Matters Relating to the National Paediatric Hospital Development Board Financial Statements 2017: Professor Chris Fitzpatrick

We will now commence our third session. At our meeting last week, we agreed to invite Professor Chris Fitzpatrick to attend this meeting following his correspondence with the committee regarding the National Paediatric Hospital Development Board's financial statements for 2017. I welcome Professor Fitzpatrick, who is a consultant obstetrician and gynaecologist at the Coombe Women and Infants University Hospital and a clinical professor with the UCD school of medicine. He is also one of the authors of the report Putting Children First - Proposal for a Word Class Tri-located National Paediatric Hospital, which was circulated to members for information.

I remind members, witnesses and people in the Public Gallery to turn their mobile phones off or to place them in flight mode. I advise Professor Fitzpatrick that, by virtue section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if he is directed by the committee to cease giving evidence on a particular matter and he continues to so do, he is entitled thereafter only to a qualified privilege in respect of his evidence. He is directed that only evidence connected with the subject matter of these proceedings is to be given and he is asked to respect the parliamentary practice to the effect that, where possible, he should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

Members are reminded that Professor Fitzpatrick is here on a voluntary basis to inform our examination of the financial statements as part of our work looking at the National Paediatric Hospital Development Board financial statements. They are also reminded of the provision in Standing Orders to the effect that the committee should refrain from inquiring into any merits of a policy or policies of the Government, or a Minister of the Government, or the merits of the objectives of such policy. Our focus is on whether proper financial public procedures have been followed and whether value for money has been achieved by the work of the National Paediatric Hospital Development Board to date.

I propose that, following Professor Fitzpatrick's opening remarks, we have a round of clarifying questions from the members present. Members can indicate when they want to speak. I call on Professor Fitzpatrick to make his opening statement.

Professor Chris Fitzpatrick

I thank the Chair and members of the Committee of Public Accounts for the opportunity to speak to them about the national children's hospital. I am here today in a personal capacity. I am also representing the children with the highest mortality rates in the State - the 200 or so critically ill newborn infants who, every year, within hours of birth, are separated from their mothers and transported in ambulances between the Dublin maternity hospitals and the children's hospitals in Crumlin and Temple Street and for whom nothing will change in this hazardous journey when the national children's hospital is built. These are babies who are diagnosed before birth with life-threatening conditions and, of the 600 newborn babies who are transferred between hospitals in the State, these are the 200 who are most likely to die.

Best international practice dictates that these very high-risk babies are delivered in a co-located maternity hospital and, after initial stabilisation, immediately transferred across an internal link corridor to a tertiary children's hospital. This model of care is supported and endorsed by the medical director of the National Paediatric Hospital Development Board.

We got Professor Fitzpatrick's opening statement. Is he reading a long version of it?

Professor Chris Fitzpatrick

No, this is an edited version. I will read it within five or six minutes.

Professor Fitzpatrick is reading a summarised version.

Professor Chris Fitzpatrick

Yes.

I have the long script here and was not following it line by line.

Professor Chris Fitzpatrick

It is a summarised version of that.

We will publish this and put it on the record.

Professor Chris Fitzpatrick

Sure.

The professor is giving us the key points.

Professor Chris Fitzpatrick

I am giving the committee an edited version.

I understand now.

Professor Chris Fitzpatrick

This model of care was endorsed by the medical director of the National Paediatric Hospital Development Board at a hearing of An Bord Pleanála in 2015. It is also of the utmost importance that these critically ill babies are cared for close to their mothers during the most vulnerable period of their lives and that mothers are not kept apart from their sick babies, stressed and worried on the post-natal wards of maternity hospitals in different parts of the city. I hope, by coming here today, that the committee will strongly recommend that the best interests of these critically ill babies, who have mortality rates between 5% and almost 20%, are addressed as a matter of priority for financial reasons, as this is the Committee of Public Accounts, but also, more importantly, for medical and compassionate reasons. If we are building the most expensive hospital in the world, these babies need to be looked after.

By way of background, in November 2012, the then Minister for Health and current Senator, Dr. James Reilly, announced that the national paediatric hospital was to be developed on the current site at St. James's Hospital. There was no reference to when a maternity hospital might be built although there was an aspiration to do so. In October 2014, the then Minister for Health and current Taoiseach, Deputy Varadkar, suggested that a planning application be submitted for a maternity hospital alongside the children's hospital. This was not done.

A document supplied by the National Paediatric Hospital Development Board to the Committee of Public Accounts in January states, in reference to St. James's, that it is not known when or if it is certain that a maternity building will be constructed. It is also of note that the National Paediatric Hospital Development Board's PowerPoint presentation to the Committee of Public Accounts on 31 January last contained not a single reference to maternity co-location. It is fair to state that there is widespread scepticism that maternity co-location will happen unless it starts soon.

Why come before the Committee on Pubic Accounts? The State is building the most expensive hospital in the world, namely, the national children's hospital. It is intended that a maternity hospital will be built beside it in the interests of critically ill babies. If a maternity hospital can never be built on this site or if, when the national children's hospital is built, there is simply no room left for such a facility, then the State will have built the most expensive hospital in the world on the wrong site. This would be both a financial and medical catastrophe.

Although PricewaterhouseCoopers, PwC, did not mention it, it should also be noted that the original cost estimates for the development of the national children's hospital, including a basement car park as cited by St. James's Hospital in April 2012 to the all important Dolphin review, was €297.75 million. In the same submission, it was also stated that, "The site proposed has very limited decanting requirements and thereby prompt access to site for development commencement (< 6 months)." Importantly, this proposal also contained a co-located maternity hospital of 42,000 sq. m.

There are certainly issues of concern as to how back-of-the-envelope financial calculations, assertions about easy site clearance and the availability of a very generous footprint for a maternity hospital, which seems to have evaporated, became the shaky foundations for the construction of the most expensive hospital in the world, the national children's hospital. Added to this remains the intrigue surrounding reports in the media of a last-minute switch of sites by the Government. Lessons also need to be learned from this. With projected costs in excess of €1.73 billion, a completion date now reset at 2023 and no sign of a co-located maternity hospital, the committee will agree that there is a need to think more carefully about what we are doing on this site, not just continuing blindly as though there are not very serious issues to deal with and not just believing everything that we are being told.

As I see it, there are two options for the current crisis relating to funding and maternity co-location. One is to stop the current development and relocate to Connolly Hospital. The advantages of Connolly Hospital are well known when it comes to construction methodology, space, nationwide access and the opportunity to co-locate the Rotunda Hospital. The analysis of this option, however, must take into consideration the money spent, or lost, on the St. James's site to date, expenditure on the satellite centre at Connolly, estimated contractual liabilities and legal costs resulting from stopping the development of St. James's Hospital and the need to significantly upgrade the adult services in Connolly to the levels of St. James's Hospital, the Mater Hospital or St. Vincent's University Hospital to support the co-location of a maternity hospital and paediatric hospital. That would be an enormous strategic and financial undertaking, which is often not factored into the equation, and also the long delay that would happen in that case.

At a pragmatic level, the project at St. James's Hospital, the site of which I visited last night, is probably past its tipping point. In addition, there appears to be limited public support to stop and start again for the third time. The political consequences of changing the site are considerable. There are certainly no votes in stopping this building.

The other option is to continue with the development on the current site. This should only continue if there is evidence that the overall projected costs can be properly estimated and are affordable; in other words, that there are no unknown unknowns, that the proper governance and cost control structures are put in place and that the recommendations of the PwC report are implemented. The overall cost must also include a maternity hospital, which should have been included from the start and the current site must be stress tested, in the same way that PwC stress tested the finances, to ensure that it can accommodate a maternity hospital, the Coombe, and that the co-location of the latter is, in accordance with Government policy, now prioritised among other planned projects on a very busy St. James's Hospital site and included in the national capital plan, with a short timeline for delivery and ring-fenced funding. It is of note now that St. James's Hospital is planning to build a cancer hospital.

This is a site that does not stand still, it is the busiest hospital in the State. It needs to be prioritised that a maternity hospital is developed on this site if it is to happen at all.

Taking all this into consideration, I propose that this co-location of the maternity service on the St. James's campus be accelerated while, at the same, time fulfilling the ambitions of the national women and infants healthcare programme run by the HSE and Department of Health in respect of women's healthcare needs. This proposal involves the transfer of maternity services only from the Coombe to St. James's Hospital. The Coombe Hospital caters for both gynaecology services and maternity services. It has the largest gynaecology service in the State. It exists on 5.5 acres or 17,500 m2. The site currently earmarked for the maternity hospital at St. James's is 3 acres, so there is an issue about fitting onto the site. The way I propose that this be done is to move the maternity service but to retain the large gynaecology service on its current site in the context of an integrated campus. This would allow the development of a benign gynaecology services as well as the national cervical screening laboratory services on the present Coombe site. Any investment in that site would be future-proofed. The reconfiguration of the services would also liberate space on the site which could be used to fund the co-location.

This would result in a faster tri-location, for less and on a smaller footprint and with considerably less campus disruption. I will not give ballpark figures or back-of-the-envelope calculations but this would cost a minimal amount in comparison with the amount that has been squandered on the St. James's Hospital site. This would develop an integrated campus across two sites.

Over the past week, "Liveline" has heard how the maternity services over the years have failed mothers and babies, how clinicians have failed at times to listen and to act with compassion and how things need to improve. I am not sure what it takes for politicians to also listen and make decisions based on medical evidence and compassion as well as economics. We do not want to be told in years to come how when we had the chance to do what was right, that we failed to respond to the critical needs of the most vulnerable children in the State and their mothers. This is not a legacy that any Government or supply party in opposition in a confidence and supply agreement would want to leave behind.

Critically ill babies should not be made to suffer because of poor decision-making at the start of this project and reckless spending since it commenced. In the end, we bailed out the banks. Babies and children are far more important than banks. We need to bail out this hospital. We need to build a maternity hospital as quickly as possible. If that means going to the European Investment Bank, EIB, for another extension on a loan, so be it. We also need to learn from our mistakes, including the mistakes that were made by the Dolphin review and that were made at the origin of this decision. We must take account of our actions. This is now a beleaguered project and we need to rediscover the vision that inspired us to bring three different types of hospitals together and to make it into a truly world-class centre. There is no option but to make it work.

I thank Professor Fitzpatrick. He has been very direct and straight to the point which we appreciate. I call Deputy Connolly first.

I thank Professor Fitzpatrick for attending. I read his letter asking to come in and it encouraged me to invite him. He has made a number of comments, apart from rediscovering the vision. He said mistakes were made and it is certainly not the best site. Even if we park that, the most important issue is to look at the site to see a maternity hospital can be built. That is fundamental to the success of the tri-location.

Professor Chris Fitzpatrick

I agree. Those who object to the site do so for many reasons. The key objection at the present time relates to the absence of maternity co-location. Other reasons are cited including cost, nationwide access, expansion capability and space, but the key issue is the absence of a maternity hospital co-location. That is what will stop it being a world-class centre. My argument is that if we are building the most expensive hospital in the world, and calling it a centre of excellence, and if it is going to be a world-class hospital, it should not exclude those babies who have the highest mortality rates, the children who need to have access to this.

The other issue in respect of Connolly Hospital is its range of specialty expertise in the context of its academic prowess. St. James's Hospital, the Mater and St. Vincent's Hospital are at a different level in the support they would provide to a co-locating maternity hospital, and to a co-locating paediatric hospital. Academically, and in terms of its medical specialties, St. James's hospital is the right site. There was no ideal site for this. We put in a proposal which was short-listed to the final three. It was an imaginative proposal but the decision has been made. There were flaws in how that decision was made but the one issue that will convert much of the angst, frustration and criticism of this site is to somehow ascertain whether it can accommodate a maternity hospital, which I believe it can. There is a way of establishing flexible arrangements between the Coombe and St. James's Hospital can be achieved, and we should go ahead and do it. Everyone would row in behind that.

There has been a lot of criticism of the project and the wow factor that should pertain to this hospital has been lost. It needs to be rediscovered and we need to work together to make it happen. My concern is that St. James's Hospital is a busy site academically and clinically. It is fanciful to think that a space can be held or sterilised for five or ten years and then made available. I am also concerned that if it goes on for years, some 200 babies annually will not have access to this hospital. This figure will increase with increasing pre-natal diagnosis. The Coombe is also seeing referrals from the North of Ireland. This hospital will have a referral basis from the whole island of Ireland. A lot of babies will lose out on this. We need to get the co-location. People are looking at the finances but somebody needs to look at the site and reassure everyone the maternity hospital will go in there. It should be put in the capital plan with the design started now, whether it is done back-to-back or some works can be started in advance, but it should be prioritised in relation to St. James Hospital and the capital plan. It currently exists nowhere.

Professor Fitzpatrick mentioned the St. James's site and the building of a cancer centre or hospital.

Professor Chris Fitzpatrick

My understanding is that plans are being made to develop a cancer hospital at the St. James's site. According to an Irish Times editorial, there is a need to address cancer issues in the hospital, which is the largest cancer hospital in the State. That site has a maximum capacity. What one would not want to happen is that in 2023, when the doors of the new paediatric hospital open, that there will be no space for a maternity hospital. That is why I believe the space should be identified, along with planning, decanting and demolition issues, and that process should start now. The Taoiseach, when he was Minister for Health, asked for a planning application to be submitted at the same time for the children's hospital and the maternity hospital. I am not certain why that did not happen. It may have been because after the Mater site had failed planning, that were it made any more complex, it could fail planning again but it is time to grasp the nettle. There is a total lack of credibility and trust on this. Those of us who work on the front line in relation to babies feel that we have been sidelined regarding the patients whom we feel are important.

There is a way of dealing with this. It is too late to stop the project. Academically and in terms of the specialties, St. James's is the best place and we must make it work. Regarding the space available and what it would entail in co-locating onto that site, flexibility could be put into place that would allow this to happen sooner rather than later. The message needs to go out to all those who genuinely object to the site because of the absence of co-location that this is now a Government priority.

I am reluctant to throw out figures because I have seen back-of-the-envelope calculations before which were widely out of range. The St. Vincent's Hospital project is now at approximately €300 million, whereas it began at €150 million. It is more than 45,000 m2.

Professor Fitzpatrick might be a very brave man to talk about figures.

Professor Chris Fitzpatrick

Those figures and the space should be examined, and due diligence could be brought to bear on maternity co-location.

However, it must go to the top of the agenda.

I thank Professor Fitzpatrick for attending the meeting today. Our paths have crossed and I alerted the committee that we know each other to an extent. I thank Professor Fitzpatrick for the time he served as master of the Coombe hospital. It is something people do and it is not often recognised. It is a very important role and I have told the health committee previously that I am a big fan of the mastership model of care. Professor Fitzpatrick will know that I have experience of having a child in a Dublin hospital who had to be transferred for the reasons Professor Fitzpatrick outlined. The child was taken from me at birth and brought to Crumlin hospital. That is not much of an effort when one is in Dublin and people might say, "what about it?". However, Professor Fitzpatrick knows the risks involved in such transfers as well as the knock-on effects of having a child, handing it over to somebody else in a different hospital and being left alone. It is not something people think about until they are in that situation. The figures are stark that in that transfer period bad things can happen and children's lives are lost.

Before becoming involved in politics I was initially not in favour of the St. James's site but I bought into the idea based on the concept of the tri-location of an adult hospital, a paediatric hospital and a maternity hospital on the same site, supported by the sub-specialties Professor Fitzpatrick has discussed. My argument for supporting the site diminishes, however, if there is no chance of a maternity hospital on site. It is critical that a maternity hospital be on the site and I thank Professor Fitzpatrick for his clear argument today that it must happen and that it must start now so it is ready and fit for purpose as well as ticking the boxes for An Bord Pleanála and all that was planned from the start. It is not the right site if there is no maternity hospital because that was one of the fundamental reasons for putting it there.

The cancer unit on the site concerns me. In St. James's Hospital and through the cancer strategy we have very good survival rates for cancer now, and I will be discussing this later in the Dáil. If there is a space there for the cancer unit does Professor Fitzpatrick think it could be put somewhere else? If he were to juggle the cancer unit and the maternity hospital, he appears to be saying today that the maternity hospital should get priority.

Professor Chris Fitzpatrick

I am not certain about where at the St. James's Hospital site the cancer hospital is going. I would not wish to second guess or somehow inhibit the development of cancer services in St. James's Hospital. I am a patient in St. James's Hospital as well, where I am very well looked after. I believe it is possible to do all these things. St. James's Hospital has a can do attitude. It does things and is a very ambitious hospital. I am saying that in that ambition we must make certain that there is a protected space, and the way to protect the space is to start doing something about it now and not to wait. Basically, it would be a travesty of everything that has happened in this regard to find out a couple of years hence that we could not get planning for a hospital that should have been built at the start. The flawed decision was not to put in a dual application at the start and have a co-build. I believe we should examine how the fastest build can be achieved, what the site is, what the specification is and issues regarding access, but this work should start now. The work must be funded because obviously we require experts to help us with it. That process can start.

In terms of neonatal transport, we have a wonderful neonatal transport service. However, it is recognised that babies decompensate during transport. Certainly, the model of care that is recommended by the National Paediatric Hospital Development Board is that babies who have critical illnesses and pre-identified problems and who need to be transferred to a paediatric hospital ideally should go across a corridor rather than in an ambulance. The term "world class" has often been bandied about in regard to this hospital, as well as its expense. It behoves us to do it right and not find ourselves short changed. Much of the criticism regarding this site relates to the absence of maternity co-location and a disbelief and lack of trust that it might happen. I was speaking about this in 2006, 2012 and subsequently, but nothing has happened. It is time to act.

I do not know if the Committee of Public Accounts can recommend or what authority it has in this regard. I appeared before the Oireachtas Joint Committee on Health previously and I should have walked out asking for something. I am asking for the strongest recommendation that the Committee of Public Accounts can give to accelerate the co-location of a maternity hospital on the St. James's Hospital site. That would mean it would have been worthwhile for me to have appeared before the committee in that regard. I do not know whether that is possible. I like the consensus politics we have here at present when one considers what is happening abroad, and I believe there is a consensus on the fact that there is a need for a maternity hospital there.

On the issue of the site, if we were to do it all again we might do it differently, but we are where we are on this. I believe people want to work together and that they will contribute. I will contribute whatever I can to it. I have been critical of this for a long period of time. Medicine is like politics in that one gets things done through compromise. We must compromise on this and consider what the important thing is, which is a maternity hospital on that site. If the committee can do anything to get it there quickly, I would be very grateful.

One could argue that it is not a world class hospital if the maternity hospital is not on site, in terms of the spend. If we do not put the maternity hospital there, it will not tick the boxes we set out to tick.

Professor Chris Fitzpatrick

Absolutely.

This might go outside the remit of the Committee of Public Accounts, but it is Thursday afternoon. I am also a member of the health committee. We have the maternity strategy and I am aware that Professor Fitzpatrick and many of his colleagues had an input into that. One of the criticisms of the maternity strategy was that it separated obstetrics and gynaecology. It is the separation of having babies and just being a woman, in layman's terms. There are many Cinderellas in politics but gynaecology, as we have seen from the massive waiting lists, is often a Cinderella because women will put up with things where other people would not. In terms of Professor Fitzpatrick's idea of leaving gynaecology in the Coombe and moving births onto the St. James's site, I am concerned that we would have a clinic or a building that might not be fit for purpose. Not being a doctor, is there an issue there in respect of quality? By practising operations and doing procedures one gets better, but if one separates obstetrics and gynaecology does one damage the level of expertise or the quality of care?

Professor Chris Fitzpatrick

It is a valid question. I do not believe so. The issue with benign gynaecology is that it is deprioritised in the general hospitals. It is very difficult. A percentage of women with symptoms that are suggestive of benign disease will actually have an occult cancer. Where women have, for example, problems with menstrual dysfunction and are on a waiting list to go into a maternity hospital or a general hospital, unfortunately a small percentage of them may change from pre-cancer conditions to cancer conditions because there is such a long delay in evaluating them, which is a tragedy. The issue is the model of care we need for gynaecology care. I am looking at the development of an integrated campus. It is not that what would happen in the Coombe would be very different from what happens in St. James's. The distance between our hospital and St. James's Hospital is less than the distance across St. James's Hospital. Our vision is that over time this part of Dublin, and a great deal of spin-off development will happen with the paediatric hospital coming into it, will be a medical quarter and over 20 to 40 years both hospitals will grow together.

There are governance issues to be addressed, but the main thing is to focus on patient outcomes, quality of care, access and choice. There is a wonderful opportunity to develop a customised gynaecology centre, an ambulatory centre, where women would have a range of treatments that are very difficult to access now. The Coombe hospital currently has a submission with the HSE to develop a new day care centre to cater for all women's reproductive needs, in terms of a one-stop-shop with en suite scanning and so forth and procedures on the day of presentation.

That is a wonderful model. It does not necessarily sit well in a cancer hospital. The spatial organisation of a hospital has to be flexible and allow for a configuration of services in the right spaces. Regarding space, if we moved our maternity hospital to St. James's Hospital, we would retain our gynaecology services as an integrated service across both sites. What is currently needed in Dublin and in our hospital group network is ready access to day-case, ambulatory and short-stay gynaecology surgery. Not only would that be possible in St. James's Hospital, it could be integrated with what is happening in Tallaght University Hospital, Midland Regional Hospital, Portlaoise and Naas General Hospital. That would allow a network of care, not segregated but integrated.

I have seen issues around staff flexibility, concerning new contracts for nurses and midwives and how people work across sites. I would like the Committee of Public Accounts and the Government to give impetus to prioritising the development of women's healthcare services and the co-location of a maternity hospital on the site of St. James's Hospital. I am concerned with space, money, and providing the best possible access. We can be flexible in how we could do that. It would not be a segregated service, but an integrated one.

Hypothetically speaking, if the space was available, would it be better to leave gynaecology and obstetrics together?

Professor Chris Fitzpatrick

There are advantages to that, yes. However, I am also considering the site. Sometimes there is a compromise. Parking, access and traffic in the area are all considerations. We would have to consider how that would work. Our proposal for the national children's hospital was a two-site single campus solution, with the children's hospital to be developed in a site beside St. James's Hospital. The vision was that the whole campus would work as a single campus. I am concerned with what works. The really important thing is to start to make it happen. These are the questions we need to ask. We need support from HSE estates and we need a design team. We need to start planning this hospital now. I have asked whether work could be done in advance, simultaneously to what is happening in the national children's hospital or back-to-back, but this needs to happen. There must be a very strong message from the Government saying that the money will be found. The problem with the overspend is that it will hit lots of things that are on the list to be done. It could affect the co-location of the Coombe and St. James's Hospital. Things are going to be cut because of the money lost in the national children's hospital project, and that is one of them. That would be regrettable. It would fulfil Deputy O'Connell's worst fears in that this would not end up being the hospital we planned. It would be a very bad legacy for politics and for medicine.

I thank the professor for his time. I apologise, but I have to leave. I have business in the Chamber.

I apologise in advance as I will have to go as well. I thank the professor for coming in. Where did this go off the tracks? How are we now in a position where Professor Fitzpatrick is before the Committee of Public Accounts on a Thursday afternoon? I am not quite sure this is the correct committee but I am delighted he is here. Trilocation was the key vision for this site from day one. What happened?

Professor Chris Fitzpatrick

There were issues arising from both medical politics and politics. I have written about this before. This was played out as a competition between various institutions to acquire the national children's hospital. Acquiring the national children's hospital would bring such kudos and status to a hospital that it would become the de facto national adult hospital. There are several issues. We were emerging from a recession so perhaps money was an issue. The decision was made after a failed planning application to build on the Mater Hospital site. Members may remember the visual imagery. It was a very imaginative, almost surreal hospital in terms of magnitude. When this was played out for a second time six years later, there was a fear that if the proposal for the St. James's Hospital site was overly complex it might fail to get planning permission. That rang an alarm bell for me. We needed to prove that we could build both hospitals on that site.

Moreover, it is a very busy site. Obviously-----

There were all those practical difficulties but if trilocation was essential for the three hospitals, how did this happen? Let us leave the planning difficulties aside. The issue of a maternity hospital went off the radar completely.

Professor Chris Fitzpatrick

It was not due to a lack of pressure from those of us who were involved in the provision of neonatal care, foetal medicine etc. However, we represent a minority-----

That is what I was wondering.

Professor Chris Fitzpatrick

-----of children. From our point of view, they are the children with the greatest need. Because of their fragility we felt the greatest commitment to advocating for them. The number of children is small but the consequences of excluding them from this iconic trilocation are not. I also refer to the exclusion of mothers. We are very conscious of the fact that mothers now need access to adult sub-specialty services because of increasing risk, co-morbidities and body mass indices, BMIs. This is needed for mothers and particularly for babies.

The Taoiseach asked for an application for a co-build in 2014. That did not happen. We can revisit the history and note that deadlines were missed and calculations were erroneous. Starting from this point however, I would love for the committee to make a recommendation in its meeting with the National Paediatric Hospital Development Board. The board's PowerPoint presentations to this committee mentioned wider community spin-offs, such as raising educational aspirations in the community, benefit to businesses in the community and employment and training opportunities. However there was not one mention of the Coombe or of babies, and we are down the road from that hospital. To me, that symbolised the way babies and maternity hospitals were excluded from the process. As a maternity hospital, we do not have the same political clout and influence as the bigger hospitals. I think that is the case for all maternity hospitals. However, at the present time there is a willingness to make this work.

I welcome Professor Fitzpatrick's presentation and his vision and ambition. We all agree with it. We have gone around in circles about this hospital for the guts of 20 years. There was controversy about the Mater Hospital, we looked at a site in Crumlin and then we came to St. James's Hospital. Many are still of the opinion that it should not be on any of those sites, but in a new greenfield site or outside Connolly Hospital. Building on a greenfield site would avoid all the problems that we have in fitting into the St. James's Hospital site. It would be a lot cheaper to build on a new site than to go in with bulldozers and starting on a brownfield site.

Is it bad planning? The Taoiseach said in 2014 that we should have trilocation. That should be our ambition; to have a general hospital, a children's hospital and a maternity hospital together, a corridor away from one another. One could open a door and go from one to the other instead of trying to transport patients across Dublin in an emergency, or in my constituents' case, all the way from Waterford or Kilkenny. What Professor Fitzpatrick is saying makes sense. He has covered this already, but why are we only now talking about the third part of the trilocation project? Why was a maternity hospital not part of the recent planning for the national children's hospital?

I refer to the overspend. We do not have the remit to make the recommendations Professor Fitzpatrick seeks. This is the Committee of Public Accounts. We follow the money when it is spent and make sure it is spent correctly. We cannot recommend how money is spent. That is not our remit.

We cannot tell the Government what to do, what decisions to make on policies or how to spend money. It is our job to ensure money is spent to the taxpayers' benefit and value for money is achieved.

On the site, is it large enough to facilitate the three hospitals and all of the associated facilities such as parking? I am aware of the rail connection, but last week I read an article in one of the newspapers regarding the problems experienced by a man from rural Ireland trying to get into St. James's Hospital. People are experiencing problems accessing the St. James's site even before the children's hospital has been built there or consideration given to the location of the maternity hospital there. When all of that work is completed there will be even bigger problems in this area in terms of traffic congestion and parking. The ambition is positive but is it possible to have all three facilities at this location? There are many professionals in this country. Why was the survey not undertaken before the JCBs were allowed on site? The cost of the national children's hospital has increased from €600 million to €1.7 million and may increase further. Is this another case of bad planning? Was there no proper analysis of the site in its totality? It is frustrating and annoying to hear that there may not be room for the maternity hospital on this site. Is the lack of available space for a maternity hospital at this location going to be talked about for the next three years?

Professor Chris Fitzpatrick

That is what we need to find out now. It needs to be stress tested. We are where we are on this issue. PwC did not refer back to the original decision. I would go back to the original decision, namely, the submission of St. James's Hospital to build a hospital at a cost of €297 million plus, to have a massive maternity hospital space there and to have site clearance in six months. That was the foundation document for the acquisition of the national children's hospital. The due diligence on how that was examined leads-----

Is the site large enough?

Professor Chris Fitzpatrick

At this stage, PwC has looked at the finances. Pragmatically, it is just too late to stop it now. I do not think there is a political will to do it or a will among the public to do it. The other issue is there is no ideal site. A greenfield site sounds fantastic but to make that into the type of location on which one wants to locate the national children's hospital, a maternity hospital that is delivering the highest risk babies in the State and adult services of the magnitude of St. James's Hospital, the Mater hospital and St. Vincent's Hospital-----

Could it be done at the Connolly Hospital site?

Professor Chris Fitzpatrick

No. We would have to start moving services onto the greenfield site and reconfiguring services nationally. Medically, it would not work. Space-wise, co-location-wise in terms of how to do it and access-wise, it works. That is the issue. What weighted the decision strongly in relation to St. James's Hospital is the fact that it is the largest adult hospital in the State and that cannot be undermined. It is also the largest academic hospital in the State and that cannot be undermined. In terms of what I would do, I would turn it on its head. The decision is made. We are now well into the project and massive excavation has been carried out. The site should be stress tested now to ensure a maternity hospital can be co-located on it. The money that this will cost is small fry given all the money that has been wasted. We need to be absolutely certain that a maternity hospital can be provided on the site and then do it as quickly as possible. There would be issues in terms of access and parking but the bottom line is the medicine and care that would be provided would be at the level that we aspire to. It is a compromise. If the choice is access and double parking versus having the best people in the best place providing the best service I would put up with double parking. That is not, I suppose, ideal, but this in the end is a compromise. We have started it and I think it is too late to stop. I want to make absolutely certain that a maternity hospital is provided. I am looking at flexible ways this could be done in terms of space, cost and delivery. If the remit of the committee is to ensure that money is spent appropriately, expenditure should not continue on this site with the expectation that it is going to deliver a maternity hospital if it cannot be proven that it will. That work needs to start now otherwise value for money will not be achieved and a fortune will be wasted on this project only to find out that it has not delivered what it set out to deliver.

I share the committee's concerns. I have been neutral on the location of this hospital and I have advocated that it should go to Connolly Hospital when there were issues with space and access. We are where we are and we need to deliver this hospital. We need to bring people together to solve the problems that exist and accelerate the solution. In the end, if the maternity hospital, the children's hospital, the adult hospital, the training, the teaching, the education and the innovation are there, all of which one wants in a brilliant health care centre, that could be the best thing in the world. There may be a payoff in terms of access and parking but those issues could be sorted out in time. Cities evolve and space around hospitals evolves. Transport will evolve in terms of what is happening at the present time.

I appeal to the committee to somehow put babies back in the frame in relation to this.

It is possible to provide high-rise and underground parking in small spaces.

Professor Chris Fitzpatrick

Yes.

Parking does not always have to be at ground level.

Professor Chris Fitzpatrick

True.

I have two questions for Professor Fitzpatrick. On the tri-location, we all had heard that it was a key element.

Professor Chris Fitzpatrick

Yes.

When did it enter the mix as a relevant issue or was it always in the mix?

Professor Chris Fitzpatrick

The decision in the McKinsey report was that the children's hospital should co-locate onto an adult campus and the tri-location model was the ideal model to aspire towards. The initial expressions of interest in the children's hospital in 2006 favoured its location on an adult hospital site. Shortly after, due to representation by the children's hospitals and by the maternity hospitals, that was opened to include the provision of a maternity hospital. In regard to the Mater project, it was a tri-location of the Mater hospital, the children's hospital and the Rotunda Hospital. In regard to the St. James's Hospital project, it was the Coombe, St. James's Hospital and the children's hospital. Every adult hospital that pitched to have the children's hospital on its site emphasised the importance of having a maternity hospital there. The St. James's Hospital pitch for it included space for a maternity hospital with a footprint that would deliver a hospital of 42,000 sq. m., which was significant. It was an important issue. The reason it was not included in the planning permission at that time was, perhaps, cost and a little bit of fear in relation to making it too complex. The Coombe does not have the same punching power as the adult hospitals. It is their site and the Coombe is moving on-site and so we do not have control over what is happening. Unfortunately, despite our very good relationship with St. James's Hospital I think we were sidelined in relation to it and sidelined also by politicians. The problem with this project is that there are so many recriminations in relation to it. The past is the past and we need to learn from the experience. We need to bring people together to sort this out.

Professor Fitzpatrick mentioned the tri-location of the Coombe with the children's hospital on the St. James's Hospital site. The Coombe is currently only a short distance from St. James's Hospital and, similarly, the Rotunda Hospital is only a short distance from the Mater Hospital. These were never, in any equation, contiguous sites.

Professor Chris Fitzpatrick

Sure. Our argument was-----

There is a tenuous link to a maternity hospital in that in either case there is one approximately half a mile down the road.

Professor Chris Fitzpatrick

The argument in terms of the maternity service is that we would need it to be on the site in St. James's Hospital next to the children's hospital. Our maternity service and neonatal service for babies needs to be on the campus of St. James's Hospital.

On an issue I have not got an answer to yet, and Professor Fitzpatrick might be of help by way of general information, what will happen to Crumlin children's hospital and Temple Street Children's University Hospital? We were told this project will integrate all of them and that everything will be in the one location. What will happen to those? Does Professor Fitzpatrick have any idea?

Professor Chris Fitzpatrick

Does the Chairman mean in respect of their sites?

Yes. What will happen to those buildings?

Professor Chris Fitzpatrick

I do not know.

Does anyone know?

Professor Chris Fitzpatrick

I am not certain. There is an opportunity to use them in regard to decanting other-----

Step-down facilities.

Professor Chris Fitzpatrick

Yes, step-down. There are-----

Other health facilities but not the children's hospital.

Professor Chris Fitzpatrick

The Crumlin site is a very generous site in terms of its space and Temple Street Hospital is beside the Mater Hospital. I am sure there is a lot of opportunity there to redevelop those spaces in terms of their location and their relationship with other hospitals as well.

Professor Fitzpatrick mentioned that the original idea was that the national paediatric hospital would be located adjacent to the Coombe Hospital.

Professor Chris Fitzpatrick

Yes.

Is that site there or is it gone?

Professor Chris Fitzpatrick

It was an integrated site between a private property and a large football field owned by Dublin City Council. It had been earmarked for development, but when the crash happened, it was not. The debt was in NAMA. We went to the owner, NAMA and Dublin City Council. It was a 15-acre integrated site.

It is not the Player Wills site.

Professor Chris Fitzpatrick

Player Wills, Bailey Gibson and the Dublin City Council-the Boys' Brigade field. It is just next to our hospital. That gives 20.5 acres. It is 600 m down Reuben Street from St. James's Hospital.

I have the map, yes.

Professor Chris Fitzpatrick

We put that in as an option. We never said it was the best option but we said it would deliver a maternity co-location beside an adult hospital. St. James's Hospital would have ranked it as their second option. The advantage was that it was a massive site. The hospital could have been built on it. It would not have disturbed our hospital or St. James's Hospital.

Is that still available?

No. Player Wills is out of NAMA now.

Professor Chris Fitzpatrick

Yes. It is in private ownership. I believe it is earmarked for housing development. It was a wonderful site that was available at the time. However, because it was a distance from St. James's Hospital, we said it was not ideal, but in terms of Blanchardstown and St. James's hospitals, there was a choice and there were options. The issue is that if it had been built there, the hospital would be built now because there was a very low planning risk with it and ease of access onto it. At that time, the purchase of the land would have been very reasonable. We could have had the paediatric hospital there and it would only have occupied 60% of the footprint, so there was a lot of room for other development on the site. Our understanding was that the decision was changed at the last minute, and that is what was reported. That was certainly the feedback we got through the grapevine on it, but that is history. I am not coming here-----

I know. I just wanted to know.

Professor Chris Fitzpatrick

-----in any sense with a grievance or a disappointment. I want to make sure that the 200 babies whose mothers are travelling around the city in ambulances will be delivered in the Coombe Hospital on the St. James's Hospital site, a corridor away from the children's hospital. If we can do that, many of the criticisms and the other issues relating to the site will be addressed.

When we meet the National Paediatric Hospital Development Board, we will talk money, but we need to understand the medical background to ensure we ask the right questions. Of the 200 babies Professor Fitzpatrick just mentioned, how many of them are being born in the Rotunda or Holles Street hospitals?

Professor Chris Fitzpatrick

They will come into the three hospitals.

They would not all be happening in the Coombe Hospital anyway.

Professor Chris Fitzpatrick

No.

Under this plan, would it have involved taking the babies at risk-----

Professor Chris Fitzpatrick

At present, we have a cardiology service in the Coombe that works between our hospital and Crumlin. We take referrals from the Twenty-six Counties and from the North of Ireland. Babies identified with critical heart conditions who need intervention within hours of delivery are delivered in the Coombe. Mothers come from throughout the country-----

And Northern Ireland.

Professor Chris Fitzpatrick

-----and from Northern Ireland. They have their babies in the Coombe and then they are stabilised and transferred to Crumlin. We are the closest hospital to Crumlin and we will be the closest hospital to the paediatric hospital in St. James's, and we are saying that distance is too long for those very fragile, critically ill babies. There are other non-cardiac conditions - babies can have lung disorders etc. - that have the same requirement. Those babies identified before delivery would come onto the site of a maternity hospital on that campus, be pre-identified, the mothers would have their babies there and then would be wheeled across a corridor to access all the services. This is the model of care the members of the National Paediatric Hospital Development Board, when one meets them, including the medical director, are espousing. They say that that is what they want. Their brief is to build the children's hospital. They will say, "Our brief is not to build a maternity hospital." The members have seen what happened in respect of this project. There was a children's group, a National Paediatric Hospital Development Board, HSE estates, the Department of Health, and many other people looking at this development and things falling in between them. What we want is a person to take a decision to say this hospital goes onto this site. It is a priority. There are other hospitals that need to be moved. There is the Rotunda and Limerick hospitals and there are elective hospitals to be built, but the paediatric hospital is the number one development and it will not deliver the goods and it will not save babies from these dangerous ambulance journeys. In terms of the record, the transfers have been very good but babies do not arrive in the shape they should in circumstances like that. I do not know what the Committee of Public Accounts can do in respect of that, but in terms of money alone, we could have built a hospital on the wrong site because we cannot put in a maternity hospital.

I want to be sure we understand that before we speak to the paediatric board, and Professor Fitzpatrick will know this off the top of his head. We are the Committee of Public Accounts. We are not the Committee on Health, so we do not have this information, but it would be helpful for our understanding of the position to know approximately how many children are being born in the Coombe, Holles Street and Rotunda hospitals.

Professor Chris Fitzpatrick

There would probably be one third. We would probably have more because we are closer to Crumlin Hospital. In terms of those critically-----

In other words, would sorting out one of the three maternity hospitals in Dublin by having it adjacent to Professor Fitzpatrick's hospital do much for the other two thirds of children being born in the other hospitals? I am just asking the question.

Professor Chris Fitzpatrick

In terms of-----

In terms of being close to the new paediatric hospital. If Crumlin hospital is integrated into the St. James's Hospital site, that is fine for Crumlin hospital, but it does not solve anything for babies born in Holles Street or the Rotunda. I am probably asking the question in a very-----

Professor Chris Fitzpatrick

There will always be babies we will not identify beforehand. I refer to the particularly unfortunate circumstances. There are babies born with conditions we have not diagnosed who are remote from Dublin and who have to be transferred to Dublin, and the outcome for those babies would be grave. There are very considerable advantages to being born in Dublin because the distances are short. We have a wonderful neonatal transport team with experts who will stabilise babies and transfer. In terms of bad outcomes during the transfer, they are few or rare. In terms of what happens, the baby goes into the ambulance in one condition and comes out in a different condition. It is not the ideal form of transport. There will be babies born in the Rotunda Hospital who will require transfer to the national maternity hospital, but with increased availability of prenatal scans, we will be looking to minimise the chance of a baby that has a serious abnormality being born in the wrong place. These are not universally diagnosed conditions but it is to maximise the outcome for these babies.

There are very premature babies that we know about because we expect them to be born and they need concentration in intensive care units because they are high risk, having gut surgery, for example. Centralising the services for critically ill babies into one unit will maximise outcomes.

While he did not say it, I detect from Professor Fitzpatrick that because St. James' is an adult hospital and has a cancer specialty, it is possible that staff from there may be more interested in having spare capacity on the site for cancer services rather than maternity services. I get the impression that this is a worry.

Professor Chris Fitzpatrick

It is a concern because it is the biggest cancer hospital in the State and cancer is a priority. The service provided is an excellent, world-class service. Its list of priorities as a cancer hospital has to include a maternity hospital. St. James's wanted to acquire the national children's hospital and made itself available to do so.

Is that Holles Street?

Professor Chris Fitzpatrick

The national children's hospital.

Professor Chris Fitzpatrick

St. James's provides a wide range of services. Cancer services are only one part of its specialist services. Our concern is that because it has so many other sub-specialties that it wants to advance, and it is an academic hospital, space for such a hospital is a priority. Since we are not a co-build and we are not looking for planning permission, there is a real financial risk that, in five years' time, the space will be gone and what was built, with nearly €2 billion spent, was the wrong hospital on the wrong site because it was not a tri-located hospital. The only positive thing that will emerge out of the current crisis is that people need to think and ascertain if a maternity hospital can be put there, which I think can be done, and then to make it happen. If that was the outcome of this costing crisis and the issue of maternity co-location coming in, it would be the silver lining that we have needed for this big cloud. This hospital should have a "wow" factor about it and we should be really proud of it. How it is portrayed in the media, how people look at it, and the recriminations with regard to how it went completely out of control, need to be reined back in. I have been very critical of it but I am coming here in a spirit of compromise to say that I will be happy to work with the development board in any way to try to make this happen.

Professor Fitzpatrick said that it is important to at least commence talking about the design, to start a process and to get it into the Government capital plan. I take it Professor Fitzpatrick is saying that it is not specifically in the capital plan. Is the move of Holles Street to St. Vincent's-----

Professor Chris Fitzpatrick

That is funded. It is part of the capital plan.

I am thinking out loud. Somewhere in the ether, people are saying that they will build a new maternity hospital at St. Vincent's and that is it for the moment. Professor Fitzpatrick must be a bit concerned.

Professor Chris Fitzpatrick

That does not address-----

I know it does not. Professor Fitzpatrick must be concerned that some people are thinking that they will do one at a time.

Professor Chris Fitzpatrick

For a period, I was on the project team for the co-location of the National Maternity Hospital at St. Vincent's, representing the HSE's clinical programme. I would be fully supportive of that. With regard to medical politics, hospitals are in competition with each other, but I think the maternity hospitals are mutually supportive. I would want to see that happen. The conditions at the National Maternity Hospital required it to be relocated. We see what money has been squandered. I do not think that is somehow undermining the fact that a second maternity hospital is needed. There is not a week in which the maternity hospitals are not in the High Court or the news. That is somewhat due to a legacy of underinvestment in them. I fully support Holles Street's development. It is at quite a distance from the national children's hospital. We are the closest hospital. It is supposed to be a Government priority. I think it needs to be done. There are other hospitals, including the Rotunda and Limerick, but prioritisation needs to be given and work needs to commence. The top priority project for this State is to build the children's hospital. The project could become a legacy of failure and disappointment if it does not deliver what it set out to deliver. I emphasise that what happens elsewhere does not concern me. What happens with regard to this does.

For our background information, we keep hearing about the satellites in Tallaght and Blanchardstown. Give us a layperson's version of what will be different in the new national paediatric hospital. Are they outpatient clinics?

Professor Chris Fitzpatrick

I am not a paediatrician and would not specifically know the models of care. They would be for ambulatory care. The national paediatric hospital will have the centralised care in terms of complexity. I am not a paediatrician and cannot second-guess what they will do in those centres except that all of the complexity that a children's hospital should be developing for a national context will all be in the centralised children's hospital.

Will they be routine items rather than critical care?

Professor Chris Fitzpatrick

Exactly. The critical care will all happen on the site of St. James' Hospital.

There might be referrals from those satellites or directly from maternity hospitals around the country.

Professor Chris Fitzpatrick

Yes.

If we got this hospital at St. James's and the new one at St. Vincent's, would the others such as the Coombe close down because they are outdated, having been built years ago? Will we concentrate on just the maternity hospitals, if it came to pass, at St. James's, St. Vincent's and Tallaght?

Professor Chris Fitzpatrick

In European terms, the three Dublin hospitals are the three biggest hospitals in the British Isles and in Europe. The birth rate is still going up. With 60,000 births, three big maternity hospitals are needed.

Three are needed in Dublin anyway.

Professor Chris Fitzpatrick

Three are needed in Dublin. The problem is that all three have been operating above capacity for a long time. Not only are they maternity hospitals, they are neonatal centres and gynaecology hospitals. Where the three need to be has already been decided. One is to be in St. Vincent's. That was the neatest fit because of the fact that St. Vincent's was never going to have the paediatric hospital. When the Mater was the designated site for the children's hospital, the Rotunda was to move to the Mater. Since the site changed, the Rotunda is now instead to move to Connolly hospital. Three hospitals are needed in Dublin. I do not think we could ever get to the stage where we could rationalise them down to two. We support what is happening in the other two hospitals. The critical thing is that the big project is the children's hospital. One cannot build a hospital that does not deliver what one sets out to deliver, especially if one spends more money on it than on any hospital in the world. This will be a spectacular example of failure if a maternity hospital is not put there. It is time now to get that work done. The financial piece has been done but this is equally important and feeds into the finances too. The money that this will cost is insignificant in the context of what has been wasted to date on it.

I am glad that Professor Fitzpatrick said that. There are difficult pregnancies in the rest of Ireland and special cases have to come to Dublin. In my local area, they cannot come to Waterford, Kilkenny or such. This hospital would be available. It would not be just for Dublin.

Professor Chris Fitzpatrick

No, this is a national hospital.

It is for the Thirty-two Counties. There will always be difficult pregnancies that have to be brought to Dublin for special care that is needed, whether before or after birth.

Should the improved maternity facilities lead to an improvement in health, the safety of deliveries and fewer claims in terms of obstetrics?

Professor Chris Fitzpatrick

I think so. In international terms, the statistics from the maternity services in Dublin and elsewhere in Ireland are exceptionally good, although there are obviously cases where adverse circumstances happened that, looking back, could have been avoided. One of the things we have been very concerned about over a long period of time is the resourcing of the maternity hospitals. I cannot remember how many reports came out when I was master of the hospital which made recommendations for co-location, recommendations in terms of staff, recommendations in terms of infrastructure, etc., but very few of them were delivered. We have a women and infants healthcare programme, which is still cash strapped. We have the lowest number of obstetricians in the OECD. These are issues that need to be addressed, but I think front-loading the maternity services with money improves outcome, improves quality of care and reduces adverse outcomes, and in reducing adverse outcomes, it reduces medical legal claims. In terms of escalating medical legal claims, the way around that is to front-load investment into the service, and that, in a sense, would minimise risk. The answer is "Yes" in terms of the development of new hospitals and new models of care and improving staffing levels and attracting people back from abroad who have gone away to train because they are looking at our maternity hospitals and are saying that they will not come back from Toronto or Sydney because they are working in state-of-the-art, tri-located centres. Why would they come back?

There may be difficulties recruiting people to work in the children's hospital, because they have seen a hospital mired in controversy. To get the best and the brightest to come back to this country to work in our maternity and paediatric services, we need to deliver to them what they require in terms of infrastructure. That is for the mothers and babies, not for the staff.

Professor Fitzpatrick talking about outcomes for patients brings us nicely into the remit of the Committee of Public Accounts. We have been dealing with the State Claims Agency and there is about €2 billion in cases there relating to medical negligence, the vast majority of which relate to obstetrics. In view of this conversation, we will send the transcript to the State Claims Agency and see if it can respond. We have asked it for a breakdown of that on a hospital-by-hospital basis, but it is reluctant to do that because it might give a hospital a bad name if it is hit by five or six serious claims worth €50 million. In terms of reducing claims and providing a better service, there is information in the system that people do not want released for other purposes, but that would be a valuable source of information to help people make important decisions in this regard. Ultimately, prevention of some of these serious incidents is the best outcome for everyone, with no legal and medical bills coming five or six years down the road.

Professor Chris Fitzpatrick

In terms of the hospital's relationship with the State Claims Agency, it is not just the issue of indemnity in the finances that it deals with. It is very active in the relationship with the hospital on risk minimisation and improving quality of care. We get a lot of feedback from the State Claims Agency in relation to our services and dealing with risk as well. It would be very proactive in that regard.

That is good to hear, because we have not heard that before.

I thank Professor Fitzpatrick. I know there is only a small number of us here but this is all on the record and is part of committee's workload. We will consider the information in advance of our next meeting with National Paediatric Hospital Development Board. We cannot say what the outcome will be as there are only two of us here at the moment but Professor Fitzpatrick has definitely improved our knowledge and awareness for when we talk to the National Paediatric Hospital Development Board in the next couple of weeks. I thank Professor Fitzpatrick for the information and assistance he provided and the very straight and upfront manner in which he answered questions.

The clerk will seek any necessary follow-up information arising from the three sessions today. We will adjourn until next Thursday when we will meet the Environmental Protection Agency in relation to its 2017 financial statement.

The witness withdrew.
The committee adjourned at 4.15 p.m. until 9 a.m. on Thursday, 18 April 2019.