It is not easy to convey the state of the Children's Hospital, Temple Street. But even from the outside it is apparent that it is well past its sell-by date. This is not the type of hospital in which you would find a Minister for Health posing for photo calls.
Temple Street, as it is known, stands in the middle of the Taoiseach's Dublin constituency, in the shadow of Croke Park, but there have been no windfalls here. It is about as far away from ER as you are likely to get and still be in first-world medicine. Many plans have been made to renovate and relocate, but they have never made it past the drawing board.
The hospital was founded in 1872. If you were treated there as a child the chances are, regardless of your age, that very little has changed. In the casualty department the tiles on the floor were laid almost 60 years ago. In Temple Street terms they are relatively young. Like everything else, they have served well but their time has come and gone. From the front door to the top floor, conditions are cramped, ancient and decrepit. Valiant efforts have been made with artwork, bright paint and coloured curtains but there is only so much you can do to paper over the cracks. "If you are here, you do get used to it," confirms secretary-manager Paul Cunniffe. "The type of buildings they are, there is a limit to what you can do and we are already pushing the boundaries of those limits." More than 105,000 sick children, from tiny babies to teenagers, are treated at the hospital each year. Between staff, relatives, and friends, about three times that number of people come through the hospital, putting a huge strain on this old building and, therefore, on the staff, who manage to deliver a high standard of care despite the conditions.
This was never meant to be a hospital. In fact, it is a combination of up to three townhouses and other assorted buildings, on over two acres - a higgledy-piggledy combination of stairwells, wards of wildly varying sizes, and narrow corridors with walls scuffed by trollies and machinery. Those working here may be inured by familiarity to the conditions, but the building is quite a shock for first-time visitors.
A quick look at the cramped intensive care unit (formerly the radiology department), reveals the incongruous sight of gravely-ill babies and children lying hooked up to high-tech machinery - the best modern medicine has to offer - in a room which probably used to be a small bedroom or dressing room. In the neo-natal ward, the tiny babies lie in little cubicles, their parents sitting beside them, squashed into chairs. The cubicles were designed at a time when parents were allowed to see their infants for half-an-hour each day. Elsewhere, there is a shortage of isolation wards.
The hospital was founded in 1872 in a house in Upper Buckingham Street by a group of charitable lay people led by a Mrs Eileen Woodlock. It began with eight beds. In 1876, the Sisters of Charity were invited to take it over. Once the lease expired in Buckingham Street they sought alternative accommodation and a bequest enabled them to purchase the former residence of the Earl of Belamont on Temple Street. Over the following year adjoining houses were purchased, including No 14, the residence of the Parnell family.
It was not until the 1930s that further development of the hospital was undertaken with the inauguration of the Irish Hospitals' Sweepstake. Today, the hospital still relies heavily on fund-raising.
No particular era describes the building - it has passed through so many, and signs of each remain. Cunniffe, who has worked there for 24 years, puts it simply: "The building here is very old and cramped and unsuitable for modern medicine. It is a poor quality of service but we do deliver a good quality of medicine."
Accident and emergency consultant Dr Peter Keenan agrees. "While you can get a wonderful meal in a tent, you would prefer to get it in a dining room," he says simply. Indeed, the conditions under which Keenan works in the casualty department are little better than if he were working in a tent. They have hardly changed at all since he was treated there as a child. Those tiles laid in 1939, combined with the tiling arrangement on the wall, actually give the place the feel of a public toilet. And ironically, despite the 50,000 attendances a year - making Temple Street's casualty department one of the largest in the country - there are just two toilets serving this department.
It has just one resuscitation room with two resuscitation trollies, side by side. It is not unusual to have one child in the room, another child involved in a road traffic accident due in, and a third needing immediate treatment.
"When you bring in other doctors down the narrow, tiled corridors, you really begin to see it through their eyes," says Keenan. "When they say `Where's the toilet?' it is embarrassing. They are quite amazed by what they see." For the "walking wounded", there is one big room in which up to three doctors may be working at one time. A wailing three-year-old may be getting stitched on one bed, while a couple of yards away a doctor may be examining another child's twisted ankle. To add to the over-crowding, most children will be accompanied by one parent if not two, perhaps a grandmother and often other siblings. The hospital does not discourage this, but it makes for difficult manoeuvring.
The waiting room, with seating for around 23 people, is hardly bigger than your average front room. There is no nursing station. In side-rooms, doors are always being opened with people pushing their heads in to see if the room is available. "I can understand people coming in here and saying `God this is a hell-hole'," Keenan says. Nonetheless, he describes Temple Street as intimate, bustling and friendly. Everyone is working together somewhat against the odds and the staff are proud to be able to deliver a high quality of health care despite the constraints.
He points out that the hospital has 140 beds "for little less than half the city". This shortage of beds poses daily, dangerous difficulties for the doctors. "If you are manifestly very ill, you will get admitted. But at the `maybe' end of things you have to run a much tighter ship. Doctors on the front line have to take tight decisions, and we are being pushed too close to the wire. Doctors do not have the margin of error they need in front-line clinical medicine, which is essentially an educated guessing game. Not every child is lying there with meningitis written all over him. The population of the northside deserves better than this." And the pressure is increasing. Since the National Children's Hospital in Harcourt Street moved out to Tallaght in June, there has been a four per cent increase in activity in Temple Street's accident and emergency department.
And this has been during the traditionally quiet summer period: it is expected to increase still further in the winter months. Dr Keenan believes medical staff may have to shoulder some of the blame for the situation - perhaps, for instance, consultants should be acting more as advocates on patients' behalf, pushing for change. "We have let them down to some extent by failing to extract better facilities for the children of north Dublin. I know of people on the northside who prefer to go across the river to get their children treated there because of the conditions here." Another doctor, who did not wish to be named, believes the Department of Health only responds once a clamour has been created. "We obviously don't make enough noise. We don't have enough clout. Even the crumbs from Tallaght Hospital would be an improvement." One of the biggest difficulties for hospital management is finding somewhere for parents to stay. There is accommodation only for around 20 parents in the hospital. This raises problems for those from outside the city, particularly as their child may be in hospital for weeks at a time. Most parents end up on couches, chairs or mattresses on the floor.
"We are glad when parents want to stay because they are very good at monitoring the child and give valuable information," explains Dr Mary King, consultant neurologist and secretary of the hospital's medical board. "But the rooms we do have are very small and often now both parents will want to stay. Up to 70 per cent of my referrals are from outside Dublin." With just one playroom in the hospital, there are further difficulties providing play space for the children. Two teachers are employed to run classes, to ensure children don't fall behind in their schoolwork, but again space is a problem.
"We don't want children just staying in bed when they are well enough to be out of it, but finding recreation space is extremely difficult," says Cunniffe. "In a new hospital we would envisage a play-room in each ward, instead of one for the whole hospital." The hospital, which serves all of Dublin and parts of Co Meath and Co Kildare, and has referrals from all over the country for various specialities including neurology, nephrology, ENT and plastic surgery, is also the base for the National Meningococcal Reference Laboratory, where ground-breaking work is being carried out. But even a visit to this pioneering unit reveals fridges standing in hospital corridors. Despite such drawbacks, the hospital is to be home to the national metabolic unit. King says that as a doctor she has no problem with the standard of health care she sees given to her patients. Her department, she says, has led the way in a number of medical developments. But there is no escaping the fact that the physical conditions pose problems.
"I know when colleagues come in they cannot believe this is a hospital, but then they experience the atmosphere and when they are leaving they say `don't change it'. But then, they are not talking about casualty or the wards where there are major problems," she says.
She is amazed at parents' tolerance of the state of the hospital. "I was doing a clinic for years without a changing or feeding area but no-one ever complained." Security has long been another problem. Across the road, a sign adorns the front wall of a block of corporation flats: "Children Say No To Evil Drugs." A nurse was apparently attacked a number of years ago while going off duty. Cars are regularly broken into, including those parked in the staff car-park at the back of the hospital. The situation improved considerably with the erection of security cameras, employment of additional security guards and the considerable efforts of the local community.
A rather squalid laneway leads across to the new out-patient department, opened in 1996. Until then, conditions were similar to those in casualty, with the overflow housed in an ancient prefab. In the past decade, Cunniffe estimates, around £10 million has been spent on the hospital, a substantial amount from fund-raising. There is more change in the air. Written approval for a £2 million extension and refurbishment of the accident and emergency department, and also for the provision of a new 20-bed day ward, was received recently from the Department of Health. But this raises questions as fast as it relieves problems. Many wonder why funding is forthcoming for improvements when a more permanent solution is really needed - and has long been promised.
There has been talk of a new hospital for more than 20 years, but plans are still at the drawingboard stage. They have been there before. In 1983, a design team was appointed for the refurbishment of the hospital. This plan disappeared along with so many others during the health cutbacks of the 1980s. Since then various plans have been mooted. The current plan is to move the hospital to the Mater Hospital campus nearby. Another design team has been appointed. It must first prepare a plan for the entire development at the Mater, including the children's hospital.
According to a statement from the Department of Health, Temple Street will form part of Phase II, and work is well advanced on the preparation of the design brief. In the interim, the statement says, it is intended that the hospital will be provided with adequate facilities to enable it to perform its important functions in the delivery of paediatric hospital care. Pending relocation, a programme of improvements is ongoing at the hospital. Despite the conditions, some staff say they will be sorry to go. "The hospital does have some advantages for children," says King. "It does not look like a hospital. It is small and intimate."
Optimistically, all going to plan, the hospital will be finished within five years. But cynics, looking to Tallaght Hospital, suggest it could be far more. Paul Cunniffe says the "dream" hospital would be a stand-alone building on the Mater site, with around 170 beds, where children would be treated separately from adults. He does not yet know how much it would cost. Some do raise questions about the need for three paediatric hospitals in a city the size of Dublin, and the subsequent splitting of resources. The wait has already been long enough, says King. "We don't want to be panned off by politicians about the construction of a new hospital. It needs to get going straightaway. We need more money, more space and more beds - now."
