Never one to baulk at a challenge, Professor John Higgins is relishing the prospect of his latest role — first clinical director of maternity services for a hospital group. He talks to Health Correspondent Catherine Shanahan about budgets, waiting lists, anomaly scans and why obstetricians do not need to be in the vanguard of debate on Repealing the Eighth
Seated in his office on the fifth floor of Cork University Maternity Hospital (CUMH), John Higgins is delighted to be returning to his definitive permanent post — UCC Professor of Obstetrics and Gynaecology and consultant obstetrician at the maternity hospital he helped get off the ground. Back in the day, he provided the clinical leadership that led to the successful amalgamation of three maternity hospitals in Cork City.
He’s been busy since — Director for Reconfiguration of Acute Hospital Services in Cork and Kerry from 2009-2011, Head of the College of Medicine and Health at UCC for the last five years plus, a post he will today vacate.
In 2012/2013 he chaired the national group that provided recommendations to the government on the establishment of hospital groups. And he has been chief academic officer for the South/SouthWest hospital group (SSWHG).
But from next Monday, Prof Higgins becomes clinical director of the group’s maternity services, the first role of its kind in the country.
He takes up the post at a time when conditions are not ideal: appalling waiting lists for gynaecology, with more than 4,200 women on an outpatient waiting list; unhappiness with the level of access to foetal anomaly scans, and at the tail end of a row between consultants at CUMH and hospital management over chronic underinvestment in the gynaecology service — a row in which the health minister ultimately intervened.
There’s a lot going on in the SSWHG at the moment — what is the scope of your new role?
The [maternity] service will be managed across the group and I will have responsibility for clinical governance which, by now, is a pretty well-established component of clinical directorships. But I will also have the executive authority around the budget and resources and that’s what makes it different and new.
So you will have control of the maternity budget for the group?
Delegated authority. It delegates down the line from the director general, it will come through the acute hospitals, it will go to the CEO of the group (Gerry O’Dwyer) and through the CEO down to me. Not through CUH.
In 2008, the CUMH budget was €55m. In 2015, it was €34.8m. What is your plan to bring the budget back up to the level it was at?
I think it would be fair to say that we have lost out somewhat, so the first step in correcting that will be to have an organisational structure that allows us to grow again. I think our number one priority certainly, will be gynaecology. We need additional resources to deliver additional capacity for gynaecology services. I was very heartened by the minister’s visit (Health Minister Simon Harris visited in January to hear the consultants’ concerns).
I think if we get the governance right we will have the opportunity to build the service up again.
Simon Harris made it very clear that he wanted to return and receive a plan as to how we were going to tackle the gynaecology waiting lists. So he’s promised to be back in six weeks and I look forward to welcoming him back.
How is that plan progressing?
“A lot of that work is well and truly done. I think colleagues here — both clinical and non-clinical — have done a lot of work around the capacity planning so we are not starting from a blank sheet. We’ve a good idea what resources we need.”
Was it the case when CUMH opened in 2007 that the budget was on the basis of having two fully functioning gynaecology theatres open 8am-8pm five days a week? (Currently, just one theatre is open to gynaecological surgery lists, three-four days a week).
Why has that never happened?
We didn’t get the resources to open those theatres.
Your consultant colleagues say four additional consultant obstetrician/gynaecologists, dedicated mainly to gynaecology sessions, are needed for the service. Of 26 such posts advertised nationally last year, none was advertised for the SSWHG. All you’ve been given is a locum for six months. If you are not able to offer permanent posts, how do you expect to hold on to high-quality trainees? How do you expect to attract consultants?
I would think that if we had posts, we would be one of the most popular places in the country. I’m not saying that it would be easy to recruit staff, but I think that we would be very well placed to find consultants if we had permanent jobs to offer.
What is the point in a six-month locum post?
A: It wasn’t a decision that I was party to but I wouldn’t underestimate the benefit of it. But the plan we now have would be clear on the resources that are required to run our service on a sustainable basis. We are not talking about elastoplast quick fixes. I think it would be fair to say that the waiting list is so long, that you really have to think in terms of years to actually get in front of that.
And I think if you come back in five years’ time, you know, the waiting list is gone and we are in a steady state. It’s plannable work, it’s within our remit and you can calculate pretty well the capacity requirements. Dealing with trolleys is much more difficult.
Has reconfiguration of hospital services worked well for the SSWHG?
I think the reconfiguration process is an essential one. We couldn’t continue with the same structure. I think that we needed to look at our hospitals and reset, re-jig them. And the fact that we, at the end of the hospital groups process, ended up with six hospital groups — that to me is a framework from which you can deliver care in this day and age. Each of them can be looked upon as a mini hospital system, each of them has a primary academic partner, each has a major maternity hospital. So what we’ve done is put a framework in place that allows you to organise the Irish hospital system.
Regardless of what funding model is decided on, you still need to organise the hospitals in some way.
Are you confident that the groups will progress to Trusts?
I don’t like the word ‘Trusts’. It’s a term from the UK. I suppose I’ve been waiting and disappointed that the boards haven’t been put in place in the three Dublin groups and in the SSWHG. “(The Higgins Report recommends every hospital group have an interim board).
Gynaecology services were part of the reconfiguration process. Yet over the past four years, the outpatient waiting list increased by 1,000 year-on-year. Why?
In many respects this is about prioritisation. I think running a hospital is like trying to conduct a huge orchestra, you’ve got many different components and you’ve got to keep it in balance. If one part of the service is drowned out, you run into problems. What happened to us is that we didn’t get the prioritisation which we believe we should have had.
We have to change the governance and that is the first step. If we get the governance right, then we need additional resources, in that order.
So in retrospect, should the maternity hospital have been an independent hospital with its own budget and its own CEO or Master, or whatever you want to call it, from day one?
Look I’ve spent years campaigning for advanced clinical leadership. I am completely philosophically and practically convinced of the need for clinicians to take on leadership roles. So if you are asking me what my preference would have been in 2007/8, my preference would have been that we had a clinical director with a budget. And we didn’t.
But we are now reaching a point where we are going to have a formal delegation [of budget]. It’s similar to a Master, you have both clinical and executive authority. And that’s the essence of it.
Will the buck stop with you?
Yes, you’re accountable for the service. I don’t believe a clinician can be accountable and responsible for a service as clinical director unless they have control of the resources of that service. So that’s been my problem.
“This will be the first time that a clinical director will formally have the clinical and executive authority in the HSE system, as far as I am aware.
How difficult was that to achieve?
Real change is always difficult, it’s always worthwhile. Nothing worthwhile is easy.
Was there resistance?
No more than you’d expect to fundamental change.
You’re in a position now that is being welcomed by your colleagues — but you were also on the SSWHG leadership team — and as Tony McNamara, CEO of CUH pointed out in a letter obtained under FOI — you have been “in a position to influence these [gynaecology] developments” but have been “clearly unable to do so”. Is that a fair point?
With regard to my role in the leadership team, I want to pay tribute to the SSWHG, to the leadership team, to the chairperson, Prof Geraldine McCarthy and to the acute hospitals division in the HSE, because they have moved forward, they have taken this proposal from us, they have approved it and we are putting in place a directorate across the group that combines clinical and executive leadership in the one post and that’s a big change. So I’m happy to be judged on that and I’ve certainly been an advocate, an enthusiastic advocate for that change and I’ve worked as hard as I can. It’s appropriate to point out that my role in the leadership team was as the chief academic officer, not as a representative of maternity services.
What can be done to tackle the deficit in foetal anomaly scans? (Less than half of pregnant women attending CUMH are able to access this 20-week scan, which is routinely available in the Dublin maternity hospitals).
We are short capacity. But also training sonographers (specialists in reading ultrasounds) is very time consuming. The training is currently based in Dublin and it does mean us sending midwives to Dublin and we need more resources and we need a certain amount of time to be able to do that.
We started from zero with no trained sonographers. We had radiographers but not trained sonographers and we have built that up slowly but surely. And I think after gynaecology, that’s the most important service thing we need to do here in Cork.
We need to ensure across the group that we have the same high standards, the same quality of scanning everywhere across the four units (Cork, Kerry, Tipperary and Waterford) and that’s very, very important.
Now that you are presiding over four maternity units — where do you stand in terms of the Eighth Amendment? (The Constitutional amendment that acknowledges the right to life of the unborn and the equal right to life of the mother)
I actually was the expert witness at the first meeting of the Citizens’ Assembly and I spoke about the current practice with regard to termination and we had a Q&A and then a workshop with the Assembly. I did ask them why they were contacting me to do it and the answer was because I hadn’t spoken publicly on this issue. So my attitude is that these are very fundamental decisions for society to decide what their attitude is. I am not someone who believes that obstetricians need to be in the vanguard of commenting on either side of this debate.
Certainly among obstetricians there would be a range of views and I would prefer to see society reflect on it deeply. My main concern is that people take time, think about it very carefully and that we allow a range of voices to be heard before a decision is made.
I don’t think obstetricians need to take the lead in these issues.”
I suppose the reason they have is because they are the ones in the room when decisions have to be made. You must have your own opinion?
I have my own opinion. And from my point of view and the service we provide here, we’ll work within the law and provide a range of services that the law allows us to do.
But would you prefer to see the law changed for foetal anomalies or rape or incest cases?
I think I’m going to stick to the answer that I gave to the Assembly when they asked me to speak and explain what currently happens — they said they were asking me because I hadn’t commented.
Q: But surely you did comment if they asked you?
I explained what the current practice was. But I didn’t give any opinions and I’m going to keep my opinions. I’m a citizen and I think a mistake has been made in the past where obstetricians were in the vanguard on both sides of this debate and I think we need a deep reflective decision and everyone needs to hear the views and society needs to decide.
It’s a fundamental issue and I think I’m very comfortable with not partaking in the debate but providing services within the law. The law may change after the referendum and whatever framework we have to work in, we will.
You don’t have to have a strong view. I have practised in countries and in hospitals where termination is freely available. I had no problem practising there but I am quite happy to wait and see what society, Irish society, thinks of this issue. Clearly it’s an area where views are changing radically, I would have thought.
Asking obstetricians to contribute to the debate regardless of what their views are —‘I don’t think it’s fair. I don’t think it’s required either. I think obstetricians have good insights but they shouldn’t be the arbiters on a constitutional situation.
If we go back a little bit in time, obstetricians led one particular approach on this issue and now some are leading another approach.
I think we will practice within the law and provide services within the law.
Q: Getting back to your new role — when will the budget be officially yours and what will it be?
From February. I think there’s work to be done to work out exactly what it will be. Obviously it’s going to be a point of significant discussion.
Q: How do you feel about leaving the post you’ve held for five-and-a-half years as head of UCC’s College of Health and Medicine?
We’ve done a lot of positive things. We’ve just announced in the last few weeks that we are going to build a new clinical medical school, a new dental school and hospital and we are going to build a new health innovation hub here in Cork. The funding is in place, we’ve got a European Investment Bank loan. That’s a very big agenda that I am happy has come to pass. The loan is already drawn down so we are ready to build. And I think that will energise the whole hospital reconfiguration in the city again.
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