‘Perfect storm’ of pandemic, increased demand and shortage of staff causing worrying delays in Gynaecology care

Lack of modern public hospital facilities, capacity and expertise means those with non-urgent conditions can face significant delays in receiving care – says leading Consultant 

• Ageing facilities, lack of adequate theatre space and shortage of specialist surgical teams is causing ‘competition’ between Obstetrics and Gynaecology care and creating a trade-off in delivery of women’s health services; 
• Patients can routinely be waiting up to 6 to 8 months for an assessment, risking delayed diagnoses of gynaecological cancers or preventing timely access to care for painful conditions such as uterine fibroids or endometriosis;
• Longest average wait times for outpatient gynaecology appointments are at Tallaght (652 days), Ennis (506 days) and Nenagh (355) Hospitals;
• Hospital Consultant recruitment and retention crisis worsens with more than 830 permanent posts not filled as needed – as regional and smaller hospitals face additional recruitment challenges;
• Professor Sam Coulter-Smith: “Services that can take patients that would originally have gone to theatre and treat them on an outpatient basis will significantly help to reduce waiting lists – however, you need the space and the staff to do it.”

The Irish Hospital Consultants Association (IHCA) has today (4 May) warned of mounting delays for people waiting for planned Gynaecology procedures as a result of competition between services for scarce capacity and resources.

Professor Sam Coulter-Smith, a Consultant Obstetrician and Gynaecologist at the Rotunda Hospital, has said the Covid-19 pandemic over the past two years has led to a “perfect storm”, exacerbating existing constraints caused by increased demand, ageing facilities, insufficient capacity and long-standing recruitment challenges.

“We’ve had increased demand for Gynaecology services, while levels of anxiety and stress have increased, and referrals to hospitals have increased. At the same time, we have been unable to provide the same level of service that we would like to because we have had staff shortages.”

Speaking on behalf of the IHCA as part of its Care Can't Wait campaign, Prof Coulter-Smith explains what this has meant for staff and patients.

Competition between Obstetrics and Gynaecology
In many Irish hospitals, Obstetrics and Gynaecology are competing for scarce resources, and with space at a premium, patients are facing a trade-off between those waiting for planned procedures and those needing urgent care. 

“Obstetrics and Gynaecology is one specialty, delivered by mostly the same people within the same institutions. With the increasing number of Obstetric patients, Gynaecology takes second place, as demand-led Obstetrics services take precedence. That’s when you can see delays happen,” said Prof Coulter-Smith. 

“This has an impact on staff morale. When you put that together with the fact that many of our institutions are old and not fit for purpose, and with pay levels that are inequitable, it has a very significant effect on the service and our ability to attract and retain our staff.”

Around 10-20% of women attending a Gynaecology service will require surgical intervention, either to assess, diagnose or treat a condition. The competing demands for Obstetrics and Gynaecology can lead to long waiting lists for those requiring planned surgical care, which Prof Coulter-Smith says risks leading to delays in cancer investigations or leaving patients to live with painful conditions. 

“The majority of gynaecological cancers start by going through benign gynae services – that’s where they are assessed and diagnosed. The pandemic saw the postponement of a lot of these services leading to referrals without a patient being seen in person, as well as people not being able to attend appointments due to Covid. So between this and the existing waiting lists, there is now a ripple effect of delays meaning it is taking some patients up to 6 or 8 months to get assessed. This can be an issue especially if gynaecological cancer is present, as delays to treatment can reduce the prognosis for that patient.” 

Waiting times for gynaecology outpatient appointments vary significantly across the country. The hospitals with the longest average waiting times for a gynaecology appointment at the start of the year were¹:

Alongside the potential for missed early cancer diagnoses, conditions such as endometriosis, uterine fibroids or ovarian cysts can take longer to diagnose and commence treatment, meaning many women face having to live with debilitating pain for months or even years.

Staffing needed to support service delivery
Budget 2022 saw €5.3 million committed to enhancing gynaecology services, including the expansion of ‘see and treat’ Gynaecology clinics, specialist menopause clinics, and specialist endometriosis services – but without adequate Consultant staffing, some of these services may face challenges in getting off the ground. 

Prof Coulter-Smith says increasing these ‘see and treat’ Gynaecology services can have a significant impact on waiting lists and wait times: “In the Rotunda, we have a new ambulatory Gynaecology centre, which has been revamped to provide a gynae service, with day case hysteroscopy, clinics that allow patients to come and go without anaesthetic, have their investigation and possibly their treatment as well.

“That has taken some of the patients that would originally have gone to theatre and treated them on an outpatient basis. That’s the sort of thing that will significantly help to reduce the waiting lists for gynae theatre – however, you need the space to develop that, and you need the staff to do it as well.”

According to the most recent figures, 1 in 5 permanent Consultant posts nationally (over 8302) are currently vacant or filled on a temporary basis. There were 29 Consultant Obstetrics & Gynaecology posts vacant or filled on a temporary basis in March, of which 15 posts were totally vacant, 11 posts filled on a temporary/locum basis and three posts filled by agency staff. Patients attending hospitals with such recruitment and retention challenges are facing inequitable and delayed access to services.

“The bigger teaching hospitals probably find it easier to recruit staff, because that’s where most people want to come to work. The smaller hospitals around the country, where there’s a more general service and there isn’t the same level of sub-specialisation, find it increasingly difficult to recruit and retain staff,” explains Prof Coulter-Smith.

“What we’ve done within Obstetrics and Gynaecology at the Rotunda is create a ‘hub and spoke’ model, where we’ve co-located specialists in bigger hospitals, with smaller, regional hospitals giving them dedicated sessions or clinic time with patients in both areas so everyone can have access to sub-specialist services. That’s worked quite well and is something that could be replicated where appropriate.”

Meanwhile, talks on hospital Consultant contracts have stalled since December 2021, despite calls from the IHCA urging the Minister for Health to agree a replacement Independent Chair with the representative organisations to oversee what is an urgent and critical process towards addressing the root causes of the Consultant staffing crisis – including ending the ongoing pay discrimination faced by Consultants contracted after 2012. 

ENDS

Notes: 
Professor Sam Coulter-Smith’s comments were made in a new video released on social media today by the IHCA as part of its #CareCantWait campaign. The video is available here: https://vimeo.com/705652666

Professor Sam Coulter-Smith is Clinical Professor of Obstetrics and Gynaecology at the Royal College of Surgeons in Ireland and the Rotunda Hospital, and a Consultant in Obstetrics and Gynaecology. He is also Chair of the Institute of Obstetricians and Gynaecologists.

1. Response to Parliamentary Questions 726 and 727 from Deputy Sorca Clarke, 8 March 2022: https://www.oireachtas.ie/en/debates/question/2022-03-08/726/?highlight%5B0%5D=gynaecology
2. HSE NDTP PQ Response to Deputy David Cullinane, 24 March 2022: https://www.ihca.ie/_fileupload/PQ%20ref%2012721%2022%20Cullinane%20Consultant%20Posts%2024%20March%202022.pdf 

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