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Decision time on the children’s hospital

At offices in central Dublin, a decision fundamental to the future of paediatric healthcare is being analysed and discussed.  

A team in the Strategic Infrastructure Division of An Bord Pleanála has been assessing the planning application to locate the 473-bed new National Children’s Hospital (NCH) at the campus of St James’s Hospital, Dublin. The hospital and a 53-bed family accommodation unit is planned to be located on a 4.85-hectare site (just under 12 acres) and a children’s research and innovation centre situated on a 0.14-hectare site on the campus.

Moreover, two paediatric urgent care and outpatient satellite centres are proposed for suburban Dublin at Connolly Hospital and Tallaght Hospital.

The application does not include the proposed development of a maternity hospital at the Dublin 8 site (under Government policy, the Coombe Women and Infants University Hospital will move to the St James’s campus), although information on all known future developments on the campus will have been provided. A 1.2-hectare site has been earmarked for the maternity hospital development.

Structurally, there are key differences to the previously-proposed  application for the NCH at the site of the Mater Hospital, Dublin, which had a footprint of around 2 hectares (just under 5 acres). The north Dublin proposal rose to 74 metres above ground (see panel on next page), a major factor in its rejection. The parapet height of the principal building at the St James’s site is at just under 30 metres.

An Bord Pleanála has been analysing the planning submission and the written and oral responses since the application was lodged in August 2015. Last February, when its decision was due, the timeline was extended to 12 May because of the number and complexity of the issues involved. All stakeholders, whether in favour or against the proposed site, are keen for a planning decision to be finally announced.

If the planning application is successful, it is intended that the new NCH will be fully operational in 2020. It will provide tertiary/quaternary specialist paediatric services for the whole island and, in conjunction with its satellite centres, secondary paediatric services for greater Dublin. The satellite centres are due to open in 2018.

In offices across town, at the proposed St James’s site, the ‘big guns’ have been wheeled out for the Medical Independent (MI). Over the best part of an hour, Children’s Hospital Group (CHG) CEO Ms Eilish Hardiman and National Paediatric Hospital Development Board (NPHDB) Project Director Mr John Pollock deliver a comprehensive PowerPoint presentation on the new NCH. Also in attendance is a PR executive from Q4 Public Relations.

The vision involves successful integration of the three existing Dublin children’s hospitals into a single organisation before moving to the new NCH.

The premise that the three Dublin children’s hospitals unite to form a ‘hub’ is not disputed. Our Lady’s Children’s Hospital, Crumlin, dates back to the 1950s; Children’s University Hospital Temple Street to the late 19th Century; while Tallaght Hospital was established in the late 1990s.

Ms Hardiman speaks of “heart-breaking” scenes of parents of children attending Temple Street sleeping on the floors. Some of the facilities are “Dickensian”, she says. “I think people lose sight of that.”

She emphasises that the €650 million NCH project is “a positive development” for children. The “current people delivering services” are “110 per cent behind this project”.

Opponents

Among the most vociferous opponents to the St James’s campus location are retired paediatric consultants Dr Fin Breatnach and Dr Róisín Healy. Dr Healy claims some staff in St James’s and the children’s hospitals are afraid to speak out, a claim flatly rejected by Ms Hardiman.

The CHG/NPHDB says that, prior to the submission of the planning application, there were over 1,000 hours of engagement and consultation with staff from the three Dublin children’s hospitals, clinical leads in paediatric specialties, families, young people and children, as well as with residents from the Dublin 8 area.

Dr Breatnach and Dr Healy believe the NCH should be constructed at the site of Connolly Hospital, Blanchardstown, due to its advantages of space and access. They opposed the ill-fated proposal to locate the hospital at the Mater site. Like the NPHDB and the CHG, they have actively engaged with the media. They have also been involved in developing a petition and social media campaign in recent weeks.

Opposition to the St James’s location hinges on access and scope for future expansion. Opponents query the Government’s rationale that the range of specialties and subspecialties at St James’s would improve paediatric clinical outcomes in the context of ‘synergies’ with the adult hospital

Dr Healy believes the development in Dublin 8 is “more about building up St James’s Hospital” in respect of research profile and opportunities. 

Opposition to the St James’s location hinges on access and scope for future expansion. Opponents query the Government’s rationale that the range of specialties and subspecialties at St James’s would improve paediatric clinical outcomes in the context of ‘synergies’ with the adult hospital. St James’s was chosen by the Government on foot of the 2012 Dolphin Report.

Dr Breatnach, formerly a Paediatric Oncologist at Our Lady’s Children’s Hospital, Crumlin, says if this clinical outcomes argument was valid, then the debate would be over. “But of course the claim is complete and utter nonsense, unsupported by any scientific study anywhere in the world. Anyone with common sense would say, ‘hold on a minute, why do you need the adult physicians and surgeons to look after sick children?’”

He maintains tri-location of adult, paediatric and maternity hospitals supports better outcomes for neonates and mothers. In this regard, he notes that another maternity hospital, the Rotunda, is scheduled to relocate to the campus of Connolly Hospital under Government policy. 

In agreement with Dr Breatnach is Dr Eamonn Faller, an SHO at St James’s, who supports the Connolly site for the new NCH. Dr Faller undertook his medical school placements at St James’s and completed his intern year there. Nevertheless, he considers it an unsuitable location for the NCH for a number of reasons.

He says he has a very personal perspective. As a teenager, he had a condition requiring two-to-three weekly trips from Galway to Crumlin. The clinical services at Crumlin were excellent but there was “a huge amount of stress” involved in navigating the inner city and getting parking.

The new NCH would have 675 parking spaces for visitors/patients. It has been pointed out that the three children’s hospitals currently have only 230 such spaces combined.

Dr Faller doubts that the range of specialties and subspecialties at St James’s would have a significant impact on paediatric services if the NCH was on-site.

“I think James’s is a fantastic hospital. I really enjoy working here and it does work very well as an adult hospital,” he tells MI. “But the national specialties that James’s has wouldn’t translate particularly well to children. Things that would be useful at a co-located site would be cystic fibrosis, spinal surgery in particular, and transplant medicine. There is a bit of crossover between adult and children specialties there.

“James’s is a huge cancer hospital; it has a bone marrow transplant unit but it’s completely independent of the children’s bone marrow transplant unit, so there is no crossover of expertise there. It has oral and maxillofacial, and plastics, which would probably be the two that would be most beneficial — there would be crossover between the surgeons there.”

But overall, he does not believe the mix of specialties at St James’s, in the context of co-location, would be particularly useful.

“Admittedly, the services available at Connolly would be less so,” he adds.

He believes there is a case for upgrading the Connolly site. “For instance, it would be ideally placed to have a Level 1 Trauma Centre, which Dublin currently lacks and which a city the size of Dublin, a capital city, really should have.”

Some services could be transferred to Connolly from Beaumont in the context of this upgrade. “I think they should be looking at this more longer-term, to consolidate a lot of services thinly spread around Dublin in a site such as Connolly.”

Advocates

Advocates for the St James’s site point out that there are facilities on campus that will benefit paediatric patients, such as the St Luke’s Radiation Oncology Centre.

The CHG considers that it will likely be “decades” before the NCH has a fully paediatric-only consultant staff. This may never be practical or appropriate for some specialties, it says.

A recent analysis by the CHG HR Department of the workforce of the three Dublin children’s hospitals (cited at An Bord Pleanála’s oral hearing by Dr Emma Curtis, NPHDB Medical Director and Consultant Paediatrician, Tallaght) looked at 9,341 consultant hours per week worked by the consultants attached to the three hospitals.

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The proposed National Children’s Hospital concourse

Of those hours, 75 per cent (7,489) were in the children’s hospitals, 20 per cent (1,458) were in adult hospitals and 5 per cent (394) were in maternity hospitals.

A CHG spokesperson tells MI there are “a broad range of international clinical studies” which determine that co-location of children’s hospitals with adult teaching hospitals provides optimal clinical outcomes for children and young people. “For example, when considering international best practice, the 2006 Children’s Health First: McKinsey Report concludes that ‘optimal’ paediatric service for a population of up to five million must be co-located with an adult teaching hospital.

“[The] Scottish Review of Paediatric Services and the Bristol Inquiry also have the same conclusions. An international group of leading children’s hospital executives from Boston, London, Colorado and Queensland, in a Ministerial National Paediatric Hospital Independent Review 2011, stated: ‘We unequivocally believe that co-locating with tertiary adult and maternity hospitals is essential to the development of an excellent paediatric service’.”

Position

Dr John Duddy, a Specialist Registrar in Neurosurgery at Beaumont Hospital, Dublin, notes that one of the key criteria in the selection of the NCH location in Dublin was the strength of the co-located adult centre. He says Cork University Hospital is the only adult hospital with all surgical and medical facilities on one site and “James’s would probably be the closest to it in Dublin”.

He adds that a number of major surgical subspecialties are spread across adult hospitals on both sides of Dublin city, which makes choosing a site problematic. He says the crossover between adult and paediatric services was “a reasonable consideration”, particularly in the context of allowing for an “easier transition” for some patients.

Dr Duddy is also Chair of the IMO’s NCHD Committee and incoming IMO President. He confirms that the Organisation has no position on the proposed location.

“The members haven’t expressed any preference for a specific site and that probably reflects the divisions that have existed among doctors, particularly in Dublin, regarding the site. So the Organisation has taken a neutral position really on the site and has just wanted to see a new children’s hospital built as soon as possible.”

The IHCA and INMO also have no official position on the proposed site.

‘Merit’

Dr James Gray, Emergency Medicine Consultant (in the adult service) at Tallaght, says building the new NCH on an established adult site “has merit”, although it “remains to be seen” whether the optimum location is St James’s. “For kids outside of Dublin, access would be vital and I would have thought a site close to the M50 might be better suited. I think at this stage, we need it built for the sake of the State’s children.”

The issue of staff parking has also presented concern. Mr Pollock at the NPHDB believes a “culture change” will be required. Staff parking at the St James’s campus is 1,124 but this will drop to 880 spaces, according to CHG literature. When the NCH is operational, there will be an extra 3,000 staff on the campus. The existing daily core staff at the St James’s campus is also around 3,000.

Mr Pollock of the NPHDB comments: “When we go to Crumlin [to do staff presentations], one of the questions I always get asked is, ‘what about car parking?’ I go to Tallaght and they always ask me, ‘what about car parking?’… I have yet to be asked a question about staff car parking in Temple Street, because they don’t have it. And they get used to working that way.

“So the plan is to prioritise those staff who need access to a car parking space… James’s has appointed a management mobility manager who is now working with James’s to introduce things like tax saver schemes… The management mobility manager who is implementing that plan is the same manager who implemented the plan in the Mater Hospital. In the Mater, back about 2008, they had 600 staff car parking spaces. Do you know how many staff car parking spaces they have today? 100. And they said the sky would fall in, that it could never be done. It was delivered there.

“And we have got between now and 2020 to implement that plan, so there is a gradual process, engaging with staff, telling them basically what needs to be done, introducing a parking charge, because there are a number of people who live within, certainly a mile and even less, of James’s who drive to work… I wouldn’t regard them as a priority for a parking space.

“So you prioritise those who don’t have access to public transport, those who are travelling from the country, and introduce a parking charge. We have got between now and 2020 to implement that plan.”

Recruitment

However, in the high-stakes arena of healthcare recruitment, one wonders if staff car parking could be a ‘deal-breaker’ in some cases.  There are worrying nursing shortages in the health service, particularly in specialist areas. The proposed NCH will accommodate 60 critical care beds.

“Yes, correct, but we won’t be opening up the 60 [initially], because we know we don’t need them at opening; that is part of our future expansion… ” says Ms Hardiman.

She says that, with the HSE and Department of Health, the CHG has commenced a supply-and-demand analysis for children’s nursing. “Because we are the ones with the universities that are training the nurses, for the future pipeline, and we are saying there aren’t enough of them… The reason why Dublin has been so impacted around the nursing shortages is that the moratorium was lifted in July 2014 and we have had an exodus from Dublin down to the country that has left us with a vacancy rate that reminds me of the days when I was Director of Nursing in James’s.”

Ms Hardiman does not believe that limited staff parking will inhibit recruitment at the NCH. 

She says she spoke to Prof Mary Day, CEO of the Ireland East Hospitals Group who was Mater CEO, who said the Mater did not have a specific problem with recruitment associated with reduced staff parking.

Recruitment will be a challenge and that is why making the NCH “a very attractive place to work” will be a key focus, says Ms Hardiman.

Space

Ms Hardiman notes the new NCH has been designed to include “soft space” — that is, a design that allows clinical areas to expand in the future. For example, ICU will be situated next to Corporate Services, as the latter could be moved to expand the former.

Minutes of the 3 September 2015 meeting of the National Retrieval Steering Committee noted that the National Transport Medicine Programme (NTMP) was allocated space in the NCH, in respect of the neonatal and paediatric aspects of the programme. According to the minutes, the Director of the National Clinical Programme in Transport Medicine, Dr Dermot Doherty, did not believe the space was adequate for the programme. The matter was to be raised with Ms Hardiman, said the minutes.

Ms Hardiman tells MI the space allocation was concluded to the satisfaction of the NTMP. This followed discussions about the space requirements for equipment storage.

Helipad

The design for the new children’s hospital also features an elevated helipad. However, as first revealed by MI, the five-strong Sikorsky helicopter fleet at the Irish Coast Guard, which is also tasked with air ambulance missions, will not be permitted to access the proposed elevated helipad under current regulations.

At present, the Aircraft Flight Manual for the Sikorsky S92A helicopters used by the Coast Guard does not include rooftop helipad take-off/landing profiles. However, helicopters used by the Irish Air Corps can land on rooftops designed and certified for such operations.

The Coast Guard’s helicopters would land in the grounds of the Royal Hospital Kilmainham and patients would be transferred by road. This is the current process for patients being transported to St James’s.

Retired consultant anaesthetist Dr Tony Healy, who made a critical written submission to An Bord Pleanála on issues surrounding the proposed elevated helipad, points out that improvements in emergency care will likely increase demand on air ambulance services.

There is also the possibility of St James’s becoming a Level 1 Trauma Centre — he notes that it is proposed that the helipad would be a shared facility on the campus.

Given such factors, Dr Healy feels it is essential that a ground helipad be available on-campus to accommodate the Coast Guard.

These are among the numerous issues that have arisen in the debate over the location of the NCH.

In the heart of the Mater — a ‘visually incongruous structure’

Following the 2006 McKinsey Report, a HSE/Department of Health task group was formed to advise on the best location for the national children’s hospital.

This group advised that the hospital be built on the Mater Hospital campus, a recommendation endorsed by the HSE and Government. In 2007, the NPHDB was established to deliver the project.

In late 2010 and early 2011, pre-planning consultations took place with An Bord Pleanála. In 2011, a Government-commissioned independent review further endorsed the suitability of the Mater site. The application was lodged in July 2011.

Planning permission was refused in February 2012. According to the decision, the footprint afforded to the proposed development on the Mater campus, (circa 2 hectares), had resulted in a proposal for “a very significant building in terms of bulk and height, including a 164-metre-long ward block, rising to 74 metres above ground”.

“Notwithstanding the general acceptability of the proposal in terms of medical co-location on this inner city hospital site, it is considered that the proposed development, by reason of its height, scale, form and mass, located on this elevated site, would result in a dominant, visually incongruous structure and would have a profound negative impact on the appearance and visual amenity of the city skyline.”

The proposed development would contravene the Dublin City Development Plan, 2011-2017, “which seeks to protect and enhance the skyline of the inner city and to ensure that all proposals for mid-rise and taller buildings make a positive contribution to the urban character of the city”.

The development as proposed, notwithstanding the quality of the design, would “be inconsistent with, and adversely affect, the existing scale and character of the historic city and the established character of the local area… ”

Around €35 million in State funding went towards the proposed Mater development.

In 2013, the NPHDB recorded expenditure of €1.7 million, including payroll and related costs of €0.45 million and non-payroll costs of €1.25 million. In 2014, expenditure increased to €7.83 million, including €1.48 million in payroll costs and €6.35 million in non-payroll costs.

The expenditure for 2015 had not yet been audited.

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