Letter to Leo Varadkar from Dr. Fin Breatnach 10th September 2014

By March 12, 2017Blog

September 10th, 2014.

Minister Leo Varadkar,

Department of Health,

Hawkins House,

Hawkins Street,

Dublin 2.

 

Dear Minister,

I understand from Jonathan Irwin, whom you will be meeting on September 25th, that you were happy for me to accompany him. Unfortunately, I will be abroad on that date and am due to return, a few days later, on the 28th. I am writing to document my significant concerns regarding the decision to build the National Paediatric Hospital (NPH) next to St. James’s Hospital. But, before I do that, let me present my bona fides.

I am a graduate of University College Cork and will not be awarded or rewarded with a Professorial Chair if I am successful in having the decision overturned. I am retired from clinical practice so, no personal gain there. My oncology training, over almost three years, was at Great Ormond Street in London from January 1979 until my appointment in late 1981 as Ireland’s first, resident paediatric oncologist at Our Lady’s Children’s Hospital, Crumlin. I took early retirement in June 2008. I was single handed, continuously on call, for the first 14 years. I set up The Children’s Cancer Fund in 1982. Many evenings, weekends and holidays were spent fundraising to build a Haematology/Oncology (Haem/Onc) department as none existed. With the support of the parents of the children I was caring for, we opened Ireland’s first Haem/Onc and bone marrow transplant facility in October, 1991. I performed Ireland’s first bone marrow transplant there, without any additional funding. We paid IR£300,000 in VAT when building the unit. No funding was provided by Government. (The reason given for this by a former Assistant Secretary some years later was that “We knew you would raise the money”!). Our fundraising paid for an upgrade to the Radiology Department at the hospital which included the purchase of the Country’s first, dedicated CAT scanner for children. The fund also purchased expensive surgical lasers for hepatic surgery. I paid the salary of 7 essential staff members for many years with the funds raised – these included social workers, secretary, data managers and, following the setting up of a shared care network from 1987, the salaries of what may well have been the first Haem/Onc liaison nurses in the world. Amongst many other achievements, our fundraising also paid for the entire cost of building the existing Haem/Onc out-patient department, administration and data management centre, tutorial rooms and senior staff offices in the new Medical Tower. Our efforts to provide the best outcomes for children were independently audited by the National Cancer Registry 12 or 13 years ago which resulted in a publication, in a peer reviewed journal, which demonstrated that, on average, our survival rates were better than both those of both Europe and the United States – not bad for an under-resourced, stand-alone children’s hospital! Throughout my professional life, my focus has always been on what is best for the children and their families. Following my retirement, that focus remains unchanged.

I am told that you supported the building of the NPH at Blanchardstown when you wrote to the Dolphin Committee. Whilst your support for the site may have been partly politically motivated, I would like to think that you also saw, as do I, the enormous potential of such a large site, much like the new, large Academic Health Science Campus sites on the periphery of cities in Holland which your Department officials were so impressed by when they visited. I am aware of your predecessor’s interest in having the NPH built at the site in Belcamp which was offered for the NPH. I am led to believe that height restrictions imposed in view of that sites adjacency to Dublin Airport precluded building there. So, another cramped inner city site has again been chosen for this project.

 

Collocation with an adult hospital

Whenever one is looking to justify a particular approach, then naturally, you will seek information to support you. McKinsey looked at 17 children’s hospitals and found that 15 were collocated with an adult hospital to some degree; some on the same block, some physically linked and others on a large campus, quite some distance from an adult hospital. Many of the hospital’s they reviewed would not be on my list of comparators!

When everyone thought that adult collocation was no longer going to be an issue (with the selection of the Mater as the site for the new children’s hospital) RKW set about producing a Framework Brief for the New Children’s Hospital on the Mater site and, in the process, reviewed 17 Children’s Hospital worldwide. Of these 17, only 4 (23%) were collocated with an adult hospital in the manner proposed for the St. James’s site i.e. physically connected. Four others had an adult hospital on the same large campus. Less than half had any adult hospital nearby. Significantly, given that there are lots of children in a Maternity Hospital and none in an adult hospital, 10 of the 17 were co-located with a maternity hospital.

If adult collocation is so incredibly important, then why are stand-alone children’s hospitals still being built? Alder Hey Children’s Hospital in Liverpool is the newest children’s hospital being built in the UK and will be the largest in Europe. It is entirely stand-alone in a large parkland setting (much like the new Melbourne Children’s Hospital which opened in 2012), surrounded by acres of green space on three sides. You will be interested to learn that children who require surgery for heart disease are transferred from the new collocated Manchester Children’s Hospital to the stand-alone Alder Hey Children’s Hospital in Liverpool for treatment!

Eilish Hardiman and others continue to claim that McKinsey stipulated the absolute need for adult collocation; she knows full well that this is not the case! I quote from McKinsey: “The preferred option would be co-location. If so, needs to be specific about level of integration and sharing of services. If not co-located, need to be specific about how to address the challenges of isolation from adult services”. And, most importantly they added; “International experience has shown that it is important to weigh a decision to co-locate (with an adult hospital) against pragmatic considerations including space and quality of access to potential sites”.

And why this obsession with adult collocation? The latest mantra being continually repeated by proponents of the St. James’s site is that “the Clinical outcomes for the children will be better if the New Children’s Hospital is built adjacent to St. James’s Hospital”! As we are in the era of “Evidence based Medicine”, it is not unreasonable to ask for the evidence to support this claim? Well, you have to look no further for this than to read the 2006 report of the Location Task Group entitled “Prioritisation exercise for the collocation of adult specialties with a tertiary paediatric hospital in Dublin”. On page 2, the first sentence of the review, under the heading “The Literature”, states that “The literature does not directly address the specific added value of specific adult clinical specialty collocation with a paediatric hospital”! No supportive literature – that says it all. It would appear that the St. James’s site proponents, unable to defend the location on the basis of the major McKinsey site requirements such as space, access, parking or room for expansion, are trying to take shelter behind unproven, nebulous concepts and the ill-defined but emotional promise of improved outcomes for the children. Perhaps they would be good enough to inform us as to which adult surgeons and physicians, unskilled and unqualified as they are in the management of diseases of childhood, will bring about such improved outcomes? Arguably, there might be some benefit, as outlined in both the McKinsey and Task Group reports (perhaps of greater benefit for the doctors than for the children as stated by the late Maurice Nelligan) in having some of the very rare specialties available in the adult St. James’s Hospital,:- the three most important listed by the Task Group are:

1.      Neurosurgery,

2.      Liver, kidney, pancreas and heart/lung transplants and

3.      Interventional neuroradiology.

Unfortunately, none of these are available in St. James’s. It is worth recording that both McKinsay and Dolphin recognise that paediatric healthcare worldwideis changing and both acknowledge that, within a relatively short period of time, paediatric dependency on any adult service will become a thing of the past. Perversely, the one collocation which will result in lives being saved; that of the New Children’s Hospital with a Maternity Hospital, is being jeopardised by the blind perseverance with this deeply flawed site. The likelihood of a maternity hospital ever being built on this constricted site is remote. If it is not built, then the paediatric surgeons, cardiologists and intensive care specialists are all agreed that it is inevitable that babies will die each year as a result. Let me explain why:-

The risks posed from a lack of physical collocation between a tertiary children’s hospital and a tertiary maternity hospital are:

  1. The need for ambulance transfer – whether this results in a journey of 100 metres or 100 kilometres, the greatest risk of loss of hardware e.g. accidental extubation/loss of IV access etc., in these tiny, vulnerable babies occurs at the point of transfer from cot to transport trolley, when either loading and unloading the trolley on/off the ambulance or when transferring back from the trolley to the cot at the far end. There is also the inability to access support in the event of a clinical deterioration in the back of an ambulance.
  2. Delays caused by the need to involve ambulance services – with the best planning in the world, involving an ambulance in the transfer, rather than wheeling the child across a corridor in their cot, inordinately increases the time to transfer. For some children, every minute makes a difference – e.g. those with certain congenital heart defects – TGA (Transposition of the great arteries) with an intact septum, or obstructed TAPVD (total anomalous pulmonary venous drainage) – where they will remain deeply hypoxic until they receive interventions (balloon atrial septostomy or corrective surgery) which are only available at the NPH.

It is important to acknowledge that there is overwhelming acceptance of the need for a single tertiary care children’s hospital for Ireland and that the amalgamation of the expertise within the existing three children’s hospitals, more than any other change, will bring about the greatest improvement in outcomes for the children.

Proponents of the St. James’s site argue that collocation will improve access to expensive equipment (such as PET, MRI scanners). The NPH will be self-sufficient in MRI scanners and CAT scanners etc. and, in any event, would require its own specialist team to prepare and scan the children. The need for PET scans in children is small but slowly growing and, as all such scans are performed electively, there is no current pressure in having the needs of the children met by the existing adult services. The children’s hospital would have absolutely no difficulty in raising the funds to purchase its own dedicated PET scanner if needs be – current, significant fundraising by the existing children’s hospitals goes towards modernising outdated facilities – a new NPH will obviate the need for this leaving large sums available to develop new services and facilities.

Another argument made in favour of collocation is synergies in education and research. Adult physicians and surgeons have never been involved in paediatric education, other than to receive it! There would be some synergies in research – current research collaboration by Our Lady’s occurs by arrangement, both onsite and offsite i.e. whilst ideally it should be onsite, it is not a clinical imperative that it be so.

Much is made by supporters of the St. James’s site who claim that it would facilitate continuity in the care of the adolescent/young adult with chronic disease. In our experience, as a national paediatric service provider at Our Lady’s, we admit children up until 19 -20 years of age if they have an illness predominantly associated with childhood. We would see patients up to the same age and older in our out patients department. Subsequently, in our experience, these patients transition nationally to their nearest adult centre – they would not be transitioned to St. James’s unless they were from within St. James’s Dublin catchment area.

The Task Group, in their report, recognised that the fragmentation of adult specialties and the freestanding nature of the maternity hospitals in Dublin mean that there is no readymade ideal tri-location site. Such fragmentation of adult specialties is the principal reason why our Capital City still does not have a Level 1 Trauma Centre – we may be unique in Europe in this regard? With too many adult hospitals providing, for example, relatively small cardiac and oncology services in the same city, this is both inefficient and expensive. With the NPH expected to last for up to 100 years (Planners Martin and Clear), if it were built on a large enough campus, a tertiary adult hospital could be developed over time (as occurred in Auckand, NZ.) This would be the ideal hospital with which to collocate the NPH.

Parking: The Dolphin report states that “It is to be expected that most ED patients who do attend the children’s hospital will arrive by car, and adequate on-site parking needs to be provided for their needs. We note that the approximately 750 public parking spaces proposed on the Eccles Street site exceeded the existing total number of such spaces at the three children’s hospitals in Dublin (Temple Street had no car park and most of the parking in Crumlin occurred on side streets!!), and that An Bord Pleanála did not raise any planning objection to this level of provision. This provides an indication of the minimum level of public parking spaces which should be provided on whichever site is chosen for the hospital. A higher level may be required if the selected site has a lower level of public transport accessibility.”

Isn’t it quite extraordinary how wasteful it was of those who designed the new Melbourne Children’s Hospital and the new Queen Elizabeth adult hospital in Birmingham and Boston and Cincinnati children’s hospitals to provide such an excess of parking facilities (somewhere between 3.13 and 13 spaces per bed) when, according to those planning the NPH, only 1.6 spaces per bed are all that will be required! If you applied the parking allocation of the new adult Queen Elizabeth hospital in Birmingham (3.13/bed) and the parking provided for the new Children’s Hospital in Melbourne (6.6/bed)  to the St. James’s site, in excess of 7,000 car parking spaces should be made available – Dublin City Council will allow a maximum of 2,000 spaces on that site. (I pity the local residents). John Pollock, Project Director at the St. James’s site, pitifully tried to underplay the significant parking shortfall available on the St. James’s site in a recent interview in the Irish Times by stating that hospitals are there to provide care for patients and are not there to build car parks! Can you imagine a supermarket saying that they are there to sell food and not to provide car parks? If Mr Pollock wants some information on parking, he should ask Dr Jim Shmerling for his advice. Dr. Shmerling was Chief Executive Officer of the Children’s Hospital Colorado from January 2007 and has 33 years of leadership experience in children’s hospitals. He now actually sits on the Children’s Hospital Group Board for the St. James’s project – this is what he has to say about parking:

“When we built Children’s Hospital Colorado [opened 2007] on the Anschutz Medical Campus, we miscalculated the number of parking spaces we needed. We spent more than two years driving in circles, walking extra blocks and discussing in Town Halls before we finally completed a second parking garage to accommodate our employees.  As we embark on more large-scale construction projects on Anschutz [a 48 acre University medical school and research campus] we will, without a doubt, work to ensure we provide ample parking to accompany them. You can never have enough parking!” Note that staff at St. James’s has been informed that when the Children’s Hospital is built, there will be no parking available for them.

Excerpt from the McKinsey report:

It is accepted that over 90% of children access hospital by car. In relation to access and parking, it should be remembered that this new hospital will be the only tertiary facility for all the children of Ireland and, whilst the numbers of children with problems requiring tertiary care are outnumbered by those who will require secondary care, the workload generated by these tertiary children is enormous. An analysis of children with cancer, cardiac problems or haematological diseases alone attending the national services for these specialties at Our Lady’s Children’s Hospital shows that this relatively small cohort of patients account for almost 50% of all day cases attending the entire hospital and for over ⅓ of all admissions. If you add in the children from the other tertiary services e.g. burns, spinal surgery, endocrinology, cystic fibrosis, spina bifida etc., these figures will increase significantly. The majority of day cases arrive and depart at peak hours. Therefore, accessibility of the chosen site and adequate parking, from a National perspective, are absolutely essential. Inadequate parking onsite will have an inordinately negative impact on the most vulnerable tertiary patients.

As regards the cost of providing car parking space, below are the figures from the Dolphin report – parking at St. James’s will all be Multi-basement level!

Type of car-park Indicative cost per car space Indicative c cost for 1000 car spaces
Surface €2,000 €         €2,000,000
Multi-storey €5,000           €5,000,000
Multi-basement level €35,000 €       €35,000,000

 

Future expansion: All hospitals enlarge over time – this applies to both adult, children’s and maternity hospitals. Toronto Children’s Hospitals has effectively doubled in size every 10 years. Texas Children’s Hospital was rebuilt, not once, but twice in 20 years. The clinical space at Our Lady’s Children’s Hospital in Crumlin increased by 75% over the past 10 years. An allowance of 20% for future expansion at St. James’s will prove to be woefully inadequate.

Adult Specialties: St. James’s continue to attempt to justify the chosen site by stating that it has more National specialties than any other adult hospital in Dublin. The majority of these National Specialties have absolutely no relevance whatsoever to a Children’s Hospital. And I repeat my previous question, which of these unskilled and unqualified adult specialists will be treating the children? Of the specialties which they should have at St. James’s, according to the reports, none are available. NOTE: Our Lady’s has significantly more specialist services than any hospital, either adult or children’s in the country.

From the St. James’s Website

National Specialties/Services

  1. National Medicines Information Centre (Non-clinical service – of no value to on site NPH)
  2. National Pharmaco-Economics Centre (Non-clinical service – of no value to on site NPH)
  3. National Demential Information and Development Centre (Non-clinical service – of no value to the NPH)
  4. National MRSA Reference Laboratory (Non-clinical service – of no value to on site NPH)
  5. National TB Reference Laboratory (Non-clinical service – of no value to on site NPH)
  6. Plastic Surgery ( My Comment: To my knowledge, there is no full time paediatric plastic surgeon at present – current service is shared with the adult hospital – if the NPH were on the St. James’s site, the plastic surgeons would benefit!)
  7. Burns (My comment: The paediatric burns service in Our Lady’s is directed by a plastic surgeon shared with St. James’s Hospital – if the NPH were on the St. James’s site, the plastic surgeons would benefit!)
  8. Reconstructive Surgery (My comment: Depending on the site in need of reconstruction, would need a plastic surgeon + Maxillo-facial surgeon for head and neck sites. Numbers again very small.)
  9. Haemophilia Services (Shared service with St. James’s but paediatric component delivered from Crumlin)
  10. Bone Marrow Transplant Unit (Our Lady’s BMT service is fully independent)
  11. Maxillo-Facial Surgery (My comment: No maxillo-facial surgeon in Our Lady’s. Small numbers of patients require this service. When needed, surgeon either provides service at Our Lady’s or at St. James’s, depending on age of patient)

Those few clinicians whose particular expertise spans the full age range traverse between their adult and paediatric clinics with relative ease.

I favour trilocation, but only with an appropriate tertiary adult hospital on a suitable site. If you persist with the plan for the NPH on the St. James’s site, I beg of you to insist that planning for an onsite maternity hospital, physically linked to the NPH, is submitted simultaneously. I am greatly concerned that a delayed planning application for the maternity hospital will be refused because of site constraints/traffic issues/access/site overdevelopment which will result in the continuing, needless deaths of babies. The success or failure of this project will eventually hinge on concrete issues and will inevitably be inextricably linked to your period of tenure.

I suspect that, from a political perspective, the Cabinet may fear reversing their decision to build the NPH at St. James’s. I believe that such fear is unfounded. Unlike other jurisdictions, where parents were consulted and involved in deciding on the location of their children’s hospital, the views of parents in Ireland were not officially sought. Unofficially, their views were sought by Joe Duffy on RTE in a “snap” unannounced text poll regarding the inner city Mater site. The poll had more respondents than Mr Duffy had ever received before (16,500 over 10 minutes i.e. 27.5 texts per second) and the result was 89% against the city site and 11% in favour. I am certain that the result would be exactly the same if repeated for the St. James’s site. Overwhelmingly, parents are against the chosen site with the vast majority favouring a Greenfield location. The Blanchardstown site is absolutely ideal for a national facility such as this, not because there is an adult hospital there, but because of the sites size, accessibility, unlimited parking potential, room for expansion and development, open spaces, ownership by the State and especially because of the low planning risk associated with it. The NPH and a new, physically connected maternity hospital could be built on that site for the same cost as building the NPH alone on the St. James’s site!

Currently, almost 85% of tertiary care is provided (and will be in the NPH) by staff at Our Lady’s in Crumlin, 8 or 9% by Temple Street and the remaining 6 or 7% provided by Harcourt St. in Tallaght. Does it not strike you as odd that neither the lead clinician’s in Paediatrics and Neonatology for the NPH or the clinician sitting on the Development Board works in the children’s hospital which provides the vast bulk of tertiary care? And no representative from this major tertiary hospital on either NPHD Board or the CHG Board?

You may remember Dr Andrew Rynne who wrote a weekly article in one of the medical magazines? He once wrote that, to his mind that “The two most difficult areas in medicine are Oncology and Paediatrics”. I wrote to him and asked “Have you tried Paediatric Oncology”? Mind you, however challenging my specialty was, I’m sure that it bears no comparison to the challenges of your ministry. I would not have your job for love nor money!

I will be happy to respond to any queries which arise.

With my good wishes,

Dr Fin Breatnach

Irish Mail on Sunday Article 12th March’17