It was very much part of their job, a job that they took on knowing, or understanding, that there was some additional remuneration for those other jobs.”

Dr Coulter Smith says he no longer gets top-up payments.

A chilling diagnosis of the Irish health service

On complications of the job:

The increasing number of overweight women who are attending maternity services is a trend that makes pregnancy and childbirth more difficult, Dr Coulter Smith says.

“We’ve a population whose average weight is steadily increasing, so patients with high BMI, patients who are obese or grossly obese, they are increasing in number and they bring with them very significant risks for themselves and their babies; increased level of complexity, of instrumental deliveries, of C-section. And the morbidity, and, very occasionally, the mortality, that goes along with that can be significant.

“That’s been a real challenge and it’s something that’s not going away and needs to be addressed.”

A more international population has also brought challenges from a communication and cultural point of view, and also from a disease point of view.

On medical breakthroughs:

“We’ve a much-better-developed foetal medicine service, which is much better at identifying problems in-utero,” says Dr Coulter Smith. “We’ve developed interventions, such as lasers for twin-to-twin transfusions and anaemia, some more complicated procedures that we certainly wouldn’t have had the expertise in before.

“Technology is improving and changing all of the time. Our ability to diagnose people with fatal-foetal abnormalities has improved and will continue to with less-invasive technologies coming on stream all the time. It used to be that you had to do an amniosynthesis to get a diagnosis. Now, you can get it from blood tests.

“I think the whole area of understanding the genome and being able to manipulate embryos, and being able to pick and choose which embryo you are going to put in, because it doesn’t carry a particular disease, is the future of things.

“I’m disappointed that we don’t have publicly funded IVF. That’s a huge regret — but that boils down to finances, in many cases.”

On the protection-of-life-during-pregnancy act:

“I was very glad to see that the term ‘abortion’ isn’t used within the legislation, where a mother’s life is at risk and a pregnancy being terminated,” says Dr Coulter Smith. “To use the term abortion, in that case, is probably not correct.”

He says the legislation has given comfort to doctors to intervene. However, he still has reservations about the risk of suicide as grounds for termination.

“There isn’t universal agreement among all psychiatrists, even people working in the perinatal psychiatry field, that termination of pregnancy is a treatment for someone who is suicidal, so I think that’s still a difficult one.”

Dr Coulter Smith’s initial concern that the legislation could open the floodgates, in terms of the number of women seeking terminations on the grounds that they were feeling suicidal, has not come to pass.

Where he continues to have concerns is the failure to address the issue of gestational age in the legislation.

A chilling diagnosis of the Irish health service

On the viability of smaller maternity units:

“We don’t want to have six or seven big hospital units, with nothing in the midlands,” says Dr Coulter Smith. “That would be wrong. But people should have access to appropriate care and if it’s low-risk, led by midwives at a community level, then that’s fine for the vast majority.”

One problem for a lot of maternity units was that they had no neonatologist (specialist in medical care of newborns). However, for smaller units without a full range of specialists, it did not mean they should close.

“It just means they need to tailor the care provided in those units appropriately,” Dr Coulter Smith says.

On open disclosure:

“I would be fully supportive that open disclosure is absolutely the way to go and I’ve tried to practice it during my time as master. If we haven’t performed well, if we haven’t served somebody well, if we’ve made errors or mistakes, then I would always put my hand up and say ‘sorry, we didn’t do well here’.

“And then we try to learn from those errors and change the way we do things, so that it’s less likely to happen again.”

On births:

The Rotunda is expecting to deliver 8,500 babies this year, and while the numbers have dropped slightly, the hospital is still 20% busier. The most babies delivered in the hospital in 24 hours was 45, in late December, 2012.

Advice for his successor:

“Try not to take work home. I think, other than getting away from the coalface every so often to recharge the batteries, I think that’s the main thing, that’s the most important thing. I probably didn’t get away as much as I should have. I made a promise to myself that I wasn’t going to bring work home, and mostly I didn’t. I didn’t bring it home in a briefcase, but I brought it home in my head. That, I think, is probably one of the most challenging things. To get away from it sufficiently that you can actually have time for you and time for your family.”

Dr Sam Coulter Smith steps down as master of the Rotunda on December 31.


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