Medical politics, and indeed national politics, have always played a role in the configuration of hospital services in Ireland, writes Martin Wall
Perhaps it is not surprising given the history involved that the Government's plan for the development of a new national children's hospital on a site at the Mater hospital in Dublin has run into so much trouble in recent days.
Many previous attempts to reform paediatric services in the city have been beset by territorialism and rivalry between the medical establishments on the northside and southside.
A row, for example, between Our Lady's hospital in Crumlin and the Children's University Hospital in Temple Street over the future of specialist surgery for young children has waged for about 15 years.
Moves to centralise haematology and oncology services at Crumlin a number of years ago also generated much heat, although this process was eventually successfully achieved.
Senior Department of Health figures have always believed that the difficult part of the Government's move to develop a new children's hospital was not going to be getting the various parties to sign up to the project but to keep them on board for the implementation of the programme.
Medical politics, and indeed national politics, have always played a role in the configuration of hospital services in Ireland. Indeed, one of the arguments in favour of the establishment of the HSE was that it would get away from the traditional local rivalries that undermined reform in this area and allow for decisions to be taken which were considered necessary although controversial.
The decision on the location of the new national children's hospital will be one of the first main tests of whether the new system can stand up to pressure.
The original plan for the development of paediatric services envisaged the existing three hospitals, Crumlin, Temple Street and Tallaght developing separately.
Up to last year Our Lady's hospital in Crumlin had plans either for a redevelopment on its own site or to move to a greenfield location. Temple Street was earmarked for a move to the new Mater complex where planning permission for such a development had been secured and around €47 million already spent.
Chief executive of the HSE Prof Brendan Drumm said on Sunday that he would not sign off on these plans as he felt that the development of one world-class facility was the way forward.
Consultants McKinsey later proposed that a new children's facility be co-located with an adult hospital.
All sides agreed with this vision initially, although the unanimity ended when a health service task group recommended the Mater as the location of the new hospital last May. Crumlin objects because it feels that the Mater site is too small, is inaccessible due to traffic congestion, has inadequate car parking and has little accommodation for parents.
The HSE says that the Mater site, at 100,000 square metres, is double the size of the existing three paediatric facilities and will have a metro line running underneath. There is also to be a multi-storey car park beneath the new hospital.
Design consultants, who will make recommendations on issues such as the number of beds and the location of services, will report in mid-March and the HSE argues that now is the time for interested parties to give their point of view while the architectural and engineering process is underway. One problem for the Government is that just as there is no agreement on the Mater, there is also no unanimity among the interested parties on what should replace it.
Tallaght hospital, where the existing National Children's Hospital is based, wants a meeting with Taoiseach Bertie Ahern to outline plans for a children's hospital on two campuses with one governance structure.
However, this is not acceptable to Crumlin. Crumlin is seeking a facility for children and adults as well as a maternity unit on a single site or alternatively a children's and maternity hospital on a unified site.
Crumlin chief executive Michael Lyons yesterday said that "one thing not on the agenda is the splitting of tertiary [ or complex procedures] between two sites". He said that the division of tertiary services appeared inherent in the Tallaght proposal for twin locations.
Crumlin wants the new hospital to contain clinical, educational and research facilities as well as family accommodation. It is worried that some clinical services such as chemotherapy, would be fragmented under the Mater plan.
It is seeking an international peer review group to examine the whole plan and has said that it would be prepared to accept the Mater site if it was recommended by such a body. Fine Gael, Labour and the Greens support the call for a new review of the hospital plan.
However, the Government does not agree. The HSE has been told that the Cabinet fully backs its plans to develop the Mater site.
Opponents have suggested that the Mater was chosen because it is in the Taoiseach's constituency. Mr Ahern sought to deflect this charge on Monday when he suggested that he had misgivings about the proposal as it could delay a long-planned redevelopment of the Mater itself. However, Mr Ahern, in the past, has lobbied on behalf of Temple Street in the row over surgical services.
Last year, the chairman of the Mater Des Lamont publicly thanked the Taoiseach for delivering on a promise to develop a children's hospital on the site. The Government has argued that Mr Ahern's commitment referred to a children's hospital rather than the national children's hospital. However, political opponents have refused to accept this.
Whatever about political interference in the past what seems clear is that the only way the Mater project can be stopped now is by a ministerial decision.
However, this could have unforeseen consequences. Later this year the HSE will announce an equally contentious decision on the site of a new hospital in the northeast. Any indications that such decisions could be altered as a result of pressure could fatally undermine the process.
There is also the position of Prof Drumm to be considered. He has publicly declared that it would be madness to develop a children's hospital on two sites.