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Wednesday 20 August 2014

Eddie Hobbs: Little hope children's hospital will pull through

A triumph of short-term compromises over long-term plans will derail project

Eddie Hobbs

Published 15/06/2014 | 02:30

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CRITICAL CONDITION: St James’s Hospital in Dublin where the national children’s hospital is set to be built
CRITICAL CONDITION: St James’s Hospital in Dublin where the national children’s hospital is set to be built

For nearly two decades, the main arterial junction of the capital city of a developed country was a roundabout. Engineers who'd warned that putting a roundabout instead of a tight spaghetti junction would lead to massive disruption to motorists as millions of hours were lost in tailbacks and, in the end would be scrapped having indirectly cost many times more, lost the debate to mandarins who'd argued limited resources.

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The need to foresee expansion in demand caused by the building of infrastructure like the M50 and soft planning for population growth was pretty hard learned after the Red Cow debacle – you'd think – after all Ikea, off the M50 was not scrunched into a medieval city centre location. But not so when you factor in the distorting effect of medical lobbies competing for the children's hospital, the location of which might predetermine the overarching question of where to ground Ireland's centre of excellence, the Ark of the Covenant for hospital professionals.

This was never simply about the national children's hospital but about where Ireland ought to locate a tertiary hospital with a level one trauma centre, a pathway to combining three modern hospitals, children, maternity and adult, bristling with leading sub-specialists, research and education and acting as a beacon to attract the best talent available – fit for purpose for up to 100 years. It's a worthy goal, considering that if a visiting dignitary like the Pope, the British monarch, or the US president and their entourage were the target of a terrorist attack leading to very serious injuries, they'd probably need to be evacuated to Belfast.

In the current chapter of the national children's hospital saga, the location is now to be at St James's Hospital despite the high risk of the application running foul of An Bord Pleanala for being nearly as daft as the earlier one to construct the Monster at the Mater, 164 metres long and 74 metres high.

Nobody seemed to have deemed it prudent, in the early stages, to run the idea by planners or check against the local development plan and non-recoverable fees are thought to amount to €24m following a stinging rebuff from Ireland's overarching planning agency.

A myth spun around the McKinsey report in 2005 is that it contained a prerequisite to co-locate with an adult teaching hospital – except McKinsey didn't say that at all. What McKinsey said, no doubt influenced by Dublin's scattered adult hospitals, was that, ideally, it should be co-located with one but if you go to a green field site you need to plan services for a standalone hospital accordingly.

It was the report which followed McKinsey in 2006, written exclusively by mandarins at the HSE and the Department of Health that stitched in co-location with an adult hospital as a prerequisite, overwhelming all other considerations, despite evidence throughout the world of children's hospitals functioning free of adult co-location. International experience is that any decision to co-locate needs to be checked against pragmatic considerations including space, quality of access, cultural and managerial fit with the adult hospital and the quality of managed services at the site, but that cut no ice.

If anything, a children's hospital should be adjacent to a maternity hospital purely on the basis that, of the numbers of transfers, 90 per cent are babies and not their mothers. Specialist skills get much mention in the plethora of reports and reviews that followed the mandarins' report, including emphasising the need for nearby transplantation and neurosurgery – neither of which is available at St James's.

The project killer, however, is the critical issue of accessibility and parking for families which, when added to population growth, makes it impossible to see how St James's Hospital makes any more sense than the Mater.

If the long-term vision is for a best-in-the-class tri-location of children, maternity and adult teaching hospitals, how can that happen at already crowded hospital locations? The compromise attempt to add a children's hospital to James's Street looks doomed.

The maximum number of car parking spaces possible ranges from 1,000 to 1,500 but using international hospital build-to-parking ratios, the number required is closer to 5,000, over half of those needed to support the children's hospital where the numbers of spaces required for children's families is 80 per cent more than for adults because they get more visitors.

The build alone, likely to come in at €2,000 to €2,600 per square metre, must also cater for rapid expansion to something at least two-thirds bigger to allow for population trends. But pushing the Jumbo into James's would be a critical error when you consider that Crumlin Children's Hospital was required to add 75 per cent more clinical space over the past 15 years or that Toronto's Children's Hospital doubled in size every 10 years since the Seventies.

Professional fees at five per cent of the build and VAT at 13.5 per cent is universal to any location, as is equipment but an unresolved issue is how to get the modern technology for the hospital, given that a patient management system is a HSE responsibility whose budget is minced.

Put the children's hospital at St James's and that means underground car parking. Digging under the site must begin with relocating a main sewer which traverses the current location and the destruction of some existing buildings which means excavation at St James's will add to the build cost and cause disruption to a hospital already creaking at the seams.

One thousand surface car spaces costs about €2m, a multi-story two and half times more but an underground costs over 17 times more at €35m adding between 10 per cent and 15 per cent to overall costs. Quite clearly the plan at St James's to go underground, combined with a massive parking shortfall at the complex, looks like another 'Mad Cow' in the making, forcing many patients and their families to fight for parking around nearby estates before hoofing it across Dublin 8 traffic to Ireland's new hospital.

Looking back on the saga of reports, reviews and debates about the hospital over the last decade, it's hard not to think that Ireland would have been better served had we lost the Battle of Clontarf!

The battle at St James's Hospital continues, trying to squeeze an unworkable project into an unwilling site, a triumph of short-term compromises over long-term thinking.

The only hope, saving the arrival of a fairy godmother, is for An Bord Pleanala to rescue the next Minister for Health from the folly and send it to the morgue before more money and time is wasted.

Sunday Independent

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