KiITTY HOLLANDanalyses the reasoning behind a long-awaited report, released at the weekend, which recommends closing Dublin's three maternity hospitals and transferring them elsewhere
A “TRANSFORMATION” in services for mothers and babies in the greater Dublin area is promised in a major new report on maternity and gynaecology services, and the Health Service Executive (HSE) has vowed to act on its recommendations.
“It is absolutely going to be implemented,” says Fionnuala Duffy, assistant national director of the HSE National Hospitals Office. “We are using this as a blueprint.”
Statistics indicate the current birth rate in the Dublin area is more than 26,000 a year and is likely to rise over the next decade. Current services must therefore adapt to meet demand and expectations, according to Duffy.
The major headline from the report, titled Independent Review of Maternity and Gynaecology Services in the Greater Dublin Area, was its recommendation that the three main maternity hospitals be closed on their current sites and moved to share sites with adult acute hospitals.
Services currently delivered at the Rotunda Hospital will be moved to the Mater site; services at the Coombe Women and Infants’ University Hospital are to be moved to the Adelaide and Meath Hospital in Tallaght; and services at the National Maternity Hospital in Holles Street are to be moved to St Vincent’s hospital.
This recommendation, which will be implemented over the next five years or so, according to Duffy, is based on international recognition that the best outcomes are achieved when maternity services are located with adult acute services.
“This allows the mother to access the full range of medical and support services should the need arise for, for example, cardiac and vascular surgery, diabetes services, intensive care facilities, haematology services, psychiatric services among others,” says the report.
There is, however, as Duffy points out “so much more in the report” than the news of plans to move the three maternity facilities. And though the physical transfer of services from the three widely known sites is bound to get people’s attention, the thrust of the report is a profound change in the maternity and neonatal care model in Dublin, so that a whole new model is transferred when the time comes.
Much in the report is said about choice, more midwives, shorter hospital stays for new mothers and a less medicalised approach to pregnancy and birth.
The current service model is “relatively hospital focused with a strong emphasis on medically led [doctor] services”. There is no provision for midwife-led antenatal care which has led to “relatively under-developed services led by and/or delivered by midwives”.
Though a doctor-led, hospital-centred model is undoubtedly suitable and even necessary for non-routine clinical conditions, given that 60 per cent of women have a totally straightforward, normal birth, the current set-up limits choices for women whose routine clinical needs could be provided for in a wider range of services.
The report’s authors examined models in Canada, New Zealand and the Netherlands where there is greater choice in the spectrum between acute hospital settings, low-intervention birthing units and home births. The midwife has a far greater role in these countries, and so capacity is freed up in the maternity hospitals.
Turning to the condition of the three maternity hospitals, it says the clinical areas are “inadequate for the delivery of healthcare by today’s modern standards” – particularly at the National Maternity Hospital at Holles Street.
“Many of the public wards experience higher than recommended occupancy levels in a Nightingale-style lay-out. This compromises privacy and dignity for patients whilst also increasing the likelihood of the spread of infections,” they say.
The authors would also like to see the average length of stay in hospital shortened, arguing it is longer here than international benchmarks. They partially blame private health insurers as they provide, for example, a five-day stay after a C-section. This, and underdeveloped community services, means “obstetric beds are being blocked when women/infants are clinically fit to return home”.
Length of stay could be reduced “through improved discharge planning, enhanced community-based services and a reassessment of the role the private insurance market plays in length of stay”.
Overall, it is clear, say the authors, “fundamental change is required”. It is not just desirable, but essential.
As well as moving the maternity hospitals to sites adjacent to adult and paediatric hospitals and the development of more community based antenatal and postnatal care options in the community, the report recommends an end to the Mastership system of governing maternity hospitals. While it is a system of great tradition and pride to each of the organisations, the report questions where it is suitable “for optimal clinical governance in a 21st century healthcare facility.
“We recommend that each of the maternity facilities be led by a clinical director, accountable to the CEO, but with clear autonomy and budgetary control for the management of the hospital unit.”
The authors say that, reform “on this scale” must be implemented in a “rigorous and robust manner”. The reform will “require significant capital investment in areas such as staffing both in primary and secondary/tertiary care”.
“The existing maternity hospital estate may be of value in this regard,” they say.