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Speech by Minister for Health Leo Varadkar on the Private Members' Motion on Maternity and Other Services in Portlaoise Hospital, in Dail Eireann on Tuesday May 26th


A Cathaoirligh,
First of all, I want to thank Deputies Kelleher, Browne, Calleary, Collins, Cowen, Dooley, Fleming, Keaveney, Kirk, Kitt, Martin, Moynihan, McConalogue, McGrath, McGuinness, Ó Cuív, O'Dea, Ó Fearghaíl, Smith and Troy for giving me the opportunity to address the issues surrounding services in Portlaoise Hospital.

I want to begin once again by recognising the fortitude and courage of families who shared their stories and have given us the opportunity to improve things for the future, by learning from the past. Two weeks ago, in a hotel room in Portlaoise, a group of over 100 people shared their experiences with my officials, the Chief Medical Officer, my advisors and me. It was harrowing but an invaluable education for us all.

I heard for myself just how difficult it can be for patients when things have gone wrong to get even basic information. Quite rightly, people want to know what happened and why. And they want to know that all that can be done will be done, to ensure it does not happen again. Often the truth was not forthcoming even when it was known. And all that could have been done to learn from mistakes was not done soon enough.

Trust breaks down at the very point at which patients and their families need it most and are at their most vulnerable.

I am sorry that patients, in their greatest need, did not receive what anyone in those circumstances should expect - honesty, respect, care and compassion. Families and patients were treated badly. While inadequate staffing levels and expertise form part of the context, this was not a resource issue alone. It costs nothing to care. Families and patients needed help and needed to know that their loss mattered. They needed comfort, information and follow-up. They didn’t get these things.

Honesty also costs nothing. If anything, it saves lives and money.

What is clear, above all else, is that the patients and families at the centre of what happened in Portlaoise wanted, and still want to make sure, that other families do not go through what they experienced. They are giving us the chance to learn from what happened to them, and to change how we do things. I hope that this brings them some consolation.

I should, of course, recognise that the number of patients and families who have had a bad experience of Portlaoise extends beyond the families who lost newborn babies in recent years and beyond the maternity unit and we should remember that in our contributions. We should remember that many patients in Portlaoise speak well of it, based on their own experiences.

We should also remember that in Ireland, every year, there are about 12 maternal deaths and about 450 perinatal deaths. These include stillbirths and newborn deaths. Each one is a human tragedy and a loss. But these mortality rates are at, or below, the average for the developed world, and the vast majority occur for natural or biological reasons, not as a result of poor standards of medical or midwifery care, let alone negligence. While our maternity services have their shortcomings, there is little evidence to support the view that they are unsafe or that they compare poorly with other countries. That is unfair to frontline staff and causes unnecessary worry for pregnant women and their partners and families.

This is a serious issue that should be debated in this House, but not with a view to political point-scoring or grandstanding, and I ask the Opposition to give that some thought.

Portlaoise Report
I welcome the publication of the HIQA Report. As the House will know, it followed the 2014 report by the Chief Medical Officer into perinatal deaths at Portlaoise. The Report is critical of the hospital and the HSE at regional and national level. I believe that the criticism is justified, and I am disappointed that our health service was found to be so lacking in compassion and care, two core values of the service we strive to deliver.

I accept in full the findings and all eight recommendations outlined in the report. I want to ensure that this report is a watershed report that brings about real change and helps to drive much needed improvements in Portlaoise, and by extension, all hospitals.

I have written to the HSE Director General indicating that a specific targeted local response must be put in place immediately, including providing counselling and other supports to the families and former patients.

I have asked that a senior midwife or nurse from outside the hospital be assigned to act as a service liaison, to enable an assessment of counselling or other requirements that these families and former patients may have, and to ensure the early provision of such services.
I have also indicated that a local senior community based manager should be assigned to act as a liaison to facilitate an early and effective response to specific issues they raised regarding difficulties accessing services locally. I am mindful too of the need to provide some answers to the families and former patients regarding their care, where possible, so I have emphasised the importance of a speedy completion of the individual case reviews. I expect a weekly progress report from the HSE regarding their response on the ground and the first such report is due this week.

One critical issue for me to deal with at the outset is the issue of resources. I have heard many people rush to judgement to say that a lack of resources explains what happened in Portlaoise and adverse incidents elsewhere. They often do so, before knowing the full facts or even any facts. The opposition in its motion here today, and some others, have been cynical in the speed and superficiality of their response in this regard.

I can only assume that some of these comments were made by people who have not fully read or understood what HIQA has had to say about Portlaoise.

At the meeting with the families and former patients, I did not hear many complaints about a lack of resources. In general, I did not hear that staff were run off their feet. Yes, I heard that there were some infrastructural deficits. But mostly I heard of patients being treated with indifference and with a lack of compassion and empathy, a cold shoulder and a deaf ear.

It is a report with profound patient safety implications - I have heard its message. I understand it. This House needs to understand it too. A service does not become safe simply because it has a certain ratio of doctors or nurses; or because it has been given a particular designation or status; or because it has a particular location or size. That's not it at all.

Safe services are those in which patients are treated with clinical competence and human kindness, in which people and families are listened to, in which staff are honest and open with patients about what they can and cannot do for them, and above all, are honest and open when things go wrong.

Safe services are services where staff work as a team, communicate well with each other as well as with patients. Where adverse events, complaints and serious incidents are reported, analysed and responded to as opportunities to learn and to improve. They are services where audits are done regularly to show up any anomalies or differences with comparable centres. They are services in which staff being adequately trained is a given.

They are services in which saying that patient safety is the top priority is not rhetoric – but something real. Management teams and boards of such organisations listen to and learn from the experiences- good and bad- of their patients and staff. This has to be the standard we expect of every service, no matter how small, no matter where it is, and no matter what types of services it provides, its budget or its status or classification.

Service Changes
Improvements have been, and continue to be, made at Portlaoise. New management and governance structures, clinical and operational, are in place.

Appointments have been made to key posts of concern in maternity and general services. This includes additional consultants sanctioned in anaesthetics, surgery, emergency medicine, paediatrics and obstetrics. 16 additional midwives have been appointed and approval has been given for further midwifery posts, to include shift-leaders, as well as posts in diabetics and ultra-sonography. There is now a risk manager on site. A director of midwifery has been seconded from the Coombe. All emergency department patients are now under the care of a named consultant. Ambulance bypass protocols are in place.

Structural change has begun. Governance of the maternity service will transfer to the Coombe following on from a memorandum of understanding agreed with that hospital. This will become the country’s first managed clinical maternity network. This is a very significant development, which will address the clinical governance and oversight shortcomings identified in the report. It will also ensure that women in Portlaoise have the same high quality maternity care experienced by women attending the Coombe. Capital investment will be required but will have to be subject to prioritisation like all such developments.

I know that questions have arisen about the future of Portlaoise Hospital, in light of this and previous reports.

I can assure the House that the future of Portlaoise is as a constituent acute hospital within the Dublin Midlands Hospital Group. Any change to services in the hospital will be undertaken in a planned and orderly manner, guided by what is best in terms of patient safety and outcomes. This will take account of existing patient flows, demands in other hospitals and the need to develop particular services at Portlaoise that are part of the overall service reorganisation in the Group.

We will need to make sure that any services currently provided by the hospital, which are not viable, are discontinued and we need to ensure that viable services are safe and adequately resourced.

Every hospital in the Dublin Midlands group, large and small, will play a key role within the Group. I am confident that these changes will make Portlaoise Hospital a better, busier and safer hospital.

The establishment of hospital groups is one of the most radical modernisations of acute care since the State’s foundation, and is a key building block in delivering our Programme for Government commitments on health reform. Hospital groups provide the optimum configuration for hospital services, for high quality, safe patient care in a cost effective manner.
As hospitals move to working as part of a group, services will be reviewed and evaluated to ensure the delivery of high-quality, safe patient care which results in better outcomes for patients.

In the context of the Dublin Midlands Hospital Group, relationships among Portlaoise and Tullamore, Tallaght, Naas and St. James' Hospitals are being further developed, particularly in emergency medicine, critical care, ICU, surgery and bed capacity.

Maternity Strategy
Maternity services in all parts of the country will be subject to review and evaluation this year, as part of the development of the National Maternity Strategy, which is now under way. The Strategy will map the future of maternity services, to ensure that women in Ireland have access to safe, high quality maternity care, in a setting most appropriate to their needs.
I have established the National Maternity Strategy Steering Group to advise on the strategy. The Group, which has wide representation across stakeholder groups, had its second meeting this week. It is intended to publish the new Strategy later this year.

Developing the Strategy gives us the opportunity to take stock of current services, and identify how we can improve the quality and safety of care provided to women and babies. The Strategy will ensure that our maternity services are developed and improved in line with best available national and international evidence.
Among those on the steering group are two of the mothers who lost babies in Portlaoise, Shauna Keyes and Roisin Molloy. I want to thank them in particular this evening for agreeing to serve on the group and provide their insights.

National Women and Infants Health Programme
I have also decided to establish a National Women & Infants Health Programme, to address and improve maternity services across the country. The Programme will span the delivery of maternity services across primary, acute and community care. Modelled on the highly successful National Cancer Programme, it will provide the leadership and have the authority to deliver the strategy and to drive reform and standardise care across all 19 maternity units.

Ireland has a relatively low ratio of staff per birth in our maternity services. However, the numbers of obstetricians and midwives are increasing. In 2015, we have 123 whole time equivalent consultant obstetricians, compared with 116 in 2011, when this Government came into office. Midwife numbers have increased significantly from 1,189 whole time equivalents in 2011 to 1,424 in 2015.

This on-going increase in staffing came at a time when the country was in a financial emergency. This is significant and shows that government and the HSE protected maternity services during the toughest financial environment.

It's disappointing, but true to form, that the opposition should ignore this. Now that the economy is growing again we can do better still. Increasing staff numbers, coupled with a falling birth rate, means that, although there is a way to go, the ratio of obstetric and midwifery staff to births is improving and will continue to do so.

Spending cuts and freezes across the health service from 2008 onwards had an inevitable effect on services. However, this year an extra €2m has been provided in the HSE National Service Plan 2015 to address current pressures in maternity services. This includes provision for recruitment of additional obstetricians, midwives and other front line staff.

As I have already outlined, the issues in Portlaoise are not directly related to resources. There have been recent media reports suggesting that Portlaoise was in some way drastically underfunded, compared to similar hospitals. In fact, the funding for Portlaoise, is broadly on a par with hospitals such as Portiuncula, Wexford and South Tipperary, all so-called 'model three' hospitals and most with a larger population to serve.

There has been a lot of commentary about accountability. As I am sure the House will agree, everyone involved in this matter has a right to a fair hearing in accordance with stated disciplinary procedures. HIQA does not name any individual and it is not in my power to effect summary dismissals or sanctions against people who are not in my employment.

I do not propose to comment further at this time, other than to say that a number of staff have had complaints made to their professional regulatory bodies, in relation to their involvement in care in Portlaoise. These will be investigated in line with standard procedures and the law.

In addition, the HSE is finalising an investigation, in line with its Code of Governance and Disciplinary Procedures. This may result in disciplinary action being taken against some individuals, in management positions.

Patient Safety
A culture of patient safety needs to be embedded in our health service. We need a health service where the patient, and the patients’ needs, are at the centre.

I have a very clear focus on patient safety and I have ensured that it has been made a priority within the HSE’s Annual Service Plan. My officials meet with the HSE each month about the Service Plan and patient safety is a standing item on that agenda. There are many facets to the patient safety agenda and several initiatives have the potential to drive significant change over the coming years.

Leadership of this change, through governance and management, will be a key dimension.
Guaranteeing better outcomes for patients is a fundamental principle of our health reform programme. We all continue to strive to ensure that patients receive the best care possible when they need to access health and social care services. Recent reports show that we still face many challenges to ensure that our health and social care services are truly safe and of the highest quality.
I am, however, confident that implementation of the HIQA and Chief Medical Officer reports into Portlaoise will ensure that patient safety is everyone’s priority, and reassure patients that the services they access are of the highest quality and safety.

Patient Advocacy Service
Before I became Minister for Health, there was a plan to create a patient advocacy agency as a sub-agency of the HSE. I strongly believe that any new patient advocacy service should be independent of the HSE. That is why the HSE was told to remove the proposed agency from its Service Plan for 2015. My view has been supported by the recommendation in the Portlaoise Report.

I plan to establish a fully independent national service before May 2016.
The scope, role and functions of the service need to be considered, along with the structural, governance and funding arrangements needed. My Department will consult widely on the best way to get the service up and running in the shortest possible timeframe.

Informed by HIQA reports on various hospital services, and based on analysis and internal discussions on patient safety priorities, I intend to strengthen the patient safety role and functions of my Department.
I will develop a significantly enhanced patient safety function in my Department, with a clear mandate for leadership, direction and oversight for national improvements in patient safety, clinical effectiveness and patient experience.

This new function is in addition to other patient safety policy initiatives in progress, including legislative proposals for the further regulation of healthcare, patient safety provisions in the Health Information Bill and the recently completed work on the “Code of Conduct” for employers, that clearly sets out employers’ responsibilities in relation to achieving an optimal safety culture, governance and performance of the organisation.

My Department continues to progress the Patient Safety Licensing Bill. However, as an interim step towards licensing, I will shortly bring a Memo to Government seeking approval to draft amendments to the 2007 Health Act. This amendment will seek to extend HIQA's remit to the private healthcare sector in the shorter term. This will ensure that HIQA has the necessary powers to set and monitor standards and, where necessary, undertake investigations, in both the public and private healthcare sectors.

I also intend to bring forward legislation to give effect to recommendations made by the Commission on Patient Safety and Quality Assurance to facilitate open disclosure of adverse events to patients. Meanwhile, the HSE has begun to implement the National Policy on Open Disclosure across all health and social services. The Policy is designed to ensure an open, consistent approach to communicating with patients and their families when things go wrong in the provision of their healthcare.

Oversight Group
The HIQA Report on Portlaoise called for a group to oversee the implementation of the recommendations contained in the Report. I have approved the composition and terms of reference of this Group. It will be chaired by the Chief Medical Officer and will include senior officials in my Department as well as patient representation.

I have also written to the HSE Director General, requesting a plan and timetable to implement the HIQA recommendations. This plan will be used by the Oversight Group to monitor the HSE’s progress on implementation. A named person in the HSE will have responsibility for reporting to the Oversight Group, on behalf of the Directorate, on progress made on a monthly basis.

The House will be aware that one of the priorities for 2015, identified by Minister Lynch and me, is to develop a mechanism to monitor the implementation by the HSE of the recommendations contained in previous HIQA Investigation Reports. I will be seeking regular updates on this and intend to use it to drive a much improved commitment to implementation than we have seen in the past.

I want to finish by reassuring this House that I will do everything in my power to ensure that the recommendations in this report are implemented without delay. We cannot undo the loss that families have suffered. But we can ensure that the lessons learned will not be ignored. I spoke earlier of the bravery of those who spoke out. I think it is now time for some political bravery from all of us here.

All of us have a responsibility to act as leaders either nationally, or in our constituencies, to ensure that all decisions made in health are made on the grounds of what is best in terms of patient access, safety and clinical outcomes, rather than giving in to vested, institutional or political interests.

Over the next few years as we implement the Hospital Groups we will need to examine reconfiguring and restructuring how services are delivered across the Groups. There is a role for us all as public representatives to ensure that we deliver the best health service possible. But we need to ensure that in so doing, we do not approach reconfiguration through the ‘save our local hospital at all costs’ lens. Nor should it be about financial savings. Rather, we need to view things from the perspective of what is best for patients, see what services can be safely delivered from each hospital within a group, and plan our services accordingly.

Thank you.