Relocating the Rotunda, lock, stock and babies, from Dublin City centre to Blanchardstown, is Prof Fergal Malone’s ‘number one goal’. But the hospital’s new master isn’t one to shirk a challenge, reports Catherine Shanahan
‘MY MAIN vision,” Professor Malone says at our round-table interview “is our relocation to, and indeed co-location at, the Connolly Hospital site.
“While there’s a great affection after 250 years for the building and the site here, I think everyone accepts the Rotunda on its current campus is no longer fit for purpose.” No argument there. The current site on Parnell St has no scope for expansion and vehicular access is now at a premium. Some of the buildings date back almost 260 years. The move to James Connolly Memorial in Blanchardstown, will shift it to what is “effectively a greenfield site at the junction of the N3 and the M50” and has huge potential for the Rotunda, Prof Malone says.
Fortunately, the desire to move is supported by government policy and the Rotunda’s board of governors.
The move will see an increase in births per annum, from circa 9,000 currently to 12,000, and an additional 20 beds in the neonatal intensive care unit. It should also facilitate a “properly developed” gynaecological service for both the city and region and a new paediatric development that’s already approved.
“So that’s probably my number one goal and project that I would like to achieve and that I would like to leave as a legacy for the Rotunda for the future,” Prof Malone says.
The 47-year-old consultant obstetrician and gynaecologist is bravely (or madly) setting a target date of opening the hospital within his seven-year Mastership, while fully acknowledging the track record of healthcare building in Ireland “could cause some scepticism and cynicism around that. But they’ve already hit the ground running,” he says, with a number of working groups looking at the financial, legal and infrastructural elements of the move. The fact it’s supported by government policy means the hospital has a “jump start”, eliminating the need for examining multiple sites.
But what about co-location with a children’s hospital? Is that not the optimal arrangement — a maternity, adult and children’s hospital on a single site?
The good news is the new site is earmarked for a paediatric ambulatory centre which will effectively operate as a satellite unit of the new children’s hospital, albeit providing less complex paediatric care.
“Irrespective of what happens with the children’s hospital at [St] James’ Hospital [Kilmainham] we will see a paediatric development out there [Connolly] and most of the reason we as obstetricians would need paediatric support is... for [problems like] complex foetal abnormalities. If paediatric cardiologists are already out there at an ambulatory facility, they can absolutely support us.
“So I’m quite happy with the current proposal and configuration, that there are going to be paediatric facilities on the campus,” he says.
Pre-requisites for the move
Moving out of the city centre will mean the Rotunda no longer has level 4 hospitals like the Mater close by — Connolly is level 3. This essentially means less specialist services at hand. There will be no move unless this deficit is addressed, Prof Malone says. Upgrading Connolly is “an absolute pre-requisite” and a working group has been established “for this very specific reason”.
The fate of the existing hospital building
So what will happen to the Rotunda as we know it when the move eventually takes place?
“We don’t know yet,” Prof Malone says. The premises are owned by the board of governors, the Rotunda is a charity and has a charitable foundation “and there would be an obligation on the board to use whatever proceeds come from this for the original mission of the hospital which is of course the betterment of care for women and children in the region.” This would not include using the proceeds of a sale to fund the building of a new hospital.
And will the name “Rotunda” survive the move?
“Very much so. The brand name is of huge international and national importance. Obstetricians and paediatricians the world over have heard of the Rotunda. It would be silly to lose that brand.” Other priorities aside from re-locating, improving gynaecological services in the greater Dublin area is another key priority for the new Master. He describes them as “inefficient and under-served at the moment, in particular the lists for benign gynaecology”.
“We have a certain number of patients waiting up to a year for routine benign gynaecology services,” he says. “The difficult thing about benign gynaecology is it could be something like irregular heavy periods, post menopausal bleeding, it may be benign. But what you don’t know is — are there certain cases of cancers lurking in there?
“If you’ve 10 women presenting with post menopausal bleeding, you don’t know which one or two or three might actually reflect an underlying cancer. So while they start presenting to you as a benign patient, they could evolve into a gynaecological cancer patient, so you have to be able to find these patients and manage them efficiently.”
Figures supplied by the hospital show there are currently 1,506 patients waiting to be seen, all of whom have an appointment, four of whom will not be seen within target times. These patients have incontinence issues and are waiting more than a year to be seen.
Prof Malone said patients awaiting surgery for issues such as prolapsed womb after childbirth or urinary incontinence have scheduled procedures “commonly cancelled” “because of emergency department problems and things like that”.
As part of his plan for improving these services, interviewing will take place early in 2016 with a view to a joint Rotunda/Connolly appointment of three consultant obstetrician/gynaecologists and two consultant anaesthetists.
“One of the main goals for these appointments will be to significantly boost our benign gynaecology throughput. We would like to see Connolly developed as a major benign gynaecology centre for our group, and indeed if we organise our services as efficiently as possible, we could provide a 24/7 emergency gynaecology service for the region,” he says.
Prof Malone is also hoping for a significant improvement in midwifery numbers. The deficit for the coming year based on the level of births is 45.
“It’s a critical issue, even if tomorrow there was money for it [to hire midwives] we actually couldn’t find them.
“There used to be a time when there was severe competition and a waiting list to get into the midwifery training scheme in the Rotunda. We actually couldn’t fill all the places last year.”
Improvements in reading ultrasounds
When he arrived back from the US over a decade ago, Prof Malone spoke to the ‘Irish Examiner’ about the lack of trained personnel to read ultrasounds which could lead to up to 90% of foetal abnormalities going undiagnosed. Have things improved since then?
“We have seen improvements. There is no doubt that consultants who have been appointed in obs/gynae, certainly in the last 5/6 years, have all been trained in an era where [reading] ultrasounds is part of their training, so you’d be much more confident now that consultants in the last number of years would have the skill set, by and large, to supervise ultrasounds,” he says.
However the challenge remains to find skilled ultrasonographers. Trying to attract midwives is a problem.
“There remains no incentive for midwives to... take on two years of training in obstetric ultrasound and then become midwife ultrasonographers. There is no differential in salary.
“Indeed for some of those midwives, they actually lose money because if they move into a 9-5 job they tend to lose their on-call and night working allowances. So it’s very hard for us within current structures..the way jobs are structured... to encourage sonographers to get into it.” The upshot is some hospitals, such as Cavan General, are not in a position to offer pregnant women a 20-week anomaly scan routinely available in the bigger maternity units. Prof Malone concedes this means some women are inevitable losing out.
“You will only find the anomalies if doing routine 20-week anomaly scanning on the entire population. If you just restrict it to women over a certain age or who previously had a baby with an abnormality, that will only cover the minority of cases with foetal abnormality.
“If we had the personnel [problem] solved, we could easily implement this in 19 units,” he says.
Fatal foetal abnormalities
The Rotunda’s position on fatal foetal abnormalities is that they “would want to provide all services for our patients who are facing a difficult situation”, Prof Malone says. This includes termination of pregnancy.
However, against a backdrop of restrictive abortion laws, the hospital confines itself to offering non-directive counselling.
“So at the moment if a patient in the Rotunda is diagnosed with a very severe foetal abnormality that is going to lead to death of the child at birth or very shortly afterwards, we offer non directive counselling.
The language used is “no different to what they would get if sitting in London or NY...the choices that we present to patients is in no way watered down, no euphemisms, it’s very much ‘these are your choices now’,” Prof Malone says. They would never advise a patient to abort, he says.
“If the patient chooses the journey that ends in termination, then there are other details that we have to get into that are unique to Ireland. But as regards choices that are available to patients, we are completely open.
“My personal view on abortion...has no place in that discussion and we never reveal our personal viewpoints because we have to remain completely objective with the patient.
“The patient has to trust the advice we are giving is completely objective and in her interest.” To this end, if women want to continue with a pregnancy involving a fatal foetal abnormality, they have the support of a “well developed perinatal hospice system” which includes social workers, bereavement counsellors, chaplaincy, midwives and paediatricians. The hospital even provides cuddle cots so that when a baby dies, the parents can spend time with the child in the mother’s own room.
For those who opt for termination, the UK is the most common destination and Prof Malone says they have developed a good relation with the hospitals that look after their patients.
“Our staff have actually gone over to the hospitals to look at the journey our patients will take. So we know the individual names of practitioners and counsellors that they will meet and we are able to demystify it as much as possible. Because we know if you are changing hospital location, that can be very intimidating. Once the patient has had their termination, they return here and we give them complete care in a non-judgemental way.” The most tragic aspect of these journeys is the extreme trauma it causes for patients, Prof Malone says.
“We have been struck by the number of patients over the years who chose that particular journey as to how emotionally difficult that added step is for them.
“We have had parents bring their child’s remains back in a shoebox in the back of a car.
“We’ve had parents have their child’s remains sent back by courier, to arrive by DHL. I mean this causes huge added emotional trauma. So our position at the Rotunda is we would wish to provide all care to our patients here. We do not believe that it is right that individual patients who make the choice [to travel to the UK]... that they should not be able to have that procedure done here. So we would like to see that situation change.”
About 75% of those given a diagnosis of anencephaly — and there are 20 to 30 each year at the Rotunda — choose to terminate, Prof Malone says.
A fraught profession
As an obstetrican/gynaecologist, does Prof Malone feel he and his colleagues are under immense pressure to practise defensive medicine?
“We are under tremendous pressure and there is significant stress and anxiety and indeed eventual burnout among obstetricians,” Prof Malone says.
“I am personally aware of obstetricians and midwives who have stopped practising after a case, they’ve been so badly affected and traumatised.
“One of the problems of our medical malpractice system in the western world is the growing expectation of perfection.
“And while we have made huge advances in science, medicine remains an imperfect science.
“Things happen in obstetrics that are just unexplainable. We have unfortunate cases where women come into us at 39 weeks with an unexplained stillbirth, where despite a complete autopsy, genetic studies, US scans, we still can’t explain what happened.” While doctors like to say they practise “evidence-based” medicine, the reality was they also practise “anecdotal medicine” “meaning if something happened to you that went well last year you’ll repeat it. If something happened that went poorly last year, you’ll avoid it. That’s life.
“So I think that does lead to a certain amount of defensive medicine and that could be why the C section rate is gradually going up.”
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